Bone Tumors

Orthopedic oncology is dedicated to the management of tumors of the musculoskeletal system, both primary and secondary, as well as benign and malignant lesions, through surgical and non-surgical approaches.

In recent years, due to the complexity and specificity of these diseases, orthopedic oncology has developed as a distinct subspecialty within orthopedics.

The primary objective of this discipline is the complete removal of tumor-affected bone segments, combined with reconstruction procedures that allow the patient to preserve mobility, daily function, and social independence, thereby maintaining the best possible quality of life, alongside achieving effective disease control.

The choice of the most appropriate therapeutic strategy, including reconstructive techniques, is always based on multidisciplinary evaluation involving all relevant specialists. In some cases, it may be appropriate to delay surgery in favor of medical or radiation treatments, while in other situations surgery should be performed promptly, for example to reduce the risk of pathological fracture or due to proximity to critical anatomical structures.

Only through close multidisciplinary collaboration is it possible to optimize outcomes, achieve effective pain control, and preserve affected structures, all of which are essential to ensuring the patient’s quality of life.

Radiation therapy consists of the use of high-energy radiation to destroy cancer cells. Treatment is delivered at the Radiotherapy Division in consecutive daily sessions from Monday to Friday, over cycles that may range from a single session to approximately 10–15 sessions, depending on the treatment intent and prescribed dose.

Radiotherapy is widely used in bone metastases due to its well established analgesic effect.

It is also indicated for the prevention of pathological fractures, taking advantage of its effect on bone stabilization, as well as in cases of compression of critical structures by tumor tissue, such as the spinal cord.

It may also have a postoperative role, for example after a decompressive laminectomy, a surgical procedure aimed at relieving compression of the spinal cord and/or nerve roots. In this setting, radiotherapy is used to sterilize residual tumor tissue in the treated area.

In selected cases, radiotherapy may be delivered with curative intent, particularly when there are a limited number of bone lesions and long-term disease control is still achievable. In these situations, advanced techniques such as stereotactic radiotherapy are used. This approach delivers high-dose, highly focused radiation over a limited number of sessions, typically between one and five.

Interventional radiology is a subspecialty of medical radiology that uses image guidance (ultrasound, CT, fluoroscopy) to perform minimally invasive diagnostic and therapeutic procedures, providing alternatives to traditional surgery for several conditions, including bone diseases.

Main Procedures in Bone Interventional Radiology

Bone biopsy
This procedure involves the collection of bone tissue samples suspected of tumor involvement under ultrasound or CT guidance. It is usually performed on an outpatient basis under local anesthesia and uses a specialized cannula to obtain a small core of tissue without the need for surgical incision.

Vertebroplasty and osteoplasty
These techniques involve the percutaneous insertion of small cannulas under radiological guidance to inject bone cement or resins into fractured or weakened bone areas, with the aim of preventing further deterioration and reducing pain. These procedures are often combined with radiotherapy and medical treatments. In selected cases, they may be associated with the percutaneous placement of screws or prosthetic devices. Vertebroplasty can also be used in non tumor related fractures to control pain and improve stability.

Thermoablation and cryoablation
These procedures consist of the targeted destruction of tumor cells using probes that deliver high temperatures (thermoablation) or very low temperatures (cryoablation). They are typically used in patients with a limited number of lesions, particularly when radiotherapy is not feasible, and may be combined with vertebroplasty or osteoplasty for structural support.

Pain associated with bone metastases is the most frequent type of cancer related pain, affecting approximately one third of patients. It has a major impact on quality of life, limiting mobility and increasing the risk of neurological complications and pathological fractures.

Bone pain typically includes three components: baseline pain, spontaneous pain, and movement induced pain.

Management is multimodal and may include systemic analgesics, bisphosphonates, chemotherapy, radiotherapy, orthopedic interventions, and neuromodulation techniques.

There are no specific pharmacological guidelines exclusively for bone metastases; therefore, treatment follows World Health Organization (WHO) and European Society for Medical Oncology (ESMO) recommendations.

Evaluation of treatment efficacy is based on patient reported pain levels, quality of life, and overall clinical judgment.

WHO Analgesic Ladder

The WHO approach is organized into a three step ladder:

• Step 1: non opioid analgesics such as paracetamol and NSAIDs, with or without adjuvant therapies
• Step 2: weak opioids for mild to moderate pain, including codeine, tramadol, and tapentadol, with or without adjuvants
• Step 3: strong opioids for moderate to severe pain, including morphine, methadone, fentanyl, buprenorphine, oxycodone, and hydromorphone, with or without adjuvant therapies

This ladder may be extended:

• Step 4: opioid rotation or change in administration route, such as subcutaneous or intravenous continuous infusions
• Step 5: invasive procedures in refractory cases, including intrathecal pumps, spinal cord stimulation, or cordotomy

Adjuvant Therapies

Analgesic drugs, both non opioid and opioid, may be combined with:

• Corticosteroids
• Antiepileptics
• Local anesthetics
• Antidepressants
• Antiemetics and laxatives, depending on symptoms and side effects

Anti inflammatory drugs may be used in early stages or combined with opioids in severe pain, with careful consideration of the patient’s clinical status.

Principles of Effective Pain Management

According to WHO principles, effective analgesic therapy should:

• Prevent pain through regular scheduled dosing, reserving “as needed” dosing for breakthrough pain
• Prefer the oral route of administration whenever possible
• Be promptly adjusted when efficacy decreases
• Be individualized in dose, drug selection, and route of administration

A properly managed pharmacological approach can control pain in more than 90% of patients with bone metastases.

Cancer patients often have complex needs that extend beyond the treatment of the disease itself and require comprehensive, multidisciplinary care.

At INOC – Istituto Nazionale Oncologico Candiolo, patients who need additional support have access to specialists from a range of disciplines, ensuring personalized management of cancer-related symptoms and associated conditions. Services may include nutritional counseling, physical rehabilitation, pain management, and support for other medical needs that may arise during the course of treatment and recovery.

The goal is to improve quality of life, promote overall well-being, and provide comprehensive care tailored to each patient’s individual needs.

Treatment for bone tumors may be associated with side effects that can affect a patient’s quality of life to varying degrees. Many of these effects can be prevented, reduced, or effectively managed through appropriate supportive care, targeted interventions, and healthy lifestyle measures.

At INOC – Istituto Nazionale Oncologico Candiolo, patients are supported by a dedicated multidisciplinary team of physicians, nurses, and allied health professionals who work together to help prevent and manage treatment-related side effects throughout the course of care. The team provides personalized guidance, symptom management, and ongoing support to help patients maintain the best possible quality of life during and after treatment.

The impact of cancer also extends to the psychological sphere. A cancer diagnosis is often a traumatic event that affects all aspects of a person’s life and may generate anxiety, fear, anger, and depression.

At the Canciolo Cancer Institute, alongside advanced medical therapies, the care pathway always includes specialized psycho-oncological support, helping patients cope not only with treatment but also with the delicate phases of physical and psychological recovery.

Patients may also participate in psychological support groups, where they can share experiences with others who are facing or have faced a similar condition.

To ensure timely support and provide prompt answers to questions or concerns, INOC – Istituto Nazionale Oncologico Candiolo offers a dedicated assistance service for all patients.

From Monday through Friday, between 8:00 a.m. and 5:00 p.m., patients can contact the Oncology Day Hospital Secretariat at +39 011 993 3775 to request an urgent consultation.

The Social Work Service at INOC – Istituto Nazionale Oncologico Candiolo provides information, guidance, and support to patients and their families regarding access to community services and the welfare and social security benefits available under current legislation.

During dedicated consultations, social workers assist with matters such as disability recognition, access to aids and prosthetic devices, employment-related benefits and leave, and other social support services.

The service is available on Wednesdays and Fridays from 9:00 a.m. to 1:00 p.m. and can be contacted at +39 011 993 3059.

Thanks to the large number of cases treated each year, INOC – Istituto Nazionale Oncologico Candiolo is a national reference center for the care of this disease. This extensive experience allows us to manage even the most complex cases, always using a personalized approach, tailored to the clinical and individual profile of each patient. 

The development of an effective treatment plan begins with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies, enabling precise assessment of the extent and characteristics of the disease.

The Institute also provides advanced diagnostic and laboratory testing, including molecular and genomic analyses, which play a key role in identifying the biological and genetic features of the tumor. These insights support personalized treatment planning, helping clinicians select the most appropriate therapeutic strategy for each patient.

When appropriate, surgeries are performed using minimally invasive, laparoscopic or robotic techniques. These approaches involve the use of camera-equipped instruments introduced into the abdomen through small incisions, thus reducing surgical trauma. Benefits to the patient include shorter hospital stay times, faster recovery, and lower risk of complications compared with traditional open surgery.

As an IRCCS (Scientific Institute for Research, Hospitalization, and Healthcare), INOC – Istituto Nazionale Oncologico Candiolo combines clinical care with a strong focus on scientific research. Patients can be considered for participation in active clinical trials, offering access to innovative therapies not yet available in standard practice. This integration of care and research is a distinctive strength that translates into tangible benefits for patients.

The Interdisciplinary Care Group (GIC or MDT) supports the patient at every stage: from diagnosis, through treatment, to follow-up. Special attention is paid to nutritional support, psychological health and reintegration into daily life. The organization of checkups, examinations, and treatment is designed to ensure continuity, serenity, and a humane, caring approach to each patient’s needs.