Malignant Musculoskeletal Tumors

  • What are malignant musculoskeletal tumors that can affect the spine?

    Malignant musculoskeletal tumors that can affect the spine are abnormal growths or masses of cells in or surrounding the spinal cord. They are very rare in children.

    Unlike benign musculoskeletal tumors, which are non-cancerous and do not spread, malignant tumors are cancerous, and can spread quickly to other organs in the body, such as the lungs.

    As the cells grow, they may damage the spinal cord during children's crucial developmental years.

    At The Children's Hospital of Philadelphia, we have extensive experience diagnosing and treating children with a wide range of malignant musculoskeletal tumors that can affect the spine, including:

  • Causes

    The causes of malignant musculoskeletal tumors vary. In some cases, such as Ewing sarcoma, the disease may be linked to a genetic factor. In others, such as osteosarcoma, the cause is unknown.

    Primary vs. secondary spinal tumors

    Tumors that start in spinal tissue are called primary spinal tumors. Musculoskeletal tumors that spread to the spine from other places (for example, lung) are called secondary spinal tumors.

    Primary or secondary tumors can be malignant or benign. Primary spinal tumors often progress slowly over months to years. Secondary spinal tumors often progress quickly.

  • Symptoms

    Symptoms of malignant musculoskeletal tumors depend on a variety of factors including the type of tumor, location of the tumor, and your child’s age and general health.

    Indications of a spinal cord tumor, however, may include:

    • Chronic neck or back pain. This is the most common symptom and the pain can be either very localized or radiating.
    • Pain, stiffness or tenderness at the site of the tumor.
    • Swelling or mass around the affected bone.
    • Fatigue, fever, weight loss and/or anemia.
    • Bone pain, especially at night or at rest.
    • Weak bones, which may lead to a fracture.
    • Spinal deformities such as scoliosis occur in up to one third of children with spinal cord tumors.
    • Specific neurological complaints. As the tumors expand and grow, they can create pressure within the spinal cord. These symptoms can be confused with “growing pains.” Specific symptoms can include:
           o Decreased motor skills, including difficulty walking or limping
           o Loss of sensation (numbness)
           o Decreased or increased sensitivity to cold or hot
           o Muscle weakness or spasms
           o Loss of bowel or bladder control

    Tumors in the spinal cord may cause diffuse symptoms. Tumors outside the spinal cord may grow for a long time before becoming symptomatic.

  • Diagnosis

    Symptoms of a malignant musculoskeletal tumor can be difficult to identify in children, so regular check-ups are extremely important. Prompt diagnosis and identification of cancer as early as possible is crucial to overall treatment.

    Diagnostic evaluation begins with a thorough medical history and physical examination of your child. A detailed neurological assessment may also be performed. This involves a series of questions and tests to check the brain, spinal cord and nerve function.

    At The Children’s Hospital of Philadelphia, clinical experts use a variety of diagnostic tests to diagnose tumors, including:

    • X-rays, which produce images of bones.
    • Magnetic resonance imaging (MRI), which uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
    • Computed tomography (CT) scan, which uses a combination of X-rays and computer technology to produce cross-sectional images ("slices") of the body.
    • Angiography, a radiograph-type X-ray test which reveals the inside of blood vessels and organs.
    • Radioisotope bone scan, which can help locate areas of abnormal growth.
    • Positron emission tomography (PET) scan, which uses radioactive sugar injected into a vein and a scanner to make detailed, computerized pictures of areas of the body.
    • Blood tests, which can help determine drug usage and effectiveness, biochemical diseases and organ function.
    • Biopsy, which is a surgical procedure to take a sample of the growth, may be necessary to confirm any findings.
    • Bone marrow aspiration, a surgical procedure in which a small amount of bone marrow fluid and cells are removed by a needle inserted into a bone to check for problems with any of the blood cells made in the bone marrow.
    • EOS imaging, an imaging technology that creates 3-dimensional models from two planar images. Unlike a CT scan, EOS images are taken while the child is in an upright or standing position, enabling improved diagnosis due to weight-bearing positioning.
  • Treatment 

    At The Children’s Hospital of Philadelphia, we practice collaborative, family-centered care. A team of expert clinicians — including leading orthopedic and oncology physicians and surgeons, advanced practice nurses and physician assistants, pediatric nurses, physical and occupational therapists, psychologists and other specialists — will partner with you in the care of your child.

    Unlike benign tumors that may only require “watchful waiting” to see if pain or dysfunction develops, malignant tumors require more active treatment.

    Medication (such as corticosteroids) and physical therapy can help reduce swelling around the spinal cord and improve muscle strength in the early treatment phase. Both can help a child with a malignant tumor to function as independently as possible as they prepare for stronger treatment to shrink or remove the tumor.

    Treatment options include:


    Surgical treatment for musculoskeletal tumors may be used alone or in conjunction with chemotherapy, radiation therapy or proton therapy. 

    Surgeries performed are typically:

    • Wide resection with margins
    • Resection and reconstruction

    In a wide resection with margins, the tumor is surgically removed, as well as some of the healthy tissue that surrounded the tumor — the margins of the tumor. In some cases, the child will need reconstructive surgery after the tumor has been cut out.

    Reconstruction can include:

    • Endoprosthetics, which can be expanded as the child grows
    • Free vascularized fibular grafting, which includes moving one bone from  the lower leg to replace a diseased thigh bone
    • Amputation of a limb 
    • Other

    Though surgery for malignant tumors is highly effective, we understand that any surgery can be a stressful experience for children and families. At CHOP, we offer a wealth of resources about how to prepare your child for surgery and what to expect during surgery.

    Additionally, we employ numerous best practices before, during and after surgery to decrease the risk of infection and increase positive outcomes. For more details about safety protocols at The Children's Hospital of Philadelphia, see safety in surgery.


    Chemotherapy refers to medicines that help fight cancer. They are given by mouth, in the vein, in the muscle or under the skin. Intrathecal chemotherapy is chemotherapy that is injected into the spinal fluid to prevent or treat a malignant tumor in the brain and spinal cord.

    Radiation therapy

    Radiation therapy uses high-energy waves such as X-rays to kill or shrink cancer cells. It is sometimes used to treat cancer in the central nervous system or other places such as the eye or the testes.

    Proton therapy

    Proton therapy is an innovative form of radiation treatment that allows for more precise radiation doses delivered to cancerous tumors. Proton therapy’s greatest benefit is that it is less damaging to the surrounding healthy tissue because it delivers most of its energy to a very narrow field at the location of the tumor. Learn more about proton therapy

  • Follow-up care

    Most children are able to go home shortly after surgery. They may require pain medications until the surgical site heals or ongoing physical therapy, but most are encouraged to resume their regular daily activities, like school, social events and play.

    Your child will see the orthopedic surgeon about one to two weeks after surgery, then again at three and six months post-surgery. Annual monitoring by trained clinicians is strongly encouraged to monitor for possible recurrence of the growth.

    Malignant tumors can reoccur — even after being successfully treated — so it is important for your child to see a physician regularly, especially if any symptoms reoccur.

    During follow-up visits, X-rays and other diagnostic testing of the tumor site are recommended to closely monitor your child’s health and ensure there are no side effects from surgery, chemotherapy or proton therapy.

    Follow-up care and ongoing support and services are available at our Main Campus and throughout our CHOP Care Network. Our team is committed to partnering with parents and referring physicians to provide the most current, comprehensive and specialized care possible for your child.

  • Long-term outcomes

    Experts agree: the earlier malignant musculoskeletal tumors are diagnosed and treated; the better the outcome.

    Outcomes for children with malignant tumors are varied and depend on type, location and size of the tumor; age and overall health of your child; and how your child responds to treatment.

    In the case of primary tumors, the goal of treatment is to completely remove the tumor through surgery. In best cases, this leads to a permanent cure for the child. In other cases, the cancer may reoccur and need additional treatment.

    In the case of metastatic tumors (tumors that have spread), the goal is almost always to manage the pain caused by pressure on nerves, improve your child's quality of life, and prolong life expectancy.

    Our musculoskeletal team, led by orthopedic surgeon John P. Dormans, MD, FACS, continues to research ways to improve diagnosis, treatment and outcomes for children with malignant bone tumors. With ongoing research and advances in treatment options, outcomes for children with malignant musculoskeletal tumors will continue to improve.

Reviewed on May 16, 2014