How is osteosarcoma treated?



This information has been written for patients, their families and friends, and the general public to help them understand more about chondrosarcoma: what it is and the different types. This information is produced in accordance with BCRT's information policy.

Going to a Bone Cancer Centre for treatment

When patients arrive at their Bone Cancer Centre, more tests will be carried out to show how well organs such as the kidneys, heart, liver and ears are working, before treatment can begin. Tests may include blood tests, echocardiograms (heart) and an audiogram (hearing test).  

The measurements from these tests show doctors if these organs are working normally.  This gives the doctors a ‘baseline’ to compare how well these organs are working as your treatment goes on.

The drugs used to treat osteosarcoma can affect these organs, so the tests are repeated during treatment.  The measurements taken from the repeated tests are compared to the baseline; this helps the doctors to see if the organs are being affected. 

Specialists in many different areas of medicine at hospitals in Ireland and at Bone Cancer Centres and the Regional Cancer Centres in the UK work together as a ‘Multidisciplinary Team’ (MDT).  The Multidisciplinary Team will work out the details of the treatment needed.

Multidisciplinary Team during treatment for osteosarcoma

Patients being treated for osteosarcoma will be under the care of the treatment and rehabilitation part of the multidisciplinary team including:

  • Specialist bone sarcoma surgeons

  • Specialist sarcoma oncologists (oncologists are doctors that look after and treat people with cancer)

  • Cancer Nursing Specialists (CNS)

  • Physiotherapists and occupational therapists will help with rehabilitation (rehab) after surgery.

  • Dieticians

  • Social workers and psychologists will help with patients’ emotional, social and educational needs.

Where will the treatment take place?

Treatment for osteosarcoma can take place at different hospitals around the UK and Ireland.  For patients whose nearest specialist hospital is too far away, a ‘shared care’ arrangement with a closer hospital might be set up.  This means that the specialist hospital recommends a treatment plan, which is used to treat the patient at a hospital closer to home. 

England and Wales
For patients in England, diagnosis and surgery should take place in one of the Bone Cancer Centres (see map below). 

For young patients chemotherapy and radiotherapy treatment should be provided at one of the UK Specialist Children’s Cancer and Leukaemia Cancer Centre, Young Adult Cancer Centre, or Teenage Cancer Trust Unit.

Scotland
In Scotland the patients are treated at one of the five Sarcoma Centres that are part of the Scottish Sarcoma Network.  These hospitals are in Aberdeen, Dundee, Edinburgh, Glasgow and Inverness.  Patients visit one of these five Sarcoma Centres for any chemotherapy or radiotherapy treatment.  For surgery, primary bone cancer patients are seen in Glasgow, Edinburgh or Aberdeen.  

Republic of Ireland
Most patients in the Republic of Ireland aged under 16 receiving chemotherapy for osteosarcoma are treated at Our Ladys Hospital, Crumlin, Dublin. 

Patients aged 15-19 are treated at Mater Misercordiae Hospital, Our Lady’s Hospital, Crumlin and Waterford Regional Hospital.

Patients aged over 20 are treated at Mater Misercordiae Hospital, Our Lady’s Hospital Crumlin, Sligo General Hospital, Cork University Hospital, Waterford Regional Hospital, St Vincent’s Hospital and Mercy Hospital. 

For surgery, most patients in the Republic of Ireland (all ages) go to St. Marys Orthopaedic, Cappagh .  For radiotherapy most patients attend St Luke's and St Anne's Hospital, Dublin.  However, some patients may also attend other hospitals in Dublin and Cork.

Figure 4.  Bone Cancer Centres and Children and Young Adult Treatment Centres in the UK and Ireland.

Figure 4.  Bone Cancer Centres and Children and Young Adult Treatment Centres in the UK and Ireland.

Key

Red starsSpecialist Children’s Cancer and Leukaemia Centre
Blue starsBone Cancer Centre
Green starsChildren and Young People’s Integrated Cancer Service
Purple starsTeenage Cancer Trust Unit
Yellow starsScottish Sarcoma Network Hospital


Bone Cancer Treatment Centres:

Most surgery for primary bone cancers in England and Wales is carried out at one the five Bone Cancer Treatment Centres:

  • North of England Bone and Soft Tissue Tumour Service, Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Nuffield Orthopaedic Centre NHS Trust, Oxford
  • Royal National Orthopaedic Hospital, Stanmore, Middlesex
  • The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry
  • The Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham

Children's and Young Adults Specialist Cancer Treatment Centres:

For children, teenagers and young adults chemotherapy and radiotherapy are usually given at a Children’s and Young Adults Specialist Cancer Treatment Centre. If this is a long way from the patient’s home then a “shared care” arrangement can be made with a local hospital. This means that the MDT at the Children’s Centre designs a treatment plan, and the local hospital administers it.

  • The Royal Liverpool and Broadgreen University Hospitals NHS Trust
  • Children’s Hospital for Wales, Cardiff
  • Great Ormond Street Hospital, London
    • Shared care from here is offered at:
             St Georges Hospital
             Queen Elizabeth the Queen Mother Hospital
             Royal Alexandra Children’s Hospital, Brighton
             William Harvey Hospital
             Buckland Hospital Dover
             Kent and Canterbury Hospital
             Medway Maritime Hospital
  • Great North Children’s Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne
  • Royal Belfast Hospital for Sick Children
  • Sheffield Children’s Hospital
  • Leeds General Infirmary
  • Our Lady’s Children’s Hospital, Dublin
  • Birmingham Children’s Hospital
  • Western Park Hospital, Sheffield
  • Beatson West of Scotland Cancer Centre, Glasgow
  • University College Hospital London
    • Shared care from here is offered at:
             Royal London Hospital
             Meadway Maritime Hospital
             Royal Alexandra Childen’s Hospital, Brighton
  • Bristol Royal Hospital for Children
    • Shared care from here is offered at:
             Great Western Hospital, Swindon
             Gloucester Royal Hospital
             Derriford Hospital Plymouth
             Royal United Hospital Bath
             Musgrove Park Hospital Taunton
             Yeovil District Hospital
  • Alder Hey NHS Foundation Trust
    • Shared care from here is offered at:
             Wrexham Maelor Hospital
             Ysbyty Glan Clwyd
  • Addenbrooks Hospital Cambridge
    • Shared care from here is offered at:
             Ipswich Hospital
  • The Royal Marsden Hospital
    • Shared care from here is offered at:
             St Georges Hospital
             Royal Alexandra Children’s Hospital, Brighton
             East Surrey Hospital, Redhill
  • East Midlands Children’ and Young People’s Integrated Cancer Service
    • Formed from:
             Leicester Royal Infirmary
             Queen’s Medical Centre, Nottingham
  • Queen Elizabeth Hospital, Birmingham
  • Yorkhill Royal Hospital for Sick Children, Glasgow
    • Share care from here is offered at:
             Raigmore Hospital, Inverness
  • Royal Manchester Children’s Hospital
  • Southampton General
    • Shared care from here is offered at:
             Royal Alexandra Children’s Hospital

For older teenagers and young adults there are also specialist centres. These are sometimes part of a usual hospital ward, or some are designed and built by the Teenage Cancer Trust.

Teenage Cancer Trust Units:

  • Birmingham
    • Queen Elizabeth Hospital Young Person Unit
    • Birmingham Children’s Hospital
    • Royal Orthopaedic Hospital
  • Addenbrooke’s Hospital Cambridge
  • University Hospital of Wales, Cardiff
  • Royal Hospital for Sick Children, Edinburgh
  • Glasgow:
    • Beatson West of Scotland Cancer Centre
    • Royal Hospital for Sick Children (Yorkhill)
  • Castle Hill Hospital, Hull
  • Leeds:
    • St James’s University Hospital Young Adult Unit
    • Leeds General Infirmary
  • Liverpool:
    • Alder Hey Children’s Hospital
  • London:
    • University College Hospital
    • University College Hospital Cancer Centre
  • Manchester:
    • The Christie Hospital Cancer Centre
  • Newcastle:
    • The Great North Children’s Hospital
    • The Freeman Hospital
  • Republic of Ireland
    • Our Lady’s Hospital, Crumlin (under construction)
  • Sheffield:
    • Weston Park Hospital
    • Royal Hallamshire Hospital
  • Southampton General Hospital
  • Surrey:
    • The Royal Marsden Hospital
  • The Wirral
    • Clatterbridge Centre for Oncology
What kind of treatment is used for Osteosarcoma?

Since the 1970s the survival rates for osteosarcoma have improved dramatically as treatments have been revolutionised by the use of chemotherapy (key-mo-therapy) and improved surgical techniques.  

Chemotherapy is a type of medicine that is given into the bloodstream and travels around the whole body, and so any cancer cells that have spread outside of the bone tumour can be killed. 

For information about survival rates for osteosarcoma please see the section entitled ‘How will Osteosarcoma affect me in the long term?

During the 1980s the way osteosarcoma is treated became standardised throughout much of the world.  The usual curative treatment for high grade osteosarcoma involves chemotherapy and surgery.

Treatment Overview

Phase 1 – neo-adjuvant chemotherapy
Following the diagnosis and the first tests, patients are given a combination of chemotherapy drugs.  The number of drugs and how long for and how many times they are given can be different from country to country.  The number of chemotherapy drugs can vary from 2 to 4 and these can be given for between 6 and 12 weeks.

In the UK, Ireland, much of Europe and the USA the current standard treatment before surgery is made up of 3 chemotherapy drugs given over 10 weeks.  Chemotherapy given before surgery is called neo-adjuvant (NEE–oh-AJOO-vant) chemotherapy. The aim of this course of chemotherapy is to shrink the primary tumour and to kill any cancer cells that have spread to other parts of the body.

Phase 2 – Surgery
Following this first round of chemotherapy, the aim is to treat the main tumour site.  Where possible, patients have surgery to remove the primary bone tumour.  This is more likely to be possible if the tumour is in a limb (arm or leg) or easily accessible position in the body.  For many patients the main tumour is not easily removable, for example if the tumour is in the pelvis or spine.

The decision about whether surgery is possible is usually taken by the multidisciplinary team.

The aim of surgery is to remove the primary tumour safely and at the same time try to keep the body working as normally as possible.  If the primary tumour is in a limb then ‘limb preservation surgery’ is usually possible.  Limb preservation surgery is where the surgeon can remove the tumour without amputating a limb or reducing the limb’s function too much.

There are many different ways that surgeons have developed to protect the function of limbs, the main one being replacement of the affected bone with a metal implant and a false joint. 

Another technique is to carry out an autologous (aw-TOH-low-gus) bone graft.  This where healthy bone is taken from another part of the body to replace the bonetht has been removed or damaged by the tumour

Even with these advances in surgery around 10 per cent of patients require an amputation (removal of the limb) to safely remove the tumour.

Tumour removal from places other than the limbs (such as the spine or pelvis) can be very complicated and requires very careful individual planning for each patient.

Phase 3 – Pathology
When the tumour is removed by the surgeon, it is examined under a microscope by the pathologist.  This is to check whether the tumour has been completely removed and to find out how much of the tumour has been killed by the chemotherapy. The results of this examination will help to inform the next phases of treatment after surgery.

Phase 4 – adjuvant chemotherapy
Following surgery, patients will go on to receive further chemotherapy courses.  Once again, the number of drugs and length of treatment may be different from country to country.  Most treatment courses last for a further 16 -30 weeks after surgery.  

In the UK, Ireland, much of Europe and the USA, current standard treatment is made up of the same 3 drugs and lasts for 18 weeks after surgery.  Chemotherapy given after the surgery is known as adjuvant (AJOO-vant) chemotherapy.

Phase 5 – surgery to remove secondary tumours, if they are present (only in some patients)
If there is evidence that the tumour has spread to other parts of the body then an oncologist and surgeon may want to think about the possibility of removing the secondary cancers by surgery.

The doctor (oncologist) is the best person to describe treatment choices.  The doctors will also tell patients what to expect from the treatment.  Treatment of cancer involves patients and the doctors working together to find a care or treatment plan that fits their needs.

Treatment in more detail

Chemotherapy
In most cases, chemotherapy for osteosarcoma is used before surgery to kill the cancer cells within the primary tumourChemotherapy also shrinks the tumour to make it easier for the surgeon to remove it during surgery, and kills any cancer cells that have escaped from the bone tumour.  It is also used after surgery to kill any remaining cancer cells that might have been left behind after surgery and to kill any cancer cells in the rest of the body.

Chemotherapy may be given as part of a clinical trial - a study used to investigate new or different treatments or side effects of treatments.  Your MDT will let you know about any clinical trials that are available to you, and ask whether you would like to take part. 

In some patients, chemotherapy is given to help slow down the growth of the tumour and decrease pain and other symptoms when their cancer is very advanced and unable to be cured.  This is known as palliative chemotherapy.

What are the chemotherapy drugs called that are used to treat osteosarcoma?

What is chemotherapy and how does it work?

Chemotherapy, often called chemo (key-mo) for short, is the name for drugs used for the treatment of cancer.  These drugs kill cancer cells or stop their growth by interfering with the way cells divide and grow (also known as the cell cycle), or by damaging the cell’s DNA (instructions).

Cancer cells are different to healthy cells because the cancer cells divide very rapidly.  This fact is exploited by chemotherapy drugs, which target only rapidly dividing cells.  Different chemotherapy drugs achieve this by targeting slightly different parts of the machinery that makes cells divide, and so often these different drugs are used together in combinations, to hit different parts of the cancer cell at the same time.  This is called combination chemotherapy.

Most healthy cells do not divide very rapidly.  However, some types of healthy cell do divide rapidly, and these include hair follicle cells, skin cells, bone marrow cells, and the cells lining the digestive system.  This means chemotherapy drugs can also affect these healthy quick-dividing cells and this is what causes the side effects that are associated with chemotherapy treatment.

Side effects can be unpleasant, such as nausea, diarrhoea, hair loss, mouth sores, an unusual taste in the mouth and tiredness (fatigue).  Medications can be given before and after chemotherapy to help with some of these side effects.  There are also tips on some good websites about dealing with side effects such as mouth sores, skin care and coping with hair loss.

Coping with hair loss: Teenage Info on Cancer (TIC) and Teenage Cancer Trust

Mouth sores and eating problems: Teenage Cancer Trust and TIC and Macmillan

One former osteosarcoma patient, Megan Blunt, has written a book filled with tips on how to cope with chemotherapy.  This book is called Chemotherapy, Cakes and Cancer is available to download as a PDF published by CLIC Sargent.

How is chemotherapy given?

There are different ways patients are given chemotherapy: tablets, liquid medicine, injection or directly into the blood.

When a patient is given chemotherapy directly into their blood, the drug is given through a cannula (venflon), which is a flexible thin plastic tube that sits in a vein in the arm or hand.  Alternatively, patients may have a central line, PICC (peripherally inserted central catheter) or implantable ports (Portacath®).

Portacaths®, PICCs and central lines can be kept in for weeks or even a few months.  These lines enable the number of needles required during treatment to be minimised and more than one drug or treatment (such as fluids or nutrition) can be given at the same time because the lines can have multiple openings or ‘lumens’.  Because central lines, PICCs and Portacaths® are all slightly different; the decision on which type of line will best suit the patient will be discussed by the nurses and the doctor in the medical team.

Figure 1(a). A Central Line, also known as a Hickman line. Image Courtesy of The Christie NHS Foundation Trust.

A central line (also known as a Hickman) is a tube that runs straight into a vein under the skin. The line is fitted under local anaesthetic. The outside end of the tube can be connected to a drip, and chemotherapy drugs can be given to the patient through the tube.

Figure 1(b). Peripherally Inserted Central Catheter (PICC). Image Courtesy of The Christie NHS Foundation Trust.

A PICC is a long, thin tube that is inserted into a vein in the arm, usually near the elbow. The tube is fed through the vein until the tip reaches a vein near the heart. The PICC is inserted under local anaesthetic.

Figure 1(c). Implantable Port, (Portacath®). Image Courtesy of The Christie NHS Foundation Trust.

Implantable ports (Portacath®) consist of a thin tube (catheter) and a port or chamber. The tube is implanted under the skin in the chest and sits in a vein near to the heart. The port is attached to the end of the tube and sits just under the skin. The port contains a thin rubber disc through which special needles can be attached to give chemotherapy and other I.V. treatments, fluids, and, to take blood samples. Implantable ports are usually inserted under a general anaesthetic, which means the patient is asleep.

The chemotherapy drugs enters the blood through the cannula by an infusion usually called a drip.  An infusion or drip is a method of giving a set amount (dose) of I.V. (IntraVenous) medications such as chemotherapy over a set period.  This period can be hours or days.  The infusion can also be controlled by an infusion pump, which is connected to a central line or a PICC line.  Some of the pumps are small enough to fit in a pocket meaning that patients can use them at home.

Chemotherapy is given in ‘cycles.’  A cycle is the treatment time plus a resting time.  For example, a patient may be given a combination of chemotherapy drugs over 3-4 days and then there may be a resting period of 2½ weeks.  Therefore, the cycle is 3 weeks long.  The resting period helps the healthy cells of the body to recover before the next treatment cycle begins.

New Drugs

Mifamurtide (mih-FAM-yoor-tide) marketed as Mepact, is a new drug for osteosarcoma treatment.  A clinical trial in the USA showed that the drug used alongside chemotherapy and surgery may improve long-term survival in patients with non-metastatic disease (no spread of the cancer).  The drug stimulates a type of white blood cell to attack the cancer cells.  Mepact is given twice per week for 12 weeks and then once per week for the next 24 weeks. 
Mepact is now available for osteosarcoma patients in the UK and Ireland.  It is suitable for patients aged 2-30 years who have already had surgery to completely remove their osteosarcoma, and whose disease is non-metastatic (the cancer has not spread).
BCRT was active in supporting the approval of Mepact for patients in the UK, and were consulted by (NICE) during the appraisal process.

In England, there are currently five Bone Cancer Centres where the surgical treatment of bone cancer is carried out.  These are at Birmingham, Newcastle, Oswestry, Oxford and Stanmore.

In Wales, Scotland and Northern Ireland the organisation is slightly different: patients from Wales often go to Oswestry or Birmingham for surgical treatment. In Scotland, patients are seen in one of three centres in Glasgow, Edinburgh and Aberdeen. In Northern Ireland, patients are seen in Belfast. Other treatments such as chemotherapy and radiotherapy can often be given closer to home.

In the Republic of Ireland, there are no specific ‘Bone Cancer Centres’; patients are initially seen by their local hospital and subsequently referred to specialist hospitals in Dublin or Cork for further tests and treatment (see, ‘Going to a Regional Cancer Centre for treatment,’ for further details).   

Surgery is used to remove the primary tumour so that it can’t grow or spread anymore.  For most patients, limb sparing surgery is possible.  This is complex surgery, which aims to keep as much normal function in the limb as possible.  If a joint has to be removed patients may be supplied with a prosthetic (artificial) joint.  Another surgical technique that is sometimes used is an Autologous bone graft.  This where healthy bone is taken from another part of the body to replace the bone that has been removed during surgery or damaged by the tumour.

Other surgical techniques include resection alone (where only the tumour is removed) allografts (which use non-self tissue to replace damaged bone), and irradiation/ reimplantation (where the damaged bone is removed and treated with radiation to kill any cancer cells, before being put back into its original place in the body).

Very occasionally, because of the position or size of the tumour, the surgery involves removal of the whole limb (amputation).  If possible a prosthetic (artificial) arm or leg can be made for the patient.  Amputation may also be needed if the cancer has spread to major blood vessels or nerves or if the patient develops a bad infection or other serious complication after limb sparing surgery.
Not all osteosarcomas are found in the limbs.  Tumours from the pelvis, skull, spine and jaw can be difficult to remove completely by surgeryRadiotherapy is used occasionally in special situations where it is not possible to remove the whole tumour surgically.
Surgery may also be used to remove secondary tumours in the lungs.  Surgery may be needed in future if the reconstruction of the limb wears out or if the tumour comes back.

Radiotherapy

Because osteosarcomas are not very sensitive to radiation, radiotherapy is not used very often for osteosarcoma.  Occasionally, in special circumstances, radiotherapy might be recommended to treat osteosarcoma following surgery.  Also, radiotherapy might be used if surgery to remove the tumour is not possible.

The importance of clinical trials

Doctors use clinical trials to test new treatments or changes to existing ones.  Clinical trials usually have three stages called phases:

Phase 1 or I: If a drug looks promising in laboratory studies, a phase 1 trial may be carried out.  This is usually the first time a new drug is tried in people.  These types of trials do not usually look at the effect on specific types of cancer but look at things such as side effects and the safest and most effective dose.  These types of trials are usually done with a small number of people, usually 10-30.

Phase 2 or II:  This type of trial may be open to people with specific types of cancer or a number of different cancers.  They are usually carried out on more patients than phase I trials, usually around 100; mainly to look at, which type of cancer the drug works best against, to look at the best dose and side effects again, and to find out if the drug is worth taking to a much larger phase 3 trial.

Phase 3 or III: If a drug in a phase II trial looks as if it works as well or better than an existing treatment, a phase III trial is carried out.  These trials are usually open to people with a specific type of cancer.  Many more people are included in these trials, this helps to make sure doctors can see how well the drug may or may not help.  The new drug or treatment is usually compared to an existing treatment.  Patients will be put into one of at least two groups, for example, either the ‘new drug group’ or the ‘existing treatment group.’  This is done randomly by a computer, and prevents any human bias from putting certain patients into certain groups.  This removes any possibility that the trial results could be cheated, for example by selecting healthier patients to take the new treatment.     

You may see the terms ‘blind’ or ‘double blind’ randomised clinical trial.  A blind trial means the patient does not know whether they are receiving the existing treatment or the new treatment.  In a double blind trial neither the doctors nor the patients know which treatment they have received, until the end of the trial when the labels are decoded. 

A single phase III trial can be carried out in several hospitals per country in many countries.  This means that an even larger number of patients can be recruited and this provides more information about the new treatment.   

Clinical trials may not always be available, as the patient may not meet some of the requirements to be treated on a trial.  If a clinical trial is suggested by the doctor, they will give the patient information to read about the trial and time to think about whether they wish to take part in the trial.

For a patient to enter a clinical trial, they must always give informed consent.  This means that the patient must have been told all about the trial, understood all of the information, and agreed to take part. 

CCLG (Children’s Cancer and Leukaemia Group) produce a booklet called  A Guide to Clinical Trials, which describes the process of taking part in a clinical trial

Complementary or Alternative Medicine (CAM)

Although complementary and alternative medicines are often called CAM for short as if they mean the same thing, there are differences between them.  Other names you may see to describe CAMs are ‘traditional medicines,’ ‘unconventional medicines’ and ‘integrated healthcare/ medicine.’

Alternative medicines or therapies, such as extract of mistletoe (iscador) and laetrile (bitter almonds) are used ‘instead’ of what are called conventional medicines.  Conventional medicines for cancer are the treatments prescribed by doctors, for example, chemotherapy and radiotherapy.

Some people may choose to stop taking conventional medicines because they may no longer be working, or they may not wish to begin their treatment using conventional medicines for many different reasons.  However, alternative medicines do not have to go through the very careful testing (trials) that conventional medicines do, and therefore may not be safe.

Adverts for alternative medicines on websites may claim to cure cancer.  However, there is no scientific evidence to back these claims up.  It is always best to talk to an oncologist if people are thinking about trying alternative therapies.

Complementary medicines are used alongside conventional medical treatment.  Some patients use complementary medicine to help with symptoms or to aid relaxation. 

Techniques used by some osteosarcoma patients include:

  • Acupuncture
  • Massage therapy
  • Herbal products
  • Vitamins* or special diets*
  • Visualization
  • Meditation
  • Spiritual healing.

* Patients should make sure they tell their doctors about any supplements they may be taking.  Some complementary medicines, such as antioxidants may interfere with conventional treatments.


The authors and reviewers of this information are committed to producing reliable, accurate and up to date content reflecting the best available research evidence, and best clinical practice. We aim to provide unbiased information free from any commercial conflicts of interest. This article is for information only and should not be used for the diagnosis or treatment of medical conditions. BCRT can answer questions about primary bone cancers, including treatments and research but we are unable to offer specific advice about individual patients. If you are worried about any symptoms please consult your doctor.

The Information Standard Disclaimer
BCRT shall hold responsibility for the accuracy of the information they publish and neither the Scheme Operator nor the Scheme Owner shall have any responsibility whatsoever for costs, losses or direct or indirect damages or costs arising from inaccuracy of information or omissions in information published on the website on behalf of BCRT.

Version 2 produced January 2013
Information will be reviewed in January 2015

A A A
Social Networks
Follow us on Twitter
What a wonderful total @AECarstairs and @BiologyatYork! Thank you so much for baking it for bone cancer!
View us on Flickr
Join us on Facebook
The Information Standard - Certified Member