Bone tumors

defination,classification,haemopoeitic tumors,osteogenic,chondrogenic,investigations of bone tumors,surgical management,etiology,

1. BONE TUMORS PREPARED BY DR BADAL KHAN PGR.2 ORTHO UNIT 3 BMCH

2. Introduction A   bone tumor is a neoplastic growth of tissue in  bone . Abnormal growths found in the  bone  can be either benign (noncancerous) or malignant (cancerous

3. CLASSIFICATION Bone tumors can be classified into PRIMARY BONE TUMORS SECONDRY BONE TUMORS Primary bone tumors further classified into Benign tumors malignant tumors

4. CLASSIFICATION (cont….) BENIGN TUMORS Exostosis Osteoid osteoma Osteochondroma Chondroma Fibroma Aneurysmal bone cysts

5. CLASSIFICATION(cont….) Malignant Tumors Osteosarcoma Chondrosarcoma Fibrosarcoma Synovial sarcoma Giant cell tumor Ewing tumor

6. CLASSIFICATION(cont….) Secondry bone tumors Mostly from Thyroid Lungs Breast Kidney prostate

7. CLASSIFICATION(cont….) Radiological classification Depend on their site within bone Epiphyseal lesion giant cell tumor chondroblastoma Metaphyseal lesion osteochondroma osteosarcoma Diaphyseal lesions ewing,s sarcoma osteoid osteoma

8. CLASSIFICATION(cont….)

9. CLASSIFICATION(cont….) X-ray showing an osteoid osteoma of the tibial diaphysis with reactive bone formation

10. CLASSIFICATION(cont….) Bone tumours can be classified according to the tissue of origin. These include : • metastases –may show histological features of their tissue of origin ; • haemopoietic tumors – e.g. myeloma ; • osteogenic tumors – e.g. osteosarcoma ; • chondrogenic tumors – e.g.chondrosarcoma ; • others – e.g. Ewing’s sarcoma

11. 1.metastasis The vast majority of tumours spreading to the skeleton are carcinomas Metastases are rare in children, but can occur from neuroblastoma , rhabdomyosarcoma and clear cell carcinoma of the kidney Most common bone metastases (93 per cent) Breast Prostate Lung Renal Thyroid

12. Most common sites of bone metastases Spine Proximal femur Proximal humerus

13. 2 . Haemopoietic tumors There are no benign neoplasms of the haemopoietic system. Malignant tumours can be divided into two groups: 1 solitary plasmacytoma /multiple myeloma 2 lymphomas (malignant neoplasm of the lymphoid cells)

14. Radiological findings of mutilple myeloma  The skull contains innumerable small lytic lesions of more-or-less uniform size. This has been likened to an "oil-droplet" appearance.  Metastases are generally fewer in number and of different sizes and shapes .

15. Radiological findings of mutilple myeloma The pelvis contains numerous lytic lesions without reactive sclerosis which have an almost "soap-bubbly“ appearance in the ischia . There are also lytic lesions in both proximal femoral

16. 2.OSTEOGENIC TUMOURS These tumours produce osteoid or bony matrix Osteoid osteoma is a benign bone forming lesion small but very painful Usually, symptoms occur at night and are typically relieved by anti- inflammatories . Children and adolescents are frequently affected. They can occur in any bone but are common in the proximal femur. usually diaphyseal in location give rise to a dense cortical reaction

17. Osteoid osteoma Axial (CT) scan showing an osteoid osteoma nidus in the distal tibia. CT-guided radiofrequency thermocoagulation of an osteoid osteoma of the distal femur.(electrode)

18. 2.OSTEOGENIC TUMORS Osteoblastoma Larger more aggressive counterpart of osteoid osteoma Commonly occurs in the spine Dull pain Not relieved by aspirin produces osteoid and bone.

19. Osteoblastoma a lytic lesion that involves the posterior elements of the C3 vertebra . Cortical expansion of the spinous process and an ossified matrix are noted

20. Osteosarcoma it is malignant tumor of bone Types primary osteosarcoma Secondory osteosarcoma Primary osteosarcoma It arises in the appearent abscenc of underlying Bone disesase predisposing influences Occurs mostly in 2 nd decade of life Most common in distal femur followed by proximal tibia and proximal humerus

21. Osteosarcoma Secondary osteosarcoma it occurs on a background of some predisposing influences Usually occurs in later in life Predisposing factors Paget,s disease of bone Irradiation Fibrous dysplasia Spread maily via blood stream to lungs

22. Osteosarcoma Sclerotic osteosarcoma of the distal femur in a child. Sclerotic osteosarcoma of the distal femur in a child.

23. 3.CHONDROGENIC TUMOURS These tumours produce chondroid matrix. The biological spectrum of these tumours ranges from very benign to highly malignant

24. Osteochondromas is a benign cartilage capped bony projection. It is thought to originate from the physis . The bony projection is always growing away from the joint; towards the diaphyseal region of the bone. Osteochondromas can be pedunculated or sessile. The stalk or base is always continuous with the intramedullary cavity of the bone. They are usually solitary, but can be multiple

25. Osteochondromas Pedunculated osteochondromas of the proximal fibula with pseudarthrosis . Excised pedunculated osteochondroma showing cartilage cap

26. Enchondroma is a benign cartilaginous neoplasm within the intramedullary cavity of bone 50 per cent are in the hands and feet. most common bone tumour in the hand. They can present with pain, swelling or pathological fracture. Often symptomless Diagnosis is often incidental Associated with Ollier’s disease and Maffucci syndrome. Patchy calcification, expansion and scalloping can be visible on the x-rays. some are only diagnosed on (MR) scan.

27. Enchondroma Calcification and pathological fracture in a benign enchondroma of the proximal phalanx of the ring finger.

28. Enchondroma Ollier’s disease is a developmental condition characterised by multiple enchondromas . Maffucci syndrome the multiple enchondromas are associated with multiple angiomas . Malignant transformation to chondrosarcoma can occur inapproximately 20 per cent of patients with Ollier’s disease and is almost inevitable in patients with Maffucci syndrome

29. Chondroblastoma is a benign cartilage producing tumour occurs in the epiphysis of children. It is most common around the knee. Pain is often severe with associated inflammation and possibly joint effusion . bone scan is often helpful in diagnosis

30. Chondroblastoma Lateral x-ray with barely visible chondroblastoma in the epiphysis of the proximal tibia Sagittal CT reconstruction showing calcification within a chondroblastoma of the proximal tibial epiphysis .

31. Chondrosarcoma is a malignant tumour with cartilage differentiation. The biological spectrum is very wide ranges from very low grade lesions to highly aggressive dedifferentiated tumours . symptom is pain and/or swelling. Symptoms are often longstanding. Clear cell chondrosarcoma is a rare form of chondrosarcoma that occurs in the epiphysis

32. Chondrosarcoma Clear cell chondrosarcoma of the medial Femoral condyle . Computed tomography scan reconstruction shows calcification within the lesion

33. OTHERS Unicamberal bone cyst Aneurysmal bone cyst Giant cell tumor of bone Eosinophilic granuloma Fibrous dysplasia Ewing,s sarcoma

34. 1.unicameral bone cyst is a membrane-lined cavity filled with serous fluid. It usually occurs in proximal long bones of children Fig.Pathological fracture through a simple bone cyst with the pathognomic fallen leaf sign .

35. 2.Aneurysmal bone cyst is a benign cystic lesion of bone consisting of blood-filled spaces separated by fibrous septa. much more aggressive than a simple bone cyst often presents with pain and swelling. Fig.Abc with pathological fracture of the proximal tibia

36. 3.Giant cell tumour is a benign aggressive tumour with large osteoclast -like giant cells. It usually occurs between The ages of 20 and 45, when the physes have closed. affects the epiphysis of long bones,especially around the knee,proximal humerus and distal radius Fig.Giant cell tumour of the distal radius .

37. 4.Eosinophilic granuloma A rare neoplasm of Langerhans Cells. It can be unifocal or Multifocal In the spine it can present with Collapse known as vertebra plana . X-rays can appear aggressive And similar to Ewing’s sarcoma. Fig.Eosinophilic granuloma of the scapula

38. 5.Fibrous dysplasia it is a benign fibro-osseous lesion. It usually affects the long bones, ribs and skull. present with pain swelling or fracture. Hip fractures can produce a shepherd’s crook deformity. Cysts may well be present. There is expansion of the bone with a ground glass appearance .

39. 6.Ewing’s sarcoma is a round cell sarcoma of bone. It tends to arise in the diaphyses of long bones or the pelvis. usually present with a painful mass. may have general symptoms with fever, anaemia and increased (ESR). may show an ‘onion-skin’ periosteal reaction often significant inflammation with oedema on the M

40. Daignosing bone tumors A detailed history Examination General Systemic Local Blood tests Urine Dr Imaging X-rays Ct scan Mri Pet scan Biopsy Needle biopsy Incisional biopsy

41. Staging of bone tumors Bone tumours are usually staged using the Enneking staging system . Benign tumours are staged as: • latent (i.e. osteochondroma ); • active (i.e. osteoid osteoma ); • aggressive (i.e. giant cell tumour ).

42. Staging of bone tumors Latent lesions are usually asymptomatic and often discovered incidentally. Active lesions Do present with mild symptoms and continue to grow. aggressive lesion Aggressive lesions tend to grow rapidly A giant cell tumouris an example of an aggressive lesion

43. Staging of bone tumors For malignant tumours the Enneking system combines stage and grade of a tumour

44. Staging of bone tumors Low grade Intra compartmental 1A Extra compartmental 1B High grade Intra compartmental 1A Extra compartmental 1B Any grade metastasis 3 The Enneking staging system for bone tumours Compartment is the bone that is involved with the tumour . extracompartmental when the tumour has breached the cortex of the bone

45. TREATMENT Benign tumors Mostly benign tumors are treated by intralesional curettage. Packing of the cavity wth bone graft is not required Osteoid osteoma are treated by CT-guided thermo- Coagulation Large benign tumors might require extensive surgical Excision and reconstruction

46. TREATMENT(cont,,,,) Malignant tumors Osteosarcoma and ewing,s sarcoma require surgical Excision and neoadjuvent chemotherapy. Chondrosarcoma require surgical excision and are Insensitive to radiotherapy and chemotherapy Most malignant tumors can be treated with salvage There is no difference in survival between amputation And limb salvage