clinical approach to evalution of bone tumours

bone tumours

1. Evaluation of bone tumours Dr. Rajesh Thunuguntla Senior Resident, Department Of Orthopaedics, NRIGH & Medical College.

2. A team approach comprising an orthopaedic surgeon, radiologist ,pathologist . A team of radiation oncologist, and medical oncologist isnecessary to treat the spectrum of musculoskeletal tumors .

3. An adequate history and physical examination are the first and most important steps in evaluating a patient with a musculoskeletaltumor . Common presentation pain, a mass, The pain in malignant bone tumours can occur as rest pain or night pain . Patients with benign bone tumors also may have activity-related pain if the lesion is large enough to weaken the bone. Other benign lesions, most notably osteoid osteoma , may cause night pain initially.

4. Although some tumors show gender predilection GCT ( giant cell tumour) more common in females but less significance Family history occasionally can be helpful, as in cases of multiple hereditary exostosis and neurofibromatosis ( autosomal dominant inheritance). Age may be the most important factor ,because most benign and malignant musculoskeletal neoplasms occur within specific age ranges.

5. physical examination General condition and a careful examination of the part Examination of the swelling A mass should be measured, and its location,shape , consistency, mobility, tenderness, local temperature. Atrophy of the surrounding musculature should be recorded, as should neurologic deficits and adequacy of circulation. Potential sites of lymph node metastases should be palpated. rhabdomyosarcomas , epithelioid sarcomas, and synovial sarcomas.

6. Investigation X ray MRI Biopsy

7. Age location in the body (i.e. which bone) location within a bone zone of transition Matrix morphology periosteal reaction cortical involvement

8. Age Primary bone tumours are common in children and adolescent age group, like osteosarcoma , ewings sarcoma Secondary Metastatic bone tumours are common in Geriatric age group , 2 to breast cancer , prostate cancer. Some bone tumours like GCT, chondrosarcoma are common in middle age group (20-40 years)

9. Osteosarcoma commonly occurs in distal femur and proximal tibia ( metaphysis ) Giant cell tumour commonly occurs in distal radius Simple bone cyst and Aneurysmal bone cyst : Proximal Humerus

10. Zone of transition Zone of transition is the part of the bone between normal bone and patholgical bone

11. Narrow zone of transition Wide zone of transition

12. Type of bone destruction

13. Geographic destruction seen in both benign and malignant lesion Moth-eaten type of destruction seen in malignant tumors

14. Permeative type of destruction usually seen in malignant tumours

15. Periosteal reaction The periosteal reaction to a neoplastic process in the bone is usually categorized as uninterrupted or interrupted

16. Un- interruped or continuos periosteal reaction in benign tumour Interrupted periosteal reaction , typical SUNRAY SPICULE appearance seen in malignant tumours Interrupted ONION PEEL appearance of periosteal reaction

17. Codman triangle  is a type of  periosteal reaction  seen with aggressive bone lesions. The periosteum does not have time to ossify with shells of new bone so only the edge of the raised periosteum will ossify. The Codman triangle may be seen with the following aggressive lesions: osteosarcoma Ewing sarcoma osteomyelitis metastasis chondrosarcoma malignant fibrous histiocytoma

18. Codman triangle

19. Tumour “Matrix calcification’ All bone tumors are composed of characteristic tissue components, the so-called tumor matrix. Only two of these— osteoblastic and cartilaginous tissue—can usually be clearly demonstrated . Fluffy, cotton-like, cloud-like densities within the medullary cavity suggest the presence of tumorous bone – osteosarcoma Popcorn-like, Punctate , Annular, or Comma-shaped calcifications suggests tumour of cartilagenous origin.

20. A completely radiolucent lesion may be either fibrous or cartilaginous in origin like simple bone cyst or chondromyxoid fibroma Blank matrix in simple bone cyst

21. Cotton or Floffy like calcifications in osteosarcoma Popcorn-like, Punctate , Annular, comma shaped calcifications in enchondroma and chondrosarcoma

22. Soft tissue extension on X ray Tumours : giant cell tumors , aneurysmal bone cysts, osteoblastomas , or desmoplastic fibromas exhibit soft-tissue extension beyond the cortical wall O steomyelitis : soft-tissue mass , with poorly defined margins , with oblitderation fatty layers obliteration of fatty tissue layers . Malignant Tumours : soft tissue tumor mass is sharply defined, extending through the destroyed cortex with preservation of the tissue planes

23. Ewings sartcoma of clavicle with soft tissue mass having distin c t borders Osteomyelitis of proximal phalynx of great toe with soft tissue mas having ill defined,margins

24. Benign bone forming tumours Bone-forming neoplasms are characterized by the formation of osteoid or mature bone directly by the tumor cells . Osteoma Osteiod osteoma Osteoblastoma

25. osteoma An osteoma is a slow-growing osteoblastic lesion commonly seen in the outer table of the calvarium and in the frontal and ethmoid sinuses. O ccasionally encountered in long and short tubular bones, and at these sites is known as a parosteal osteoma . On x ray appear as dense , well demarcated ivory-like sclerotic lesion usually asymptomatic lesion that does not recur if excised surgically .

26. Well demarcated , ivory like sclerotic lesion with smooth margins

27. Osteiod osteoma Young age group usually between the ages of 10 and 35, Common sites : long bones, particularly the femur and tibia Typical presentation of night pain , dramatically relieved by taking ASPIRIN It is a benign osteoblastic lesion characterized by a nidus of osteoid tissue, which may be purely radiolucent or have a sclerotic center . The nidus has limited growth potential and usually measures less than 1 cm in diameter. It is often surrounded by a zone of reactive bone formation.  

28. Osteoid osteoma Typical lesion of osteoid osteoma with central nidus surrounded by sclerosis Ct scan of tibia showing Nidus with surrounding sclerosis

29. Osteoblastoma It is a lesion Benign lesion histologically similar to osteoid osteoma but characterized by a larger size (more than 1.5 cm in diameter and usually more than 2 cm ). Age : 10 – 30 years Vertebra more commonly invovled followed by long bones Usually asymptomatic, but pain is not as readily relieved by salicylates .  

30. Osteoblastoma Osteoblastoma has four distinctive radiographic presentations : Nidus more than 2 cm in diameter Less reactive sclerosis More prominent periosteal response than does osteoid osteoma An aggressive lesion simulating a malignant tumor

31. Benign chondroblastic lesions The lesion's radiolucent matrix, scalloped margins, and annular, comma-shaped, or punctate calcifications usually suffice to establish its chondrogenic nature Enchondroma Osteochondroma Multiple exostoses Chondroblastoma Chondromyxoid fibroma

32. Enchondroma Enchondroma is the second most common benign tumor of bone, constituting approximately 10% of all benign bone tumors usually found in the  medullary cavity of the  diaphysis  or  metaphysis of short tubular bones of hand Age :20-40 yeras They are often asymptomatic; a pathologic fracture through the tumor often calls attention to the lesion . Intralesional curettage and bone grafting 

33. Typical Radiolucent matrix with punctate calcification often seen in short tubular bones of hand ( phalynx and metacarpal)

34. osteochondroma A benign chondrogenic  lesion derived from aberrant cartilage from the  perichondral ring at level of metaphysis It is characterized by a cartilage-capped bony projection on the external surface of a bone. common in adolescents and young adult common locations include knee 1. proximal tibia, distal femur 2.proximal femur  3.proximal humerus Marginal  resection at base of stalk, including cartilage cap  

35. Typical pedunculated type of osteochondroma growing away from the physial plate Sessile osteochondroma with calcified cartilagenous cap– malignant transformation

36. Simple bone cyst Aneurysmal bone cyst Giant cell tumours

37. Simple bone cyst The simple bone cyst or unicameral bone cyst, is a tumor -like fluid filled lesion of unknown cause . More common in males than in females, Ordinarily seen during the first two decades of life . The majority of simple bone cysts are located in the proximal diaphysis of the humerus and femur Treated by aspiration/ methylprednisolone acetate injection Curettage and bone grafting +/- internal fixation in proximal femur

38. T ypical appearance of a simple bone cyst in metaphysial - diaphyseal part Proximal humerus in immature skeleton. The radiolucent lesion is centrally located and there slight thinning of the cortex and lack of periosteal reaction differentiates from Aneyrysmal bone cyst

39. Aneurysmal bone cyst   A benign and non- neoplastic  reactive bone lesion filled with multiple blood-filled cavities  < 20 yrs >60% in long bones (Femur and tibia being most common) Symptoms pain and swelling may present with pathologic fracture Aggressive curettage (+/- adjuvant) and bone grafting

40. E xpansile , eccentric and  lytic  lesion with bony septae  ("bubbly appearance")      usually in metaphyseal classic cases have  thin rim of periosteal new bone surrounding lesion no matrix mineralization

41. Giant cell tumour Also known as osteoclastoma , a giant cell tumor of bone is a benign but locally aggressive lesion. Have a high tendency for recurrence . Age : 20 and 40 years, There is a female predominance of 2:1. Common sites include distal radius , around knee

42. GCT X ray showing eccentric located Osteolytic lesion at metaphyseal region extending into subchondral region . Absent periosteal reaction Endosteal resorption

43. Osteosarcoma Intramedullary osteosarcoma is the most common primary sarcoma of bone Metaphyseal region usually occurs in children and young adults most common site is the distal femur and proximal tibia Symptoms rapidly progressive pain, fever, and swelling Physical exam Mass on examination Engorged veins Local rise temperature multi-agent chemotherapy and limb salvage resection wide surgical resection 

44. moth- eaten type of destruction with perpendicular sunburst type of perisoteal reaction Sunburst periosteal reaction Codmans trinagle

45. Chondrosarcomas Chondrosarcoma is a malignant bone tumor characterized by the formation of a cartilage matrix by tumor cell Frequently seen in males 30-50 years Pelvis and long bones, particularly the femur and humerus Chemotherapy resitant Radiotherapy resistant Wide radical resection H igh chance of recurrence

46. Large calcified mass arising from the left pubic bone and extending into the pelvic cavity.

47. Lateral radiograph of femur shows the characteristic features of a central chondrosarcoma . Osteolytic lesion in the medullary portion of the bone are annular and comma-shaped calcifications .

48. Ewings sarcoma Ewing sarcoma, a highly malignant neoplasm with decisive male predominance. Typically found in patients from 5-25 years of age Second most common malignant bone tumor in children Diaphysis of the long bones, as well as the ribs and flat bones such as the scapula and pelvis.

49. Clinically, it may present as a localized painful mass or with systemic symptoms such as fever, malaise, weight loss, and an increased erythrocyte sedimentation rate. These systemic symptoms may lead to an erroneous diagnosis of osteomyelitis . Chemotherapy sensitive Radiotherapy sensitive tumour  

50. Permeative type of destruction with onion peel type of periosteak reaction

51. Thank u