file22764.ppt1234567890--0987654321fgi87654e

lecture

1. Musculoskeletal
tumors
• bone tumors
•1- Primary:
•A -Benign is common
•B -Malignant- rare
•Important -- Either disabling or fatal. Affect young age
group
•2- Secondary- COMMON
•3- Lesions similar to tumors
•4- Soft tissue tumors.

2. Warning signs – bone tumors
•
● ●Non-mechanical bone pain ( no history of trauma) ,
Especially around the knee in young adolescents
•Osteosarcoma is serous differential diagnosis
•
● ●Concerning radiographs
When a musculoskeletal tumors is suspected, clinicians
should:
● ●stop;
● ●think;
● ●investigate.

3. Learning objectives of musculoskeletal
tumors
•1 -To know the symptoms and signs.
.12 -staging should be completed before biopsy.
.23 -Understand the principles of biopsy
•4 -Describe the principles of surgical treatment
•5 - List the aims and types of surgical treatment for bone
metastases .

4. Staging depend on
aggressiveness and spread
Bone tumors staged to:
1 -stage I – A : low grade sarcoma, intra-
compartmental.
stage I – B : low grade sarcoma, extra-
compartmental.
2 - stage II – A : High grade sarcoma, intra-
compartmental
stage II – B : High grade sarcoma, extra-
compartmental.
3 - stage III : Sarcoma with metastases.

5. Bone lesion may osteolytic or Bone lesion may osteolytic or
osteoblasticosteoblastic

6. Metastases in distal femur
Pathological fracture of the proximal femur
through metastatic breast carcinoma.

7. Classification
most system of classification depend on tissue origin
and dominant tissue

1 -osteoma, osteoid osteoma – osteoblastoma –
osteosarcoma.
2 -chondroma (inside bone; commonest in hands and
feet), osteochondroma (cartilage capped; grows away
from physis), chondromyxoid fibroma,
chondroblastoma (in epiphyses of adolescents)) ,
chondrosarcoma of varying malignancy.
3 -fibroma, fibrosarcoma, malignant fibrous
histeocytoma.
4 -haemangioma, haemangiosarcoma.
5 -giant cell tumors.
6 -Ewing's sarcoma

8. Diagnosis of bone tumors
depend on
1 -History and clinical examination :
Age, sex, history, physical examination.
2 -Imaging:
X-ray , CT, MRI, Radionuclide scanning.
3 – laboratory investigation.
4 -biopsy.

9. Biopsy
A biopsy is performed only when staging investigations
have been completed.
Because removal of the biopsy track is important principle
in the treatment of sarcomas, biopsies should be performed
in, specialist centre where the definitive surgical procedure
will be performed.
Image-guided biopsies (usually ultrasound- or CT-guided)
have a higher diagnostic accuracy because areas of
radiological concern can be targeted .
If image-guided biopsy is performed, close discussion
between radiologist and surgeon is required to ensure an
appropriate biopsy route is used

10. Open biopsy
Although most biopsies are performed with a needle, sometimes an
open biopsy is required, which should be performed according to the
following principles.
●●A pneumatic tourniquet can be used.
●●Use longitudinal incisions that are part of an extensile approach.
●●Do not cross anatomical compartments or contaminate
critical anatomical structures (e.g. nerves or blood vessels).
●●Use a biopsy track that can be excised at the time of definitive
surgery.
●●Ensure specimens are sent for microbiology as well as
histopathology.
●●Some specimens should be sent fresh to the laboratory for
cytogenetic studies.

12. Differential diagnosis
1 -infection.
2 -Soft tissue haematoma and tendon injuries .
3 -myositis ossificans.
4 -Stress fractures and callus.
5 - Metabolic disorders and dysplasia.
6 -Bone infarction.

13. Method of
treatment
1 -Tumor excision (
intracapsular, marginal , wide local ,
or radical).
2 -limb sparing
surgery.
3 -amputation.
4 -multi-agent
chemotherapy.
5 -radiotherapy.

14. Lesions similar to tumors
1 -fibrous dysplasia.
2 -fibrous cortical defect.
3 -simple bone cyst.
4 -anurysmal bone cyst.
5 -eosinophilic granuloma.

15. Fibrous dysplasia

16. Eosinophilic granuloma

17. Haemangioma
Haemangioma
Most of these
tumors are
symptomless and
discovered
accidentally during
x-ray
examination for
another reason.

18. Fibrous cortical defect
(non ossifying fibroma)
Common benign lesion formed of a Cavity filled by
Translucent fibrous tissue.

Usually discovered accidentally.
X- ray show well define osteolytic lesion in cortex of
long bone metaphysis surrounded by a thin margin of
dense bone.
No treatment or bone graft for large lesions.

20. Simple bone cyst
solitary bone cyst or unicameral bone cyst
Appear during childhood
typically in metaphysis of long
bone, most commonly in
proximal humerus , followed by
metaphysis around knee.
Either presented as pathological
fractures or found incidentally.
X-ray : well define central
osteolytic lesion in metaphysis
sometime attached to
epiphyseal plate ( active cyst).
Cyst lined by thin fibrous tissue
contain straw color fluid.

22. Treatment of simple bone cyst
Asymptomatic need no treatment.
Active cyst treated by aspiration and
Depomedrol injection.
Aspiration and bone marrow injection
is other alternative.
If cyst continue to enlarged or
pathological fracture occur in weight
bearing bone , the curettage and
bone graft is the best treatment.

23. Anurysmal bone cyst
Tumor like lesion, lining membrane is
thick soft tissue contain vascular
cavities.
It affect metaphysis of long bone and
vertebra.
It is expanding lesion, asymmetrical,
thinning cortex.
X – ray: well define, trabeculated,
eccentric metaphyseal osteolytic
lesion.
Treated by curettage and bone graft

26. Osteoid osteoma
It is a benign tumor consisting of osteoid tissue and newly formed
bone, it is less than 1 cm in diameter, oval or rounded and is
encased by dense bone.
Commonly affect the shaft of long bone in young age.
The main symptom is severe pain more at night ,relieved by
aspirin.
X-ray: small radiolucent area surrounded by dense sclerosis. CT
show lesion better, radioactive scanning show increased activity.
Differential diagnosis include infection, callus of fractures, and
tumors like Ewing's sarcoma.
Excision of lesion cures the pain by open surgery or ablation by
radiofrequency or leaser.
CT-guided thermocoagulation
Lesion larger than one cm named osteoblastoma.

30. •Tumors producing
cartilage
•
● ●Osteochondroma – cartilage
capped; grows away from
physis (joint)
•● ●Enchondroma – inside
bone; commonest in hands
and feet
•● ●Chondroblastoma – in
epiphyses of adolescents
•● ●Chondrosarcoma – of
varying malignancy

31. Osteochondroma
cartilage capped exostosis
It is the most common tumor of
bone .
It start as cartilaginous over
growth at margin of epiphyseal
plate and gradually ossified with
growth. It grow with growth of
body.
Continuous growth of mass after
maturity suggest malignant
changes.
It affect metaphysis, may be
single or multiple (diaphyseal
achalasia).

32. Patient may
complain of pain,
mass, interfere
with movement or
found
accidentally.
The exostosis my
be covered by
tender bursa

33. X-ray show well define
bone mass in
metaphysis directed
away from joint, look
smaller the clinical
examination because
it covered by
cartilage.

34. Treatment:
When exostosis cause
symptoms it should
be excised, or when
it become painful or
larger.
Malignant
transformation is 1-
2%

35. Chondroma ( enchondroma)
Benign cartilaginous tumor .it may be single or multiple
(Ollier’s disease).
Commonly affect tubular bone of hand and feet and other
long bone .
Patients may be presented as local pain or pathological
fractures.
X-ray show well define osteolytic lesion with spot of
calcification.
The lesion should be excised or curetted and replaced by
bone graft.

37. chondroblastoma
Rare benign epiphyseal
osteolytic lesion. Affect end
of long bones Presented with
pain.
X-ray well define epiphyseal
osteolytic lesion, it may cross
the epiphyseal plate to
metaphysis
Treated by local excision and
bone graft

38. Chondromyxoid fibroma
Rare benign lesion of
metaphysis.
X ray show well define
osteolytic oval or
rounded eccentric,
metaphyseal lesion
with endosteal
sclerosis.
Treatment: curettage
and bone graft.

40. Giant cell tumorGiant cell tumor
PathologyPathology::
This disease characterized by presence of This disease characterized by presence of giant giant
multinucleated cells multinucleated cells which seen in large numberwhich seen in large number..
The tumor cell is the stromal spindle shape cellThe tumor cell is the stromal spindle shape cell..
The tumor is soft and friable occupying the cavityThe tumor is soft and friable occupying the cavity
which extend to subchondral region. It occur in which extend to subchondral region. It occur in
mature bonemature bone..
One third of tumor is benign, one third locally One third of tumor is benign, one third locally
invasive, and one third metastasizeinvasive, and one third metastasize..

42. Clinical features of giant cell tumorsClinical features of giant cell tumors
Patients age: usually 20-40 yearsPatients age: usually 20-40 years..
More in femaleMore in female..
Patient presented by local pain and swelling or Patient presented by local pain and swelling or
pathological fractures. Common site is the distal pathological fractures. Common site is the distal
femur, proximal tibia, distal radiusfemur, proximal tibia, distal radius..
X-ray show eccentric osteolytic lesion in the end of X-ray show eccentric osteolytic lesion in the end of
long bone ,subchondral, trabeculated (soap bubble long bone ,subchondral, trabeculated (soap bubble
appearance). The cortex is thin, expanded or even appearance). The cortex is thin, expanded or even
perforatedperforated..

44. Treatment of giant cell tumorsTreatment of giant cell tumors
11 - -curettage and bone graftcurettage and bone graft..
22 - -curettage and bone cementcurettage and bone cement..
33 - -excision and bone graftingexcision and bone grafting..
44 - -excision and prosthetic replacementexcision and prosthetic replacement..
55 - -radiotherapy for unrespectable lesionradiotherapy for unrespectable lesion..

47. OsteosarcomaOsteosarcoma

Definition:Definition:

primary malignant tumor arise from bone primary malignant tumor arise from bone
forming cells and produce malignant osteoid forming cells and produce malignant osteoid
tissue. In addition to tissue. In addition to malignant osteoid tissuemalignant osteoid tissue
fibroblast or cartilage tissue may be fibroblast or cartilage tissue may be
predominate. It destroys the bone and form predominate. It destroys the bone and form
malignant osteoid and spread to surrounding malignant osteoid and spread to surrounding
tissue and metastasized to far organs.tissue and metastasized to far organs.

49. Clinical featuresClinical features

AgeAge : 10-20 years commonly but it may occur in old : 10-20 years commonly but it may occur in old
following irradiation and Pagetfollowing irradiation and Paget’’s disease.s disease.

SiteSite: metaphysis of long bone specially around knee : metaphysis of long bone specially around knee
and proximal humerus is common sites.and proximal humerus is common sites.

History: historyHistory: history of trauma may present. Increasing of trauma may present. Increasing
pain, worse at night is the first symptom , swelling pain, worse at night is the first symptom , swelling
may be other symptom.may be other symptom.

Examination: the affected site swollen with ill define Examination: the affected site swollen with ill define
edge , tender, and overlying skin is hot, shiny ,with edge , tender, and overlying skin is hot, shiny ,with
dilated veins. The ESR is raised.dilated veins. The ESR is raised.

51. 
: X-ray are very variable but it show combination : X-ray are very variable but it show combination
of bone destruction and bone formation.of bone destruction and bone formation.

The metaphysis show osteolytic and The metaphysis show osteolytic and
osteoblastic areas, the cortex is usually osteoblastic areas, the cortex is usually
perforated and soft tissue shadow may be seen. perforated and soft tissue shadow may be seen.

There is new bone formation in form of There is new bone formation in form of
Codman's triangleCodman's triangle at periphery of when cortex at periphery of when cortex
penetration cause periostium elevation and penetration cause periostium elevation and
vertical streaks of calcification in the adjacent vertical streaks of calcification in the adjacent
soft tissues called soft tissues called sunray appearance.sunray appearance.

56. ..

CT,MRI, RADIOISOTOPE SCANNINGCT,MRI, RADIOISOTOPE SCANNING
needed to show the extent of tumor, to stage needed to show the extent of tumor, to stage
the tumor and to plan treatment.the tumor and to plan treatment.

Chest x-ray and US to look for metastasizes.Chest x-ray and US to look for metastasizes.

Always biopsy is indicated to establish Always biopsy is indicated to establish
diagnosesdiagnoses..

59. TreatmentTreatment::

in developed countries the 5 years survival more than 50% in developed countries the 5 years survival more than 50%
by the use of chemotherapy ,early diagnosis, proper by the use of chemotherapy ,early diagnosis, proper
staging and proper surgery. prognosis in our patient is bad.staging and proper surgery. prognosis in our patient is bad.

The most certain way of eradicating osteosarcoma is by The most certain way of eradicating osteosarcoma is by
radical amputation. radical amputation.

Chemotherapy used to control metastases and to limit Chemotherapy used to control metastases and to limit
resection to degree that limited resection and prosthetic resection to degree that limited resection and prosthetic
replacement can be used (limb sparing surgery). replacement can be used (limb sparing surgery).
Chemotherapy is started soon after operation and Chemotherapy is started soon after operation and
continued for at least one year.continued for at least one year.

Inaccessible tumors are treated by radiotherapy combined Inaccessible tumors are treated by radiotherapy combined
with chemotherapy.with chemotherapy.

61. EwingEwing’’s sarcomas sarcoma

Definition: it is rare primary Definition: it is rare primary
malignant tumor of vascular malignant tumor of vascular
endothelial tissue of bone marrow endothelial tissue of bone marrow
(neuroectodermal origin).it give rise (neuroectodermal origin).it give rise
florid periosteal reaction (onion peel ) florid periosteal reaction (onion peel )
and early metastasesand early metastases

Age: commonly 10-20 years.Age: commonly 10-20 years.

Site: usually diaphysis of long bone.Site: usually diaphysis of long bone.

Clinical features: pain and swelling Clinical features: pain and swelling
are the chief presenting symptoms. are the chief presenting symptoms.
Fever and features of osteomyelitis Fever and features of osteomyelitis
may seen. The swelling is ill-define, may seen. The swelling is ill-define,
warm and tender. warm and tender.

ESR is elevated.ESR is elevated.

62. Ewing’s tumor –Ewing’s tumor –
histology There is a monotonous pattern of small round cells histology There is a monotonous pattern of small round cells
clustered around blood vesselsclustered around blood vessels..

66. 
X-RAY:X-RAY:
show ill-define osteolytic lesion with overlying show ill-define osteolytic lesion with overlying
periosteal reaction in form of layers (onion peel). periosteal reaction in form of layers (onion peel).
Radioisotope scanning show active area.Radioisotope scanning show active area.

Treatment:Treatment:
chemotherapy together with amputation or chemotherapy together with amputation or
radiotherapy used. prognosis in our patient is bad.radiotherapy used. prognosis in our patient is bad.

67. chondrosarcomachondrosarcoma

Definition: primary malignant Definition: primary malignant
tumor of cartilage forming cells. tumor of cartilage forming cells.

It may be primary and arise from It may be primary and arise from
remnant of cartilage in the bone. remnant of cartilage in the bone.

It may be secondary and arise It may be secondary and arise
from previous lesion like from previous lesion like
cartilage capped cartilage capped
Osteochondroma or chondroma. Osteochondroma or chondroma.

Metastases are usually late.Metastases are usually late.

69. 
AgeAge : usually more than 40 years. : usually more than 40 years.

Clinical featuresClinical features: :

pain , swelling .pain , swelling .

swelling and pain over previous cartilage capped swelling and pain over previous cartilage capped
Osteochondroma or chondroma Osteochondroma or chondroma

or pathological fractures are the common or pathological fractures are the common
presenting feature. presenting feature.

70. 
ImagingImaging : :
X-RAY: ill-define medullary osteolytic lesion X-RAY: ill-define medullary osteolytic lesion
with flecks of calcifications or large exostsis with flecks of calcifications or large exostsis
with ill-define margin with flecks of with ill-define margin with flecks of
calcifications in cartilage cap.calcifications in cartilage cap.
CT, MRI, Radioisotope scanning used to establish CT, MRI, Radioisotope scanning used to establish
extent of lesion and to plan treatment.extent of lesion and to plan treatment.

TreatmentTreatment::
wide local resection applied when possible, wide local resection applied when possible,
amputation , radiotherapy and chemotherapy are amputation , radiotherapy and chemotherapy are
other alternative.other alternative.

75. AdamantinomaAdamantinoma
Rare tumor of shaft of tibiaRare tumor of shaft of tibia . .
Affect young adult, presented as pain and swellingAffect young adult, presented as pain and swelling . .
The lesion formed of epithelial like cell in dense The lesion formed of epithelial like cell in dense
stromal cellstromal cell..
X-ray show multilocular osteolytic lesion of tibial X-ray show multilocular osteolytic lesion of tibial
cortexcortex..
It is low grade malignant tumor rarely metastasizedIt is low grade malignant tumor rarely metastasized..
Treated by excision with adequate margin of normal Treated by excision with adequate margin of normal
bonebone..

78. Fibrosarcoma and malignant fibrous Fibrosarcoma and malignant fibrous
histeocytomahisteocytoma..

Both rareBoth rare

These tumor affect adults and old patients, These tumor affect adults and old patients,

Pain and pathological fractures are common Pain and pathological fractures are common
presentation. presentation.

X-ray show ill define osteolytic lesion in bone.X-ray show ill define osteolytic lesion in bone.

Treatments by surgical resection and Treatments by surgical resection and
chemotherapychemotherapy

81. Multiple mylomaMultiple myloma
Malignant disorder of B cell Malignant disorder of B cell
(plasma cell) of (plasma cell) of
lymphoproliferative tissue lymphoproliferative tissue
of marrow, stimulate of marrow, stimulate
osteoclastic activity result in osteoclastic activity result in
osteoporosis and multiple osteoporosis and multiple
small osteolytic lesionsmall osteolytic lesion . .
Presented usually by pain and Presented usually by pain and
pathological fracturespathological fractures

85. Secondary metastasesSecondary metastases

The commonest bone tumors is secondary The commonest bone tumors is secondary
metastases. It had bad prognosis.metastases. It had bad prognosis.

It arise from It arise from breast, prostate, lung, breast, prostate, lung,
kidney ,thyroidkidney ,thyroid and gastrointestinal tract. and gastrointestinal tract.
Some time no primary tumor can be found Some time no primary tumor can be found
even after meticulous search.even after meticulous search.

Metastases usually appear in central skeleton Metastases usually appear in central skeleton
(bone contain red marrow) like vertebra, (bone contain red marrow) like vertebra,
pelvis, ribs, and proximal end of femur and pelvis, ribs, and proximal end of femur and
humerus.humerus.

86. Carcinomas usually spread to bone by blood : the spine is Carcinomas usually spread to bone by blood : the spine is
the third most common site for metastases, after the lung the third most common site for metastases, after the lung
and liverand liver . .
Although most patients with metastatic cancer will have Although most patients with metastatic cancer will have
bone metastases in the spine before they die, only 10% are bone metastases in the spine before they die, only 10% are
symptomaticsymptomatic..
Tumor cells metastasize to the spine via Batson’s venous Tumor cells metastasize to the spine via Batson’s venous
plexus. These retroperitoneal veins have no valves and allow plexus. These retroperitoneal veins have no valves and allow
retrograde embolic spread to the spine and proximal longretrograde embolic spread to the spine and proximal long
.1.1bonesbones ((

87. 
Most metastases are osteolytic by replacing bone Most metastases are osteolytic by replacing bone
by their gradual expansion and by stimulating by their gradual expansion and by stimulating
active bone resorption. Rarely metastases are active bone resorption. Rarely metastases are
osteoblastic( prostate ca.).osteoblastic( prostate ca.).

Clinical features: common age 50-70 years. Clinical features: common age 50-70 years.
Common symptom is local pain, pathological Common symptom is local pain, pathological
fracture or local pressure may occur. The fracture or local pressure may occur. The
primary tumor might be obvious.primary tumor might be obvious.

Detailed clinical examination including neck, Detailed clinical examination including neck,
breast, axillae, abdomen, chest, genitalia and breast, axillae, abdomen, chest, genitalia and
(PR&PV) are essential.(PR&PV) are essential.

89. 
InvestigationsInvestigations : :

x-ray of chest and urogental tract.x-ray of chest and urogental tract.

CBP, ESR, protein electrophoresis, serum CBP, ESR, protein electrophoresis, serum
alkaline and acid phosphatases.alkaline and acid phosphatases.

Radioisotope scanning may reveal increased Radioisotope scanning may reveal increased
activity of other unsuspected lesion.activity of other unsuspected lesion.

X-RAYX-RAY: Commonly there were ill-define : Commonly there were ill-define
moth eaten osteolytic lesion. Sometime there moth eaten osteolytic lesion. Sometime there
are osteoblastic deposits.are osteoblastic deposits.

92. TreatmentTreatment

The treatment are mainly palliative.The treatment are mainly palliative.

Quality of life improved by careful Quality of life improved by careful
management. management.

Pathological fractures , large osteolytic lesion Pathological fractures , large osteolytic lesion
or neurological compression need surgical or neurological compression need surgical
fixation with bone cement and decompression. fixation with bone cement and decompression.

Radiotherapy chemotherapy, hormone therapy Radiotherapy chemotherapy, hormone therapy
and analgesia ere used also.and analgesia ere used also.

Prophylactic internal fixation my used.Prophylactic internal fixation my used.

94. Synovial sarcomaSynovial sarcoma
Malignant tumor of joint or tendon sheath synovial Malignant tumor of joint or tendon sheath synovial
tissue in adult and adolescenttissue in adult and adolescent..
Patients usually complain of painful swelling in large Patients usually complain of painful swelling in large
joints or related to tendon sheathjoints or related to tendon sheath..
X-ray show soft tissue swelling with extensive X-ray show soft tissue swelling with extensive
calcification ( snowstorm)calcification ( snowstorm) , ,
MRI is usefulMRI is useful . .
Biopsy done to confirm diagnosisBiopsy done to confirm diagnosis..
Treated by wide excision in early cases, amputation in Treated by wide excision in early cases, amputation in
advance lesion with chemotherapy and radiotherapyadvance lesion with chemotherapy and radiotherapy..