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Bone tumours
1) Bone tumours can be benign or malignant and are classified based on features seen on imaging such as location within the bone, pattern of bone destruction, and presence of a periosteal reaction. 2) Imaging plays an important role in evaluating bone tumours and includes plain radiographs, CT, MRI, and bone scans. Biopsy is also important to determine the specific diagnosis. 3) Treatment depends on whether the tumour is benign or malignant but may include surgery, chemotherapy, and radiation therapy. The surgical margin taken is a key factor in oncology outcomes.
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Bone tumours
- 1. BONE TUMOURSBONE TUMOURS Dr.SidharthYadav Orthopaedic Dept. N.K.P.SIMS
- 2. IntroductionIntroduction Bone tumours arevery diverse in morphology and biological potential. Most bone tumours are benign lesions Most benign lesions are seen <30 years of age Benign lesions typically present as incidental finding.
- 3. ApproachApproach Age of thepatient :- mature or immature skeleton. Location of tumour :- Epi/Meta/Diaphyseal Number of lesion :- solitary/multiple Nature of lesion :- lytic/sclerotic/mixed Matrix :- osteoid/chondroid/fatty Zone of transition Peiosteal reaction
- 4. LOCATION 1.In the transverseplane: a) Central – Enchondroma b) Eccentric -GCT, osteosarcoma, chondromyxoid fibroma c) Cortical - Non-ossifying fibroma, osteoid osteoma d) Parosteal - Parosteal osteosarcoma, osteochondroma 2. In the longitudinal plane: Diaphyseal: Ewings, Osteoid Osteoma, Mets, Adamantinoma, Fibrous Dysplasia Epiphyseal: Chondroblastoma,GCT. Metaphyseal: Osteosarcoma ,Osteochondroma
- 5. • < 20yrs - Osteogenic Sarcoma, Ewings. simple bone cysts and chondroblastomas • 20-40 yrs - GCT, Chondrosarcoma, MFH, Lymphoma, Mets. • >40 yrs - Mets, Myeloma, Chondrosarcoma, MFH – Late Osteogenic, Fibrosarcoma. Age of the patient
- 6. Clinical featuresClinical features Pain - deep & consistant. - may be present from a week to as long as 3-4 yrs. - poorly localized. - may be associated with antalgic limp with muscle waisting. - night cries. Mass Pathological fractures due to excessive bone replacement by tumour. Generalised weakness. Neurological symptoms such as paraesthesia. Deformity
- 7. InvestigationsInvestigations Blood investigation X-rays Bone scan Ctscan MRI Arteriography Biopsy
- 8. Laboratory investigationsLaboratory investigations Completeblood count. ESR C-reactive protein (CRP) Urine for bence jones protein. Serum electrophoresis. Acid phosphatase. Alkaline phosphatase.
- 9. RadiographsRadiographs Exact location ofthe tumour Borders of the tumour Pattern of bone destruction Matrix formation Periosteal reaction
- 10. Pattern of bonedestructionPattern of bone destruction Bone destruction is due to osteoclastic resorptive activity on both trabecular & cortical level. 2 stages :- Removal of mineral content Followed with enzymatic digestion. 3 types of bone destruction Geographic Moth eaten Permeative
- 11. Geographic bone destructionGeographicbone destruction Seen as a well circumscribed hole in the bone with a narrow zone of transition. Divided into 3 types :- A – with sclerotic margins B – with out sclerotic margins C – with ill defined margins
- 12. Type 1 aGeographic Lesion. Eg. – unicameral bone cyst, enchondroma. Well-defined lucency with sclerotic rim. Associated with benign / slow growing Disorders.
- 13. Well-defined geographic lyticfocus without sclerotic rim , Endosteal scalloping seen. Type 1 b Geographic Lesion well-defined lucent lesion without sclerotic rim. myeloma
- 14. Large ill-defined lyticlesion , Codman’s triangle Periosteal interruption, Tumor-induced new bone . . Type 1 c Geographic Lesion ill-defined lytic lesion. Focally destructive & locally Invasive. Wider zone of transition. osteosarcoma
- 15. IA: GEOGRAPHIC DESTRUCTION WELL– DEFINED WITH SCLEROSIS IN MARGIN IB: GEOGRAPHIC DESTRUCTION WELL – DEFINED BUT NO SCLEROSIS IN MARGIN IC : GEOGRAPHIC DESTRUCTION WITH ILL DEFINED MARGIN increasing aggressiveness Margins: 1A, 1B, 1C
- 16. Type 2 Moth-eatenAppearance Aggressive pattern. Areas of destruction with ragged borders Implies more rapid growth Presents as multiple scattered hole vary in shape & size These scattered hole coalesce to form large defect. osteosarcoma
- 17. Type 3. PermeativePattern Ewing sarcoma. ill-defined lesion with multiple “worm-holes” Wide transition zone Total penetration of cortex is assumed. Eg. Round cell tumours, fibrosarcoma. Leukemia
- 18. Patterns of BoneDestructionPatterns of Bone Destruction Geographic Moth-eaten Permeative Less malignant More Malignant
- 19. Periosteal reactionPeriosteal reaction Periosteumof adult is minimally cellular & mainly fibrous in inactive stage. Reaction must mineralize to become visible on radiographs. Usually take 10 days – 3 wks. Classified as :- Solid Interrupted Ragsdale (1981) expanded this classification by adding subclasses.
- 20. SolidSolid Is further dividedas :- Smooth shell Lobulated Ridged
- 21. Solid Periosteal ResponseSolidPeriosteal Response Related to a slow form of irritation osteoid osteoma Slow-growing tumors provoke focal cortical thickening A continuous layer of new bone that attaches to outer cortical surface
- 22. Single layer ofreactive periosteum. thick unilamellated periosteal reaction. Smooth and continuous Unilamellated periosteal reaction Hypertrophic osteoarthropathy
- 23. Aggressive PeriostitisAggressive Periostitis appearanceof aggressive periostitis in Ewing’s sarcoma Layered, onion-skin, lamellated • Alternating layers of opaque and lucent densities • Can be seen with aggressive tumors and infections growth spurt.
- 24. Spiculated periosteal reaction. Perpendicular,brushed whiskers, hair-on-end, Fine linear spiculations of new bone oriented perpendicular to the cortex or radiating from a point source indicative of very aggressive bone tumors Osteosarcoma
- 25. Bone is formedin a disorganized fashion Process may destroy spicules of bone as they are being formed This is a very aggressive process Sunburst
- 26. Too fast growthfor periosteum to respond only the edges of raised periosteum will ossify forming a small angle with the surface of bone. Codman's triangle seen in malignant bone tumors and in rapidly growing lesions , aneurysmal bone cyst, subperiosteal hematoma.
- 27. Solid onion-peel SunburstCodman’s triangle Less malignant More malignant Periosteal reaction
- 28. Matrix mineralizationMatrix mineralization Matrixrefers to acellular /intracellular substance produced by mesenchymal cell. Types :- Osteoid Chondroid :-
- 29. Solid Patterns of mineralizationof osseous matrix Ivory-like opacityCloud like Osteoid tissue mineralise in a confluent manner that result in radiographic density Ranging from hazy ground glass to ivory like pattern.
- 30. Patterns of mineralizationof cartilaginous tumour matrix Stippled Flocculent Ring and arc
- 31. CT ScanCT Scan Veryuseful in early diagnosis Determine intra/extramedullary extension. More accqurate in demonstrating integrity of cortex in a area contaning tumour. Also demonstrate matrix mineralization. Differentiate between solid & lytic lesion. Early detection of pulmonary secondaries Exact measurement for limb salvage procecures (Prosthesis/allograft)
- 32. MRIMRI Intra medullary extension Softtissue extension Defines the relationship to the nearby major blood vessels T1 – differentiate tumour from fat. T2 – differentiate tumour from surrounding muscle
- 33. Radio nuclide bonescanningRadio nuclide bone scanning For pre biopsy staging Dissemination of tumour Silent secondaries and skip lesions
- 34. ArteriogramArteriogram Planning limb sparing surgery Therapeutic embolization Toassess vascularity of tumour
- 35. BiopsyBiopsy Closed biopsy FNAC Needle biopsy Openbiopsy Incisional biopsy Excisional biopsy
- 36.
- 37. RadiotherapyRadiotherapy Radiation cause celldeath by inducing formation of free radicles that cause DNA damage. Sensitivity of cell depends upon :- Cell’s position in cell cycle. Tissue oxygenation Cell’s ability to repair DNA damage or its inability to undergo apoptosis.
- 38. Primary bone tumour’sare resistant to radiotherapy except marrow cell tumour. CarcinomaMetastatic to bone except renal cell carcinoma are sensitive to radiation. Radiation therapy is associated with acute(erythema anorexia) & chronic complications(oedema,fibrosis). Rarely used for benign conditions.
- 39. Conventional external beamradiation can be delivered by brachytherapy. Hollow catheters are implanted in tumour bed at the time of resection. This techinique allow high dose of radiation to be delivered to target cell.
- 40. ChemotherapyChemotherapy With the useof new chemo protocol the 5 yrs survival rate is approx 70% for osteosarcoma. Similar rates has been noted for other maligant conditions. Chemotherapy is not useful for cartilagenous lesions & other low grade malignancies. Pre operative chemotherapy may decrease the spread of tumour cells at the time of surgery.
- 41. 2 types :- Adjuvant chemotherapy. Administered post operatively to treat metastases. Neoadjuvant chemotherapy. Administered before surgical resection of primary tumour. Preoperatively chemo regress the primary tumour . Drugs used in chemotherapy are more effective when they are used against a small lesion. They are more effective when used in combination rather then single drug.
- 42. SurgerySurgery In orthopaedic oncologysurgical margins are defined by :- Intralesional Marginal Wide Radical
- 43. Intralesional marginIntralesional margin Plane of surgical resection is with in the tumour. This is a/k/a debulking because it leaves behind gross residual mass. Procedure may be appropriate for benign tumours when only option is to sacrifice important anatomical structures.
- 44. Marginal marginMarginal margin Tumours suppress the surrounding tissue & appears to become encapsulated . This surrounding is k/as pseudocapsule. A marginal margine is achieved when the plane of dissection passes through pseudocapsule. In high grade malignancy pseudocapsule may contain satellite lesion.
- 45. Wide & RadicalmarginWide & Radical margin Wide resection is acchieved when the plane of resection is in normal tissue. If the plane of dissection touches the pseudocapsule at any point then it would be defined as marginal margin. Radical margine are achieved when all the compartment that contain tumour are removed en bloc.
- 46. CurettageCurettage Many benign lesioncan be treated adequately by curettage. Local recurrence rate is high in curettage as compared to resection. Allows better functional results. Curretage is first done by creating a large cortical window over the lesion , atleast the size of lesion. Bulk is removed with curets.
- 47. Cavity is enlargedby 1-2 cm in each direction. Cavity is filled with bone graft / cement.
- 48.
Editor's Notes
- #7 MFH – malignant fibrous histiocytoma.
- #8 Question has to be asked about recent trauma which could have lead to the episode & to differentiate it from stress fractures & myositis ossificans. As the pain associated with stess fracture is aggravted on exercise & relieved on taking rest where as pain associated with myositis ossificans relieved after some time. h/o of recent & chronic infection should be taking as some times pain due to chronic osteomyelitis can mimic. Usually pat. With chronic infection give H/o of fever with chills . Mass :- questions about any other swelling should be asked & any swelling near the joints should be asked so as to rule out OLLIER’S DISEASE & MAFFUCCI’S SYNDROME. Pt. should be looked for café au laite spots & subcutaneous neurofibromas :- sign’s of VON RECKLINGHAUSEN DISEASE. Extremity should be looked for raised temp ( infective pathology) , varicose veins ( due to obstruction of venous return coz of mass above ) & mass should be checked for any trill or bruit. Chronic infection such as fungus or tb can mimic neoplasm.
- #10 Cbc :- pt. might have anaemia coz of marrow involvement. ESR :- Raised coz of infection & raised wbc count. Alkaline phosphatase :- its raised in new bone formation as it’s a active product of osteoblastic activity . Acid phosphatase :- if the metastasis is from prostrate. Serum electrophoresis :- m band protein ( albumin, alpha 1 globulin , alpha 2 ,beta globulis & gamma globulin) gamma globulins are looked.
- #21 Periosteal reaction is the formation of new bone in response to injury or other stimulai to the periosteum surrounding the bone.
- #22 Smooth shells are caused by lesions that apply uniform pressure over the cortex. Lobulated - develop’s due to focal variation in growth rate. Rigded – a/k/a trabeculated septataed or soap bevel reaction. Develops when growth of a destrucyive lesion is uneven.
- #31 Mineralization of the tumour bone is initally seen in the center of the lesion where cellular maturity is greatest. When a tumour bone is produced by the fibroblast which are converted to osteoblast through metaplasia , the pattern of bone formed is woven or fibrous in appearance. Woven bone of this type is usually less densely mineralized then the osteoid bone hence hazy glass appearance.
- #40 Benign :- villonodular synovitis
- #49 Autogenous bone graft provides most rapid & reliable healing rate because its osteogenic ,osteoinductive & osteoconductive. Cancellous allografts is reliable though its only osteoconductive.