Bone Tumor

&

Tumor-like lesions

By : dr. Manal Nageeb

tumor OR tumor-like lesion .“classification”>Types

> Dx in general .

>DDx .

>staging .

>principle ttt in general .

>specific .

Aim :

Diagnosis :

> Clinical presentation 1- History

2- examination

> Imaging >> X-Ray

>BIOPSY

> Laboratory investigation

- Asymptomatic >> more likely with benign Lesions

>>Malignant tumors, too, may remain silent if they are

slow-growing and situated where there is room for

inconspicuous expansion (e.g. the cavity of the pelvis).

- Age

- Pain

- Swelling

- Neurological symptoms

- Pathological fracture

HISTORY:

* If there is a lump,

Where does it arise?

Is it discrete or ill-defined?

Is it soft or hard, or pulsatile?

And is it tender?

EXAMINATION :

X-RAYSQUESTIONS TO ASK WHEN STUDYING AN

X-RAY

Is the lesion solitary or are there multiple lesions?

What type of bone is involved?

Where is the lesion in the bone?

Are the margins of the lesion well- or ill-defined?

Are there flecks of calcification in the lesion?

Is the cortex eroded or destroyed?

Is there any periosteal new-bone formation?

Does the tumors extend into the soft tissues?

IMAGING :

>> RADIONUCLIDE SCANNING

Scanning with 99mTc-methyl diphosphonate (99mTc-

MDP) >> this can be helpful in revealing the site of a small tumors .

>> COMPUTED TOMOGRAPHY (CT)

>> it shows more accurately both intraosseous and extraosseous

extension of the tumor and the relationship to surrounding

structures.

Others :

MAGNETIC RESONANCE IMAGING (MRI)

Its greatest value is in the assessment of tumor spread:

(a) within the bone.

(b) into a nearby joint.

(c) into the soft tissues.

BIOPSY- Needle biopsy

- Open biopsy

Blood tests >> are often necessary to exclude other

conditions.

E g :- infection or metabolic bone disorders, or

a ‘brown tumor ’ in hyperparathyroidism.

>> Anemia, increased ESR and elevated serum alkaline

phosphatase levels are non-specific findings they may

help in differentiating between benign and malignant

bone lesion

LABORATORY INVESTIGATIONS:

1. Soft-tissue haematoma

2. Bone infection Osteomyelitis

3. Myositis ossificans

4. Stress fracture

5. Tendon avulsion injuries

6. gouty tophus

DIFFERENTIAL DIAGNOSIS

Benign >> Latent , Active , Aggressive

Malignant :

i. SURGICAL STAGE >> low grad OR high grad

ii. STAGING OF SOFT-TISSUE TUMOURS >> TNM

STAGING OF BONE TUMOURS

Benign Malignant

According to type :

Benign >> asymptomatic OR symptomatic

Malignant

Methods of management:

TUMOUR EXCISION

1- Intracapsular excision and curettage .

2- Marginal excision.

3- Wide excision.

4- Radical resection.

Principle of ttt in general

LIMB SALVAGE

>Short diaphyseal segments can be

replaced by vascularized or non-vascularized bone

grafts.

>Longer gaps may require custom-made

implants.

>Osteo-articular segments can be replaced by

large allografts, endoprostheses or allograft–prosthetic

composites.

AMPUTATION.

MULTI-AGENT CHEMOTHERAPY.

RADIOTHERAPY

1 - NON-OSSIFYING FIBROMA (NOF)

Age : childern ‘ < 30 yrs ,

Clinical : asymptomatic Or may pathologic # (rare)

On x-ray : well defined ,radiolucent area surrounded by a thin margin of dense bone , may be cystic .

Location : metaphysis of long bones .

ttt : if asymptomatic >> not need ttt ,,, if patho - # present >>curettage and bone grafting.

1- benign bone tumors :

2 FIBROUS DYSPLASIAAge : < 30 yrs. Clinical : asymptomatic Or if large pain , deformity , patho- # .On x-ray : well-defined , radiolucent ‘cystic’ areas ‘ground-glass’ appearance. ‘shepherd’s crook’ deformity of the proximal femur.Location : metaphysis & shaft of proximal ,femur, tibia, humerus, ribs and cranio-facialbones.ttt : if asympt >> no ttt , but if large curetted and grafted.

3 - OSTEOID OSTEOMA

Age : < 30 yrs.

Clinical : persistent pain, is relieved by salicylates.

On x-ray : small radiolucent area, the so-called ‘nidus’.

Location : diaphysis or metaphysis of long bones

ttt : complete removal

5- OSTEOBLASTOMA

Age : usually adult

Clinical : pain and local muscle spasm.

On x-ray : well-demarcated osteolytic lesion

which may contain small flecks of ossification.

Location : spine and the flat bones

ttt : excision and bone grafting.

4- CHONDROBLASTOMAAge : young adult or children

Clinical :constant ache in the joint; the tenderspot is actually in the adjacent bone.On x-ray : well-demarcated radiolucent area with no hint of central calcification.Location : epiphysis, of the proximal humerus, femur or tibia.ttt : marginal excision or by curettage and alcohol or phenol cauterization –and replaced with bone grafts

6- CHONDROMA (ENCHONDROMA)Age : all age

Clinical : asymptomatic Or discovered incidentally ,, pathological fracture.

On x-ray : well –defined osteolytic with calcification

Location : phalanges , humerus , femur.

ttt : if asympt >> no ttt , but if large curetted and grafted.

Signs of malignant transformation in patients over

30 years are:

(1) the onset of pain;

(2) enlargement of the lesion; and

(3) cortical erosion.

7- OSTEOCHONDROMA (CARTILAGE-CAPPED

EXOSTOSIS)

Age: teenager or young adult

Clinical: occasionally there is pain

On x-ray : well-defined exostosis emerging from

the metaphysis,

its base co-extensive with the parent bone. It looks

smaller than it feels because the cartilage cap is

usually

invisible on x-ray

Location : metaphysis of fast-growing ends of

long bones and the crest of the ilium.

ttt : excision

8- cystic Lesions of bone

1- SIMPLE BONE CYSTAge: childhood

Clinical: discovered after a pathological fracture or as an incidentalOn x-ray : well-demarcated radiolucent area inthe metaphysis, often extending up to the physealplateLocation : metaphysis of one of the long bones and most commonly in the proximal hummers or femur.ttt : sometime healed spontaneously If the cyst enlarging, or if there is a pathological #, the cavity cleaned by curettage and then packed with bone chips

Others

ABC vs. GCT

ttt :, curetted and then packed with bone grafts.

ttt :curettage and ‘stripping’ of the cavity with burrs and gouges, followed by swabbing with hydrogen peroxide or by the application of liquid nitrogen; the cavity is then packed with bone chips.

Cysts and cyst-like lesions of bone

1- PRIMARY MALIGNANT BONE TUMOURS .

CHONDROSARCOMA

OSTEOSARCOMA

EWING’S SARCOMA

MULTIPLE MYELOMA

2- METASTATIC BONE TUMOURS .

MALIGNANT BONE

TUMOURS

CHONDROSARCOMA

Incidence : The highest incidence is in the fourth and fifth

decades and men are affected more often than women.

Clinical : Patients may complain of a dull ache or a

gradually

enlarging lump. Medullary lesions may present as a

pathological fracture.

1- PRIMARY MALIGNANT BONE

TUMOURS .

Location : may develop in any of the bones that normally develop in

cartilage,

Almost 50 % , appear in the metaphysis of one of the

long tubular bones, mostly in the lower limbs. The

next most common sites are the pelvis and the ribs.

Despite the relatively frequent occurrence of benign

cartilage tumors in the small bones of the hands and

feet, malignant lesions are rare at these sites.

Chondrosarcomas take various forms:

Depending on :

A- their location in the bone (central or peripheral);

B- whether they develop without precedent (primary

chondrosarcoma) or by malignant change in a pre-existing

benign lesion (secondary chondrosarcoma);

C- the predominant cell type in the tumour.

Types :1- Central chondrosarcoma develops in the

medullary cavity of either tubular or flat bones

2- Peripheral chondrosarcoma arises

in the cartilage cap of an exostosis (osteochondroma) –cortex-

3- Juxtacortical (periosteal)

chondrosarcoma

4- Clear-cell chondrosarcoma

5- Clear-cell chondrosarcoma

X-ray : well-defined >> low grade

ill-defined >> high grade

Wide excision and prosthetic replacement

The tumour does not respond to either radiotherapy or chemotherapy.

OSTEOSARCOMAIncidence : occur predominantly in children and adolescents and men are affected more often than women.

Treatment

Clinical : Pain is usually the first symptom; it is constant, worse

at night and gradually increases in severity. Sometimes

the patient presents with a lump. Pathological fracture

is rare.

Location: It may affect any bone but most commonly involves the

long-bone metaphyses, especially around the knee and

at the proximal end of the humerus.

X-ray : The endosteal margin is poorly defined.

sunburst’ effect and Codman’s triangle .

eradicate the primary lesion completely

Depending on the site of the tumour, preparations

would have been made to replace that segment

of bone with either a large bone graft or a custommade

implant; in some cases an amputation may be

more appropriate.

respond to chemotherapy.

Treatment

EWING’S SARCOMA

Incidence : It occurs most commonly between the ages of

10 and 20 years , and males more than females .

Clinical : The patient presents with pain – often throbbing

in character – and swelling. Generalized illness and

pyrexia, together with a warm, tender swelling .

Location : usually in a tubular bone and especially in the

tibia, fibula or clavicle.

X-ray : area of bone

destruction

New bone formation ‘onion-

peel’ effect.

‘sunray’ appearance and

Codman’s triangles.

The best results are achieved by a combination of all three

methods: a course of preoperative neoadjuvant

chemotherapy; then wide excision if the tumour is in a

favorable site, or radiotherapy followed by local excision

if it is less accessible; and then a further course of

chemotherapy for 1 year.

Treatment

MULTIPLE MYELOMAIncidence : The patient, typically aged 45–65, presents.

Clinical : weakness, backache, bone pain or a pathological fracture.

Hypocalcaemia may cause symptoms such as

thirst, polyuria and abdominal pain.

Localized tenderness and restricted hip movements could be due to a plasmacytoma in the proximal femur.

In late cases there may be signs of cord or nerve root compression, chronic nephritis and recurrent infection.

Location : any bone .

X-rays: generalized

osteoporosis .

Treatment :

treatment of

pathological fractures

Incidence : in patients over 50 -70 years bone metastases are seen

more frequently than all primary malignant bone tumors together.

Source : The commonest source is carcinoma of the breast; next in

frequency are carcinomas of the prostate, kidney, lung, thyroid,

bladder and gastrointestinal tract.

Location : The commonest sites for bone metastases are the

vertebrae, pelvis, the proximal half of the femur and the humerus.

Spread is usually via the blood stream;

occasionally, visceral tumors spread directly to adjacent

bones (e.g. the pelvis or ribs).

2- METASTATIC BONE TUMOURS

Clinical : Pain is the commonest – and often the only – clinical feature. The sudden appearance of backache or

thigh pain in an elderly person.

Sudden collapse of a vertebral body or a fracture of the mid-shaft of a long bone .

In children under 6 years of age, metastatic lesions

are most commonly from adrenal neuroblastoma. The

child presents with bone pain and fever; examination

reveals the abdominal mass.

X-rays : osteolytic and appear

as rarified areas in the

medulla or produce a moth-

eaten appearance in the

cortex; sometimes there is

marked bone destruction,

with or without a

pathological fracture.

> combined chemotherapy, radiotherapy and surgery targeted

at a solitary secondary deposit.

> multiple secondaries, treatment is entirely symptomatic.

Treatment

FIBROUS TUMOURS

SYNOVIAL TUMOURS

MUSCLE TUMOURS

Other tumors

GOOD LUCK