Approach to a case of musculoskeletal tumour

Approach to a case of Bone Tumour

Criteria• Age• Duration of Symptoms• Site of lesion

– In the bone– In the body

• Margins*• Type of Destruction*• Periosteal reaction*• Matrix of the lesion• Blood Investigations

Age

1st DecadeEwings, Eos,granuloma, Wilms Tr, Ostefibrous dysplasia, Enchondroma,

2nd DecadeEwings, OSA, ABC, UBC, NOF, Chondrobalstoma, CMF, Osteoblastoma,

3rd DecadeOSA, GCT, CMF, Osteoblastoma, Adamantinoma,

4th Decade CSA, GCT, Browns Tr,

5th Decade CSA, MM, Mets, Brown tr

6th Decade Mets, MM, Brown tr

Symptoms

• Pain– No Pain– Recent onset pain– Pain at presentation

Duration of symptoms

• Longer duraton – Benign

• Shorter duration - Malignant

Site of lesion

Margin of the lesion

Margin of the lesion

Lodwicks Grading

• Grade 1- Geographic lesion– A – Thick sclerotic margin– B – Narrow sclerotic margin– C – No margin

• Grade 2 – Moth eaten destruction

• Grade 3 – Permeative destruction

Periosteal Reaction

• Simple Elevation and Ossification– Any slow process– Periosteum laid down fast enough to contain the lesion

• Lamellated Elevation– Aggressive tumour growth in fits and starts

• Sunburst or Hair on End Elevation– Rapid steady growth

• Codman’s Triangle– Very rapid expansion

Simple Elevation

Lamellated Elevation

Sunburst Elevation

Matrix of the lesion

Bone Scan

• Other sites– Metastatic lesion– Skip lesion– Multicentric lesions

• CT Scan– Subtle cortical erosion– Extent of destruction– Matrix calcification– Lung metastasis

• MRI Scan– Soft tissue extent– Neurovascular bundle– Gadolinium <2hrs Malignant. >2hrs Infection.Benign– Cartilage involvement

Staging

• Benign– Latent– Active– Aggressive

Staging

• Malignant

– IA Low grade malignant IC

– IB Low grade malignant EC

– IIA High grade malignant IC

– IIB High grade malignant EC

– III I or II with metastasis

Reading an Xray

• Site in the bone– Vertical– Horizontal

• Site in the body

• What has the guest done to the host?

• What has the host done to the guest?

Site – in the bone

• Vertical Orientation – Epiphyseal, Metaphyseal, Diaphyseal

• Horizontal Orientation– Central Eccentric

Site – in the body

• Around the knee

• Proximal Humerus

• Distal radius

• Red marrow sites

What has the guest done to the host?

• Destruction– Sclerotic– Lytic– Mixed

• Expansion

• Matrix

What has the host done to the guest?

• Sclerotic rimming

• Periosteal reaction

Blood Investigations

• CBC, ESR

• S. Alk PO4ase

• LDH

• S. Ca

• PSA

• S. Electrophoresis

14 yrs old

57 yrs old

10 yrs old

High degree of Suspicion