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bone tumours
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BONE TUMOURSBONE TUMOURSDr. Sidharth YadavOrthopaedic Dept.N.K.P.SIMS
IntroductionIntroduction
Bone tumours are very 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.
ApproachApproachAge of the patient :- 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
LOCATION
1.In the transverse plane: a) Central – Enchondroma b) Eccentric -GCT, osteosarcoma,
chondromyxoid fibromac) Cortical - Non-ossifying fibroma,
osteoid osteomad) Parosteal - Parosteal osteosarcoma,
osteochondroma2. In the longitudinal plane:
Diaphyseal: Ewings, Osteoid Osteoma, Mets, Adamantinoma, Fibrous DysplasiaEpiphyseal: Chondroblastoma,GCT.Metaphyseal: Osteosarcoma ,Osteochondroma
• < 20 yrs - 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
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
Investigations Investigations Blood investigationX-rays Bone scanCt scanMRIArteriography Biopsy
Laboratory investigationsLaboratory investigationsComplete blood count.ESR C-reactive protein (CRP)Urine for bence jones protein.Serum electrophoresis.Acid phosphatase.Alkaline phosphatase.
RadiographsRadiographsExact location of the tumour
Borders of the tumour
Pattern of bone destruction
Matrix formation
Periosteal reaction
Pattern of bone Pattern of bone destructiondestruction
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
Geographic bone Geographic bone destructiondestructionSeen as a well circumscribed
hole in the bone with a narrow zone of transition.
Divided into 3 types :-
A – with sclerotic marginsB – with out sclerotic margins C – with ill defined margins
Type 1 a Geographic Lesion.
Eg. – unicameral bone cyst, enchondroma.
Well-defined lucency with sclerotic rim. Associated with benign / slow growingDisorders.
Well-defined geographic lytic focus without sclerotic rim , Endosteal scalloping seen.
Type 1 b Geographic Lesion
well-defined lucent lesion without sclerotic rim.
myeloma
Large ill-defined lytic lesion , Codman’s triangle Periosteal interruption, Tumor-induced new bone .
.
Type 1 c Geographic Lesion
ill-defined lytic lesion.Focally destructive & locallyInvasive.Wider zone of transition.
osteosarcoma
IA: GEOGRAPHIC DESTRUCTIONWELL – DEFINED WITH SCLEROSISIN MARGIN
IB: GEOGRAPHIC DESTRUCTIONWELL – DEFINED BUT NO SCLEROSISIN MARGIN
IC : GEOGRAPHIC DESTRUCTIONWITH ILL DEFINED MARGIN
increasing aggressiveness
Margins: 1A, 1B, 1C
Type 2 Moth-eaten Appearance
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
Type 3. Permeative Pattern
Ewing sarcoma.
ill-defined lesion
with multiple “worm-holes”
Wide transition zone
Total penetration of cortex is assumed.
Eg. Round cell tumours, fibrosarcoma.
Leukemia
Patterns of Bone DestructionPatterns of Bone Destruction
Geographic Moth-eaten Permeative
Less malignant More Malignant
Periosteal reactionPeriosteal reactionPeriosteum of 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.
Solid Solid Is further divided as :-
Smooth shell Lobulated Ridged
Solid Periosteal ResponseSolid Periosteal Response
Related to a slow form of irritation osteoid osteoma
Slow-growing tumors provoke focal cortical thickeningA continuous layer of new bone that attaches to outer cortical surface
Single layer of reactive periosteum. thick unilamellated periosteal reaction. Smooth and continuous
Unilamellated periosteal reaction
Hypertrophic osteoarthropathy
Aggressive PeriostitisAggressive Periostitis
appearance of 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.
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
Bone is formed in a disorganized fashion Process may destroy spicules of bone as they
are being formed
This is a very aggressive process
Sunburst
Too fast growth for 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.
Solid onion-peel Sunburst Codman’s triangle
Less malignant More malignant
Periosteal reaction
Matrix mineralization Matrix mineralization
Matrix refers to acellular /intracellular substance produced by mesenchymal cell.
Types :-
Osteoid
Chondroid :-
Solid
Patterns of mineralization of osseous matrix
Ivory-like opacity Cloud like
Osteoid tissue mineralise in a confluent manner that result in radiographic density Ranging from hazy ground glass to ivory like pattern.
Patterns of mineralization of cartilaginous tumour matrix
Stippled Flocculent Ring and arc
CT ScanCT ScanVery useful 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)
MRIMRIIntra medullary extension
Soft tissue extension
Defines the relationship to the nearby major blood vessels
T1 – differentiate tumour from fat.
T2 – differentiate tumour from surrounding muscle
Radio nuclide bone scanningRadio nuclide bone scanning
For pre biopsy staging
Dissemination of tumour
Silent secondaries and skip lesions
ArteriogramArteriogram
Planning limb sparing surgery
Therapeutic embolization
To assess vascularity of tumour
BiopsyBiopsyClosed biopsy FNAC Needle biopsy
Open biopsy Incisional biopsy Excisional biopsy
Treatment Treatment Chemotherapy Radiotherapy
Surgical resection
Radiotherapy Radiotherapy Radiation cause cell death by inducing
formation of free radicles that cause DNA damage.
Sensitivity of cell depends upon :- Cell’s position in cell cycle.Tissue oxygenationCell’s ability to repair DNA damage or its
inability to undergo apoptosis.
Primary bone tumour’s are 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.
Conventional external beam radiation 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.
ChemotherapyChemotherapyWith the use of 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.
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.
Surgery Surgery In orthopaedic oncology surgical
margins are defined by :-
Intralesional
Marginal
Wide
Radical
Intralesional marginIntralesional marginPlane 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.
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.
Wide & Radical marginWide & 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.
Curettage Curettage Many benign lesion can 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.
Cavity is enlarged by 1-2 cm in each direction.
Cavity is filled with bone graft / cement.
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