Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 12 Malignant Bone Tumors Lecture Notes
Malignant bone tumors
Classification (W.H.O.)
? Bone-forming tumours
? Cartilage forming tumours
? Giant-cell tumour
? Marrow tumours
? Vascular tumours
? Secondary malignant tumours of bone
Bone forming tumors
? Benign-
Osteoma
Osteoid osteomaor osteoblastoma
? Intermediate - Aggressive osteoblastoma
? Malignant ?
Osteosarcoma Central (Medullary) and Peripheral (Surface)
Parosteal
Periosteal
High grade surface
Cartilage forming tumors
Benign ?
Malignant -
? Chondroma/Enchondroma
? Chondrosarcoma
? Osteochondroma
? Differentiated chondrosarcoma
? Chondroblastoma
? Juxtacortical chondrosarcoma
? Chondromyxoid fibroma
? Mesenchymal chondrosarcoma
? Clear cell chondrosarcoma
Giant cell tumor
? Osteoclastoma
Marrow tumors
? Ewing's sarcoma
? Neuroectodermal tumour
? Malignant lymphoma of bone (Primary/secondary)
? Myeloma
Vascular tumors
Benign
? Haemangioma
? Lymphangioma
? Glomus tumour
Intermediate
? Haemangio endothelioma
? Haemangio pericytoma
Malignant
? Angiosarcoma
? Malignant haemangio pericytoma
Secondary
Metastasis to bone from
? Thyroid
? Breast
? Bronchus
? Kidney
? Prostate
APPROACH TO DIAGNOSIS OF MALIGNANT
BONE TUMOR
Multi phased work up
Steps
? History
? Local examination
? Laboratory test
? Radiological test
? Histopathological examination
History
? Age- some tumors are very age specific. Eg- Ewing sarcoma 10-20yrs;
osteosarcoma 15-25yrs and > 45yrs (bimodal); chondrosarcoma
>45yrs; multiple myeloma >50yrs.
? Non specific
? Dull aching painful lump
? Pathological fracture
? Sometimes as incidental finding
? H/o exposure to radiation and chemical carcinogens
? History of any malignancy anywhere in body or treatment history for
any malignancy at present or past
Examination
? Swelling- tenderness, location, shape, consistency, fixity to skin and
adjacent structure, mobility, skin over swelling , dilated or engorged
veins.
? Joint range of movement limitation
? Sign of inflammation may be present
? Any other skin lesion anywhere else in the body
? Regional lymph node
? Systemic examination to diagnose primary tumor in case of
metastasis
Laboratory
? Hemogram
? Lactate dehydrogenase
? Erythrocyte sedimentation rate
? Parathormone
? C- reactive protein
? Urinary Bence Jones protein
? Serum calcium
? Urinary 24hrs calcium
? Serum phosphorus
? Electrophoresis
? Alkaline phosphatase
? Bone marrow examination
Hemogram and ESR
? Anaemia may be seen
? To rule out infection, myeloma and leukemia.
? ESR is raised particularly in
Metastasis
Ewing's sarcoma
Lymphoma
Leukemia
S calcium and phosphorus
? Hypercalcemia is most common metabolic complication of metastatic
bone disease.
? Increased level than normal indicates
Metastasis
Myeloma
Hyperparathyroidism
S alkaline phosphatase
? Raised alkaline phosphatse indicates high turn over of the bone
? Raised in osteoblastic lesion
Blastic metastasis from prostate and breast
Active Paget's disease
Hyperparathyroidism
Radiological tests
? X-ray
? Chest X-ray
? CT scan
? CT thorax, abdomen and pelvis
? MRI
? Mammography
? Bone scan
? Thyroid scan
? PET scan
? Arteriogram
OSTEOSARCOMA
o Characterized by the production of osteoid by malignant cel s.
o It is the second most common primary malignant tumor of bone, accounting for approximately 20% of
primary bone cancers.
o The most common nonhematologic primary malignancy of bone
o Onset can occur at any age; however, primary high-grade osteosarcoma occurs most commonly in the second
decade of life.
o Parosteal osteosarcoma has a peak incidence in the third and fourth decades.
o Arise from multipotent mesenchymal cel s
Clinical y
? Radiographic appearance of osteosarcoma can vary
? lesion can be either predominantly blastic or predominantly lytic
? The lesion usually is quite permeative, and the borders are ill defined.
? May take the form of a "Codman triangle," or it may have a "sunburst" or
"hair-on-end" appearance.
? Magnetic resonance imaging (MRI)
? They may be primarily osteoblastic, fibroblastic, or chondroblastic
Plain X-ray (Most valuable)
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Lytic
sclerotic
Mixed (most common)
Plain X-ray
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Lesions are usual y permeative
Associated with destruction of the cancel ous a n
d
cortical elements of the bone
Ossification within the soft tissue component, if
tumour has broken through cortex
Intra medullary
Borders are ill defined
Plain X-ray
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Periosteal reaction may appear as the characteristic Codman triangle.
Classification:
PRIMARY OSTEOSARCOMAS are
Conventional /classic osteosarcoma (high grade, intra medullary)
Low-grade intramedul ary osteosarcoma
Parosteal osteosarcoma
Periosteal osteosarcoma
High-grade surface osteosarcoma
Telangiectatic osteosarcoma, and
Small cell osteosarcoma.
Classification:
SECONDARY OSTEOSARCOMAS
Osteosarcomas occurring at the site of another disease process.
more common in >50 years of age
The most common causes are
Paget disease
Previous radiation treatment
Other associated conditions are
Fibrous dysplasia Bone infarcts
Osteochondromas Chronic
osteomyelitis
Dedifferentiated chondrosarcomas
Osteogenesis imperfecta
Conventional Osteosarcoma
? High grade
? Common type of Osteosarcoma
? Common radiographic appearance is
aggressive lesion producing osteoid matrix
? Periosteal reaction may take the form of
"codmans triangle" or "sunbrust" or "hair
on end" appearence
Periosteal Osteosarcoma
? Intermediate grade
? Arises from surface of bone
? Commonly on femur and tibia.
Intramedul ary Osteosarcoma
q Rare
q Low grade
Parosteal Osteosarcoma
? Low grade malignancy
? Rare
? Arises on surface of bone and invades
medulary cavity only at later stages.
? It has peculiar tendency to occur as a
lobulated mass on the posterior aspect of
femur
High grade surface Osteosarcoma
? High grade
? Least Common
? Radiographs show invasive lesions with
ill defined borders
Telangectic Osteosarcoma
Lytic lesion
Smal cell Osteosarcoma
? Rare
? High grade
? Resemble Ewing sarcoma or Lymphoma
Treatment
Current standard of care
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Radiological staging
Biopsy to confirm diagnosis Preoperative
chemotherapy
Repeat radiological staging (access chemo response, finalize surgical treatment plan)
Surgical resection with wide margin
Reconstruction using one of many
techniques
Post op chemo based on preop response
Chondrosarcoma
? 9% of primary malignancies of bone
? Age: broad, primary chondrosarcoma peak around 40 ? 60yrs, secondary chondrosarcoma
25 ? 45 yrs.
? Any location but common around pelvis, proximal femur, proximal humerus.
? Most common malignancy in hand.
? Clinical y: increasing pain and palpable mass.
? Pain in absence of pathological fracture is helpful to dif erentiate between enchondroma
and low grade chondrosarcoma
Secondary Chondrosarcoma
? Olliers disease (multiple enchondromatosis)
? Maffuci syndrome (multiple enchondromatosis + soft tissue haemangioma)
? Multiple hereditary exostoses
? Solitary osteochondroma
? Synovial chondromatosis
? Chondromyxoid fibroma
? Periosteal Chondroma
? Chondroblastoma
? Previous radiation treatment Firbours dysplasia
Chondrosarcoma - xrays
? Appearence similar to enchondroma,
it is a lesion arising in medulary cavity with irregular
matrix calcification.
? Pattern is described as "punctate," "popcorn," or
"comma-shaped".
? Compared with enchondroma,
chondrosarcoma has more aggressive appearence
with bone destruction and cortical erosions,
periosteal reaction, and rarely soft-tissue mass.
Mesenchymal chondrosarcoma
Clear cell chondrosarcoma
Epiphyseal Gaint Cel Tumor
Chondroblastoma
Clear cel chondrosarcoma
Dedifferentiated chondrosarcoma
Radiographic features of dedif erentiated chondrosarcoma often
show a more aggressive radiolucent area juxtaposed on a
otherwise typical chondrosarcoma.
POP CORN CALCIFICATION
DIFFERENCE FROM ENCHONDROMA
o Endosteal scal oping of more than 2/3rd of cortical thickness- chondrosarcoma
o Aggressive changes such as cortical erosion , bone destruction, periosteal reaction, soft
tissue mass- chondrosarcoma
o size> 5 cm in axial skeleton- predictor of malignancy
o Apperance of lysis in previously calcified area- malignancy
Intramedullary ,soft
tiisue extention of tumour
with calcification
Chondrosarcomas Treatment
? Low grade ? Extended curettage with use of intraoperative adjuvant
treatment.
? High grade ? Wide or radical resection or amputation.
? Radiotherapy as palliative for inaccessible lesions.
Ewing's Sarcoma
Ewing sarcoma, a highly malignant neoplasm
Third most common nonhematologic primary malignancy of bone
The second most common in patients younger than 30 years of age and the
most common in patients younger than 10 years of age
Ewing's sarcoma
Approximately 90% of Ewing sarcomas occur before age 25
Histogenesis: neurally derived small round cel malignancy very similar to the
so-called primitive neuroectodermal tumor (PNET)
Disease is extremely rare in black persons
Areas of
involvement
Clinical presentation
Present as a localized painful mass
With systemic symptoms such as fever, malaise, weight loss, and
An increased erythrocyte sedimentation rate.
These systemic symptoms may lead to an erroneous diagnosis of osteomyelitis.
Radiological features
lesion is poorly defined,
Marked by a permeative or moth-eaten type of bone destruction,
Associated with an aggressive periosteal response that has an onionskin (or
"onion peel")
less commonly, a "sunburst" appearance,
Large soft tissue mass, Occasionally, the bone lesion itself is almost
imperceptible, with the soft-tissue mass being the only prominent radiographic
finding
Radiological
Features
Onion skin appearance
MRI
1. T1 : low to
intermediate signal
2. T1 C+ (Gd) :
heterogeneous but
prominent
enhancement
3. T2 : heterogeneously
high signal, may see
hair on end low signal
striations
Nuclear medicine:
Ewing sarcomas demonstrate increased uptake on both
Gallium-citrate and
Technetium99m methylene diphosphonate scans
Differential diagnosis
other Ewing sarcoma family of tumours
pPNET : large soft tissue component with extension into bone
Askin tumour : chest wall
osteosarcoma (ALP is not elevated in Ewing sarcoma)
Leukemia
Multiple myeloma
Ostyeomyelitis
Ewing sarcoma ? treatment
? Radiosensitive
? Large central unresectable mass ? radiotherapy.
? Smaler more accessible lesions surgery.
? Neo adjuvant and adjuvant chemotherapy
This post was last modified on 07 April 2022