1. BONE TUMOURS

2. • Discussion on:
• Tumours
• Tumour –like lesions
• Cysts
• Benigh lesion are quite common
• Primary malignant are rare
• Often they mimick each other

3. classification
• Based on recognition of dominant tx in the
various lesions
• Assignment: Find Modified WHO
classification;

4. Clinical features
History
• Usually prolonged & there is delay in
obtaining rx
• Asymptomatic –abnormality seen on X-ray/
more likely benigh.
– Mostly benigh in children. Rare after 30yrs. So
resolve on their own/spontaneously eg. fibroma
– Malignant- slow growing or situated where there
is room incospicuous expansion (cavity eg. pelvis)

5. Age; The age of the pt gives a useful clue
– childhood & adolescents- benigh. Also some
malignant primary tumors eg. ewings sarcoma, &
osteosarcoma.
– 4th and 6th decade; Chondrosarcoma &
fibrosarcoma- typically occur occur in older
people.
Myeloma – the commonest of all primary
tumors is seldom seen before 6th decade.
> 70 years- metastatic bone tumors are more
common than all primary tumors together .

6. Pain- mmemonic = socrates
• Common
• Non-specific; cannot tell nature of lesion
• Severe pain of rapid onset
– Rapid expansion with stretching of surrounding txs
– Central hemorrhage or degeneration in the tumor.
– Pathological #.
– Tiny lesion can be encapsulated in dense bone e.g osteoid
osteoma.
Swelling- lump,
– patient seek advice when its painful or continues to grow.

7. Trauma
• is usually a ‘red herring’.
• ?initiate a pathological change or draw attention
Neurological symptoms –
• paraesthesia/ numbness may present upon or
stretching of a peripheral nerve.
• Progressive dysfxn is more ominous & suggest
invasion by an aggressive tumor.
Pathological #s may be the first & only clinical
symptom
• Suspicion- slight injury
• Elderly with midshaft #.

8. Exam;
Lump;
• Where does it arise
• Is it discrete or ill defined
• Soft or hard
• Pulsatile
• Tender
Swelling-? haematoma / infection. Diffuse overlying skin is warm &
inflamed.
Near joint-cause effusion & limitation of movement.
Spinal lesions- cause muscle spasms, back stiffness or painful scoliosis.
Limited R.O.M.
Lymphatic drainage-pelvis abdomen chest or spine.

9. Radiological exam
• X-ray
• Radionuclide scanning
• CT SCAN-More accurate( intra & extra-osseous
extension)& relationship to the surrounding
structures
– Inaccessible sites eg. spine
– Pulmonary mets –more reliable.

10. MRI
Assessment of tumor spread
a. Within the bone
b. Into nearby jt
c. Into soft txs
Blood vessels & perivascular tx relationship
Soft tx tumors and cartilage lesions.

11. Radiographs/ xray
Plain x-rays are still the most useful of all
imaging techniques
Abnormality (obvious) in the bone:
Cortical thickening
Discrete lump
Cyst
Ill- defined destruction
Where: metaphysis or diaphysis

12. • Solitary or multiple lesions/ skip lesions
• Margins: well defined- cyst, ill defined-
malignant
• Note: fibroma or chondroma may look like a
cyst
• Stipled calcification within a cystic area is xtic
of cartilage tumors

13. • Bone surface-
– periosteal new bone formation
– Extension of tumor into soft txs
• Muscles: muscle planes/calcification
• Bone scans, CT & MRI before undertaking a
biopsy

14. Radionuclide scanning/ scintigraphy
• Small tumors e.g osteoid osteoma
• Skip lesions or silent secondary deposits.

15. LABORATORY EXAM/ BLOOD TESTS
Used to exclude other conditions e.g infection or
metabolic bone disorders, or brown tumor in
hyperthyroidism.
Anemia
Raised esr
Raised serum alkaline phosphatase
• Not specific but Levels can differentiate btn malignant
& benigh
Serum protein electrophoresis , Bence jones proteins-
myeloma
Raised Serum acid phosphatase in ca prostate

16. Biopsy
Needle biopsy- may be u/s or ct guided
Sample for histologic diagnosis or microbiology
OPEN BIOPSY; incisional biopsy.
More reliable to obtain representative sample
As little as possible of the tumor is exposed
Block of tx is removed from the boundary zone;
normal tx, pseudocapsule, abnormal tissue.
Benigh tumor- excision biopsy.

17. Differential diagnosis
Diseases that mimick tumors
• Clinically
• Radiologically
• Histopathology difficult to interpret
Soft tx hematoma
Myositis ossificans
Stress #.
Tendon avulsion injury- osgood-Schlatter dx
Bone infection
Gout
Other bone -Fibrous cortical / medullary infarct & bone
islands

18. Staging of benigh tumours;
enneking staging
BY enneking in 1986
Treating tumours
• The lesion must be removed widely enough to prevent recurrence
• Damage must be kept minimum
Treatment depend on how tumor usually behaves;(aggressiveness)
• Cytological
• Clinical behaviour
How far it has spread
Benigh; latent, active, aggressive.
Least aggressive disappear spontaneously
Most aggressive undergo malignant change

19. MALIGNANT;
• Low grade- moderate aggressive, take long to
metastasize eg. chondrosarcoma, parosteal
osteosarcoma
• High grade- very aggressive- metastasize early
eg osteosarcoma, fibrosarcoma.

20. spread
• If there are no mets, local spread determine
how much to be removed
• Intracompartmental- confined to an enclosed
space eg a bone, jt cavity, or a muscle group
within a fascial envelope
• Extracompartmental;- those that extend into
interfascial or extrafascial planes with no
natural barrier to proximal or distal spread
• Eg perivascular sheath, pelvis, axilla

21. • Ct and mri are important to determine spread
• Skip lesions are revealed by scintigraphy

22. Staging of benigh bone tumors as
described by enneking
latent Well defined marginsgrow
slowly and then stopsremain
static / heal spontaneously eg
osteoid osteoma
Active Progressive growth limited by
natural barriersnot self
limiting. Tendency to recur. Eg
aneurysmal bone cyst
Aggressive Growth not limited by natural
barriers eg giant cell tumour

23. Surgical stage
• Staging the tumour is an important step towards
selecting the operation best suited to the
particular pt and carrying a low risk of recurrence
• Bone sarcomas are broadly divided as follows
• Stage1 all low grade sarcomas
• Stage2; histologically high grade lesions
• Stage 3 sarcomas which have metastasized
• Each category is further subdivided into type A
INTRACOMPARTMENTAL
• & type B -EXTRACOMPARTMENTAL

24. Staging malignant tumours
surgical staging by enneking
Stage Grade Site Metastases
1A LOW INTRACOMPARTME
NTAL
NO
1B LOW EXTRACOMPARTME
NTAL
NO
2A HIGH INTRACOMPARTME
NTAL
NO
2B HIGH EXTRACOMPARTME
NTAL
NO
3A LOW INTRA OR
EXTRACOMPARTME
NTAL
YES
3B HIGH INTRA- OR
EXTRACOMPARTME
NTAL
YES

25. • Examples
• 1A (Chondrosarcoma)- wide excision without
exposing the tumour
• 2A (osteosarcoma) wide excision/ amputation
• 2B (Osteosarcoma has spread into soft tissues)-
radical resection or disarticulation
• 3- pulmonary mets
• Remember that staging of soft tissue tumours is
different from bone tumours-american joint
committee for cancer staging system

26. Principles of management
• MULTIDISCIPLINARY TEAM
• In a tertiary center specializing in rx of bone & soft tx
tumours
• Orthopedic surgeon, radiologist, pathologist,
oncologist, physiotherapist, occupational therapist,
prosthetist.
• Benigh asymptomatic lesion- diagnosis beyond doubt;
no treatment. If not clear diagnosis,biopsy by excision
or curretage.
• Benigh symptomatic or enlarging- removal by
local(marginal excision) or curretage
• Suspected malignant tumour

27. • Primary malignant tumor
• admitted for detailed exam, blood tests
imaging and biopsy
• Discuss with patient, parents or relatives
• Amputation, limb sparing operation &
different types of adjuvant therapy

28. Methods of treatment
• Tumor excision; the more aggressive the lesion, the
more widely does it to be excised.
• Intracapsular (intralesional) excision and curretage-
incomplete form of tumor ablation. Applicable to
benigh lesions- low risk of recurrence or incurable
tomor- debulking to relieve local symptoms. Acrylic
cement prevent recurrence.
• MARGINAL EXCISION- goes beyond the tumor. Through
reactive zone, there is risk of recurrence(50%).
Therefore benigh lesions. Resulting cavity is filled with
bone graft.

29. • WIDE EXCISION: dissection is carried out ell clear
of the tumor, through normal tissues
• Good for grade 1A, providing risk of recurrence
below 10%
• Wide excision +chemotherapy for grade 2A
• RADICAL EXCISION: the entire compartment in
which the tumor lies is removed without
exposing the lesion
• Can also be achieved through amputation. Grade
2A&2B.

30. • LIMB SALVAGE: amputation is not automatic
choice for grade 2 sarcomas. Advances in imaging
& chemotherapy have made limb salvage the
treatment of choice for many patients. Bone
grafting &end prosthetic replacement,
arthrodesis, distraction osteosynthesis.
• AMPUTATION: amputation and early
rehabilitation may be the wisest option. May be
curative or for local control of aggressive tumor.

31. • MULTI-AGENT CHEMOTHERAPY: neo-adjuvant &
adjuvant treatment for malignant bone and soft
tissue tumors. Reduce the size of primary lesions.
Prevent metastatic seeding & improve the chance
of survival. Methotrexatre,
doxorubicin(adriamycin) cyclophosphamide,
vincristine & cis-platinum. Rx is started 8-12
weeks pre-op. continued 6-12 months post-op
• Radiotherapy restricted to highly sensitive tumors
e.g Ewing’s sarcoma

32. complications
• Post-irradiation spindle cell sarcoma
• Pathological #s