approach to bone tumors.pptx

1. Approach to bone tumors Dr Madhuri parija

2. Epidemiology • Benign bone tumors are 5 times more common than malignant • Most common bone malignancy is metastasis • Most common primary bone malignancy is multiple myeloma • bone sarcomas account for 0.2% of all malignancies • bimodal distribution - first peak occurring in the second decade - second peak occurring in patients >60 • overall 5-year relative survival for 2001–2007 was 66.3%

11. Prognosis in primary bone tumors • Stage of disease • Presence of metastasis • Skip lesions within same bone • Histological grade • Tumor size

13. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment

15. Clinical workup - history • Age • Swelling (duration , progression, associated skin changes, associated pain ) • Pain (Typical night pain relieved with salicylates – 0steoid osteoma) • Fracture ( trivial trauma , +/-preceeding pain) • Systemic complaints ( loss of appetite, loss of weight , fever ) • History of preexisting bone lesions • Previous radiotherapy • Personal / family history

16. Age at presentation

19. • Ollier’s disease • Maffucci syndrome • Familial retinoblastoma syndrome • Rothmund Thompson syndrome • multiple osteochondromas • Paget’s disease • radiation osteitis • fibrous dysplasia, bone infarct, chronic osteomyelitis, prosthetic implants, osteogenesis imperfecta, giant cell tumor, osteoblastoma and chondroblastoma

20. Clinical workup - examination • Swelling ( site, size, plane, consistency, pulsatility, overlying skin tethering) • Draining lymph nodes • Involvement of adjacent joints and NV structures • Scars • If suspecting malignancy then work up for primary

23. Plain radiography- pattern analysis • Where is the lesion ? • How extensive is the lesion? Size, single /multiple, skip lesions • What is the lesion doing to the bone? • What is the bone doing to the lesion? • Is the lesion making matrix? • Is the cortex eroded? • Is there a soft tissue mass

24. Q1- Where is the lesion ? • Vertical axis - diaphyseal - metaphyseal - metadiaphyseal - epiphyseal • Horizontal axis - cortical - medullary

29. Q2. What is lesion doing to bone ? Lodwick classification of margin • Lytic - Type 1 : geographical (A,B,C) - Type 2 : moth eaten - Type 3 : permeative • Sclerotic

31. Type IA : well defined, sclerotic margin • Fibrous dysplasia • SBC • Non ossifying fibroma

32. Type 1B – well defined , non sclerotic • GCT • Enchondroma • Chondroblastoma • Chondromyxoid fibroma • MFH

33. Type IC margin – ill defined • Chondrosarcoma • Osteosarcoma • GCT • lymphoma

34. Moth eaten • Multiple myeloma • Metastasis • lymphoma

35. Permeative lesions • Ewing sarcoma • Osteosarcoma • Infection • Eosinophilic granuloma

37. Q3 – what does the bone do to the tumor ? • Periosteal reaction - less specific than other radiographic sign - Highly aggressive tumors often result in interrupted or multilaminar periosteal reactions - Less-aggressive processes typically produce a unilaminar periosteal reaction

39. Benign periosteal reaction

40. Lamellar / onion peel periosteal reaction

43. Cortical expansion • most commonly seen with benign tumors that grow slowly enough to allow the cortex to remain completely or partially intact. • malignancies are more likely to progress rapidly and destroy rather than expand the cortex. • Lesions that produce a larger degree of cortical expansion are more likely to predispose to pathologic fracture and local bone deformity

45. Pathological fracture Limb deformity

48. Endosteal scalloping : cartilaginous tumors

49. matrix • Osteoid matrix – cloud like densities, ivory dense • Chondroid matrix – stippled, flocculent, rings and arc • Fibrous tissue – ground glass appearance

51. Stippled calcification Popcorn calcification

52. Osteoid osteoma • Diaphyseal • Eccentric (cortical) • Type 1 B margin • Solid smooth periosteal reaction

53. Simple bone cyst • First decade • Metaphyseal • Centric • Proximal humerus

54. GCT • Adult bone • Epimetaphyseal • Eccentric • Distal femur

55. osteosarcoma • Metaphyseal • Central • Permeative • Sunburst periosteal reaction • Codman triangle

56. Parosteal osteosarcoma • 3rd- 4th decade • Metaphyseal • Eccentric • Distal femur – posterior cortex • Solid periosteal reaction • Dense matrix

58. Blood tests • To rule out differentials such as infection • When investigating bone secondaries • PAC • Weak prognostic marker

61. MRI -Indicated when lesion is indeterminate or shows s/o aggressiveness -Even when a specific diagnosis cannot be made, the differential diagnosis can be narrowed • To detect lesions not apparent or indeterminate on Xray • To help in local staging • Detects skip lesions • Helps in surgical planning by assessing the degree of intramedullary extension and invasion of the adjacent physeal plates, joints, muscle compartments and neurovascular bundles • used in assessing response to neoadjuvant therapy

64. CT scan • Complementary role in diagnosis • local staging of bone tumor – CT chest • Percutaneous biopsy

70. Biopsy • Biopsy planning is important as all tissues contaminated by biopsy track must be removed during definitive surgery • Should be performed after discussion with MDT • Culture the biopsy ( and biopsy the culture)

77. Types of biopsy • Percutaneous biopsy - fine needle aspiration (FNAC) - core needle biopsy • Incisonal /open biopsy - should be performed only if enough tissue is not obtained in percutaneous biopsy - For open biopsy close attention must be paid to haemostasis and tissue dissection must be kept to minimum - Drain must be placed in line of incision • Excisional biopsy - entire lesion is removed - for benign lesion e.g osteochondroma

97. Surgical options • Limb salvage surgery • Amputation • Palliative surgery

100. Indications of limb salvage surgery • Should be intracompartmental • good preoperative chemotherapy respnonse • Skin should be free of tumor • Wide resection of affected bone with a normal muscle cuff in all direction • All previous biopsy sites and all contaminated tissues can be removed en bloc • Adequate motor reconstruction can be achieved by regional muscle transfer

105. Arthrodesis

106. Autograft

approach to bone tumors.pptx

approach to bone tumors.pptx

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