1. Bone tumor By Ass. Prof. Dr.Zaidshahwanii Consultant Ortho.surgeon

2. Introduction Bone tumors are growths of abnormal cells in bones that fulfill no useful function **Bone tumors may be cancerous (malignant) or noncancerous (benign) IT may develop within the bone (Primary Tu.) or (Secondary metastatic Tu.) a cancerous tumors that originate elsewhere in the body (for example, in the breast or prostate gland) and then spread to bone. **Bone tumors may be cancerous (malignant) or noncancerous (benign) IT may develop within the bone (Primary Tu.) or (Secondary metastatic Tu.) a cancerous tumors that originate elsewhere in the body (for example, in the breast or prostate gland) and then spread to bone. In children, most cancerous bone tumors are primary. In adults, most cancerous bone tumors are metastatic. z

3. Origin tissue Benign Malignant Bone forming Osteoma Osteosarcoma: Osteoid osteoma central Osteoblastoma peripheral Cartilage forming Chondroma Chondrosarcoma: Osteochondroma central Chondroblastoma peripheral Fibrous tissue Fibroma Fibrosarcoma Giant-cell tumours B. osteoclastoma Malg.osteoclastoma Marrow tumours Ewing’s tumour Myeloma Vascular Haemangioma Angiosarcoma Haemangioendothelioma Other Connective tissue Lipoma Liposarcom Neurofibroma Adamantinoma Neurilemmoma Chordoma

4. Symptoms Patients may be completely asymptomatic until the abnormality is discovered on x-ray. 1) Age Many benign lesions present during Many benign lesions present during childhood and adolescence also some primary malignant tumours, notably Ewing’s tumour and osteosarcoma. …… childhood and adolescence also some primary malignant tumours, notably Ewing’s tumour and osteosarcoma. …… (fourth or sixth decades); Chondrosarcoma and fibrosarcoma typically occur in older people the sixth decade. ;- myeloma, the commonest of all primary malignant bone tumours, is seldom seen before sixty. the sixth decade. ;- myeloma, the commonest of all primary malignant bone tumours, is seldom seen before sixty. Over 70 years in these patients, Over 70 years in these patients, metastatic bone lesions are more metastatic bone lesions are more common than all primary tumours together.

5. first symptom could be 2)bone pain. progressive and unremitting pain is a sinister symptom. It may be caused by rapid expansion with stretching of surrounding tissues,due to central haemorrhage or degeneration in the tumour tissue, or presented by pathological fracture The pain can be severe (somewhat like a toothache), may occur at rest or at night and tends to progressively worsen. 3 ) (pathologic fracture) Sometimes a tumor, especially if cancerous, weakens a bone, causing it to fracture with little or no stress 4) History of truma whether the injury initiates a pathological change or merely draws attention to what is already there remains unanswered. 5) Swelling, or the appearance of a lump (painless lump), may be alarming. Often, though, patients seek advice only when a mass becomes painful or continues to grow 6) Neurological sign, (paraesthesiae or numbness) may be caused by pressure upon or stretching of a peripheral nerve.

6. Size 17.5 X 25cm Painles mass from postero medial aspect of the mid Lt. thig of a 42 years old male patient of 7 months duration that started to increase in size suddenly in the last 4weeks complete surgical resection was done.

7. x-ray. Imaging x-ray. Different types of tumors have different characteristics on X-ray. Some B.Tu cause an osteolytic lesion. Other cause an excessive osteoblast activity leading to increase bone lay down i.e additional bone formation. Some can have a mixture of these findings. Examination If there is a lump, where does it arise? Is it discrete or ill-defined? Is it soft or hard, or pulsatile? And is it tender? Swelling is sometimes diffuse, and the overlying skin warm and inflamed; it can be difficult to distinguish a tumour from infection or a haematoma. If the tumour is near a joint there may be an effusion and/or limitation of movement. Spinal lesions, whether benign or malignant, often cause muscle spasm and back stiffness, or a painful scoliosis

8. – If other forms of imaging are planned (bone scans, CT or MRI), they should be done before undertaking a biopsy,which itself may distort the appearances. Isotopis bone scaninig( TC99) computed tomography (CT) ( magnetic resonance imaging) (MRI) If an x-ray is not conclusive, these will often help determine the exact location and size of the tumor and give additional information as to the nature of the tumor( bengin & aggressive ),,(intra. Or extra compartmental),with involving of a near by Neurovascular bundle,or any skip lesion (2 nd metastasis ),or detecting expanding Tu. in (pelvis or spine)a difficult places to reach, ( magnetic resonance imaging) (MRI) If an x-ray is not conclusive, these will often help determine the exact location and size of the tumor and give additional information as to the nature of the tumor( bengin & aggressive ),,(intra. Or extra compartmental),with involving of a near by Neurovascular bundle,or any skip lesion (2 nd metastasis ),or detecting expanding Tu. in (pelvis or spine)a difficult places to reach, Open Biopsy Open Biopsy

9. Lab.Tests Blood tests, Blood tests are often necessary to exclude other conditions, e.g. infection or metabolic bone disorders, or a ‘brown tumour’ in hyperparathyroidism. Anaemia, increased ESR and elevated serum alkaline phosphatase levels are non-specific findings, but if other causes are excluded they may help in differentiating between benign and malignant bone lesions. Serum protein electrophoresis may reveal an abnormal globulin fraction and the urine may contain Bence Jones protein in patients with myeloma. A raised serum acid phosphatase suggests prostatic carcinoma

10. Biopsy a biopsy is usually necessary to confirm the diagnosis. Needle Biopsy Often it is carried out with the help of ultrasound or CT guidance. A large bore biopsy needle, such as a Jamshidi or a Trucut needle, is used,, biopsy is carried out in the line of any further surgical incision so that the tract can be excised at the time of definitive surgery Biopsy a biopsy is usually necessary to confirm the diagnosis. Needle Biopsy Often it is carried out with the help of ultrasound or CT guidance. A large bore biopsy needle, such as a Jamshidi or a Trucut needle, is used,, biopsy is carried out in the line of any further surgical incision so that the tract can be excised at the time of definitive surgery Open Biopsy either Excisional or Incisional,,,, Open Biopsy either Excisional or Incisional,,,, Points to be considered 1) Biopsy taking from the boundries …why ?. 2) From the site were the next incision is to be done. 3) Tourniqea remove.,good heamostasis,drain avoided 4) Several samples 5) Complication ; infection,pathalogical #,,,,,.haemorrage.

11. D.Dx;- 1) Soft tissue Haematoma 2)Stress FrX. 3)Infection 4)Myositis ossifican 5)Gout 6)Avulsed tendon inj.

13. Management Benign bone Tu. Asymptomatic symptomatic Malignant bone Tu, ( Sarcoma) Ennking staging St. l Low grad sarcoma St.ll High grad sarcoma Each sub divided into A- Intra compartmental B- Extra compartmental St. lll Metastatic sarcoma

14. 1. Benign: 1 Latent G 0 T 0 M 0 2 Active G 0 T 0 M 0 3 Aggressive G 0 T 1-2 M 0-1 stage 1) latent; stage 2) active ; stage 3)aggressive. stage 1) latent; stage 2) active ; stage 3)aggressive. Stage 1 lesions are intracapsular, usually asymptomatic, and frequently incidental findings. Radiographic features include a well-defined margin with a thick rim of reactive bone. There is no cortical destruction or expansion. These lesions do not require treatment because they do not compromise the strength of the bone and usually resolve spontaneously. An example is a small asymptomatic non-ossifying fibroma discovered incidentally on radiographs taken to evaluate an unrelated injury. Stage 1 lesions are intracapsular, usually asymptomatic, and frequently incidental findings. Radiographic features include a well-defined margin with a thick rim of reactive bone. There is no cortical destruction or expansion. These lesions do not require treatment because they do not compromise the strength of the bone and usually resolve spontaneously. An example is a small asymptomatic non-ossifying fibroma discovered incidentally on radiographs taken to evaluate an unrelated injury. Stage 2 lesions also are intracapsular, but are actively growing and can cause symptoms or lead to pathological fracture. They have well-defined margins on radiographs but may expand and thin the cortex. Usually they have only a thin rim of reactive bone. Treatment usually consists of extended curettage Stage 2 lesions also are intracapsular, but are actively growing and can cause symptoms or lead to pathological fracture. They have well-defined margins on radiographs but may expand and thin the cortex. Usually they have only a thin rim of reactive bone. Treatment usually consists of extended curettage Stage 3 lesions are extracapsular. Their aggressive nature is apparent clinically and radiographically. They usually have broken through the reactive bone and possibly the cortex. MRI may show a soft-tissue mass, and metastases may be present in 5% of patients with these lesions. Treatment consists of extended curettage and marginal or even wide resection, and local recurrences are common.

15. Malignant 1. Malignant aggressiveness : Stage determined by three different sub-categories -Grade :depend on Histological study with aid of radiographic findings and clinical correlation G 1: Low grade, uniform cell type without atypia, few mitoses G 1: Low grade, uniform cell type without atypia, few mitoses G 2: High grade, atypical nuclei, mitoses pronounced -Site : T 1: Intracompartmental ( Confined within limits of periosteum) T 2: Extracompartmental (Break in an adjacent joint cartilage, bone cortex (or periosteum), fascia & muscles compartment & joint capsule) -Metastasis : G 2: High grade, atypical nuclei, mitoses pronounced -Site : T 1: Intracompartmental ( Confined within limits of periosteum) T 2: Extracompartmental (Break in an adjacent joint cartilage, bone cortex (or periosteum), fascia & muscles compartment & joint capsule) -Metastasis : M 0: No identifiable skip lesions or distant metastases. M 1: Any skip lesions, regional lymph nodes, or distant metastases. M 0: No identifiable skip lesions or distant metastases. M 1: Any skip lesions, regional lymph nodes, or distant metastases.

16. Enneking's Staging System of Malignant Bone Tumors, CORR 1980 Ia Low grade, intracompartmental G 1 T 1 M 0 Ia Low grade, intracompartmental G 1 T 1 M 0 Ib Low grade, extracompartmental G 1 T 2 M 0 Ib Low grade, extracompartmental G 1 T 2 M 0 IIa High grade, intracompartmental G 2 T 1 M 0 IIa High grade, intracompartmental G 2 T 1 M 0 IIb High grade, extracompartmental G 2 T 2 M 0 IIb High grade, extracompartmental G 2 T 2 M 0 IIIa Low or High grade, intracompart. G 1-2 T 1 M 1 w/ metastases. IIIa Low or High grade, intracompart. G 1-2 T 1 M 1 w/ metastases. IIIb Low or High grade, extracompart. G 1-2 T 2 M 1 IIIb Low or High grade, extracompart. G 1-2 T 2 M 1 w/ metastases. w/ metastases. Treatment of any potentially malignant bone tumor always begins with: staging: Chest CT scan to evaluate for pulmonary metastasis, bone scan or skeletal survey for distant metastases or skip lesion- radiographic features & biopsy biopsy - -

17. Method of treatment ;- 1) Tumor Excision 1..suitable for benign tu,,.includ curratage & removal of a simple bone cyst. 1. Intra capsular excision.suitable for benign tu,,.includ curratage & removal of a simple bone cyst. 2. Marginal excision suitable for benign tu. same as above but go beyond the lesion capsule. 3. Wide local excision is suitable for low grad sarcoma.. intracompartmental Al is suitable for low grad sarcoma.. intracompartmental Al & some time for high grad intracompartmental sarcoma All & some time for high grad intracompartmental sarcoma All 1. Radical Excision means removal of the entire bone or muscles compartment were the tu, lie. 2. Limb Sparing Surgery. 3. Amputation 2) Radiation Usually used in combination with chemotherapy before surgery. & Specially for the highly sensitive bone tu.to radiation, Like Ewing sarcoma & its used for tu. In an inaccessible sites as in pelvis or spine & for myeloma & lymphoma that are beyond surgery. 3) Chemotherapy. 3) Chemotherapy. like vinicristin,methotrexat, adrimysin,cyclophosphamide, which reduce the tu. Size & prevent metastasis

19. Chemotherapy usually begins before any surgery. Decreased tumor size on x-ray, decreased pain level, and decreased serum alkaline phosphatase which indicate some response, Radiation therapyRadiation therapy uses high-energy radiation to kill cancer cells by damaging their DNA.cancercellsDNA The radiation used for cancer treatment may come from a machine outside the body, or it may come from radioactive material placed in the body near tumor cells or injected into the bloodstream,radioactivetumor

20. Thank you

21. Benign bone Tu

23. Malignant bone Tu, ( Sarcoma Malignant bone Tu, ( Sarcoma

25. Osteoid osteoma 1. Benign bone tumour consist of osteoid & dense newly formed bone 2. Small Usually less than 1 cm in diameter,oval or round in shap.encloses in a dense bone 3. Occurs in young adults, 4. Tibia and femur are the commonest site 5. Pain (relieved by aspirin) is presenting complaint 6. Xray has characteristic appearance of a tiny radiolucent area called Nidus surrounded by dense boney layer. 7. Dx;- mainly by X-ray or CT-scan 8. Local excision in block is curative

26. Osteochondroma Also called cartilage capped Exostosis, osteochondroma is an overgrowth of cartilage near the epiphysis of a fast growing bone which by endochondral ossification change into a bony protuberance covered by a cap of cartilage. The exact cause of osteochondroma is not known Most commonly, it affects the long bones in the leg, the pelvis iliac crest, or scapula Osteochondroma Also called cartilage capped Exostosis, osteochondroma is an overgrowth of cartilage near the epiphysis of a fast growing bone which by endochondral ossification change into a bony protuberance covered by a cap of cartilage. The exact cause of osteochondroma is not known Most commonly, it affects the long bones in the leg, the pelvis iliac crest, or scapula

27. 1. Commonest bone tumour 2. The lesion usually occurs during skeletal growth - between the ages of 10 and 25 years. It affects males and females equally. 2. The lesion usually occurs during skeletal growth - Appears in adolescence between the ages of 10 and 25 years. It affects males and females equally. 3. as cartilaginous overgrowth at epiphyseal plate Lesions can be single or multiple i.e (the Metaphyses of long bones are the commonest sites) 4. Symptoms may include: ( mostly symptumless ) l a hard, immobile, detectable painless lump l a hard, immobile, detectable painless lump ll soreness of the adjacent muscles ll soreness of the adjacent muscles lll pressure or irritation with exercise lll pressure or irritation with exercise l v occasionally joint pain l v occasionally joint pain 5. Dx Medical history,physical examination,X-ray,CT- scan, MRI 6. Treatment for osteochondromas varies significantly depending on the size of the overgrowth and the symptoms of the individual. Treatment may include: surgery (to remove the mass) surgery (to remove the mass) medications (to control pain) medications (to control pain) 1% possibility of Malignant transformation. 1% possibility of Malignant transformation.

28. Chondroma 1. Benign (non-cancerous) bone tumor that originates from cartilage. 2. Lesions may be single or multiple (Ollier'sdisease) 3. Appears in tubular bones of (most common) hands and feet, also in femur,humerus & tibia..presented as a painful expanding of bone or as a pathological #.or mostly discover accidentally on X-ray. 4. Xray shows well defined osteopenic area in the medulla, with flex of calcification 5. Treatment ;-Lesion should excised completely and bone grafted.

29. Prognosis Sign’s of Malignant transformation; 1)painfull bone lesion 2)rapidly increasing in size. 3)cortical erosion

30. is a developmental disorder in which the bony trabecule is replace by a fibrous tissue,osteoid & woven bone. The condition could be either( monostatic) affecting one bone or polystatic ) when it affect multiple bones (Malignant transformation in 5-10% of these cases to fibrosarcoma) symptom in a single monostatic small lesion could remain asymptomatic. Other with larg or multiply polystatic lesion will present with pain & deformity of the weight bearing bone,or presented with a pathological fractures X-ray ;-larg cyst like lesion in the metaphysis or shaft of long bone full with a hazy what is known as( ground –glass appearance the deformity of the wt. bearing bone is charactrestic (( shepherd crook ))of the proximal femur(. Pathalogy is a fibrous tissue. Replacing a normal bone. Treatment;-small lesion –curate & bone graft,,,large deformity should be prevented & corrected fibrous dysplasia

31. Giant cell tumor of bone also called( giant cell myeloma or osteoclastoma ) is a relatively uncommon tumor. It is characterized by the presence of multinucleated giant cells (osteoclast-like cells). tumor multinucleated giant cellsosteoclasttumor multinucleated giant cellsosteoclast These tumors are generally benign, slowly develop, but may recur locally in as many as 50% of cases. Metastasis to the lungs may occur. These tumors are generally benign, slowly develop, but may recur locally in as many as 50% of cases. Metastasis to the lungs may occur.benignMetastasislungsbenignMetastasislungsEpidemiology Giant cell tumor of the bone accounts for 18% of benign bone tumors,, Giant cell tumors are mostly benign, however 5-10% of patients may have a malignant tumor. Clinical Features Patients usually present with pain and limited range of motion caused by tumor's proximity to the joint space. There may be swelling as well, if the tumor has been growing for a long time. Some patients may be asymptomatic until they develop a pathologic fracture at the site of the tumor. pathologic fracturepathologic fracture Patients may also experience nerve pain which feels like an electric shock.

32. Imaging On x-ray, giant cell tumors (GCTs) are lytic/lucent lesions that have a meta- epiphyseal location and grow to the articular surface of the involved bone Imaging On x-ray, giant cell tumors (GCTs) are lytic/lucent lesions that have a meta- epiphyseal location and grow to the articular surface of the involved bone. Radiologically the tumors show characteristic 'soap bubble' appearance. They are distinguishable from other bony tumors in that GCTs usually have a non- sclerotic and sharply defined border. Metastasis;- usually to the lung, so when the diagnosis of giant cell tumor is suspected, a chest x-ray or CT may be needed. MRI can be used to assess intramedullary and soft tissue extension…Biopsy to confirm the Dx. CT

33. Treatment Surgery is the treatment of choice if the tumor is determined to be resectable. Curettage is a commonly used technique. Curettage Patients with tumors that are not amenable to surgery are treated with radiation therapy.if the situation is complicated in a patient with a pathological fracture. It may be best to immobilize the affected limb and wait for the fracture to heal before performing surgery.

34. Aneurysmal bone cyst The (ABC) is an expansile cystic lesion that most often affects individuals during their second decade of life (50-70%) ABCs most commonly affect the long, tubular bones, followed by the spine and flat bones. These 3 areas account for 80% of all ABCs. When present in long, tubular bones, ABCs tend to be eccentrically located in the metaphysis

35. Pathophysiology The true etiology of ABCs is unknown Most investigators believe that ABCs are the result of a vascular malformation within the bone; include arteriovenous fistulas and venous blockage. The vascular lesions then cause increased pressure, expansion, erosion, and resorption of the surrounding bone.ending with thin cortex. The continent of the cyst are clotted blood & on curate of the cyst massive bleeding may happened Histlogically the cyst of afibrous membrane containin avascular tissue with heamosidren deposit & multi nucleated Giant cell

36. Clinical feature Patients usually present with pain,,, a mass,,, swelling,& a pathologic fracture, or a combination of these symptoms in the affected area. The symptoms are usually present for several weeks to months before the diagnosis is made, and the patient may also have a history of a rapidly enlarging mass. Neurologic symptoms associated with ABCs may develop secondary to pressure or tenting of the nerve over the lesion, typically in the spine. Other findings may include the following: Deformity.. Decreased range of motion,,, weakness, or stiffness Patients usually present with pain,,, a mass,,, swelling,& a pathologic fracture, or a combination of these symptoms in the affected area. The symptoms are usually present for several weeks to months before the diagnosis is made, and the patient may also have a history of a rapidly enlarging mass. Neurologic symptoms associated with ABCs may develop secondary to pressure or tenting of the nerve over the lesion, typically in the spine. Other findings may include the following: Deformity.. Decreased range of motion,,, weakness, or stiffness painfracture painfracture Occasionally, Warmth & bruit over the affected area Dx;- X-ray Ct-scan or MRI. DDx ;- simple bone cyst,Giant cell Tumour Treatment by curration & bone graft packed,recurrences is common in 30%of the cases,no malignat transformation

37. Unicameral bone cyst (simple bone cyst ) Usually apper during child hood at the metaphysis of the long bone ( femur.proximal humerus..its not atumour usually heal spontaneously,,discover accidently or after pathalogical#. X-ray :-Larg osteolyticc lesion ((larg bubble inside the bone ))mainly in the metaphysis not extending to the epiphyseal plat. Treatment ;- asymptumatic left alone. active cyst should be treated by aspiration + injection 80-160 mg of methly predisolone or the cyst is curetted & bone graft. active cyst should be treated by aspiration + injection 80-160 mg of methly predisolone or the cyst is curetted & bone graft.

39. Malignant bone Tu, ( Sarcoma Malignant bone Tu, ( Sarcoma