1. Ass. Prof . Dr.Zaidshahwanii Consultant Ortho.surgeon
Bone Tumor
Ass. Prof . Dr.Zaidshahwanii
Consultant Ortho.surgeon
Dec.2017

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.
In children, most cancerous bone tumors are primary. In adults, most cancerous bone tumors are metastatic. z

3. Fibrous tissue fibrous dysplasia fibrosarcoma
non-ossifying fibroma
fibrous cortical defect
neurofibroma

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

5. 2)bone pain. progressive and unremitting pain is a provoking symptom
2)bone pain. progressive and unremitting pain is a provoking symptom. It may be caused by rapid expansion with stretching of surrounding tissues, central haemorrhage or degeneration in the tumour, or an incipient 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) fracture with little or no stress Sometimes a tumor, especially if cancerous, weakens a bone, causing it to fractures
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 ,some 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 years duration that started to increase in size suddenly in the last 4weeks complete surgical resection was done .

7. 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
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.

8. Isotopis bone scaninig( TC99) computed tomography (CT)
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 or aggressive ) ,,(intra. Or extra compartmental),with involving of a near by Neurovascular bundle ,or any skip lesion (2nd metastasis ),or detecting expanding Tu. in (pelvis or spine) which is a difficult places to reach ,
Open Biopsy
                                           

9. QUESTIONS TO ASK WHEN ASSESSING AN X-RAY
What is the age of the patient?
Which bone is affected?
Where in the bone is the lesion?
What is the lesion doing to the bone: is it osteolytic,
osteoblastic or mixed?
What is the bone doing in response?
Is there a periosteal reaction?
Is there an associated soft-tissue mass?
What is the nature of the matrix: is it osteoid,
chondroid or fibroid?
Is the lesion solitary or are there multiple lesions?

10. 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. 1) complete blood pic. Anaemia, increased ESR and 2)elevated serum alkaline phosphatase levels seen in pagets dis. Or osteoscrcoma 3)Serum protein electrophoresis may reveal an abnormal globulin fraction and the urine may contain Bence Jones protein in patients with myeloma.
4)A raised serum acid phosphatase & PSA test suggests prostatic carcinoma
5) Eleveted s.calcium in parathyroid tu.

11. Points to be considered
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 ,,,,
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 ) Complication ; infection ,pathalogical #,,,,,.haemorrage.

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

14. Management Benign bone Tu
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

15. stage 1) latent; stage 2) active; stage 3)aggressive.
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 lesions are intracapsular, usually asymptomatic, and frequently incidental found . 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 thinning 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.

16. Malignant
Malignant:  Stage determined by three different sub-categories -Grade: Histology with aid of radiographic findings and clinical correlation
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:  
M 0: No identifiable skip lesions or distant metastases.  M 1: Any skip lesions, regional lymph nodes, or distant metastases.

17. Enneking's Staging System of Malignant Bone Tumors, CORR 1980
  Ia       Low grade, intracompartmental                 G 1       T 1       M 0
  Ib       Low grade, extracompartmental                 G 1       T 2       M 0
  IIa     High grade, intracompartmental               G 2       T 1       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.
  IIIb   Low or High grade, extracompart.               G 1-2     T 2       M 1
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
            -

18. Method of treatment ;- 1) Tumor Excision
Intra capsular excision .suitable for benign tu ,,.includ curratage & removal of a simple bone cyst .
Marginal excision suitable for benign tu. same as above but go beyond the lesion capsule.
Wide local excision
is suitable for low grad sarcoma.. intracompartmental Al
& some time for high grad intracompartmental sarcoma All
4.Radical Excision means removal of the entire bone or muscles compartment were the tu, lie.
5 . Limb Sparing Surgery .
6. 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. like vinicristin ,methotrexat, adrimysin ,cyclophosphamide ,which reduce the tu. Size & prevent metastasis

20. Radiation therapy uses high-energy radiation to kill cancer cells by damaging their DNA .
…….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 ,
Chemotherapy usually begins before any surgery. Decreased tumor size on x-ray, decreased pain level, and decreased serum alkaline phosphatase which indicate some response,

21. Benign bone Tu.

22. Osteoid osteoma
Benign bone tumour consist of osteoid & dense newly formed bone
Small Usually less than 1 cm in diameter ,oval or round in shap. encloses in a dense bone Occurs in young adults ,
Tibia and femur are the commonest site
Pain (it increase at night relieved by aspirin) is the presenting complaint
X ray has characteristic appearance of a tiny radiolucent area called Nidus surrounded by dense boney layer.
Dx;- mainly by X-ray or CT-scan
Local excision in block is curative send the sample for X-Ray check for nidus

23. The important x-ray feature is a small radiolucent area, the so-called ‘nidus’. Lesions in the diaphysis are surrounded by dense sclerosis and cortical thickening. The histological features are characteristic: the nidus consists of sheets of pink-staining osteoid in a fibrovascular stroma

24. Anti inflammatory Drugs..or spontinous dissolve may take years ..
Non surgical Tr.
Anti inflammatory Drugs..or spontinous dissolve may take years ..
Surgical ;- Curettage. The standard surgical treatment for an osteoid osteoma is to scrape or scoop out the entire tumor, particularly the nidus—or central core.,, great care to ensure that the entire tumor is removed; otherwise, it may grow back.
Radiofrequency ablation. A newer treatment option is to remove the center core of the tumor with minimally invasive techniques such as CT-guided radiofrequency ablation. In this outpatient procedure, the tumor is heated and destroyed with a high-frequency electrical current. By dentify the site of the tumor using fine CT scans. A radiofrequency probe is then inserted into the tumor. The probe heats the tumor tissues to about 90 degrees Celsius, effectively killing them. There is minimal damage to surrounding tissues.
The tumor is adequately removed in most patients following one radiofrequency probe treatment. The procedure takes approximately 2 hours followed by a 2-hour recovery period, after which you may go home with a mild pain reliever.

26. Osteochondroma ((cartilage capped Exostosis )) osteochondroma is a herniation of part of a cartilage subperosital that was separated from a growth plat near the epiphysis of a fast growing bone which by endochondral ossification change into a bony protuberance covered by a cap of cartilage .usually from metaphysis of long bone growing away from growth plat… cause of Osteochondroma is unknown

28. Types either
Sessile or
Pendunculated

29. Symptoms may include: (mostly symptomless)
Commonest bone tumour
The lesion usually occurs during skeletal growth - Appears in adolescence between the ages of 10 and 25 years. It affects males and females in a ratio of 2\1
as cartilaginous overgrowth at epiphyseal plate Lesions can be single or multiple i.e (the Metaphyses of long bones are the commonest sites) (Distal feumer - Prox.tibia & prox.humerus)
Symptoms may include: (mostly symptomless)
l a hard, immobile, detectable painless lump
ll soreness of the adjacent muscles
lll pressure or irritation with exercise
lv occasionally joint pain

30. Dx ;-Medical history ,physical examination , X-ray ,CT-scan, MRI.
Treatment
for osteochondromas varies significantly depending on the
size of the overgrowth and the symptoms of the individual. Treatment may include:
A) surgery (to remove the mass)
B) medications (to control pain)
1% possibility of Malignant transformation.

31. Chondroma
Benign (non-cancerous) bone tumor that originates from cartilage consist of Islands of cartilage may persist in the metaphyses of bones formed by endochondral ossification; sometimes they grow and take on the characteristics of a benign tumour ..Lesions may be single or multiple (Ollier's disease)
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 #, and mostly discover accidentally on X-ray.

33. Xray shows a well-defined, centrally placed radiolucent area at the junction of metaphysis and diaphysis; sometimes the bone is slightly expanded. In mature lesions there are flecks or wisps of calcification within the lucent area
Treatment ;Lesion should excised completely.
((bone curettage & bone grafting))

34. prognosis
There is a small but significant risk of malignant change –probably less than 2 per cent for patients with solitary lesions but as high as 30 per cent in those with multiple lesions (Ollier’s disease) and up to 100 per cent in patients with associated haemangiomas (Maffucci’s syndrome).
Sign’s of Malignant transformation; 1)painfull bone lesion 2)rapidly increasing in size . 3)cortical erosion

35. Fibrous dysplasia is a developmental disorder in which areas of trabecular bone are replaced by cellular fibrous tissue containing flecks of osteoid and 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 large or multiply polystatic lesion will present with pain & deformity of the weight bearing bone ,or presented with a pathological fractures
fibrous dysplasia

36. X-ray ;-larg cyst like lesion in the metaphysis or shaft of long bone full with a hazy substances what is known as ( ground –glass appearance) the deformity of the wt. bearing bone is characteristic bending (( 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 by external splint & corrected by surgery & fixed internally.

37. X-rays show radiolucent ‘cystic’ areas in the metaphysis or shaft; because they contain fibrous tissue with diffuse spots of immature bone, the lucent patches typically have a slightly hazy or ‘ground-glass’ appearance. The weightbearing bones may be bent, and one of the classic features is the ‘shepherd’s crook’ deformity of the proximal femur.
Shepherd crook

38. Giant cell tumor of bone ( giant cell myeloma or Osteoclastoma)
is a relatively uncommon tumor.
It is characterized by the presence
of multinucleated giant cells
(osteoclast-like cells). originating from the undifferentiated mesenchymal cells
of the bone marrow forming
Multinucleated giant cells
These tumors are generally benign,
slowly develop, but may reoccur locally
in as many as 50% of cases.
Metastasis to the lungs may occur.

39. is more common in China and India where it constitutes approximately 20% of all bone tumors. Nearly 50% of cases occur in the region of the knee, but other frequent sites are the distal part of the radius, the proximal humerus and fibula, and the pelvic bones Giant cell tumors are mostly benign, however 5-10% of patients may have a malignant tumor. It is usually situated in the epiphysis, grows eccentrically, and may later also affect the metaphysis It appears most often in the second to fourth decades of life (60% to 75% of all cases) and the male : female ratio is 1:1.5.
Epidemiology .

40. Clinical Features
. The main clinical symptoms are non-specific, local swelling, warmth, and pain radiating independently of weight-bearing. Pathological fracture is the first sign in approximately 15% of cases.
The duration of symptoms varies between 2-6 months and by then, in one-third of cases, the size of the tumor exceeds 50% of the diameter of the affected bone, it has destroyed the cortical bone and reached the subchondral region.

41. Imaging GCT appears as a pure lytic cystic lesion, growing often but not exclusively eccentrically in the epimetaphyseal region of the bone. The affected part of the bone may be expanded and the cortical bone thinned. In an advanced stage, the GCT breaks through the cortex and there is a lack of periosteal reaction with formation of spicules around the tumour. 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.

42. GCT a ‘an aggressive, potentially malignant lesion.’
The WHO has classified
GCT a ‘an aggressive, potentially malignant lesion.’

43. Treatment
Surgery is the treatment of choice if the tumor is determined to be resectable. Curettage is a commonly used technique.
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 is best to immobilize the affected limb and wait for the fracture to heal before performing surgery.

44. 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

45. 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

46. 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
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

47. Unicameral bone cyst (simple bone cyst )
Usually apper during child hood at the metaphysis of the long bone ( femur .proximal humerus ..its not a tumour 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 mg of methly predisolone or the cyst is curetted & bone graft.

49. Malignant bone Tu, ( Sarcoma