Tumors Musculoskeletal.. VAPMS college of physiotherapy, vskp.
Dr M.Rajani Cartor MPT (ortho)
Incidence of bone tumors is very low (1 to 1.5%) of
the total malignancies of the body.
Bone being mesenchymal origin, the abnormality of
cell growth can produce a tumor containing not only
bone but also cartilage and fibrous tissue in varying
Non inflammatory lesions in bone may be broadly
grouped into tumor like lesions and true bone tumors.
Tumor like lesions of bone(simulating tumor)
• 1. Reactive bone lesions
a. Osteoid osteoma
b. Benign osteoblastoma
c. Non osteogenic fibroma
• 2. Hamartomas (abnormal proliferation, soon mature and stop proliferation)
• 3. Cystic lesions
a. Solitary bone cyst
b. Aneurysmal bone cyst
Musculoskeletal Tumour Society staging of malignant bone
III Any grade,
IIB High grade,
IIA High grade,
IB Low grade,
IA Low grade,
Role of Radiography
• Anatomical location
diaphyseal (ewing’s sarcoma)
metaphysioepiphyseal (giant cell tumor, aneurysmal bone cyst)
• Borders of tumor
benign(well defined, narrow transitional area, reactive sclerosis)
• Destruction pattern
slow growth (geographical pattern)
moderate growth (moth eaten pattern)
rapid growth (permeative pattern)
• Matrix formation (new bone formation- woolly to dense sclerosis)
• Periosteal reaction
non continuous, often laminated (sunray appearance) – osteosarcoma
(Onion peel appearance) – ewing’s sarcoma
• Malignant primary tumor characterised by direct
bone formation (proliferating tumor cells)
• Occurs in age 10-20 years
• Site: distal end of femur,
proximal end of tibia,
proximal end of humerus
• c/f: pain dominating initial symptom
swelling appears and increases in size(fusiform)
• Observation: skin stretched, shiny, vascular
swelling warm and show pulsation if very vascular
firm to hard consistency(softening areas at soft tissue)
late stages: tumor fungates
General health- anaemia, weight loss, cachexia
Tumor arises at metaphyseal region(centrally/cortically).
Mottled areas of rarefaction with areas of osteosclerosis.
Extending beyond cortex, periosteum is raised and new bone forms at
right angles. (“sunray” appearance)
Reactive new bone subperiosteally is codman’s triangle
Chest radiograph may show shadows by secondary deposits (canon ball
GIANT CELL TUMOR
Tumor arises from supporting connective tissues of
bone. As it arises from osteoclasts – OSTEOCLASTOMA
(benign but locally aggressive neoplasm with local recurrence).
Common in Indians
Occurs at age of 30-40 years.
site: metaphysioepiphyseal region of long bone
distal femur/radius, proximal humerus/ tibia
c/f: bony swelling at knee/wrist.
gradual growth and slight pain
joint not involved but movement restricted due to mechanical block
eccentric swelling (if cortex thin- “egg shell crackling” on palpation)
Some cases with pathological fracture.
• Radiological features:
- osteolytic lesion occupying epiphyseal end.
- trabeculations in the wall of cystic lesion show a “soap bubble”
• - GCT into 3 grades : latent, active, aggressive types based on
osteolysis, cortical destruction and expansion.
• Macroscopically: fleshy grayish mass with hemorrhage
• Microscopically: stroma with spindle cells(plump and ovoid)
• Treatment: surgical resection/en bloc exicision, curettage, bone
graft after adjuvant therapy like phenol/ liquid nitrogen.
• Malignant tumor of cartilagenous origin.
• 3rd most common
• Arises from diaphysio metaphyseal region of long bones
• Central type occurs in proximal femur,ilium,humerusand scapula
• Common in males aged 30-50 years
• c/f: swelling(hard and lobulated), dull aching pain.
grows slowly and restricts joint movement.
• Radiological features:
expansion of medulla(central type) and thickening cortex with spotty
Appears as lobulated swelling with patchy and fluffy calcification.
white or bluish mass of firm consistency. Appears
to have capsule and areas of myxomatous degeneration and softening.
• Microscopically: cartilage masses are hyperchromatic
• Based on cellularity, pleomorphism and mitosis chondrosacoma
classified into 3 grades
• Treatment: surgical/limb saving(en bloc resection)
• Highly malignant type (uncommon) occuring in
• 10% of all malignant tumors
• Age 10-20 years (males)
• Arises from primitive mesenchymal cells of
• Site: diaphyseal of long bones like
femur, tibia, humerus
• Occurs in flat bones like pelvic bones.
• c/f: presents with pain gradually increasing,
followed by swelling(firm to soft),indefinite margins,
fever, anaemia, leucocytosis (simulates osteomyelitis),
with soft tissues involvement ,swelling rapidly increases and
* Peculiar feature- metastasis occur in skull, vertebrae and ribs in
addition to lungs (blood stream).
• Radiological features:
mottled rarefaction in bone affected,
destruction of cortex,
involvement of soft tissues,
reactive new bone formation in layers “onion peel” appearance
tumor is pale soft mass (minimal bone)
areas of degeneration and hemorrhage
milky pus like fluid (simulating osteomyelitis)
cellular with minimal stromal tissue,
characteristic cell- small polyhedral with large nucleus,
Appearance is monotonously uniform with cells in compact
sheets with loose and vacuolated stroma some areas- pseudo
(MDT) vincristin, adriamycin, cyclophosphamide
Surgical resection, grafting,
Tumor radiosensitive and regression following therapy is
Ewing sarcoma of the proximal
presenting as tightly
elastic, tense, ulcerated
lesion with shining skin, on a greywhite background.
Note the marked veins and skin
Musculoskeletal Tumour Society staging. Surgical margins
Plane of Dissection
Within reactive zoneextra capsular
Beyond reactive zone
through normal tissue
• Radical Normal tissue