2. Bone Tumors
by
Dr M.Rajani Cartor MPT (ortho)

3. 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
degrees.
Non inflammatory lesions in bone may be broadly
grouped into tumor like lesions and true bone tumors.

5. 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)
a. Osteoma
b. Osteochondroma
c. Enchondroma
• 3. Cystic lesions
a. Solitary bone cyst
b. Aneurysmal bone cyst

7. Musculoskeletal Tumour Society staging of malignant bone
lesions
•
•
•
•
•
•
Stage:
III Any grade,
IIB High grade,
IIA High grade,
IB Low grade,
IA Low grade,
Definition:
metastatic
extracompartmental
intracompartmental
extracompartmental
intracompartmental

8. BONE TUMORS
1.
2.
3.
4.
5.
6.
Bone forming tumors (benign, intermediate, malignant)
Cartilage forming tumors (benign, malignant)
Giant cell tumor
Marrow tumors (round cell tumors)
Vascular tumors (benign, intermediate, malignant)
Other connective tissue tumors
(benign, intermediate, malignant)
7. Other tumors (benign, malignant)

9. Bone Tumors: by Age

10. Bone forming tumors
Benign :
Intermediate:
Malignant:
Osteoma,
Osteoid osteoma &
Osteoblastoma
Aggressive Osteoblastoma
Osteosarcoma
- central(medullary)
- surface(peripheral)
a. parosteal
b. periosteal
c. high grade surface

11. Cartilage forming tumors
• Benign
- chondroma (enchondroma, periosteal)
- osteochondroma(solitary, multiple hereditary)
- chondroblastoma(epiphyseal chondroblastoma)
- chondromyxoid fibroma
• Malignant
-
Chondrosarcoma(primary/secondary)
Differentiated chondrosarcoma
Juxtacortical chondrosarcoma
Mesenchymal chondrosarcoma
Clear cell chondrosarcoma

12. GIANT CELL TUMOR
• Osteoclastoma

13. Marrow tumors
• Ewing’s sarcoma
• Neuroectodermal tumor
• Malignant lymphoma (primary/secondary)
• Myeloma

14. Vascular tumors
• Benign
- Hemangioma
- Lymphangioma
- Glomus tumor(glomangioma)
• Intermediate/Indeterminate
- hemangioendothelioma
- hemangiopericytoma
• Malignant
- angiosarcoma
- malignant hemangiopericytoma

15. Other Connective Tissue Tumors
• Benign
- benign fibrous histiocytoma
- lipoma
• Intermediate
- desmoplastic fibroma
• Malignant
- fibrosarcoma
- malignant fibrous histiocytoma
- liposarcoma
- malignant mesenchymoma
- leiomyosarcoma
- undifferentiated sarcoma

16. Other Tumors
• Benign
- Neurilemmoma
- Neurofibroma
• Malignant
- Chordoma
- Adamantinoma

17. DIAGNOSIS
• HISTORY
• PHYSICAL SIGNS
• RADIOGRAPHY (X-ray, CT scan, MRI)
• LAB INVESTIGATIONS (RBC, Hb, ESR, VDRL, calcium, phosphates, urine)
• BIOPSY (open/closed/CT assisted needle biopsy)

19. Role of Radiography
• Anatomical location
diaphyseal (ewing’s sarcoma)
diaphysiometaphyseal (osteosarcoma)
metaphyseal (osteosarcoma)
metaphysioepiphyseal (giant cell tumor, aneurysmal bone cyst)
epiphyseal (chondroblastoma)
• Borders of tumor
benign(well defined, narrow transitional area, reactive sclerosis)
malignant(poorly defined)
• 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

20. OSTEOSARCOMA
• 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

21. Radiological features:
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
appearance)

23. X ray
Sun ray

25. Codman’s triangle

27. 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.

28. • Radiological features:
- osteolytic lesion occupying epiphyseal end.
- trabeculations in the wall of cystic lesion show a “soap bubble”
appearance.
• - 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.

29. GCT- soap bubble appearance

33. CHONDROSARCOMA
• 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.

34. • Radiological features:
expansion of medulla(central type) and thickening cortex with spotty
calcification.
Appears as lobulated swelling with patchy and fluffy calcification.
• Macroscopically:
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)

39. EWING’S SARCOMA
• Highly malignant type (uncommon) occuring in
children.
• 10% of all malignant tumors
• Age 10-20 years (males)
• Arises from primitive mesenchymal cells of
medullary cavity
• Site: diaphyseal of long bones like
femur, tibia, humerus
• Occurs in flat bones like pelvic bones.

40. • 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
condition deteriorates,
* 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

41. • Macroscopically:
tumor is pale soft mass (minimal bone)
areas of degeneration and hemorrhage
milky pus like fluid (simulating osteomyelitis)
• Microscopically:
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
rosette formation.
• Treatment:
(MDT) vincristin, adriamycin, cyclophosphamide
Surgical resection, grafting,
Tumor radiosensitive and regression following therapy is
remarkable.

46. Ewing sarcoma of the proximal
humerus,
presenting as tightly
elastic, tense, ulcerated
lesion with shining skin, on a greywhite background.
Note the marked veins and skin
striation

49. Musculoskeletal Tumour Society staging. Surgical margins
• Type
Plane of Dissection
• Intralesional
Within lesion
• Marginal
• Wide
Within reactive zoneextra capsular
Beyond reactive zone
through normal tissue
within compartment
• Radical Normal tissue
extra compartmental

50. THANK YOU