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Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
Bone tumours
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Bone tumours

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  • 1. Classification based on:  Histological grade (G)  Site (T)  Metastases (M) ENNEKING'S  SURGICAL STAGES    STAGE GRADE SITE    METASTASES 1A 1B Low(G1) Low(G1) Intracompartmental(T1) Extracompartmental(T2) None(M0) None(M0) 2A 2B High(G2) High(G2) Intracompartmental(T1) Extracompartmental(T2) None(M0) None(M0) 3 Low(G1) or High(G2) Intracompartmental(T1) Or Extracompartmental(T2) Yes(M1)
  • 2.  Clinical examination (age, sex, site and past history) ◦ Thyroid ◦ Breasts ◦ Chest ◦ Liver ◦ Kidney ◦ Rectal (prostate & rectal tumours)  Bloods ◦ FBC (leukaemic cells etc) ◦ ESR (often elevated) ◦ Biochemistry (Ca++, PO4, liver enzymes and Alkaline Phosphatase) -> mets ◦ Acid Phosphatase (prostate and increased with metastatic deposits) ◦ Thyroid function tests ◦ PSA ◦ Serum Protein Electrophoresis (Myeloma)  Urinalysis  Urine Bence-Jones (myeloma)  CXR  Abdominal ultrasound  Bone scan -> other sites  MRI -> soft tissue extent and association with nerves and vessels  CT of lesion and chest (-> staging)  Angiography -> tumour blood supply and relationship to major vessels  Biopsy
  • 3.  Should know probable diagnosis and stage of tumour before biopsy  Performed by the surgeon who will perform the definitive surgery  Biopsy tract orientation & location is critical - will need to be included in the definitive surgery if lesion is malignant.  Meticulous haemostasis to avoid tracking haematomas  Send samples for microbiological analysis
  • 4.  Intra-lesional  ◦ through the tumour ◦ leaves macroscopic tumour ◦ not therapeutic  Marginal  ◦ through pseudo-capsule of tumour / reactive zone ◦ controls non-invasive benign tumours ◦ recurrence of malignant tumours = 25-50%  Wide ◦ around reactive zone, leaving a cuff of normal tissue ◦ skip lesions left ◦ recurrence of malignant tumours = < 10%  Radical  ◦ removal of entire compartment or compartments ◦ distant metastases left  Amputation ◦ should be thought of as a form of reconstruction where surgical control of the tumour precludes useful function.
  • 5. Benign Malignant Other Birth - 5yr 1. Eosinophilic Granuloma [onion skin periosteal Rxn] 2. (Unicameral bone cyst- rare) 1. laeukaemia 2. Metastatic Neuroblastoma 1. Osteomyelitis 2. healing/ stress fracture 6- 18yr 1. Unicameral Bone Cyst 2. Aneurysmal Bone Cyst 3. Nonossifying Fibroma 4. Eosinophilic Granuloma 5. Enchondroma 6. Chondroblastoma 7. Chondromyxoidfibroma 8. Osteoblastoma 1. Ewings Sarcoma 2. Osteosarcoma 1. Osteomyelitis 2. Fibrous Dysplasia 3. Osteofibrous Dysplasia 19- 40yr 1. Giant Cell Tumour 2. Eosinophilic granuloma 1. Ewings Sarcoma 40+yr s 1. Metastases (lung, breast, prostate, renal, thyroid, colon) 2. Multiple Myeloma 3. Lymphoma 4. Osteosarcoma (Pagets) 5. Chondrosarcoma 6. Fibrosarcoma/ Malignant Fibrous 7. Histiocytoma 1. Hyperparathyroidism 2. Osteomyelitis 3. Paget's
  • 6. Fibroxanthoma Fibrous cortical defect Non ossifying fibroma Fibrosarcoma Fibrous dysplasia Round cell lesions Ewings Reticulum cell sarcoma Myeloma Chondromyxoid fibroma Chondrosarcoma Osteoid osteoma Cortical fibrous dysplasia Adamantinoma DIAPHYSISDIAPHYSIS
  • 7. osteosarcoma Enchondroma Giant cell tumour osteochondroma Bone cyst Osteoblastoma Chondromyxoid fibroma Chondrosarcoma Fibroxanthoma Fibrous cortical defect Non ossifying fibroma METAPHYSISMETAPHYSIS
  • 8. chondroblastoma Articular osteochondroma Dysplasia epiphysealis hemimelica Giant cell tumour EPIPHYSISEPIPHYSIS
  • 9.  Fibrous Dysplasia Osteoblastoma Giant Cell Tumour Metastasis/ Myeloma Aneurysmal Bone Cyst Chondroblastoma/ Chondromyxoid Fibroma Hyperparathyroidism (brown tumour)/ Haemangioma Infection Non-ossifying Fibroma Eosinophilic Granuloma/ Enchondroma Simple Bone Cyst
  • 10.  Vascular ◦ hemangiomas ◦ infarct  Infection ◦ chronic osteomyelitis  Neoplasm ◦ primary  osteoma  osteosarcoma ◦ metastatic  prostate  breast  other  Drugs ◦ Vitamin D ◦ fluoride  Inflammatory/Idiopathic  Congenital ◦ bone islands ◦ osteopoikilosis ◦ osteopetrosis ◦ pyknodysostosis  Autoimmune  Trauma ◦ fracture (stress)  Endocrine/Metabolic ◦ hyperparathyroidism  Paget's disease
  • 11.  Pattern of bone destruction  Tumour matrix  Cortical expansion/penetration  Periosteal reaction  Adjacent soft tissues  Size & shape of lesion  Trabeculation  Growth Plate
  • 12.  Benign lesion - during growth  20% of benign bone lesions  Age 5-15 years  Not found in adults  Sex m:f 3:1  The most common location is the proximal humerus (67%) followed by the proximal femur (15%)  unusual sites (calcaneum, pelvis) in patients >17 yrs  Cysts may be Active or Latent: Active cysts are located near the growth plate, but they move further away as the child grows and become inactive (latent)
  • 13.  Well defined, central osteolytic area with a thin sclerotic margin  Metaphyseal in young - moves towards diaphysis with growth  It fills and slightly expands metaphysis Pathology  Thin walled cavities - blood tinged fluid.  The lining cells are cuboidal,
  • 14.  Treatment goal is to minimise fracture risk until the cyst heals (but this can take years)  Steroid injection ◦ 1-3 percutaneous injections repeated at 2 monthly intervals ◦ 60-80% success rate  Curettage and bone graft - 50% recurrence rate and possibility of damage to the growth plate  Bone marrow aspirate has recently been used
  • 15. Benign solitary, expansile and erosive lesion of bone 1% of benign bone lesions Age (85% cases <20 years old) Sex f:m is 2:1 ABC's can be found in any bone in the body The most common location is the metaphysis of the lower extremity long bones, more so than the upper extremity The vertebral bodies or arches of the spine may be involved Approximately one-half of lesions in flat bones occur in the pelvis Presentation Swelling, tenderness and pain Limited range of motion due to joint obstruction Spinal lesions - neurological symptoms Pathological fractures are rare - eccentric location of the lesion
  • 16.  Placed eccentrically in the metaphysis and appears osteolytic  The periosteum is elevated; cortex is eroded to a thin margin  The expansile lesion - "blow-out”  CT scan -for pelvis or spine lesions  CT scan can demonstrating multiple fluid-fluid levels  MRI can also confirm the multiple fluid-fluid levels
  • 17.  A slow growing, indolent ABC has been observed to regress spontaneously  Most lesions can be treated with curettage and application of a high-speed burr  Recurrence was statistically related to young age and open growth plates, and may be less likely following wide excision than following curettage
  • 18.  Benign, usually solitary and locally aggressive  10% of benign bone lesions  malignant transformation (5-10%)  Not seen until after the growth plate closes  Rarely metastasises (<1% to lungs)  Age 20 - 40 years  More common females  Most commonly seen in the distal femur, proximal tibia and the distal radius  Nearly always located at the very end of a long bone (metaphyseal / epiphyseal)  Pathological fracture occurs in 10 - 15%  Neighbouring joint often irritated (effusion)
  • 19. stagestage clinicalclinical radiologyradiology histologyhistology II asymptomaticasymptomatic benignbenign benignbenign IIII symptomaticsymptomatic activeactive benignbenign IIIIII symptomaticsymptomatic AggressiveAggressive Mets +Mets + benignbenign
  • 20.  Usually well defined lesion in the epiphysis extending up to the joint surface without marginal sclerosis, cortex thinned and sometimes ballooned  soap bubble appearance  Junction with normal bone poorly defined  Soft, friable tumour  Cut surface tan in colour, with areas of necrosis and haemorrhage  Numerous multinucleated giant cells. The stromal cells are homogenous mononuclear round/ovoid with large nuclei  Up to 50% have soft tissue extension
  • 21.  Intralesional excision by "extended" curettage  Curettage alone has a high local recurrence rate (50%) and the curettage is "extended" into the bone by a few millimetres by either using a burr, liquid nitrogen or phenol  The resulting cavity can be filled with bone graft or cement  En-bloc resection is possible if the bone is expendable e.g. proximal fibula, proximal radius  Amputation reserved for massive local recurrence, malignant change or infection  Radiotherapy reserved rare cases of unresectable tumours because of increased risk of secondary malignancy
  • 22.  10% of benign bone tumours Male : Female 2:1 Peak age 5 - 25 years (85% in this range) Rare over 40 years  Location: Any bone, rarely multifocal tibia & femur in 50% spine - posterior elements Only occurs in bones formed by endochondral ossification  Clinically  Pain - commonest presentation Pain - worse at night and relieved by aspirin 10% occur in the spine Runs a self limiting course > surgery for pain relief Pain usually decreases as the lesion matures Lesion healed by 3 - 7 years
  • 23.  Lytic nidus surrounded by sclerotic bone (which may mask the nidus) Centre of nidus may be calcified CT or tomograms -> diagnosis Hot spot on bone scan Differential Diagnosis  Bone island (enostosis)  Brodie's abscess  Osteoblastoma  fatigue fracture
  • 24.  NSAIDs ◦ relieves symptoms  Surgical: ◦ Nidus excision -> no recurrence ◦ Intraoperative localisation with:  Bone scan  Tetracycline under UV light)  CT  X-Ray excised tissue -> contains nidus  Percutaneous radiofrequency coagulation
  • 25.  Cartilage capped bony projection / exostosis Commonest benign tumour Developmental abnormality of the metaphysis  Accounts for 45% of benign bone tumours  12% of all bone tumours  most become evident under 20 years  May be solitary or multiple (diaphyseal aclasis)  Any bone developing by endochondral ossification may be involved
  • 26.  Autosomal dominant  Disordered endochondral growth  Multiple osteochondromas  Short stature and bowing of limbs  Treat individual lesions as necessary and observe for malignant change  Malignancy Risk = ~ 20% overall or 0.2% per lesion  Trevor's Disease: Osteochondroma on epiphyseal side of the growth plate
  • 27.  x-ray hallmark is blending of tumour into underlying metaphysis  flat, sessile lesion or a peduculated (stalk like) process  pedunculated osteochondromas are oriented in proximal direction  Cartilaginous cap displays irregular areas of calcification
  • 28.  Nil required unless symptomatic (persistent irritation (from bursitis or tendon) or neurovascular compromise)  Extra capsular marginal excision ◦ Including the cartilaginous cap & overlying perichondrium ◦ Deep bony base has minimal activity & may be removed piecemeal ◦ The cartilaginous cap should not be traumatised during removal ◦ Recurrence = < 5%  Decreased risk of recurrence if excised after maturity
  • 29.  Risk of malignant change ~ 0.2% in a solitary lesion  Risk of malignant change in diaphyseal aclasis 20%  Sarcomatous change usually ->low grade  Evidence of transformation to Chondrosarcoma: ◦ Cartilaginous cap thicker than 1 cm in an adult (in child may be 2-3 cm thick) ◦ Cartilage cap > 8cm diameter ◦ Fluffy outline ◦ Bone scan - Marked increase in uptake in an adult ◦ CT/MRI - soft tissue mass or displacement of a major neurovascular bundle
  • 30.  10% of benign bone tumours  50% occur in small bones of the hands and feet  15% femur and 12% humerus  Peak incidence 10 - 50 years  May be solitary or multiple (Olliers, Mafuccis)  Clinically  Usually metaphyseal  75% Solitary  60% present as fractures  pathological fracture, lump  incidental finding
  • 31.  X-Rays Scalloped erosions on endosteal surface  flecks of calcification - sometimes called 'ground glass' enchondroma (typical appearance & site)
  • 32.  Macroscopically - bluish white well demarcated  hypocellular; nests of mature cartilage cells,  Ollier's disease - more cellular; 50% ->malignant transformation  Mafucci's disease - associated with multiple haemangiomata and associated with nearly 100% malignant change somewhere
  • 33.  Observe - x-ray 6 months & 1 year after presentation  Curettage and grafting if latent  Recurrence - en block excision  Prognosis  Risk of malignant change in Olliers is 50%  malignant change in Mafuccis is nearly 100%
  • 34.  5 - 20% benign bone lesions  usually monostotic  Affects children and adolescents  Median age at onset 8 years  Male > Female (Albrights - Female > Male)  McCune - Albrights Syndrome  Polyostotic disease (unilateral usually)  Skin pigmentation ◦ cafe au lait spots with serrated borders (called "coast of Maine") that tend to stop abruptly at the midline of the body  Precocious puberty (endocrinopathy)  usually presents earlier, may be unilateral or widespread, affecting long bones, hands, feet & pelvis  Malignant transformation (chondrosarcoma or osteosarcoma) is about 4 %;
  • 35.  Lucent lesion in medullary space  Sclerotic margin.  Ground glass appearance  No periosteal reaction  Shepherds crook - proximal femur  expansion of cortex  Pathology  Bone replaced by firm, whitish tissue of gritty consistency  bone trabeculae separated by fibrous tissue.  Bone is woven rather than lamellar
  • 36.  Pagets disease  FCD  Hyperparathyroidism  osteoblastoma  osteosarcoma  Treatment  Monostotic -> curettage and grafting if symptomatic  Polyostotic -> symptomatic treatment  May require osteotomy for deformity or lengthening / shortening procedures  Prognosis  Monostotic lesions cease activity at puberty but may be reactivated by pregnancy  Polyostotic - 85% -> pathological fracture  malignant change occurs after radiotherapy

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