Prepared by Dr. Sanjib Kumar Das, MPT (Musculoskeletal), Fellow (Doctoral) NITIE-Ergonomics & Human Factors.

1. Bone Tumours
Dr. Sanjib Kumar Das, PhD
School of Physiotherapy

2. INTRODUCTION
• The term ‘bone tumour’ is a broad term used for benign
and malignant neoplasms, as well as ‘tumour-like
conditions’ (e.g., osteochondroma).
• Osteochondroma is the commonest benign tumour of
the bone.
• Metastatic deposits in the bone are commoner than
primary bone tumours. Multiple myeloma is the
commonest primary bone malignancies.
• The nature of a bone tumour can be suspected based on
the type of destruction seen on an X-ray

3. OSTEOMA
• This is a benign tumour composed of a protruding bone
from the cortical surface.
• The bones involved most often are the skull and facial
bones.
• It may bulge into one of the air sinuses (frontal, ethmoidal
or others), and cause obstruction to the sinus cavity,
leading to pain.
• A simple excision is sufficient and no treatment is
generally required except for cosmetic reasons.

4. OSTEOCLASTOMA (GIANT CELL TUMOUR)
• Giant cell tumour (GCT) is a common benign
bone tumor but sometimes tends to recur after
local removal.
• These giant cells were mistaken as osteoclasts in
the past, hence the name osteoclastoma.

5. CLINICAL FEATURES
• The tumour is seen commonly in the age group of
20-40 years i.e., after epiphyseal fusion.
• Knee is commonly affected i.e., lower-end of the
femur and upper-end of the tibia. Lower-end of
the radius is another common site.
• The tumour is located at the epiphysis. It often
reaches almost up to the joint surface.
• Common presenting complaints are swelling and
vague pain.

6. DIAGNOSIS
The characteristic radiological features of
GCT:
• A solitary, eccentric location, often
subchondral.
• Expansion of the overlying cortex
(expansile lesion).
• ‘Soap-bubble’ appearance
• No calcification within the tumour.
• Cortex may be thinned out or perforated at
places.

7. TREATMENT
a) Excision:
• Excision of the tumor is the best treatment.
• For sites like the spine, where excision is not possible,
radiotherapy is done.
b) Excision with reconstruction: the defect created by
excision is made up, usually partially, by some reconstructive
procedure.
• For example, in tumors affecting the lower-end of femur,
the affected part is excised, and the defect thus created
made up by one of the reconstructive methods.

8. TREATMENT
 Arthrodesis by the Turn-o-Plasty procedure :
In this technique, the required length of the
tibia is split into two halves. One half is turned
upside down and fixed with the stump of the
femur left after excising the tumour. A similar
procedure can be used for a tibial lesion by
taking half of the femur.
 Arthrodesis by bridging the gap by fibulae,
taken from same extremity or from the
opposite leg.
 Arthroplasty: The tumor is excised, and the
joint is reconstructed using an autograft
(patella to substitute the articular defect),
allograft (replacing the defect with the
preserved bone of a cadaver), or an artificial
joint (prosthesis).

9. TREATMENT
c) Curettage with supplementary procedures:
• Curettage performed alone has the disadvantage of a high
recurrence rate because some cells are always left along the walls of
the cavity. Some supplementary procedures used with curettage
reduce recurrence.
• Cryotherapy, where liquid nitrogen is used to produce a freezing
effect and thus kill the residual cells.
• Thermal burning of the residual cells using cauterization of the
walls of the tumor is popular.
• Bone cement can also be used. The cavity is filled with bone
cement.

10. TREATMENT
d) Amputation: For more aggressive tumors, or
following recurrence, amputation may be necessary.
e) Radiotherapy: Preferred treatment method for GCT
affecting the vertebrae.

11. OSTEOSARCOMA (OSTEOGENIC SARCOMA)
• An osteosarcoma (second most
common) is a malignant tumor of the
mesenchymal cells, characterized by
formation of bone by the tumor cells.

12. CLASSIFICATION
a) On the basis of clinical setting, this tumor can be divided into
primary and secondary.
• Primary osteosarcoma, the commoner, occurs in the age group of
15-25 years. It is more malignant than the secondary one. The
secondary osteosarcoma occurs in older age (45 years onwards).
b) On the basis of dominant histo-morphology, an osteosarcoma may
be:
(i) Osteoblastic i.e., with a lot of new bone formation
(ii) Chondroid i.e., with basic cell being a cartilage cell
(iii) Fibroblastic i.e. the basic cell being a fibroblast
(iv) Telangiectatic or Osteolytic type, a predominantly lytic tumor.

13. • All osteosarcomas are aggressive lesions and
metastasize widely.
• Despite its aggressiveness, osteosarcoma rarely
penetrates the epiphyseal plate.
• The following are the important features:
 Age at onset: These tumors occur between the ages of
15-25 years, constituting the commonest
musculoskeletal tumor at that age.
 Common sites of origin: The lower-end of the femur;
upper-end of the tibia; and upper-end of the humerus.
However, any bone of the body may be affected.

14.  Gross appearance of the tumor depends upon its
dominant histo-morphology.
 Histologically, these tumors vary; but common to all
is a basically anaplastic mesenchymal with tumor
cells surrounded by osteoid.

15. EXAMINATION
• The swelling is in the region of the metaphysis. Skin
over the swelling is shiny with prominent veins.
• The swelling is warm and tender.
• Movement at the adjacent joint may be limited mainly
because of the mechanical block by the swelling.
• The tumor may compress the neurovascular structures
of the limb, and produce symptoms due to that.

16. INVESTIGATIONS
 Radiological examination
• Irregular destruction in the metaphysis. There
is new bone formation in the tumor.
• Periosteal reaction: As the tumour lifts the
periosteum, it incites periosteal reaction.
• Codman’s triangle: A triangular area of
subperiosteal new bone is seen at the tumor-
host cortex junction at the ends of the tumor.
• Sun-ray appearance: As the periosteum is
unable to contain the tumour, the tumour grows
into the overlying soft tissues, giving rise to a
‘sun-ray appearance’ on the X-ray.

17. INVESTIGATIONS
 Serum alkaline phosphatase (SAP): It is generally
elevated. A rise of SAP after an initial fall after tumor
removal is taken as an indicator of recurrence or metastasis.
 Biopsy: Performed to confirm the diagnosis.
• A small tissue sample obtained by a needle (corebiopsy), or
by fine needle aspiration cytology (FNAC).
 Methods used for precise evaluation of spread of the
tumor locally are: bone scan, CT and MRI scans for finding
the soft tissue spread.

18. TREATMENT
• It is important to know the extent of involvement of the affected bone by
the tumour for the following reasons:
• To plan amputation surgery: Complete removal of local tumor is of vital
importance in amputation surgery. The amputation is performed taking a
safe margin beyond the tumour (usually 10 cm from the tumor margin).
• To plan a limb saving operation: In cases presenting early, a radical
excision of the tumor is being performed these days (limb saving surgery),
thus avoiding amputation.
• Control of distant macro or micro-metastasis: In the majority of cases,
micro-metastasis has already occurred by the time diagnosis is made.
These are effectively controlled by adjuvant chemotherapy,
immunotherapy etc.

19. PROGNOSIS
• Without treatment, death occurs within 2 years,
usually within 6 months of detection of metastasis.
• 5-year survival with surgery alone is 20 per cent.
• With surgery and adjuvant chemotherapy, a 5-year
disease free period is reported to be as high as 70 per
cent.
• A primarily lytic type (telangiectatic) osteosarcoma
has the worst prognosis.

20. EWING’S SARCOMA
• This is highly malignant tumor occurring
between the age of 10-20 years, sometimes up
to 30 years.
PATHOLOGY
 Bones affected: It commonly occurs in long
bones (in two-third cases), mainly in the
femur and tibia.
• About one-third of cases occur in flat bones,
usually in the pelvis and in short bone
calcaneum.
 Site: The tumour may begin anywhere, but
diaphysis of the long bone is the most
common site.

21. CLINICAL FEATURES
• The tumour occurs between 10-20 years of age.
• The patient presents with pain and swelling.
• There may be a history of trauma preceding onset, but
it is usually incidental.
• Often there is an associated fever, in which case it
may be confused with osteomyelitis.
EXAMINATION
• The swelling is usually located in the diaphysis and
has features suggesting a malignant swelling.

22. RADIOLOGICAL FEATURES
• In a typical case, there is a lytic
lesion in the medullary zone of the
midshaft of a long bone, with
cortical destruction and new bone
formation in layers – onion-peel
appearance.
• In flat bones, it is primarily a lytic
lesion with hardly any new bone
formation.

23. TREATMENT
• This is a highly radio-sensitive tumour, melts quickly
but recurs.
• In most cases, distant metastasis has occurred by the
time diagnosis is made.
• Treatment consists of control of local tumour by
radiotherapy and control of metastasis by
chemotherapy.

24. MULTIPLE MYELOMA
• It is a malignant neoplasm derived from
plasma cells.
PATHOLOGY
• The neoplasm characteristically affects flat bones i.e., the pelvis,
skull, and ribs and irregular vertebrae.
• It may occur as a solitary lesion (plasmacytoma), multiple lesion
(multiple myeloma), extramedullary (myelomatosis).
• The lesions are mostly small and circumscribed.
• The bone is simply replaced by tumor tissue and there is no
reactive new bone formation.

25. CLINICAL FEATURES
• The tumor affects adults above 40 years of age.
• Men are affected more often than women.
• Usual presentation is that of multiple site involvement.
• Common presenting complaint is increasingly severe
pain in the lumbar and thoracic spine.
• Pathological fractures, especially of the vertebrae and
ribs may result in acute symptoms.
• There may be no swelling or deformity unless a
pathological fracture occurs.
• The patient is weak, and will have loss of weight.
• Neurological symptoms may result if the tumour
presses on the spinal cord or the nerves in the spinal
canal.

26. INVESTIGATIONS
Radiological examination
• Multiple punched out lesions in the skull and other flat bones.
• Diffuse, severe rarefaction of bones.
• Erosions of the borders of the ribs.

27. INVESTIGATIONS
 Blood: Low haemoglobin, high ESR, increased serum
calcium, normal alkaline phosphatase.
 Sternal puncture: Myeloma cells may be seen.
 Bone biopsy from the iliac crest, or a CT guided
needle biopsy from the vertebral lesion may show
features suggestive of multiple myeloma.
 Bone scan: This may be required in cases presenting
as solitary bone lesion, where lesions at other sites
may be detected on a bone scan.

28. TREATMENT
• It consists of control of the tumor by chemotherapy.
• Radiotherapy plays a useful role in cases with
neurological compression.
• Complications like pathological fractures must be
prevented by splinting the affected part by PoP, brace
etc.

29. OSTEOCHONDROMA
• This is the commonest benign tumour of the bone.
• It is not a true neoplasm since its growth stops with
cessation of growth at the epiphyseal plate.
• It is a result of an aberration at the growth plate, where a
few cells from the plate grow centrifugally as a separate
lump of bone.
• Though the tumour originates at the growth plate, it gets
‘left behind’ as the bone grows in length, and thus comes
to lie at the metaphysis.

30. CLINICAL PRESENTATION
• The patient, usually around adolescence, presents
with a painless swelling around a joint, usually
around the knee.
• There may be similar swellings in other parts of the
body in case of multiple exostosis

31. EXAMINATION
• The swelling has all the features of a benign bony swelling. It
may be a sessile or pedunculated swelling.
• Usual location is metaphyseal, but often it comes to lie as far
as the diaphysis.
• There may be signs suggestive of complications secondary to
the swelling. These are:
(i) signs due to compression of the neurovascular bundle of the
limb
(ii) limitation of joint movements due to mechanical block by
the swelling.

32. EXAMINATION
• Occasionally, the tumour undergoes
malignant transformation
(chondrosarcoma).
• A rapid increase in the size of the
tumour and appearance of pain in a
hitherto painless swelling may be
suggestive of malignant
transformation.
• Diagnosis is made on X-ray where
one can see a bony growth made up
of mature cortical bone.

33. TREATMENT
• The tumour should be excised.
• The excision includes the periosteum over the
exostosis; since leaving it may result in leaving a few
cartilage cells, which will grow again and cause
recurrence of the swelling.

34. ENCHONDROMA
• This is a benign tumour consisting of a lobulated
mass of cartilage encapsulated by fibrous tissue.
• The intercellular matrix may undergo mucoid
degeneration.
• The tumour is seen commonly between the ages
of 20-30 years.
• Small bones of the hands and feet are commonly
affected.
• The presenting complaint is a long standing
swelling from one or more phalanges or
metacarpals, without much pain.
• The swelling increases in size very slowly, often
totally replacing the bone.
• An X-ray shows expanding lytic lesions in one
or more bones.

35. TREATMENT
• The lesion is curetted thoroughly, and the cavity, if it
is big, is filled with bone grafts.
• Prognosis is good.
• Although, chondromas in small bones are not known
to undergo malignant change, those in the long bones
may change into chondrosarcoma.

36. THANK YOU
Dr. Sanjib Kumar Das, MPT(Musculoskeletal),
Fellow (PhD) NITIE-Ergonomics and Human Factors,
Asst. Prof., School of Physiotherapy,
P.P. Savani University, Surat, India
Mail: sanjib_bpt@yahoo.co.in
Contact No. :+91 8879485847