bone tumors

1. BONE TUMORS…

2. Dreamz Learning Innovations_____________________________________________ Page 2
• Giant cell tumour (GCT)
o Though generally classified as benign, it
tends to recur after local removal
o Pathology
n Microscopically, the tumour consists of
undifferentiated spindle cells, profusely
interspersed with multi-nucleate giant cells.
.(MCQ)
n The tumour stroma is highly vascular.
n These giant cells were mistaken as
osteoclasts in the past, hence the name
osteoclastoma. .(MCQ)

3. Dreamz Learning Innovations_____________________________________________ Page 3

4. Dreamz Learning Innovations_____________________________________________ Page 4

5. Dreamz Learning Innovations_____________________________________________ Page 5
o Clinical features
o seen commonly in the age group of 20-40
years i.e., after epiphyseal fusion.(MCQ)
o The bones affected commonly are those
around the knee i.e., lower-end of the femur
and upper-end of the tibia. .(MCQ)
o Lower-end of the radius is another common
site.
o The tumour is located at the epiphysis
.(MCQ)

6. Dreamz Learning Innovations_____________________________________________ Page 6

7. Dreamz Learning Innovations_____________________________________________ Page 7
o It often reaches almost up to the joint
surface
o Common presenting complaints are swelling
and vague pain
o Can presents for the first time with a
pathological fracture through the lesion.

8. Dreamz Learning Innovations_____________________________________________ Page 8
o Examination
o a bony swelling, eccentrically located at the
end of the bone.
o Surface of the swelling is smooth.
o There may be tenderness on firm palpation.
o A characteristic 'egg-shell crackling' is often
not elicited. .(MCQ)

9. Dreamz Learning Innovations_____________________________________________ Page 9

10. Dreamz Learning Innovations_____________________________________________ Page 10
o Diagnosis
o GCT is one of the common cause of a solitary
lytic lesion of the bone,
o Characteristic radiological features of GCT
n A solitary, may be loculated, lytic lesion.
n Eccentric location, often subchondral
n Expansion of the overlying cortex (expansile
lesion).
n 'Soap-bubble' appearance – .(MCQ)
• the tumour is homogeneously lytic with
trabeculae of the remnants of bone traversing
it, giving rise to a loculated appearance.

11. Dreamz Learning Innovations_____________________________________________ Page 11
Soap-bubble'
appearance

12. Dreamz Learning Innovations_____________________________________________ Page 12
n No calcification within the tumour .(MCQ)
n None or minimal reactive sclerosis around
the tumour.
n Cortex may be thinned out, or perforated at
places.
n Tumour usually does not enter the adjacent
joint.

13. SOLITARY
LYTIC BONE
LESION
Differential
Diagnosis
(Mnemonic =
FOGMACHIN
ES)
•
Dreamz Learning Innovations_____________________________________________ Page 13
F = Fibrous Dysplasia
O = Osteoblastoma
G = Giant Cell Tumour
M = Metastasis / Myeloma
A = Aneurysmal Bone Cyst
C = Chondroblastoma
H =
Hyperparathyroidism(brown
tumours)/ Hemangioma
I = Infection
N = Non-ossifying Fibroma
E = Eosinophilic Granuloma /
Enchondroma
S = Solitary Bone Cyst

14. Multinucleated osteoclastic giant cells intermixed
throughout a spindle cell stroma
Dreamz Learning Innovations_____________________________________________ Page 14

15. Multiloculated lesion with a very characteristic appearance
(honeycomb-like pattern) (left);
Pure lytic lesion (right)
Dreamz Learning Innovations_____________________________________________ Page 15

16. Dreamz Learning Innovations_____________________________________________ Page 16
o Treatment
o Wherever possible, excision of the tumour is
the best treatment.
o For sites like the spine, radiotherapy is done.
o Excision
o treatment of choice when the tumour affects
a bone whose removal does not hamper with
functions e.g., the fibula, lower-end of the
ulna etc. .(MCQ)

17. Dreamz Learning Innovations_____________________________________________ Page 17
o Excision with reconstruction:
o in tumours affecting the lower-end of femur,
the affected part is excised en bloc, and the
defect thus created made up by one of the
following methods.(MCQ)
n Arthrodesis by the Turn-o-Plasty procedure
n Arthrodesis by bridging the gap by double
fibulae
n Arthroplasty

18. Dreamz Learning Innovations_____________________________________________ Page 18
wide excision of the tumor mass.

19. Dreamz Learning Innovations_____________________________________________ Page 19
ulnar stump stabilization using extensor
carpi ulnaris slip.

20. Dreamz Learning Innovations_____________________________________________ Page 20
o Curettage with or without supplementary
procedures:
o Curettage alone has high recurrence rate.
o Supplementary procedures used with
curettage have been reported to reduce
recurrence.
n Cryotherapy.(MCQ)
• Liquid nitrogen is used to produce a freezing
effect and thus kill the residual cells,

21. Dreamz Learning Innovations_____________________________________________ Page 21
n Thermal burning of the residual cells
using cauterization of the walls of the tumour
n Thermal effect of bone cement
• cavity is filled with 'bone cement', which by
the heat it produces while setting, 'kills' the
residual cells.

22. Dreamz Learning Innovations_____________________________________________ Page 22
o Amputation:
o For more aggressive tumours, or following
recurrence, amputation may be necessary.
o Radiotherapy: .(MCQ)
o preferred treatment method for GCT
affecting the vertebrae.

23. Dreamz Learning Innovations_____________________________________________ Page 23
o Treatment of GCT at common sites.(MCQ)
o Lower end of femur - Excision with Turno-
Plasty
o Upper end of tibia - Excision with Turno-
Plasty
o Lower end of radius - Excision with fibular
grafting
o Lower end of ulna -Excision
o Upper end of fibula –Excision
o For fibular grafting ,proximal end of the
opposite fibula is preferred, since it matches
the lower end of radius in shape.

24. Dreamz Learning Innovations_____________________________________________ Page 24
• Osteosarcoma
o second most common.(MCQ)
o a highly malignant primary bone tumour.
o malignant tumour of the mesenchymal cells
characterised by formation of osteoid or
bone by the tumour cells.

25. Dreamz Learning Innovations_____________________________________________ Page 25

26. Dreamz Learning Innovations_____________________________________________ Page 26
o Classification
o Primary osteosarcoma
n Commoner than secondary
n Occurs in the age group of 15-25 years.
.(MCQ)
n very much more malignant than the
secondary one

27. Dreamz Learning Innovations_____________________________________________ Page 27
o secondary osteosarcoma
n occurs in older age (45 years onwards).
n pre-malignant conditions that predispose
.(MCQ)
• Paget's disease, multiple enchondromatosis
• fibrous dysplasia,irradiation to bones
• multiple osteochondroma

28. Dreamz Learning Innovations_____________________________________________ Page 28
o On the basis of dominant histomorphology,
an osteosarcoma is classified as
o osteoblastic
o chondroid
o fibroblastic
o telangiectatic or osteolytic type

29. Dreamz Learning Innovations_____________________________________________ Page 29
o osteosarcomas metastasise usually first to the lungs.
o Osteolytic type is more malignant than the
osteoblastic type.
o Despite its aggressiveness, osteosarcoma rarely
penetrates the epiphyseal plate.
o

30. Primary osteosarcomas
o Age at onset:
n occur between the ages of 15-25 years
n commonest musculoskeletal tumour at that age.
.(MCQ) .
o Common sites of origin: in decreasing order of
frequency
n lower-end of the femur(most common site );
upper-end of the tibia; and upper-end of the
humerus.
Dreamz Learning Innovations_____________________________________________ Page 30

31. Dreamz Learning Innovations_____________________________________________ Page 31

32. Dreamz Learning Innovations_____________________________________________ Page 32
o Histologically, anaplastic mesenchymal
parenchyma with tumour cells surrounded by
osteoid.
o Clinical features:
o Pain
n usually the first symptom, soon followed by
swelling. .(MCQ)
n Pain is constant and boring
n becomes worse as the swelling increases in
size.
o Sometimes, the patient presents with a
pathological fracture.

33. Dreamz Learning Innovations_____________________________________________ Page 33
o Examination:
o The swelling is in the region of the
metaphysis.(MCQ)
o Skin over the swelling is shiny with prominent veins
o The swelling is warm and tender
o Margins of the swelling are not well-defined.
o Movement at the adjacent joint may be limited mainly
because of the mechanical block by the swelling.
o The tumour may compress the neurovascular
structures of the limb, and produce symptoms due to
that.
o Regional lymph nodes may be enlarged, but are
usually reactive.

34. Dreamz Learning Innovations_____________________________________________ Page 34

35. Dreamz Learning Innovations_____________________________________________ Page 35

36. Dreamz Learning Innovations_____________________________________________ Page 36
o X-ray shows the following features
o An area of irregular destruction in the
metaphysis
o cortex overlying the lesion is eroded.
o There is new bone fomation in the matrix of
the tumour. .(MCQ)
o Periosteal reaction:
n As the tumour lifts the periosteum, it incites
an intense periosteal reaction.(MCQ)
n The periosteal reaction in an osteosarcoma
is irregular, unlike in osteomyelitis where it
is smooth and in layers.(MCQ)

37. Dreamz Learning Innovations_____________________________________________ Page 37
periosteal OS
shows that the
tumor most
commonly
arises from the
inner
periosteum of
the diaphysis of
a long bone and
demonstrates
perpendicular
periosteal
reaction.

38. Dreamz Learning Innovations_____________________________________________ Page 38
Radiograph of 20
year old female
showing destructive
lytic lesion involving
the metaphysis of
the medial aspect of
femur with new bone
formation and
periosteal reaction
(caudman triangle)

39. Dreamz Learning Innovations_____________________________________________ Page 39
T1 weighted coronal
image showing lytic
destructive lesion
with soft tissue,
periosteal reaction
and new bone
formation.

40. Dreamz Learning Innovations_____________________________________________ Page 40
Coronal STIR
image showing
the lesion.

41. Dreamz Learning Innovations_____________________________________________ Page 41
o Codman's triangle: .(MCQ)
n A triangular area of subperiosteal new bone
is seen at the tumour-host cortex junction at
the ends of the tumour.
o Sun-ray appearance: .(MCQ)
n As the periosteum is unable to contain the
tumour, the tumour grows into the overlying
soft tissues
n New bone is laid down along the blood
vessels within the tumour growing
centrifugally, giving rise to a 'sun-ray
appearance' on the X-ray.

42. Dreamz Learning Innovations_____________________________________________ Page 42

43. Dreamz Learning Innovations_____________________________________________ Page 43

44. Dreamz Learning Innovations_____________________________________________ Page 44
o Serum alkaline phosphatase (SAP):
o It is generally elevated.(MCQ)
o it is of no diagnostic significance
o considered a useful parameter for follow up
of a case of osteosarcoma.
o A rise of SAP after an initial fall after tumour
removal is taken as an indicator of
recurrence or metastasis.
o Biopsy:
o An open biopsy is performed to confirm the
diagnosis.

45. Dreamz Learning Innovations_____________________________________________ Page 45
o Why is it important to know the extent of
involvement of the affected bone by the
tumour
o To plan amputation surgery: .(MCQ)
n The tumour may have slip areas in
the medullary cavities, and can result in
recurrence even after amputation
o To plan a limb saving operation: .(MCQ)
n In cases presenting early, a radical excision
of the tumour is being performed these days
(limb saving surgery), thus avoiding
amputation.

46. Dreamz Learning Innovations_____________________________________________ Page 46
o Methods used for precise evaluation of spread of
the tumour locally are:
o bone scan for finding the intra-medullary spread
('skip' lesions) .(MCQ)
• CT and MRI scans for finding the soft tissue spread

47. o Treatment of the tumour:
o Local control of tumor:
o Amputation remains the mainstay of treatment.
.(MCQ)
o It can be a. palliative amputation, performed for
advanced disease, aiming at pain relief and a
better life.
Dreamz Learning Innovations_____________________________________________ Page 47

48. Dreamz Learning Innovations_____________________________________________ Page 48
o Are the high amputations or disarticulations
through a joint proximal to the affected bone
are done now a days to avoid stump
recurrence?
n No, with the availability of effective
chemotherapy, stump recurrence can be
prevented even if the amputation is
performed through the affected bone,
provided it is performed taking a safe margin
beyond the tumour (usually 10 cm from the
tumour margin). .(MCQ)

49. Dreamz Learning Innovations_____________________________________________ Page 49
o Osteosarcoma - Level of amputation.(MCQ)
o Lower end of femur - Mid thigh amputation ,
Hip disarticulation
o Upper end of femur - Hip disarticulation,
Hindquarter amputation
o Upper end of tibia - Mid thigh amputation
o Upper end of humerus - Forequarter
amputation

50. Dreamz Learning Innovations_____________________________________________ Page 50
o Role of radiotherapy
o Radiotherapy is used for local control of the disease
for .(MCQ)
n tumours occurring at surgically inaccessible sites
n in patients refusing surgery.
o Routine pre-operative radiotherapy is no longer a
preferred method.
o Control of distant macro or micro-metastasis:
o In the majority of cases, micro-metastasis has
already occurred by the time diagnosis is made.
o These are effectively controlled by adjuvant
chemotherapy, immunotherapy etc.

51. Dreamz Learning Innovations_____________________________________________ Page 51
o A solitary lung metastasis may sometimes
be considered suitable for excision.
o Role of chemotherapy:
o It is given pre or post-operative
o micro-metastases at the time diagnosis can
be effectively controlled.
o drugs used are .(MCQ)
n high dose Methotrexate, Citrovorum factor
n Endoxan, Cisplatinum.
o A primarily lytic type (telangiectatic)
osteosarcoma has the worst prognosis

52. Dreamz Learning Innovations_____________________________________________ Page 52
• Ewing's sarcoma
o highly malignant tumour
o occur between the age of 10-20 years.(MCQ)
o in two-third cases, occurs mainly in the femur and
tibia.(MCQ)
o About one-third of cases occur in flat bones, usually
in the pelvis and calcaneum. .(MCQ)
o diaphysis of the long bone is the most common site.
.(MCQ)
o bone may be expanded, and the periosteum
elevated, with sub-periosteal new
o bone formation, often in layers.
o The tumour ruptures through the cortex early, and
extends into the soft tissues.

53. Dreamz Learning Innovations_____________________________________________ Page 53

54. Dreamz Learning Innovations_____________________________________________ Page 54

55. Dreamz Learning Innovations_____________________________________________ Page 55

56. Dreamz Learning Innovations_____________________________________________ Page 56

57. Dreamz Learning Innovations_____________________________________________ Page 57

58. Dreamz Learning Innovations_____________________________________________ Page 58
o Histopathology:
o tumour comprises of sheets of quite uniform,
small cells, resembling lymphocytes.
o Often, the tumour cells surround a central
clear area, forming a pseudo-rosette.
.(MCQ)

59. Dreamz Learning Innovations_____________________________________________ Page 59
Most cases show necrosis, at least
focally (pink necrotic cells in the center),
and a high mitotic rate. The solid tumor
clusters are separated by fibrous bands.

60. Dreamz Learning Innovations_____________________________________________ Page 60
o The tumour grows fast and metastasizes
through the blood stream to the lungs and to
other bones.
o Clinical features:
o patient presents with pain and swelling.
o Often there is an associated fever, in which
case it may be confused with osteomyelitis.
.(MCQ)

61. Dreamz Learning Innovations_____________________________________________ Page 61
o Radiological features:
o In a typical case,
n 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 .(MCQ)
o Atypical presentations
n tumour may be located in the metaphysis
n may be confused with osteomyelitis
n have a predominant soft tissue component with little
cortical destruction, and may resemble a soft tissue
sarcoma
n In flat bones, it is primarily a lytic lesion with hardly
any new bone formation.

62. Dreamz Learning Innovations_____________________________________________ Page 62

63. Dreamz Learning Innovations_____________________________________________ Page 63

64. Dreamz Learning Innovations_____________________________________________ Page 64
o Ewing's sarcoma can be differentiated from
chronic osteomyelitis, it can be differentiated
by .(MCQ)
o Sequestrum
o Well-defined cloacae and a rather smooth
periosteal reaction
o Located at metaphysis

65. Dreamz Learning Innovations_____________________________________________ Page 65
o Treatment
o highly radio-sensitive tumour.(MCQ)
o melts quickly but recurs.
o In most cases, distant metastasis has
occurred by the time diagnosis is made.
o Treatment consists of
n control of local tumour by radiotherapy (6000
rads)
n control of metastasis by chemotherapy

66. Dreamz Learning Innovations_____________________________________________ Page 66
o Chemotherapy consists of Vincristine,
Cyclophosphamide, and Adriamycin .(MCQ)
o Prognosis -very poor.
o Bone to bone secondaries are very common
(MCQ frequently asked ).