Bone tumours- part 1.

1. INTRODUCTION TO BONE
TUMOURS
AND GCT
Dr. Lokesh Chugh
PG resident
GMC. Amritsar.

2. INTRODUCTION
• Bony lesions
• Arises from bone itself (primary)
• Arrived from distant sites (secondary)
• Benign
• Malignant

3. DIAGNOSTIC EVALUATION
• Adequate history, C/F
• Physical examination
• Radiological examination-benign vs malignant
• Biopsy- confirmatory

4. • pain, mass
• Surrounding muscle atropy – disuse of limb
• Neurological deficit- nerve involvement
• Café-au-lait spot- NF
• Lymph node metastasis- synovial sarcoma

5. MASS
• Consistency
• Mobility
• Tenderness
• Local temperature

6. • Dimensions
• Location
• Shape
• Change with position

7. RADIOGRAPHIC EXAMINATION

8. EPIPHYSEAL LESIONS - D/D
• Chondroblastoma (10-25yrs)-
central, can cross joint line
(benign)
• GCT (20-40 yrs)- eccentric, soap bubble
appaerance, never crosses joint line
(locally aggressive)
• Clear chondrosarcoma (rare)
(malignant)

9. DIAPHYSEAL LESIONS – D/D
• EWING SARCOMA (5-25 yrs)
(Onion peel )
• LYMPHOMA (ADULTS)
• FIBROUS DYSPLASIA (5-30yrs)
(Shepherd crook deformity)
• HISTIOCYTOSIS(5-30yrs)

10. SPINE LESIONS –D/D
≥40 yrs
• Metastasis
• MM
• Cordoma
≤ 30 yrs
• OO
• OB
• ABC

11. MULTIPLE LESIONS - D/D
• MM
• METASTASIS
• FD
• HEMANGIOMA
• INFECTION
• HYPERPTH

12. BENIGN VS MALIGNANT
• Low biological activity,
± surrounded by rim of
reactive bone
• Well marginated
• Narrow zone of
transition(long
standing, non aggresive)
• Geographical pattern of
osteolytic destruction
• High biological activity,
shows periosteal rxn
• Poorly marginated
• wide defined zone of
transition (fast growing,
aggressive)
• Non geographical/
poorly defined cortical
destruction

14. PERIOSTEAL REACTION
• New bone formation
• When tumour destroys the cortex
• CODMAN TRIANGLE -OS
• ONION SKINNING -ES
• SUN BURST APPEARANCE -OS
• D/D- malignancy, infection, histiocytosis

18. BONE MATRIX
• Calcific stippling- enchondroma, CS
• Matrix ossification- OS
• Ground glass app.- FD

19. TUMOUR STAGING

22. WHO CLASSIFICATION

23. Bone forming tumours
• Benign: - Osteoid osteoma, osteoma
- Osteoblastoma
• Indeterminate - Aggressive osteoblastoma
• Malignant - Osteosarcoma
conventional, variants

24. Cartilage forming tumours
• Benign: - Osteochondroma (exostosis)
- Enchondroma (chondroma)
- Chondromyxoid fibroma
- Chondroblastoma
• Malignant: - Chondrosarcoma

25. Giant cell tumours (GCT)
• Benign/ Indeterminate /Malignant
Marrow tumours
• ES/MM/Lymphoma
Vascular tumours
• Benign: - Haemangioma/
• Malignant: - Angiosarcoma

26. GCT

27. GCT(OC)
• Aggressive tumours
• Benign,
• Pulmonary mets in 3% (spontaneous
regression/ asymptomatic)
• Primary
• Secondary- previous rad therapy

28. GCT(OC)
M/C location; epiphysis of
Long bone
• Distal femur
• Prox. Tibia
• Distal radius

29. C/F
• 20-40yrs age
• F>M
• swelling
• Progressive pain
• Severe- pathological #
• Soft tissue extension
• EGG SHELL CRACKELING

30. X- ray features
• Eccentric
• Purely lytic
• Poorly defined zone of transition
• ± cortical breach
• SOAP BUBBLE APPEARANCE
• Never goes into joint, abuts subchondral bone

34. DIAGNOSIS
• History
• Physical examination
• X- ray
• MRI- soft tissue extent
- F/F level(secondary ABC)
• Biopsy- confirmatory

35. HISTOPATHOLOGY
• Multinucleated giant cells(40-60 nuclei/cell)
• Mononuclear stromal cells
• IDENTICAL NUCLEI
• ± Secondary ABC cells

37. TREATMENT
• Simple curettage- recurrance 50%
• Extended curettage – recurrance 5-15%
- liq. Nitrogen
- argon beam coagulation
- phenol
- electrocautery
- bone cement

38. POST CURETTAGE-DEFECT FILLING
BONE CEMENT
• Easier detection of
tumour recurrance
• Quicker
rehabilitation
• PMMA
BONE GRAFT
• Recurrance is
difficult to
distinguish
• Risk of pathological
#, joint must be
protected . Late
rehab

39. TREATMENT -GCT
• Excision- ulna, fibula
• Excision and reconstruction- distal femur,
- prox tibia
• Arthrodesis by the Turn-o-Plasty procedure
• Arthrodesis by bridging the gap by double
fibulae
• Arthroplasty

41. Arthrodesis by the Turn-o-Plasty
procedure
• For distal femur GCT
• Length of the tibia is split into two halves.
• One half is turned upside down
• Fixed with the stump of the femur left after
excising the tumour.
• Same for proximal tibia GCT
• By taking half of femur

42. Arthrodesis by bridging the gap by
double
fibulae
• one taken from same extremity
• the other from the opposite leg

43. Arthroplasty:
• Tumour is excised
• Attempt is made to reconstruct the joint in
some way
• Painless, mobile joint achieved

44. TREATMENT-GCT
• EMBOLISATION- spine, pelvic GCT
• RESECTION- pulm. mets

45. THANK YOU