This document discusses the classification, presentation, diagnosis and treatment of primary bone tumors. It focuses on osteosarcoma, chondrosarcoma, giant cell tumor and Ewing sarcoma. Key points include: 1) Osteosarcoma is the most common primary malignant bone tumor, typically affecting teenagers, with localized pain and swelling and characteristic x-ray findings. 2) Chondrosarcoma arises from cartilage and commonly involves the pelvis, spine or shoulder. Giant cell tumor contains multinucleated giant cells and often affects the epiphysis of long bones. 3) Diagnosis involves imaging, biopsy and staging. Treatment consists of preoperative chemotherapy, surgical resection with reconstruction

2. CLASSIFICATION
• Primary
Secondary (metastases)
• Primary tumors:
Benign
Malignant

3. Benign tumours
• Osteoma
• Osteoid ostioma
• Osteoblastoma

4. Malignent tumours
1. Osteosarcoma (Osteogenic sarcoma)
2. Chondrosarcoma
3. Osteoclastoma (Giant cell tumor )
4. Ewing sarcoma

5. Osteosarcoma
(Osteogenic sarcoma)
• Most common primary malignant tumor of
bone
• Clinically:
– Males> females
– Most occur in teenagers (age 10-25 years)
– Localized pain and swelling

6. • Classic X-ray findings:
1. Codman's triangle (periosteal elevation)
2. Sunburst pattern
3. Bone destruction

9. • Pathology:
– Often involves the metaphysic of long bones
– Usually around the knee (distal femur and
proximal tibia)
– Large firm white tan mass with necrosis and
hemorrhage

12. • Secondary osteosarcoma:
– Occurs in old people
– Associated with paget disease or chronic
osteomyelitis
– Highly aggressive

13. Chondrosarcoma
• Definition:
– Malignant tumor of chondroblasts
• Etiology:
– The tumor may arise as primary or secondary to
preexisting enchondroma, exostosis or Paget
disease

14. • Clinically:
– Male> females
– Age: 30-60 years
– Enlarged mass with pain and swelling
– Typically involves the pelvic bones, spine and
shoulder girdle

15. Chondrosarcoma

17. Giant cell tumor
(Osteoclastoma
• Uncommon malignant neoplasm containing
mult-inucleated giant cells admixed with
stromal cells
• It is a locally malignant bone tumor with a
high rate of recurrence

18. • Clinically:
– Females>males
– Age: 20-50 years
– Bulky mass with pain and fractures
• X-ray:
– Expanding lytic lesion surrounded by a thin rim
of bone
– It may have a soap bubble appearance

19. Soap bubble appearance

20. • Pathology:
– Often involves the epiphysis of long bones
– Usually around the knee
– Red or brown mass with cystic degeneration

22. Ewing sarcoma
• Malignant neoplasm of undifferentiated cells
arising within the marrow cavity
• Clinical features:
– Males>females
– Most occur in teenagers (5-20)
– Presented with pain, swelling and tenderness
• X-ray:
– Concentric, onion skin layering of new periosteal bone

24. • Pathology:
– Often affects the diaphysis of long bones
– Most common sites are the femur, pelvis and
tibia
– White tan mass with necrosis and hemorrhage

26. Clinical Presentation
• PAIN
The pain may be progressive for many months, and
initially be confused with more common sources such as
muscle soreness, overuse injury or "growing pains."
Night pain is an important clue to the true diagnosis (25%)
The primary reasons for delay in the diagnosis is failure to
obtain radiographs at the initial visit.
Pain that fails to resolve or is present at rest or wakes the
patient from sleep should alert the clinician that further
evaluation is needed.

27. • Swelling
Palpable mass is noted in up to 1/3 of patients at
the first visit.
• Limp
In smaller children, a limp may be the only symptom
• Restriction of movement of the adjacent joint
• Pathological Fracture
This can increase the rate of local recurrence of the
tumor after surgery and decrease the patient’s overall
survival
• Fever, malaise or other constitutional symptoms

28. diagnosis
Lab tests-
Full blood count, ESR, CRP.
LDH (elevated level is associated with poor
prognosis)
ALP (elevated levels at diagnosis signify increased
risk of pulmonary metastasis) .
Platelet count
Electrolyte levels
Liver function tests
Renal function tests
Urinalysis

29. Imagining studies
Plain x-rays
Obtain plain films of the suspected lesions in
2 views. With joint above and joint below
• CT scanning
CT scanning of the chest is more sensitive than is
plain film radiography for assessing pulmonary
metastases.
MRI
MRI of the primary lesion is the best method to
assess the extent of intramedullary disease as well as
associated soft-tissue masses .
Bone Scan
A bone scan should be obtained to look for skeletal
metastases or multi focal disease.

30. • Thallium scan
Monitor effects of chemotherapy
Detect local recurrence of tumor
• Angiography
Determine vascularity of the tumor
Detect vascular displacement and
determine relationship of vessels to the tumor
Identify vascular anomalies
Estimate effects of chemotherapy.
• Once all the initial imaging & lab exam has been done
biopsy is performed to conform the diagnosis.

31. Radiology
• Site
• Size
• Effect on bone
• Response of Bone
• Matrix
• Cortex
• Soft tissue

32. • Types of biopsy
Fine needle aspiration
Core needle biopsy
Open incisional biopsy

33. staging
The staging system is typically depicted as follows
• Stage I: Low grade tumors
I-A intra compartmental
I-B extra compartmental
• Stage II: High grade tumors
II-A intra compartmental
II-B extra compartmental
• Stage III: Any tumors with evidence of
metastasis

34. Treatment
1. Radiological staging
2. Biopsy to confirm diagnosis
3. Preoperative chemotherapy,Radiotherapy
4. Repeat radiological staging
(access chemo response, finalize surgical tx plan)
5. Surgical resection with wide margin
6. Reconstruction using one of many
techniques
7. Post op chemo based on preop response
•

35. PHYSIOTHERAPY
MANAGEMENT
Pain managemet
General Conditioning
Stump Management
Palliative care
Adaptive device management

36. Prognostic Factors
• Extant of the disease
– Pts with pulmonary, non pulmonry (bone) or skip metastasis have
poor prognosis
• Grade of the tumor
– High grade tumor have poor prognosis
• Size of the primary lesion
– Large size tumors have worse prognosis then small size tumors
• Skeletal location
– proximal tumors do worse than distal tumors.
• Secondary osteosarcoma: Poor prognosis

37. THANK YOU