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Bone Lesion Approach.pptx
This document provides guidance on evaluating bone lesions based on patient age, lesion location and features on imaging. For patients under 40, benign lesions are more common and may include osteoid osteoma, aneurysmal bone cyst or fibrous dysplasia in the epiphysis or metaphysis. Between 20-40 skeletal mature lesions like giant cell tumor are possible. Over 40, metastases should be considered. Imaging should assess site, size, matrix and other features to characterize the lesion before determining if biopsy is needed. Treatment options depend on diagnosis and may include observation, ablation, curettage or resection.
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Bone Lesion Approach.pptx
- 1. Dr Wazzan ALJuhani MD FRCSC Dr. Majed Aalasbali
- 2. First Task 1- Whatis the age of the pt ? above 40 yr skeletal mature ( 20-40) Skeletal immature 2- Then Look at the X-ray Feature ? Benign looking Vs more aggressive feature Matrix 3- Location of the lesion . • intra-articular • epiphysis • metaphysis • diaphysis Then put in the spectrum . Benign Lesion Metz , vs primary bone tumor ( osteo sarcoma vs chondro, ewing ) Metabolic Bone disease , e.g brown tumor, paget osteomyelitis ( local Tumor )
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- 7. What to readin X-Ray 1. Site 2. Size 3. Matrix 4. Pattern/margins incl. zone of transition 5. Effect of the lesion on bone 6. Reaction of bone to the lesion 7. Soft tissue mass
- 8. site • Which boneis affected (femur, radius,…) • Where in the bone Diaphysis, metaphysis, epiphysis, or combination Central, eccentric, intracortical, surface
- 9. matrix • Fibrous • Cartilagenous -stippled, arcs and rings • Osseous - cloud-like, dense
- 11. LESION EFFECT ONBONE • Cortical thinning Lower grade, less aggressive • Cortical expansion Low or high grade, tumor mimickers • Cortical destruction High grade, aggressive
- 12. EFFECT BONE ONLESION Periosteal reaction Absent Mild – one layer, 1-4 mm thick, adjacent to cortex Major - >5mm, multilayered or lamellated “onion-skinning”, “hair-on-end”, “sunburst”
- 14. SOFT TISSUE MASS SoftTissue Mass • Absent • Present
- 15. Biopsy Fine NeedleAspiration (FNA) not typically used for sarcoma Core biopsy (Tru-cut) allow for tumor structural examination cytologic and stromal elements of the tumor frequently used for sarcoma Incisional biopsy small surgical incision carefully placed to access tumor without contamination of critical structures Excisional biopsy small, superficial soft tissue masses
- 16. NOT FOR BIOPSY An asymptomatic (latent) or symptomatic bone lesion (active) that appears entirely benign on imaging does not need a biopsy A soft tissue lesion that appears entirely benign on MRI (lipoma, hemangioma) does not need a biopsy When in doubt, it is safer to do a biopsy.
- 17. INDICATIONS FOR BIOPSY 1)Aggressive or malignant appearing bone or soft tissue lesions 2) For soft tissue lesions - >5cm, deep to fascia or overlying bone or neurovascular structures 3) Unclear diagnosis in symptomatic patient 4) Special situation - solitary bone lesion in a patient with a history of carcinoma
- 18. BEFORE BIOPSY CBC,platelets, coagulation screen Cross-sectional imaging – depicts local anatomy, solid areas of tumour Experienced musculoskeletal pathologist available
- 19. PRINCIPLES OF BIOPSY SKIN Avoidtenuous skin , Avoid transverse incision DEEP Through muscle , meticulous hemostasis , Avoid NV SAMPLE Ensure adequate diagnostic tissue , FROZEN –SECTION CLOSURE Tight muscle closure , drain at corner , compression dressing Send for C/S
- 20. For tumourswithout soft tissue mass, plan biopsy through area of maximal cortical weakening based on CT or MRI . For tumours or with soft tissue mass, biopsy soft tissue rather than creating hole in bone .
- 21. A- bone formingTumor Benign lesion Osteoma Enostosis osteod osteoma Osteoblastoma Malignant Tumor Osteosarcoma Soft tissue ( Extraskeletal ) osteosarcoma .
- 22. B- Cartilage (chondrogenic Lesion) Benign lesion Enchondroma perisoteal chondroma osteochndroma chondroblastoma chondromyxoid fibroma Malignant Lesion chondrosarcoma
- 23. Fibrous lesion BenignLesion Fibrous cortical defect fibrous dysplasia osteofibrous Dysplasia Malignant Tumor MFH
- 24. Tumor like lesion Benign lesion GCT Simple bone cyst ABC Interosseous lipoma Malignant Tumor Adamantinoma chordoma
- 25. Intra-articular Tumor PVNS Synovial chondromatosis lipoma Arborescnes Synovial Hmeangioma
- 26. Above 40 yr DDX ( think of Metz) Metz MM lymphoma May be some thing else ( Sarcoma) Infection vs Brown Tumor
- 27. Big Five osteophilic Breast prostate Lung Kidney Thyroid Then think of GI , Melanoma
- 28. Metz some clueto DDX Most common is Breast + prostate Most common with Acral mets Lung Kidney cortical Mets : Lung , Kidney Most common to Bone + soft tissue Lung ,Kidney
- 29. Mets Most commonsite thoracolumbar spine sacrum PF pelvis ribs ,sternum PH
- 30. Approach Known Hxof cancer ? No Metastatic Work Up + Biopsy f/u MSK biopsy Principle . Yes solitary Lesion Metastatic Work up + Biopsy . Yes Multi focal Bone or Visceral Metz . Biopsy if not Proven before proven Metz treat accordingly .
- 31. Metz workup HX+ E Breast , prostate & thyroid exam abdomen for organomegaly Lab ( Blood work) ,urine anaylsis Cbc anemia ,thrombo - Ca ,Ph ,ALP ESR CRP infection ,MM - serum /urine EP INR , ptt coagulopathy - PSA Liver enzyme , - TSH
- 32. systemic workup Bone scan skeletal survey CT chest ,abdomen ,pelvis Bone marrow aspirate . Eg MM ,Lymphoma ,Ewing sarcoma ( by the medical oncolgist) Local full length x-ray CT VS MRI
- 33. Goal of treatment Pain relief . Immediate mobilization . Immediate Rigid fixation durable fixation protect the entire Bone when feasible Radio therapy Reduce need for subsequent surgery . improve post-op Function Bisphosphonate
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- 38. Brown Tumor ptlooking well /bone scan Ca , ph , ALP PTH high Radiograph - osteopeina shoulder - sub periosteal ,sub chondral , Bone Hand resorpation spine sof tissue and chondral calcification skull
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- 40. subperiosteal resorpation MainlyRadial aspect of the middle Phalanx
- 41. Soft tissuecalcification subperiosteal resorpation Mainly Radial aspect of the middle Phalanx
- 42. Tunneling ofcortices
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- 44. Salt and PepperSkull
- 45. Resorpation of theclavicle
- 46. Less than 40 more Of Benign Lesion Skeletal Immature ( Location ) UBC osteoid osteoma / osteoblastoma ABC non ossifying fibroma EG Osteomyelitis Fibrous dysplasia Skeletal Mature GCT Enchndroma infection ABC
- 47. Classification of BenignBone Tumours Benign latent (enchondroma) Benign active (Fibrous dysplasia) Benign aggressive (GCT)
- 48. Presentation Incidental finding Mass- Painless or Painful Pain without mass Pathological Fracture
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- 59. Epiphyseal lesions Chondroblastoma Clear cell chondrosarcoma Osteomyelitis (occasionally)
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- 63. Epiphyseal-Metaphyseal Benign aggressivelesions GCT ABC osteoblastoma
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- 73. Metaphyseal lesions Enchondroma UBC NOF/fibrous cortical defect Chondromyxoid fibroma Osteosarcoma Chondrosarcoma
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- 78. Diaphyseal lesions Osteoidosteoma Fibrous dysplasia Osteofibrous dysplasia Adamantinoma Ewing’s sarcoma
- 79. Treatment Observe /asymptomatic Radio frequency ablation curettage and Bone graft /cement extensive Curettage Resection and replace
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- 82. curettage and Bonegraft /cement
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- 88. And alwaysremember infection
- 89. Sarcoma treatment Bonesarcoma Chemo + wide margin + chemo Except : low grade sarcoma E.g paraosteal OS Chondrosarcoma Soft tissue sarcoma Radiotherapy + wide margin