The document discusses various types of bone tumors, including benign and malignant lesions, tumors like cysts, and their classification based on the originating tissue. It elaborates on specific conditions such as simple bone cysts, giant-cell tumors, chondrosarcoma, and osteosarcoma, covering their symptoms, diagnostic techniques, and treatment options. Emphasis is placed on the need for accurate diagnosis and appropriate management strategies tailored to the type and severity of the tumor.

1. Bone TumoursSupervised By : Dr. Ali Kharialdeen
Prepared By : - Ahmed Waad
Amjad Hazim
Abdulilah Khalid / 2020

2. Objectives
1
2
3
4
Introduction
Classification
Tumor like lesions & Cysts
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Benign tumor of the bone
Malignant tumor of the bone5

3. Introduction
• Tumours, tumour-like lesions
and cysts are considered
together because their clinical
presentation and management
are similar.

4. CLASSIFICATION
• Most classifications of bone tumours are based on
the recognition of the dominant tissue in the various
lesions.
• Knowing the cells line from which the tumour has
come may helps with both diagnosis and planning of
treatment.

5. Classification of bone tumours
Predominant tissue Benign Malignant
Bone forming Osteoma Osteosarcoma:
Osteoid osteoma central
Osteoblastoma peripheral
parosteal
Cartilage forming Chondroma Chondrosarcoma:
Osteochondroma central
Chondroblastoma peripheral
Fibrous tissue Fibroma Fibrosarcoma
Mixed ?Chondromyxoid fibroma
Giant-cell tumours Benign giant cell tumours Malignant giant cell tumours
Marrow tumours Ewing’s tumour, Myloma
Vascular tissue Haemangioma , lymphangioma Angiosarcoma
Other connective tissue lipoma liposarcoma
Other tumours Neurofibroma Adamantinoma, chordoma

6. SIMPLE BONE CYST
• This lesion (also known as a solitary cyst or unicameral bone cyst)
appears during childhood, typically in the metaphysis of one of the
long bones and most commonly in the proximal humerus or
femur. It is not a tumour, it tends to heal
spontaneously and it is seldom seen in adults. The condition is
usually discovered after a pathological fracture or as an incidental
finding on x-ray.

7. • X-rays show a well-demarcated radiolucent area in
the metaphysis, often extending up to the physeal
plate; the cortex may be thinned and the bone
expanded.

8. A typical solitary (or unicameral) cyst

9. Diagnosis
• is usually not difficult but other cyst-like lesions may need to be
excluded.
• Non-osteogenic fibroma, fibrous dysplasia and the benign cartilage
tumours are solid and merely look cystic on x-ray.
• In doubtful cases a needle can be inserted into the lesion under x-ray
control: with a simple cyst, straw coloured fluid will be withdrawn.
• Very rare cases need for biopsy.
• if curettage is thought to be necessary, material from the cyst should
be submitted for examination.

10. Treatment
Treatment depends on whether the cyst is symptomatic, actively growing
or involved in a fracture. Asymptomatic lesions in older children can be
left alone but the patient should be cautioned to avoid injury which
might cause a fracture.
‘Active’ cysts (those in young children and obviously enlarging in
sequential x-rays) should be treated, in the first instance, by aspiration
of fluid and injection of 80–160 mg of methylprednisolone or
autogenous bone marrow. This often stops further enlargement and
leads to healing of the cyst.

11. Injection with
methylprednisolone,
healing

12. • If the cyst goes on enlarging, or if there is a pathological fracture, the cavity
should be thoroughly cleaned by curettage and then packed with bone chips,
but great care should be taken not to damage the nearby physeal plate. If
the risk of fracture is thought to be high, prophylactic internal fixation should
be applied.

13. ANEURYSMAL BONE CYST
Aneurysmal bone cyst is a benign, blood-filled lesion in the
bone that tends to expand or grow may be encountered at
any age and in almost any bone, though more often in young adults
and in the long-bone metaphyses. Usually it arises spontaneously but it
may appear after degeneration or haemorrhage in some other lesion.
(specifically chondroblastoma and giant cell tumors)

14. Signs and symptoms
The symptoms of an aneurysmal bone cyst can include:
• Pain
• Swelling
• Stiffness
• Deformity in the area of the growth
• The feeling of warmth over the affected area
• Decreased range of motion, weakness or stiffness

15. • X-rays show a well-defined radiolucent
cyst, often trabeculated and
eccentrically placed. In a growing
tubular bone it is always situated in the
metaphysis and therefore may resemble
a simple cyst or one of the other cyst-
like lesions.

17. Treatment
The cyst should be carefully opened, thoroughly curetted and then packed
with bone grafts. Sometimes the graft is resorbed and the cyst recurs,
necessitating a second or third operation. In these cases, packing with
methylmethacrylate cement may be more effective. However, if the cyst is
in a ‘safe’ area (i.e. where there is no risk of fracture) there is no hurry to
re-operate; the lesion occasionally heals spontaneously

18. NON-OSSIFYING FIBROMA (FIBROUS ) CORTICAL DEFECT
• This is a developmental defect in which a nest of fibrous tissue appears
within the bone and persists for some years before ossifying. It is
asymptomatic and is almost always encountered in children as an incidental
finding on x-ray. The commonest sites are the metaphyses of long bones.
• It is the commonest benign lesion of bone.

19. • The X-ray appearance is unmistakable. There
is a more or less oval radiolucent area surrounded by
a thin margin of dense bone. Usually in the
metaphysis.
• Pathology Although it looks cystic on x-ray, it is a
solid lesion consisting of unremarkable fibrous tissue
with a few scattered giant cells.

20. Non-ossifying fibroma

21. • Treatment:
Treatment is usually unnecessary. If the
defect is very large or has led to
repeated fractures, it can be treated by
curettage and bone grafting.
Recurrence is rare.

22. FIBROUS DYSPLASIA
• Fibrous dysplasia is a developmental disorder in which
areas of trabecular bone are replaced by cellular fibrous tissue
containing flecks of osteoid.
It may affect one bone (monostotic), one limb(monomelic) or many
bones (polyostotic).
If the lesions are large, the bone is considerably weakened and
pathological fractures or progressive deformity may occur.

23. • X-rays show radiolucent ‘cystic’ areas in the
metaphysis or shaft; because they contain fibrous
tissue with diffuse spots of immature bone, the
lucent patches typically have a slightly hazy or
‘ground-glass’ appearance.

24. Treatment
Treatment depends on the extent of the defect and the
presence or absence of deformities. Small lesions need
no treatment. Those that are large and painful or
threatening to fracture (or have fractured) can be
curetted and grafted.

25. Benign bone tumours

26. OSTEOID OSTEOMA
This tiny bone tumour (less than 1 cm in diameter) causes symptoms out of all proportion to
its size.
Patients are usually under 30 years of age and males predominate.
Over half the cases occur in the femur or tibia.
The patient complains of persistent pain, sometimes well localized but sometimes
referred over a wide area.
Typically the pain is relieved by salicylates.
If the diagnosis is delayed, other features appear: a limp or muscle wasting and weakness;
spinal lesions may cause intense pain, muscle spasm and scoliosis.

27. • The important x-ray feature is a small radiolucent area,
the so-called ‘nidus’. Lesions in the diaphysis are
surrounded by dense sclerosis and cortical thickening;
this may be so marked that the nidus can be seen only
in fine cut CT scans.
• Lesions in the metaphysis show less cortical thickening.
Further away the bone may be osteoporotic.
• 99mTc-MDP scintigraphy reveals intense, localized
activity.

28. Osteoid osteoma

29. • It is sometimes difficult to distinguish an osteoid
osteoma from a small Brodie’s abscess without biopsy.
• Pathology The excised lesion appears as a dark-brown or
reddish ‘nucleus’ surrounded by dense bone; the central area
consists of unorganized sheets of osteoid and bone cells.
There is no risk of malignant transformation.

30. Treatment
The only effective treatment is complete removal or destruction of
the nidus. It is excised in a small block. The specimen should be x- rayed
immediately to confirm that it does contain the little tumour. If the excision
is likely to weaken the bone prophylactic internal fixation may be needed.
Or The lesion is carefully localized; CT-guided needle can be inserted into the
nidus and the lesion ablated with radiofrequency coagulation

31. CHONDROMA (ENCHONDROMA)
Islands of cartilage may persist in the metaphyses of bones formed by
endochondral ossification; sometimes they grow and take on the
characteristics of a benign tumour.
Chondromas are usually asymptomatic and are discovered incidentally on
x-ray or after a pathological fracture.
They are seen at any age (but mostly in young people) and in any bone
preformed in cartilage (most commonly the tubular bones of the hands
and feet).

32. • X-ray shows a well-defined, centrally placed
radiolucent area at the junction of metaphysis and
diaphysis; sometimes the bone is slightly expanded.
In mature lesions there are flecks of calcification
within the lucent area; when this present, this is
a pathognomonic feature.

33. Chondroma
chondroma
before and after
curettage and
bone grafting.

34. Treatment
Treatment is not always necessary, but if the tumour
appears to be enlarging, or if it presents as a pathological
fracture, it should be removed by curettage; the defect is
filled with bone graft or bone cement.

35. OSTEOCHONDROMA (CARTILAGE CAPPED EXOSTOSIS)
• This, one of the commonest ‘tumors’ of bone, is a developmental lesion
which starts as a small overgrowth of cartilage at the edge
of the physeal plate and develops by endochondral ossification into
a bony protuberance still covered by the cap of cartilage.
• the commonest sites are the fast-growing ends of long bones and the
crest of the ilium. In long bones, at the end of the normal growth period
for that bone it stops enlarging. Any further enlargement after the end of
the growth period is suggestive of malignant transformation.

36. • The patient is usually a teenager or young adult
when the lump is first discovered. Occasionally there
is pain due to an overlying bursa or impingement on
soft tissues, or, rarely, paraesthesia due to stretching
of an adjacent nerve.

37. Osteochondroma

38. • The x-ray appearance is pathognomonic. There is a well-defined
exostosis emerging from the metaphysis, its base co-extensive with the
parent bone.
• It looks smaller than it feels because the cartilage cap is usually invisible
on x-ray.
• Multiple lesions may develop as part of a hereditable disorder –
hereditary multiple exostosis

40. Complications
The incidence of malignant transformation is difficult to assess because
troublesome lesions are so often removed before they show histological
features of malignancy.
Features suggestive of malignant change are:
(1) enlargement of the cartilage cap in successive examinations;
(2) a bulky cartilage cap (more than1 cm in thickness);
(3) irregularly scattered flecks of calcification within the cartilage cap;
(4) spread into the surrounding soft tissues.
MRI may be needed to reveal these changes.

41. Treatment
• If the tumour causes symptoms it should be excised; if, in an adult, it has
recently become bigger or painful then operation is urgent
• If there are suspicious features, further imaging and staging should be
carried out before doing a biopsy.

42. GIANT-CELL TUMOUR
Giant-cell tumour, which represents 5 per cent of all primary bone tumours, is
a lesion of uncertain origin that appears in mature bone,
most commonly in the distal femur, proximal tibia, proximal humerus and
distal radius, though other bones also may be affected.
It is hardly ever seen before closure of the nearby physis and characteristically
it extends right up to the subarticular bone plate.
Rarely, there are multiple lesions. The patient is usually a young adult who
complains of pain at the end of a long bone; sometime there is slight
swelling.

43. X-rays show a radiolucent area situated eccentrically at the end of a long bone.
The appearance of a ‘Osteolytic’ lesion in mature bone,
extending right up to the subchondral plate, is so
characteristic that the diagnosis is seldom in doubt.
However, it is better to obtain estimations of blood calcium, phosphate and
alkaline phosphatase concentrations so as exclude an unusual ‘brown
tumour’ associated with hyperparathyroidism.

44. Giant-cell tumours

45. • Because of the tumor’s potential for aggressive behavior, detailed staging
procedures are essential. CT scans and MRI will reveal the extent of the
tumour, both within the bone and beyond. It is important to establish
whether the articular surface has been broken.
• Biopsy is essential.

46. Treatment
• Well-confined, slow-growing lesions with benign histology can safely be
treated by thorough curettage and ‘stripping’ of the cavity with burrs ,
followed by swabbing with hydrogen peroxide or by the application of liquid
nitrogen; the cavity is then packed with bone chips or bone cement.
• More aggressive tumours, and recurrent lesions, should be treated by excision
followed, if necessary, by bone grafting or prosthetic replacement.
• Tumours in awkward sites (e.g. the spine) may be difficult to eradicate;
supplementary radiotherapy is sometimes recommended, but it carries a
significant risk of causing malignant transformation.

48. Cysts and cyst-like lesions of bone

49. PRIMARY MALIGNANT BONE TUMOURS
CHONDROSARCOMA
• Chondrosarcoma is one of the commonest malignant
tumours originating in bone. The highest incidence is in the
fourth and fifth decades and men are affected more often
than women.
• The majority of Chondrosarcoma fall into two well-defined
categories: central tumour occupying the medullary cavity
of the bone, and the‘peripheral tumors' growing out from
the cortex.

50. Central Chondrosarcoma

52. Treatment
* Most Chondrosarcoma are slow-growing and metastasize late, they present the ideal case for
wide excision and prosthetic replacement, provided it is certain that the lesion can be
completely removed without exposing the tumour and without causing an unacceptable loss
of function.
*In some cases isolated pulmonary metastases can be resected.
*The tumour does not respond to either radiotherapy or chemotherapy.
*Prognosis is determined largely by the cellular grade and the resection margin. There is a
tendency for these tumours to recur late and the patient should therefore be followed up for
10 years or longer.

53. OSTEOSARCOMA
• Its classic (intramedullary) form, osteosarcoma is a
highly malignant tumour arising within the bone and
spreading rapidly outwards to the periosteum and
surrounding soft tissues. It is said to occur
predominantly in children and adolescents.
• It may affect any bone but most commonly involves the
long-bone metaphysis, especially around the
knee and at the proximal end of the humerus.

54. clinically
• Pain is usually the first symptom; worse at night and gradually
increases in severity. Sometimes the patient presents with a lump.
• On examination there may be little to find except local tenderness. In
later cases there is a palpable mass and the overlying tissues may
appear swollen and inflamed.
• The ESR is usually raised and there may be an increase in serum
alkaline phosphatase.

55. • The x-ray appearances are variable: hazy Osteolytic areas may alternate
with unusually dense osteoblastic areas. The endosteal margin is poorly
defined. Often the cortex is broken and the tumour extends into the
adjacent tissues; when this happens, streaks of new bone appear,
radiating outwards from the cortex – the so-called ‘sunburst’ effect.
• Where the tumour emerges from the cortex, reactive new bone forms at
the angles of periosteal elevation (Codman’s triangle). While both
the sunburst appearance and Codman’s triangle are typical of
osteosarcoma, they may occasionally be seen in other rapidly growing
tumours.

56. Osteosarcoma

57. Diagnosis
• In most cases the diagnosis can be made with confidence on the x-ray appearances.
Conditions to be excluded are post-traumatic swellings, infection, stress fracture and the
more aggressive ‘cystic’ lesions.
Radioisotope scans may show up skip lesions, but a negative scan does not exclude them.
CT and MRI reliably show the extent of the tumour.
Chest x rays are done routinely, but pulmonary CT is a much more sensitive detector of
lung metastases.
A biopsy should always be carried out before commencing treatment; it must be carefully
planned to allow for complete removal of the tract when the tumour is excised.

58. Treatment
• The appalling prognosis of this tumour has markedly improved, partly as
a result of better diagnostic and staging procedures, and mainly because
of advances in chemotherapy to control metastatic spread. However, it is
still important to eradicate the primary lesion completely;
• After clinical assessment and advanced imaging, the patient is admitted
to a special centre for biopsy. Multi agent neoadjuvant chemotherapy is
given for 8–12 weeks.

59. • Depending on the site of the tumour, preparations
would have been made to replace that segment of
bone with either a large bone graft or a custom-
made implant; in some cases an amputation may be
more appropriate.

60. EWING’S SARCOMA
Ewing’s sarcoma is believed to arise from endothelial cells in the bone marrow.
It occurs most commonly between the ages of 10 and 20 years, usually in a
tubular bone and especially in the tibia, fibula or clavicle. The patient
presents with pain – often throbbing in character – and swelling.
Generalized illness and pyrexia, together with a warm, tender swelling and a
raised ESR, may suggest a diagnosis of osteomyelitis.

61. Imaging
X-rays usually show an area of bone destruction which, unlike that in osteosarcoma, is
predominantly in the mid-diaphysis. New bone formation may extend along the
shaft and sometimes it appears as fusiform layers of bone around the lesion – the so-called
‘onion-peel’ effect. Often the tumour extends into the surrounding soft tissues, with
radiating streaks of ossification and reactive periosteal bone at the proximal and distal
margins. These features (the ‘sunray’ appearance and Codman’s triangles) are usually
associated with osteosarcoma, but they are just as common in Ewing’s sarcoma.
CT and MRI reveal the large extra osseous component. Radioisotope scans may show multiple
areas of activity in the skeleton.

63. • The condition which should be excluded as rapidly as
possible is bone infection. On biopsy the
essential step is to recognize this as a malignant
round-cell tumour, distinct from osteosarcoma.

64. Treatment
The prognosis is poor and surgery alone does little to improve it. Radiotherapy has a
dramatic effect on the tumour but overall survival is not much enhanced. Chemotherapy
is much more effective, offering a 5-year survival rate of about 50 per cent
• The best results are achieved by a combination of all three methods: a course of
preoperative neoadjuvant chemotherapy; then wide excision if the tumour is in a
favorable site, or radiotherapy followed by local excision if it is less accessible; and then a
further course of chemotherapy for 1 year.
• Or chemotherapy and amputation.

67. Thank you