Bone tumor a lecture for orthopedic

1. Bone tumors
• Rare tumors (< 2%)
• More in young ages

2. Classification
• Origin
– Primary
– Secondary (95%): breast, lung, prostate, kidney and
thyroid
• cell type:
– Bone Osteoma, osteosarcoma
– Cartilage Chondroma, Chondrosarcoma
– Marrow Hemangioma, angiosarcoma
– Fibrous tissueFibroma, fibrosarcoma
• Tumor type:
– Benign: Osteoma, osteochondroma
– Malignant:: Osteosarcoma, chondrosarcoma

3. Symptoms and Signs
• Asymptomatic and discovered accidentally.
• General: fatigue, fever, wt. loss
• Mass can be felt at the tumor site.
• Pain:
– May worsen at night and awakes patient, caused by
– Tumor compression on surrounding tissue
– Hemorrhage in the tumor
– Pathological fractures
• Swelling
• Local tenderness
• Warmth
• Pathological fracture: may be the first sign.

4. Malignant vs. Benign Tumors
• Rapid growth
• Warmth
• Tenderness
• Ill defined edges
All are suggestive of malignancy.

5. Investigations
• History and examination
• Imaging (x-ray, CT, MRI & radionuclide scanning)
• Biopsy
• Labs
• Ca & P: Greater than normal levels may indicate bone
metastasis.
• PTH: Lower than normal levels may indicate bone metastasis.
• ALP isoenzyme: Higher than normal ALP levels may indicate
Paget's disease, osteoblastic bone cancers, osteomalacia and
rickets.
• LDH: High values indicate poor prognosis

6. • CT and MRI
• Asses the extent of the tumor
• Relation to surrounding structures
• Radionuclide scanning:
• Helpful in revealing site of a small tumor
• Skip lesions
• Silent secondary deposits

8. Benign tumors

9. Benign bone tumors
• Non ossifying fibroma
• Osteochondroma (the Commonest)
• Osteoid osteoma
• Enchondroma
• Giant cell tumor of bone
• Osteoblastoma

10. Osteochondroma (exostosis)
• Commonest benign tumor of bone
• More in male <25y.
• Solitary
• Mature bone with cartilaginous cap.
• Common sites are the fast growing sites of long bones (lower
end of femur and upper end of tibia), crest of ileum &
shoulder.
• Flattened (sessile) or stalk-like (exostosis)
• Most likely caused by Congenital defect or trauma of the
perichondrium, which results in the herniation of a fragment of the
epiphyseal growth plate through the periosteal bone cuff.
• Osteochondromas Small risk of malignant
transformation(<1%)

11. Symptoms:
• A hard, immobile, detectable mass that is painless
• Lower-than-normal-height for age
• Muscle soreness
• One leg or arm may be longer than other
• Pressure or irritation with exercise
• X-Ray:
• Exostosis: well defined bony projection
• Calcified cartilage in large lesions
Treatment: excision if becoming bigger and more painful.

12. • Solitary osteochondroma.
• Lateral radiograph of a
sessile osteochondroma of
the distal femur

13. Osteoid osteoma
• Neoplastic proliferation of osteoid and fibrous tissue
• More in male < 30 year
• more in vertebra or long bones
• Less in mandible or other craniofacial bones.
• Small in size (<1.5 cm)
• Oval or rounded shape
• Pain (severe) worse at night ,not relieved by rest but relieved
by aspirin.
• Types: Cortical, cancellous, subperiosteal.
• Treatment: Complete removal after careful localization by
CT.

14. X-Ray
• Nidus: tiny radiolucent area
• Diaphysis  surrounded by dense bone and
thickend cortex
• Metaphysis  less cortical thickening

15. • Male 23 years old
• History of increasing pain in the knee
& relieved by aspirin.

16. • Plain radiograph in a
25-year-old male with
cortical osteoid
osteoma. shows a
radiolucent nidus
surrounded by fusiform
cortical thickening

17. Aneurysmal bone cyst
-Usually occurred in young age group at long bone metaphysis.
-Its occurred spontaneously but could be secondary to hemorrhage.
-There is pain and may be obvious swelling of bone due to expansion.
-Xray well-defined radiolucent cyst like-lesion , often trabiculated, in the long bone
metaphysis but sometimes in the flat bone and vertebrae.
-Treatment:careful curettion and pack with bone graft and if there is recurrance then
methylmethacrylate put on. If there is pathological fracture then prophylactic
fixation.

18. A 12 years old girl presented
to emergency department
with swelling and pain in
the upper arm ,X ray
showed well-defined
radiolucent cyst like-lesion ,
often trabiculated, in the
long bone metaphysic with
slight expansion of humeral
metaphysis.

19. GIANT-CELL TUMOUR
-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.
-Xrays show a radiolucent area situated eccentrically at the end of a
long bone and bounded by the subchondral bone plate.
-The centre sometimes has a soap-bubble appearance.

20. Malignant tumors
• Primary
• Secondary (metastasis)

21. Primary bone cancer
Risk factors:
1. Radiotherapy & chemotherapy
2. Paget's disease
3. Family Hx (hereditary retinoblastoma)
Signs & symptoms
• Fever, Night sweats, Fatigue & Unintended weight loss
• Bone pain that often is nocturnal
• Swelling & tenderness near the affected area
• Pathological fractures

22. Osteosarcoma
• Most common primary bone malignancy
• Incidence: 2.8 per million
• M >F
• Age 10-25 years (the 8th most common childhood cancer)
Prognosis
• Aggressive tumor
• Metastasis to the lung
• 5-year survival
– Without mets is 70%
– With mets is 25%

23. Where
Mainly affects metaphysis
of long bones
More in:
• Knee
– Distal femur
– Upper tibia
• Humerus (prox.end)
• Maxilla

24. Clinical features
• Pain:
– Dull aching
– Progressive
– Constant
– Worse at night
• Swelling
• Redness
• Hotness
• Tenderness
• Pathological fracture

25. X-ray findings
1. Lesion
2. Cortical destruction
3. Extension to the marrow or soft tissue
4. Codman’s triangle a term used to describe the triangular area
of new subperiosteal bone that is created when a lesion, often
a tumour, raises the periosteum away from the bone.
5. Sunburst Effect
Osteosarcomas can be
• Predominantly osteolytic
• Predominantly osteoblastic
• Mixture

26. Sunburst Appearance

27. Ewing sarcoma
• A malignant round-cell tumor.
• Rare disease (incidence 0.6 per million
• 2nd most common bone malignancy in pediatrics.
• M>F
• Age 10-20 years
• Usually the lesions are diaphyseal
• Mets (30%), most commonly in the lungs & other
bones & less commonly in the bone marrow.

28. Clinical feature:
• Pyrexia
• Pain:
– Constant
– Increase with movement
• Limping
• Swelling, warm, tender & red
Radiological studies:
1. X-Ray
1. Lytic medullary lesion
2. Onion skin appearance
2. CT-scan
3. Bone scan & MRI

29. • White arrow: onion skin apperance
• Red circle: sunburst periosteal reaction
• Blue circle: osteolytic lesion

30. Treatment:
1. Local radiotherapy combined with systemic
chemotherapy
2. In young children amputation may be necessary
due to severe compromise of bone growth.
Prognosis, 5-year survival
• 50% with the 1st approach
• 75% with the 2nd approach

31. Metastatic bone tumor

32. • Most common malignant lesion of the bone.
• The most common sites of spread of cancers are lung, liver &
skeleton.
• Carcinomas are much more likely to metastasize to bone than
sarcomas
• Typically multifocal BUT renal and thyroid carcinomas produce
only a solitary lesion.
• Common sites for metastasis:
– Vertebrae, pelvis, proximal parts of the femur, ribs, proximal
part of the humerus, and the skull.
– Batson venous plexus >> more mets to the axial skeleton
– Hands & feet are rare
– 50% of them originate from lung neoplasms.
• Mets:
1. Direct extension
2. Retrograde venous flow
3. Seeding with tumor emboli via the blood circulation

33. Destructive expanded
osteolytic lesion in the
metacarpal of the thumb
in a 55-year-old man with
lung carcinoma.

34. Thank You
Good Luck