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Bone tumor final
- 1. Bone Tumors Dr. Sudarshan Pandey First year Resident Department of Orthopaedics and Traumatology
- 2. Epidemiology • Bone and soft tissue sarcoma – derived from mesenchymal origin • Bone sarcoma – 0.2% • Male > Female • Age – male >85 years , female- 50-60 years
- 3. Epidemiology
- 4. Classification • Benign lesion • Non ossifying fibroma • Aneurysmal bone cyst • Intermediate (locally aggressive) lesion • Osteoblastoma
- 5. Classifications • Intermediate (rarely metastasizing) lesion • Risk of spread < 2% , often non fatal • Giant cell tumor of bone • Malignant tumors • Aggressiveness defined by histological grade • Low grade tumor- • metastatic rate: 2-10% • chordoma, parosteal osteosarcoma • High grade tumor – • metastatic rate : 20- 100 % • Osteosarcoma, Ewing's sarcoma
- 6. World Health Organization (WHO) histological classification of tumours
- 8. Field theory of bone tumors
- 9. General approach • History- patient information, Pain , Mass • Examination • Investigation • Imaging ( X rays , CT , MRI , Radionuclide scanning) • Systemic evaluation ( in case of secondaries) • PSA, Bence- Jones protein, Serum Calcium, ALP • ESR , CRP • Biopsy – gold standard
- 12. Clinical Presentation • Asymptomatic • Pain • Swelling/mass All superficial soft tissue lesions measuring >5cm and all deep seated lesions should be considered a sarcoma until proven otherwise • Pathological fractures • Systemic findings
- 14. Epiphyseal Lesions • Chondroblastoma (ages 10-25) • Giant cell tumor (ages 20-40) • Clear chondrosarcoma (rare) 15y/M 25y/M
- 15. • Ewing sarcoma (ages 5-25) • Lymphoma (adult) • Fibrous dysplasia (ages 5-30) • Adamantinoma (consider in the tibia) • Histiocytosis (ages 5-30) Diaphyseal Lesions
- 16. Location in Bone Axial • Central – • Enchondroma, • Unicameral Bone Cyst • Conventional osteosarcoma • Ewing sarcoma • Myeloma, lymphoma • Eccentric- • Aneurysmal bone cyst(ABC) • GCT, Non Ossifying fibroma(NOF) • Eosinophilic granuloma • Enchondroma , fibrous dysplasia
- 17. • Cortical • Cortical osteoid osteoma • Fibrous cortical defect • Adamantinoma • Osteofibrous dysplasia • Pagets disease • Juxtacortical • Parosteal chondroma • Surface osteosarcoma • Osteochondroma • Exostotic chondrosarcoma Surface osteosarcoma
- 18. Radiographic features • Lesion margin • Periosteal reaction • Mineralized matrix
- 19. Lodwick classification of lytic bone lesions Low biological activity/aggressiveness High biological activity /aggresiveness
- 21. Perisoteal reaction • Non aggressive • Continuous / solid • Aggressive • codman’s triangle • Sun burst appearance / spiculated/hair on end • Lamellated Benign Aggressive
- 22. Mineralized matrix • Osteoid • Chondroid • Fibrous
- 23. Lesions of the Spine Older than 40 Years • Metastases Vertebral body, pelvis Proximal femur, proximal humerus skull • Multiple myeloma • Hemangioma • Chordoma (in sacrum) Younger than 30 Years Vertebral body • Histiocytosis • Hemangioma Posterior elements • Osteoid osteoma • Osteoblastoma • Aneurysmal bone cyst
- 24. Multiple Lesions • Histiocytosis • Enchondroma • Osteochondroma • Fibrous dysplasia • Multiple myeloma • Metastases • Hemangioma • Infection • Hyperparathyroidism
- 25. Sclerotic metastasis • Prostatic Ca • Breast Ca • Transitional Cell Ca • Carcinoid • Mucinous Adeno Ca Lytic bone metastasis • Lung Ca • Renal Cell Ca • Thyroid Ca • Adrenal gland Ca • Uterine Ca • Melanoma
- 26. • Computed tomography • Shows accurately intraosseous and extraosseous extension • Great for cortical bone evaluation • Helps in staging • MRI • Defines local extent of lesion , tissue characterization • Useful in assessing soft tissue tumor and cartilaginous tumor • Radionuclide scanning • 99mTcMDP – non specific reactive changes – reveal site of small tumor (osteoid osteoma) • Detecting skip lesions , evidence of metastatic disease
- 27. Enneking staging system • Based on: • Tumor grade • Metastasis • Confinement in compartment • A compartment, for the purposes of this system, is defined as an enclosed tissue space, such as a bone, a joint space or a muscle group confined by its fascial envelope
- 28. Enneking staging system Malignant Stage Grade Site Metastasis IA Low Grade Intra- compartmental No metastasis IB Low Grade Extra- compartmental No metastasis IIA High Grade Intra- compartmental No metastasis IIB High Grade Extra- compartmental No metastasis III Any Any Metastases Benign 1. Latent—low biologic activity; well marginated; often incidental findings (i.e., nonossifying fibroma) 2. Active—symptomatic; limited bone destruction; may present with pathologic fracture (i.e., aneurysmal bone cyst) 3. Aggressive—aggressive; bone destruction/soft-tissue extension(i.e., giant cell tumor)
- 29. TNM staging Definition of regional lymph node (N)
- 31. TNM stages • Stage 1A Low-grade, small, no metastases • Stage 1B Low-grade, large, no metastases • Stage 2A Intermediate- or high- grade, small, no metastases • Stage 2B Intermediate-grade, large, no metastases • Stage 3 High-grade, large, no metastases • Stage 4 Any with metastases
- 32. AJCC System
- 33. Biopsy-Principles • Referred to the institution where definitive treatment will take place. • Should be done after clinical, lab and radiographic examinations • Planned placement of biopsy incision • biopsy track should be considered contaminated with tumor cells • biopsy track needs to be excised en bloc with the tumor • The surgeon performing the biopsy should be familiar with incisions for limb salvage surgery and standard and nonstandard amputation flaps
- 34. Biopsy- Principles • If a tourniquet is used, the limb elevated before inflation but should not be exsanguinated by compression to prevent “squeezing” the tumor’s cells into the systemic circulation • Transverse incisions should be avoided • The deep incision should go through single muscle compartment • Avoid major neurovascular structure • Soft tissue extension of bone lesion should be sampled
- 35. Biopsy- Principles • hole in the bone should be round or oval • Frozen section should be sent intraoperatively to ensure that diagnostic tissue has been obtained • meticulous hemostasis ensured before closure • Drain should exit in line with the incision • Wound should be closed tightly in layers
- 36. Biopsy- Principles • Sample should be sent for microbiology as well as histology • The pathologist reporting biopsy must have an appropriate level of experience • If risk of fracture following biopsy, bone must be splinted
- 37. Types of Biopsy
- 39. Bone tumor Mimics • Soft tissue hematoma • Myositis Ossificans • Stress fractures • Tendon avulsion injuries • Infection • Osteopetrosis • Osteopoikilosis • Melorheostosis- dripping candle wax
- 40. Management • Primary Goal with primary malignancy- make patient disease free • Goal of treatment of patient with metastatic carcinoma to bone: Minimize pain Preserve function Optimal treatment of tumor : Surgery Radiation therapy Chemotherapy
- 41. Radiation therapy • Blue cell tumor • Multiple myeloma • Lymphoma • Ewings sarcoma • Secondaries (Except – RCC) • Reduce local recurrence of malignant soft tissue tumor
- 42. Chemotherapy • Adjuvant • Neoadjuvant • Osteosarcoma • Malignant fibrous histiocytoma • Rhabdomyosarcoma • Not useful in cartilaginous lesion
- 43. Principles of Surgery • Amputation vs Limb salvage 1. Survival? 2. Morbidity ? 3. Salvaged limb vs prosthesis 4. Psychosocial conseuences
- 44. References • Campbell’s Operative Orthopaedics -13th edition • Apley and Solomon’s System of Orthopaedics and Trauma -10th edition • Millers Review of Orthopedics- 7th edition
- 45. Thank you
Editor's Notes
- Bone sarcoma – 0.2% of all new cancers diagnosed UK , Appleys
- Age-specific incidence rates (ASIR) for soft-tissue sarcomas and primary sarcomas of bone (a) Softtissue sarcomas in the UK 1996–2010; (b) primary bone sarcomas in the UK for the same period (National Cancer Intelligence Network (NICN) data). bone sarcomas demonstrate a bimodal distribution in both males and females, with peaks of incidence seen in both teenage/adolescent years and the elderly
- Benign – doesn’t invade and spread surrounding tissue, non destructive , surgical resection – curative Osteoblastoma – infiltrative and locally destructive growth pattern – en bloc resection – curative
- Higher grade tumor have > 25% chance of local recurrence and distant spread Low grade lesion< 25 % chance of local recurrence and mets
- IF tumors are analyzed, there is preferential sites of origin within each bone. A particular tumor of given cell type usually arises in the field where homologous normal cells are most active . Eg GCT
- Age , Sex (GCT: F>M), Race , Hereditary – Multiple hereditary exostosis AD
- Katanoda, K., Shibata, A., Matsuda, T., Hori, M., Nakata, K., Narita, Y., … Nishimoto, H. (2017). Childhood, adolescent and young adult cancer incidence in Japan in 2009–2011. Japanese Journal of Clinical Oncology, 47(8), 762–771
- CMF = Chondromyxoid fibroma SBC = Simple Bone Cyst EG = Eosinophilic Granuloma FD = Fibrous dysplasia HPT = Hyperparathyroidism with Brown tumor
- Pain – night pain referred pain Pathological fractures – 5-12% osteosarcoma , 21% in chondrosarcoma s/c # of femur in children, avulsion # of L/T in adults – bone tumors
- Very little trabecular bone in the diaphysis to provide an interface to allow the lesion to be seen
- Simple Bone Cyst /unicameral bone cyst
- If diaphyseal lesion is on radiograph cortex is involved , large medullary cavity diaphyseal lesion may be invisible d/t little trabecular bone in diaphysis to provide interface to allow lesion to be seen
- Osteoid osteoma
- 99mTcMDP – methyl diphosphonate
- aid in treatment decision making, provide some determination of prognosis, and allow meaningful comparisons of treatment methods.
- A compartment, for the purposes of this system, is defined as an enclosed tissue space, such as a bone, a joint space or a muscle group confined by its fascial envelope Low grade : well differentiated , few mitoses and exibit moderate cytological atypia , risk of mets<25% High grade : high cell to matrix ratio A: well defined anatomical compartment (cortex, joint capsule , fascial septa)
- Tumor node metastasis staging- applied to primary sarcomas of bone
- AJCC System – based on prognostic variables Stage I- low grade , II high grade Skip metastasis – discontinuous lesion within the same bone Since the patient with non pulmonary metastasis from osteosarcoma and ewings sarcoma have worse prognosis than with pulmonary mets
- Raw area is covered with bone wax or methylmethacrylate cement to reduce bleeding , contamination from cut bone edge because they are extremely difficult or impossible to excise with the specimen single muscle compartment rather than contaminating an intermuscular plane
- round or oval to minimize stress concentration and prevent a subsequent fracture The hole should be plugged with methacrylate to limit hematoma formation. meticulous hemostasis ensured before closure, because a hematoma would be contaminated with tumor cells Drain should exit in line with the incision so that the drain track also can be easily excised en bloc with the tumor
- Complications : infection , bleeding/hematoma , pathological fracture , tumor contamination and seeding FNAC : 90% accurate in dx malignancy Core needle biopsy : accuracy 84-98% Excisional biopsy : <3cm , sc mass , unlikely malignant – osteoid osteoma , osteochondroma Painful lesion in proximal fibula and distal ulna
- Large opacification on medial thigh separate from femur Osteopetrosis – Marble bone disease- confused with sclerotic metastates from breasr and prostate ca , Pagets disease Osteopoikilosis- AD sclerosing bone dysplasia formation of multiple bone island Melorheostosis- mesenchymal dysplasia – widening and sclerosing of cortices in sclerotomal distribution
- Adjuvant chemotherapy refers to chemotherapy administered postoperatively to treat presumed micrometastases. Neoadjuvant chemotherapy refers to chemotherapy administered before surgical resection of the primary tumor