- Bone tumors can be benign, intermediate, or malignant. Location, size, margins, and other radiographic features help determine tumor type and appropriate treatment. - Evaluation involves history, exam, imaging like x-rays, and biopsy. Staging evaluates spread and guides prognosis and treatment planning. - Treatment depends on tumor type but may include surgery, chemotherapy, and radiotherapy. The goal is complete resection while preserving limb function through techniques like endoprosthetic replacement.

1. Bone tumors
Dr. Shubhanshu Ranjan Singh

2. History
• Gross in 1879 prented a paper on sarcoma of long bone
where he mentioned amputation as treatment of choice.
• Codman in 1926 provided statistical proof of prognosis of
musculoskeletal tumors
• Blood good in 1928 recommended resection and bone
transplantation in order to restore bone function. He
considered as father of limb sparing surgery.
• In 1930 Radiotherapy came in light for treatment of mets
and primary musculoskeletal tumors.
• Coley in 1936 attempted chemotherapy using
streptococcus pyogens called as Toxin therapy.
• Moore and Bohlman in 1943 introduced Endoprosthesis in
treating GCT of femur.

3. Tumors
• Abnormal growth
• Enlarge cellular proliferation than surrounding
tissue
• Lacks structural organization and functional
coordination of normal tissue
• Prognosis depends on- Stage, metastasis,
tumor size, histologic grade, skip lesion within
the same bone.

4. Zone
• Compression zone(pseudocapsule)-grows in
centrifugal fashion leads to compress and
atrophy of normal tissue
• Reactive zone- edema and neovascularity with
inflammatory calls and micronodule of tumor
surrounding pseudocapsule.
• Resection should outside reactive zone.

5. Margin
• Intralesional
• Marginal- excised with intact pseudocapsule
• Wide – with normal tissue
• Radical – entire compartment

6. Classification
• Benign lesion
– Non ossifying fibroma
– Aneurysmal bone cyst
• Intermediate (locally aggressive)lesion
– Osteoblastoma
• Intermediate (rarely mets)lesion
– Risk of spread <2%, often non fatal
– Giant cell tumor of bone

7. Classification
• Malignant tumors
– Aggressiveness defined by histological grade
– Low grade tumors
• Mets rate 2-10%
• Chordoma parosteal, Osteosarcoma
– High grade tumor
• Mets rate 20-100%
• Osteosarcoma, Ewing’s sarcoma

12. Approach
• Clinical History
– Patient age
– Site
– Duration of symptoms – rapid growth indicate
Mets, Osteochondroma after skeletal maturity
– Symptoms- swelling, pain, pathologic fracture,
weight loss, metastatic hypercalcemia -confusion,
muscle weakness, polyuria & polydypsia, nausea
vomiting, dehydration

13. Approach
– Red flags for cancer- lethargy weight loss
– Pain history- site, character, severity, radiation,
modifying factors, periodicity. Night pain
– Fracture associated
– Previous history
– Family history

14. Key examination
• Swelling
– site,size,depth,shape,surface,edges,consistency,flu
ctuance,pulsatility,tethering,overlying skin,
draining lymph node.
• Involvement of adjacent joint, neurovascular
• Previous treatment signs

15. X-rays
• Skeletal maturity
• Site of lesion
• Extension of lesion- size,number,skip lesion
• Lesion doing in bone- zone of transition,
geographic , permeative

16. X-rays
• Bone in response- periosteum reaction
• Lesion making matrix – ground glass(FD),
fluid(SBC), Popcorn calcifcation(enchondroma,
chondrosarcoma), bone
forming(osteosarcoma), lytic lesions
• Cortex eroded
• Any soft tissue mass- osteosarcoma, ewings
sarcoma

17. Location- Long Axis
• Epiphyseal lesions
– Chondroblastoma (age 10-25)
– Giant cell tumor (age 20-40)
– Clear chondrosarcoma (rare)
• Metaphyseal tumors
– Osteochondroma
– Osteoblastoma
– Giant cell tumor child
– Osteosarcoma
– Juxtacortical osteosarcoma

18. Location- Long Axis
• Diaphyseal lesions
– Fibrous dysplasia (age 5-30)
– Enchondroma
– Ewing sarcoma (age 5-25)
– Histiocytosis (age 5-30)
– Lymphoma (adults)
– Adamantinoma (consider in tibia)

19. Location – Axial
• Central
– Enchondroma
– Unicarmeral bone cyst
– Conventional
osteosarcoma
– Ewing’s sarcoma
– Myeloma, lymphoma
• Eccentric
– Aneurysmal bone cyst
– GCT
– Non ossifying fibroma
– Enchondroma
– Fibrous dysplasia

20. Location- wrt Cortex
• Cortical
– Cortical osteoid
osteoma
– Fibrous dysplasia
– Adamantinoma
– Osteofibrous dysplasia
– Pagets disease
• Juxtacortical
– Parosteal chondroma
– Surface osteosarcoma
– Osteochondroma
– Exostotic
chondrosarcoma

21. Lodwick classification
• Radiologically
describing margins of
lucent/lytic bone
lesion, aggressive and
malignant
• Type 1- Geographic
• Type 2- Moth-Eaten
• Type 3- Permeative
Medullary destruction
Margination of lesion

22. Periosteal Reaction
• Non aggressive
– Continous/solid
• Aggressive
– Codman’s triangle
– Sunburst appearance/spiculated/ hair on end
– Lamellated

23. Lesions of Spine
• >40 years
– Multiple myeloma
– Hemangioma
– Chordoma(sacrum)
– Mets
• Vertebral body, pelvis,
proximal humerus,
proximal femur, skull
• <30yrs
– Vertebral body
• Histiocytosis
• Hemangioma
– Posterior elements
• Osteoid osteoma
• Osteoblastoma
• Aneurysmal bone cyst

24. Multiple lesion
• Histiocytosis
• Enchondroma
• Osteochondroma
• Fibrous dysplasia
• Multiple myeloma
• Hemangioma
• Infection
• Hyperparathroidism
• Mets

25. Mets
• Sclerotic mets
– Prostatic ca
– Breast ca
– Transitional cell ca
– Carcinoid
– Mucinous
adenocarcinoma
• Lytic bone mets
– Lung ca
– Renal cell ca
– Throid ca
– Adrenal galnd ca
– Uterine ca
– Melanoma

26. Bone Tumor Mimics
• Soft tissue hematoma
• Myositis ossificans
• Stress fracture
• Tendon avulsion injuries
• Infection
• Osteopetrosis
• Osteopoikilosis
• Melorheostosis- dripping candle wax

27. Tumor grading
• Histological appearance of tumor
– Nuclear atypia(structural differentiation)
– Pleomorphism(size, shape)
– Nuclear hyperchromasia(staining)
• Low grade tumor
• High grade tumor- ewings, osteosarcoma,
dedifferntiated chondrosarcoma

28. Staging
• Communicating, planning treatment,
predicting prognosis
• Benign
– Latent lesion- asymptomatic
– Active lesion- pain swelling
– Aggressive lesion- locally destructive

29. Enneking’s staging/MSTS

30. Investigation
• Imaging
• Systemic Staging -
• Biopsy- tru-cut/incision/excision
• Blood tests- PSA, Sr. Calcium, ALP, Bence-jones
protein, ESR,CRP

31. Criteria for prophylactic fixation
• Significant functional pain, >50% cortical bone
destruction
• Harington’s criteria
• Mirel’s criteria

33. Lymphatic spread
• Epitheloid sarcoma
• Synovial sarcoma
• Angiosarcoma
• Rhabdomyosarcoma
• Clear cell sarcoma

35. Chemotherapy
• Preoperative – 8-12wks
• Maintenance – 6-12 wks
– Osteosarcoma
– Ewings sarcoma
– Neuroectodermal tumor
– rhabdomyosarcoma
– Malignant fibrous dysplasia
• Not useful in cartilaginous lesion

36. Radiotherapy
• Multiple myeloma
• Ewing sarcoma
• Lymphoma of bone
• Hemangioendothelioma
• Secondaries excepts RCC

37. Amputation vs Limb salvage
• Survival
• Morbidity
• Salvaged limb vs prosthesis
• Psychosocial conseuences