This document discusses bone tumors. It defines bone tumors and divides them into primary and secondary tumors. Primary bone tumors are rare, accounting for 0.2% of adult and 5% of childhood cancers. The document describes the typical characteristics, locations, and most common types of both primary bone tumors and secondary bone metastases. It outlines the clinical features, diagnostic imaging, laboratory investigations, biopsy, staging, and management of bone tumors.

1. Bone Tumours

2. Bone Tumours
• The term bone tumour encompass benign and
malignant neoplasms, reactive focal
abnormalities, metabolic abnormalities, and
miscellaneous “tumorlike” conditions

3. Bone Tumours
… can be divided into primary and secondary.
Primary bone tumors are rare
and malignant primary bone tumors (except
myeloma and lymphoma) constitute only 0.2%
of all malignancies in adults and 5% in
children.

4. Primary Bone Tumours
• Predominant occurrence in the first 3 decades of
life
• Relatively specific radiographic presentations
• Benign tumors are more common than malignant
ones (hamartomas eg. Osteochondroma)
• Some primary bone tumors are difficult to classify
as benign or malignant
• Among primary malignant neoplasms,
osteosarcoma and multiple myeloma have the
highest incidence, followed by chondrosarcoma
and Ewing's sarcoma.

5. Secondary Bone Tumours
Can be further subdivided into:
• Metastatic tumors
• Tumors resulting from contiguous spread of
adjacent soft tissue neoplasms
• Tumors representing malignant
transformation of the pre-existing benign
lesions

6. Precursors

8. Bone Tumour Classification (WHO)
• Bone-forming tumours
• Cartilage forming tumours
• Giant-cell tumour
• Marrow tumours
• Vascular tumours
• Other connective tissue tumours
• Other tumours
• Secondary malignant tumours of bone

9. Age/Location
Tumors have a typical patient age range—
<20,
20–40, and
>40 years old—and a typical location in the
skeleton—flat versus tubular bones,
epiphyseal versus metaphyseal versus
diaphyseal, or medullary versus cortical versus
juxtacortical

11. Most common malignancies producing skeletal
metastases
Adults More than 75% of skeletal metastases
originate from carcinomas of the prostate,
breast, kidney, and lung. Also common are
metastases from thyroid and colon cancers.
And do not forget melanoma.
Children Neuroblastoma, rhabdomyosarcoma, and
retinoblastoma

17. Clinical Features
• Pain
• Swelling
• General discomfort
• Limited mobility
• Spontaneous fracture
General symptoms:
• Fever
• Exhaustion
• Loss of weight

21. Pain
• Tearing neuralgia-like pain (may also be interpreted as
"rheumatic pain“)
• Initially may occur intermittently and only at rest
• Might subsequently become more intense:
– disturb sleep at night
– spread into the adjacent joint
– frequently misinterpreted as arthritis or as a post-traumatic
phenomenon
• Further intensification of pain is experienced as a persistent and
piercing pain
• Becomes excruciating and intolerable, requiring opiate
treatment
• In case of pressure on nerve trunks or nerve plexuses, the
patient may experience radiating pain
• When the tumour is located in the spine causes radicular or
spinal compression symptoms with paralysis

22. Pain
May be a symptom of:
• Growing lesions (locally aggressive lesions eg.
aggressive osteoblastoma and GCT, and
malignant tumors)
• Pathologic fracture complicating either benign
or malignant tumor
• Significant local tissue reaction to the tumor

23. Swelling
• Very long duration, no additional complaints
• Only observed if there is an extraosseous part of
the tumour or the bone is expanded by the
tumourous process
• In malignant tumours, swelling develops more
rapidly
• Consistency is important e.g. hard, coarse, tightly
elastic or soft
• May cause skin changes (tensed shining skin with
prominent veins, livid colouring, hyperthermia,
striation of the skin and eventually, ulceration)
• Mobility of the skin

24. Limited mobility
• In cases of lesions close to the joint
• In tumours such as OB, CB, GCT and all types
of sarcomas
• Occasionally it is not the tumour but reactive
synovitis in the joint, especially in CB

25. Diagnosis
• Clinical examination
• Imaging
• Laboratory investigations
• Biopsy

27. Imaging
• Radiography
• CT scan
• MRI
• Radio nuclide bone scan
• Arteriogram

28. Radiography
Usually the first imaging technique for a
suspected bone lesion since it is inexpensive
and easily obtainable. It is also the best for
assessment of general radiological features of
the tumor.

29. Radiological Findings
• Exact location of the tumour
• Borders of the tumour
• Pattern of bone destruction
• Matrix formation/mineralization
• Periosteal reaction

31. Geographic Pattern

32. Cortical Expansion

33. Permeative Pattern

34. Focal Cortical Thickening

35. Codman’s Triangle

36. “Hair-on-End”

37. Osteoid Mineralization

38. Chondroid Mineralization

39. CT
Method of choice when plain film assessment
is difficult owing to the nature of the lesion
(eg., permeative pattern of destruction) or
anatomic site (eg., sacrum). In addition, CT is
the best technique in assessment of matrix
mineralization, cortical detail, and detection of
the cystic and fatty lesions.

40. MRI
• Local Staging
• It is superior to CT in the definition of
medullary and extracortical spread and of the
relationship of the tumor to critical
neurovascular structures. However, remember
that the MRI appearances of the majority of
bone tumors are totally non-specific.

41. Radionuclide Bone Scanning
• For pre biopsy staging
• Dissemination of tumour
• Silent secondaries and skip lesions

42. Arteriogram
• Planning limb sparing surgery
• Therapeutic embolization
• To assess vascularity of tumour

43. Bone Scintigraphy
Highly sensitive but relatively non-specific
technique. Its main role is in detection of
suspected metastases in the whole skeleton. It
may also be helpful in the detection of osteoid
osteomas ("double density sign" is present in
about 50% of cases and is highly suggestive of
this tumor).

44. Laboratory Findings
• Hb %
• ESR
• ↑Alkaline Phosphatase
• Serum electrophoretic pattern
• Bence-Jones protein
• ↑Acid Phosphatase

45. Biopsy
• Closed biopsy
FNAC
Needle biopsy
• Open biopsy
Incisional biopsy
Excisional biopsy

46. Important Histologic Features to
Consider
• Pattern of growth (eg., sheets of cells vs. lobular
architecture)
• Cytologic characteristics of the cells
• Presence of necrosis and/or hemorrhage and/or
cystic change
• Matrix production
• Relationship between the lesional tissue and the
surrounding bone (eg., sharp border vs.
infiltrative growth)

47. Staging

51. Management
• Radiotherapy/chemotherapy
(adjuvant/neoadjuvant)
• Medication
• Ablative surgeries (amputation, limb sparing
surgery, bone graft, artificial bone,
rotationplasty)

52. Management
• Benign, asymptomatic lesions
Excisional biopsy or curettage
• Benign, symptomatic or enlarging lesions
Biopsy confirmation followed by marginal
resection or curettage (cystic lesions)

53. Van Nes rotationplasty