The document discusses the evaluation and diagnosis of bone tumors. It covers the typical presentation of symptoms like pain, masses, and neurological symptoms. The evaluation process involves thorough history, physical exam, imaging like x-rays, CT, and MRI, as well as biopsy. Key factors in diagnosis are the age and sex of the patient, family history, and any exposures. Staging systems consider the grade, site, and presence of metastasis. The document also categorizes different types of bone tumors.

1. By : Dr. Utsav Agrawal

3. PAIN :- is most frequent symptom
-deep constant pain,poorly localised,worse at night
-initially controlled by analgesics,later requires narcotics
MASS:- may be painful/painless
- rate of enlargement is important
-Fluctuating mass can be cyst,ganglion or hemangioma
-Family H/O masses near the joint may be indicator of Ollier’s disease or
Maffucci Syndrome
NEUROLOGICAL SYMPTOM:- found in few patients such as sacral tumors & with
tumors located near the nerve causing compression of nerve,especially common in
sciatic notch ,inguinal canal & popliteal fossa
UNEXPLAINED SWELLING OF THE LOWER EXTREMITY:- found in pelvic tumors
which are painless & without a palpable mass & cause swelling due to compression of
iliac vein.
Patient may present with an abnormal radiographic finding detected during evaluation
of unrelated problem
Patient may also come with complaint of weight loss, respiratory , gastro or genito-
urinary disturbances.

4. Carried out in 4 phases –
1st phase – involves
High index of suspicion for tumors
Meticulous history
Thorough physical examination
Routine X-rays
Routine lab facilities
2nd phase – is prebiopsy regional evaluation to determine size,
location and type of tissue in involved in the tumor. This includes CT
and MRI
3rd phase – is the actual biopsy.
4th phase – is undertaken if presumptive clinical & path evidence is
suggestive of malignancy. Here search for metastasis is done using
CT/HRCT of lung & Tc-99 bone scan.

5. AGE:- most important as most tumors present in specific age group.
1st decade- usually ABC ,SBC
2nd decade-Chondroblastoma,osteosarcoma,Ewings
3rd decade- GCT
4th decade- chondrosarcoma
5th decade- Multiple myeloma
SEX:- less imp than age
Some tumors like GCT are more in females
FAMILY HISTORY
RACE:- little imp, Ewings rare in african descent
H/O any exposure to radiation Tt or Carcinogens- bone seeking
radionucleotide can cause sarcoma.
Various chemlcal carcinogens- methylcholanthrene,zinc beryllium
silicate, beryllium oxide.
Currently the most worrisome & controversial is Nickel which is used
in many orthopedic devices.

6. Risk
Ollier disease (Enchondromatosis)
Maffucci syndrome
Familial retinoblastoma syndrome
Rothmund-Thomson syndrome (RTS)
Moderate Risk
Multiple osteochondromas
Polyostotic Paget disease
Radiation osteitis
Low Risk
Fibrous dysplasia
Bone infarct
Chronic osteomyelitis
Metallic and polyethylene implants
Osteogenesis imperfecta
Giant cell tumour
Osteoblastoma and chondroblastoma

7. Evaluation of patient’s general health
TUMOR MASS should be measured & its location, shape, consistency, mobility,
tenderness, local temp & change with position should be noted.
SKIN & SUBCUTANEOUS TISSUE :
Small dilated superficial veins overlying the mass are produced by large tumors
Café-au-lait spots & subcutaneous neurofibromas indicate Von Recklinghausen’s
disease
A venous malformation on the same of body as the cartilagenous tumor is an
indicator of Maffucci Syndrome
REGIONAL LYMPH NODES:should be carefully palpated for signs of metastatic
disease
Atrophy of surrounding musculature/ fasciculations should be recorded
Neurological deficits
Circulation should be assessed and compared with opposite site.
Joints, specially proximal and distal to the mass should be carefully examined for
range of motion, discontinuity or intra-articular masses.

8. Location of tumors

9. Hemoglobin
CBC
ESR
CRP
Prastrate specific antigen, PAP
Electrophoresis & urinary Bence Jones protein
Alkaline phosphatase test: Normally, this enzyme is present in
high levels when bone-forming cells are very active.High levels
of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium

10. It is the most conclusive test
Types : Open Incisional Biopsy 1.Incisional
2. Excisional
Closed percutaneous core Biopsy

11. The Enneking system for the surgical staging of bone and soft-tissue
tumors is based on grade (G), site (T), and metastasis (M) and uses
histologic, radiologic, and clinical criteria.
Grade
G0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
Site
T0 - A benign tumor that is confined within a true capsule and the lesion's anatomic
compartment of origin (ie, a benign intracapsular, intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic
compartment (ie, an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie, an
extracompartmental lesion)
Metastasis
M0 - No regional or distant metastasis
M1 - Regional or distant metastasis

12. Stage Grade Site Metastasis
IA Low G-1 Intracompartmental -
T1
IB Low G-1 Extracompartmental -
T2
IIA High G-2 Intracompartmental -
T1
IIB High G-2 Extracompartmental -
T2
III Any G Any T Regional/ distant
metastasis

13. Stage Definition Behaviour Example
1 Latent Remains static or Non-ossifying
heals spontaneously fibroma
2 Active Progressive but Aneurysmal bone
limited by natural bone cyst
barriers
3 Locally Aggressive Progressive growth, GCT
not limited by
natural barriers
Barriers- Cortical bone, articular caritlage, joint capsule, fascia,
tendinous origin and inertion sites of muscles

14. Primary tumour (T) TX: primary tumour cannot be assessed
T0: no evidence of primary tumour
T1: tumour 􀀩 8 cm in greatest dimension
T2: tumour > 8 cm in greatest dimension
T3: discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: regional lymph node metastasis
Distant metastasis (M) MX: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis
M1a: lung
M1b: other distant sites
G Histopathological Grading
Low Grade
High Grade

15. Stage T N M G
IA T1 No/Nx Mo G1/2 Low Grade
IB T2 No/Nx Mo G1/2 Low Grade
IIA T1 No/Nx Mo G3/4 High
IIB T2 No/Nx Mo G3/4 High
III T3 No/Nx Mo Any G
IVA Any T No/Nx Any M Any G
IVB Any T N1 Any M Any G
Any T Any N M1b Any G

17. Classification (W.H.O.)
 Bone-forming tumours
 Cartilage forming tumours
 Giant-cell tumour
 Marrow tumours
 Vascular tumours
 Other connective tissue tumours
 Other tumours
 Secondary malignant tumours of bone

18. Bone forming tumours
Benign Malignant
 Osteoma  Osteosarcoma
 Osteoid osteoma or Central (Medullary)
osteoblastoma Peripheral (Surface)
Intermediate  Parosteal
 Aggressive osteoblastoma  Periosteal
 High grade surface

19. Cartilage forming tumours
Benign Malignant
 Chondroma  Chondrosarcoma
Enchondroma  Differentiated
 Osteochondroma chondrosarcoma
 Chondroblastoma  Juxtacortical
 Chondromyxoid fibroma
chondrosarcoma
 Mesenchymal
chondrosarcoma
 Clear cell chondrosarcoma

20. Giant cell tumour
 Osteoclastoma

21. Marrow tumours
 Ewing’s sarcoma
 Neuroectodermal tumour
 Malignant lymphoma of bone (Primary/secondary)
 Myeloma

22. Vascular tumours
Benign
 Haemangioma
 Lymphangioma
 Glomus tumour
Intermediate
 Haemangio endothelioma
 Haemangio pericytoma
Malignant
 Angiosarcoma
 Malignant haemangio pericytoma

23. Other connective tissue tumours
Benign Malignant
 Benign fibrous  Fibrosarcoma
histiocytoma  Malignant fibrous
 Lipoma histiocytoma
Intermediate  Liposarcoma
 Desmoplastic fibroma  Malignant mesenchymoma
 Leiomyosarcoma
 Undifferentiated sarcoma

24. Other tumours
Benign
 Neurilemmoma
 Neurofibroma
Malignant
 Chordoma
 Adamantinoma

25. Secondary malignant tumours of bone
From primary in:
 Thyroid
 Breast
 Bronchus
 Kidney
 Prostate