This document summarizes key information about malignant bone tumors presented at a seminar. It discusses the most common primary malignant bone tumors including multiple myeloma, osteosarcoma, Ewing's sarcoma, chondrosarcoma, and others. For each tumor, it covers clinical presentation, pathology, imaging appearance, treatment options, and prognosis. Primary bone cancers are rare but can cause pain, swelling, and pathological fractures if not identified and treated early. Surgery, chemotherapy, and radiation are often used either alone or in combination depending on the specific bone tumor.

1. SEMINAR ON
MALIGNANT TUMORS OF
BONE
PRESENTOR : DR YASH OZA ( PG in orthopaedics)
MODERATOR : DR SA LAD

2. INTRODUCTION
• Primary bone tumors are very rare.
• Osteosarcoma, Ewing’s sarcoma and Fibrosarcoma are primary
malignant tumors of bone, they rarely present as multifocal disease.
• Multiple malignant lesion usually indicate metastatic disease

3. Clinical presentation
1. Painless bony mass (usually benign)
2. Painfull bony mass (usually malignant)
3. Soft tissue mass (feature of malignant and aggressive lesion)
4. Bone tumor as incidental finding
5. Pathological fracture

4. Classification of bone tumors
Type benign malignant
Bone forming
(osteogenic)
Osteoma,
Osteoblastoma
Osteosarcoma
Cartilage Forming
(Chondrogeic)
Chondroma,
Osteochondroma,
Chondromyxoid fibroma
Chondrosarcoma,
Clear cell chondroma,
Giant Cell Tumors Classical GCT Malignant GCT
Marrow Tumors Ewing Sarcoma
Reticulosarcoma
Lymphosarcoma
Myeloma

5. Type benign malignant
Vascular Tumors Heamangioma,
Lymphangioma,
Glomus Tumor
Angiosarcoma
Connective tissue Tumors Desmoplastic fibroma
Lipoma
Fibrosarcoma
Liposarcoma
Malignant
Mesenchymoma
Undifferentiated sarcoma
Other Tumors Chordoma, Adamantinoma, Neurilemmoma,
Neurofibroma
Tumor Like lesion Solitory Bone Cyst, Aneurysmal Bone cyst, Juxta-
Articular Bone cyst, Metaphilic fibrous defect,
Fibrous Dysplasia,Myosistis Ossificans, Brown Tumor

6. Common Malignant tumors of bone
1. Multiple Myeloma
2. Osteosarcoma
3. Ewing’s Sarcoma
4. Chondrosarcoma
5. Malignant GCT
6. Fibrosarcoma
7. Histiocytic Lymphoma
8. Liposarcoma
9. Adamantinoma
10. Chrodoma

7. 1. Multiple Myeloma
• Most common primary malignant bone tumor
• 40% of primary bone tumor
• Male : Female = 2:1
• Peak at 7th decade
• Etiology :
• Not known
• Commonly seen in farmers, wood workers, leather workers, and those
exposed to petroleum products
• Chromosomal abnormalities

8. • Pathogenesis :
• Plasma cell ( Terminally differentiated cell of B-cell lineage)
• Clonal neoplastic plasma cell transformation
• Over production of single antibody that appears in plasma (M-Protein)
• This clonal plasma cell activate osteoclasts by release of chemokines
• It is also associated with increased generation of osteoclast from
monocte precursors.
Skeletal Distribution :
Ribs, Skull, Pelvis, Long bones,Spine
In long bones : Metaphysis
In Spine : Body of vertabre

9. • Patho:
• Gross – Marrow is replaced by soft, gelatinous, radish grey or
fleshy white tissue
• Histo – Atypical Plasma cells replacing normal fatty &
hematopoietic marrow

10. • Clinical Features :
• Bone pain – dull aching, intermittent, mostly localized to lower
back, upper spine, pelvis, ribs, sternum
• Persistent pain indicates pathological fractures
• Bony lesion may expand and may be palpable ( especially on skull,
clavicle, sternum)
• Susceptibility to infection
• Renal Failure ( d/t Hypercalcemia, BJ Proteins, Amyloidosis)
• Anemia
• Clotting abnormalities
• Raynaud’s Phenomenon
• Hyper viscosity
• Constitutional symptoms

11. •Investigation :
•CBC
•Unine - BJ Proteins
•Bone scan
•Bone marrow examination ( Sternum/ Iliac
crest)
•Serum Protein Electrophoresis
•Cytogenetics
•Xrays
•CT Scan
•MRI

12. Xray in MM
• Generalized reduction in bone density
• Localized are of radiolucency
• Skull – Rain drop lesion, punched out, lytic lesion
• Marked bone expansion – “ballooned” appearance
• In spine – collapse of vertebral bodies, multiple level compression #

17. • Treatment
• Chemotherapy
• Bone marrow transplant
• Corticosteroids
• MELPHALAN ( Alkylating Agent)
• Plasmapheresis
• ORTHO:
• Treatment of impending or actual pathological fracture of spine, acetabulum,
proximal femur, proximal humerus
• ORIF with packing of cavities with bone cement
• Spine fractures needs stabilization

18. 2. OSTEOSARCOMA
• Highly malignant tumor
• Cell produces bone matrix
• Second most common primary malignant tumor of bone
• Male > Female
• Peak incident in 2nd decade
• Metaphysis of long bones
• Distal Femure > Prox Tibia > Prox Humerus
• Etiology
• Virus : polyoma virus, sv40 virus
• Radiation
• Chemicals

19. • Clinical Features:
• Pain : predominant symptom
• Swelling : Tender, Large (>5cm) mass. Skin over the swelling is
stretched ,shiny with dilated veins. Local rise in Temp. Consistency
variable
• Restriction of ROM
• Pathological #
• Edema distal to the lesion – d/t compression of venous/lymphatics
• Constitutional symptoms

20. • PATHO
• Gross –
• tumors violates cortex
• Associated soft tissue mass
• Variable consistency
• Yellow-brown to white
• Necrotic cysts
• Tumor may extend into medullary cavity also
• Histo-
• Hypercellular , cytological atypia, osteoid matrix, multinucleated giant cells

21. X ray
• Lytic, Blastic or Mixed bone destruction and production
• Soft tissue extension is the rule
• “Osteoblastic” Lesion – upper shaft and metaphysis are filled with
dense, amorphous, neoplastic bone.
• Codman’s Triangle – triangle of subperiosteal new bone formation
occurs at the upper and lower angles
• Sun-burst Appearance – spicules of neoplastic bone at right angle to
the long axis of bone ,along blood vessels elevated by periosteum.

24. • Tc- Bone Scan
• Increased uptake by neoplastic lesion
CT & MRI
• Cortical break & Soft tissue invasion

25. • Angiography
• Shows increased vascularity – Tumor Blush

26. • Treatment :
• Painkillers
• Chemotherapy
• Radiation Therapy
• Surgeries

27. • Surgeries
1. Local Resection ( Limb Sparing Sx)
Enblock removal of all previous biopsy site and all potential
contaminated tissue
2. Amputation
Generally done procedure for osteosarcoma

28. • Contraindication for limb sparing SX
1. Major Neurovascular involvement
2. Pathological fractures
3. Inappropriate biopsy sites
4. Infection
5. Skeletal Immaturity
6. Extensive muscle involvement

29. 3. EWING’S SARCOMA
• Neuroectodermal origin
• Male > Female
• 5yr and 25 yrs
• 95% of pt have t(11:22)(q24;q12) or t(21:22)(22:q12) translocations
• Family History
• Common sites
In long bones : Femur > Humerus > Tibia > Forearm bones
In Truncal Skeleton : Pelvis > Scapula > Vertebra > Ribs > Clavicle

30. • Location in long bones:
Mid Diaphysis – 33%
Meta- Diaphysis – 44%
Metaphysic – 15%
Meta Epiphysis – 6%
Epiphysis – 2%
• Size:
Range from 2 cm to 30 cm
Usually less than half of the bone length

31. • Clinial Features:
Pain : Mild & intermittent initially
Increase in severity over time
Swelling : Rapidly growing and painfull; tense,hard,elastic, tender,
Local rise in Temp.
There is period of remission with decreased size and exacerbation with
increased size of tumor over period of months to years
5% cases present with pathological #
Flue like symptoms
Death occurs d/t pulmonary involvement

32. • Xray
Diffuse rerefaction at center of shaft
Permiative diaphyseal tumor with mottled opacities
Onion layer formation
Bone destruction with pathological #
• Angiogram
Hypervascular reaction & Intrinsic neoplastic
vasculature

33. • Treatment
• Highly radiosensitive
• Chemotherapy
• Recurrence Common
• Chemo+Radio Combination brings down recurrence
• Surgery Indicated for
1. Expendable site
2. Lesion near major epiphysis
3. Failed radiation therapy
4. Large lesion with irreparable pathological #
De bulking of the tumor with limb preservation is done.

34. 4. CHONDROSARCOMA
• Malignant, slow growing, purely cartilage producing tumor
• Male > Female
• 20 to 60 yrs age group
• Location :
• Prox Humerus Shaft, Prox Femoral Shaft, Distal Femoral shaft, Pelvis, Ribs,
Scapula
• Antecedent Lesion
• Enchondroma, Osteochondroma, Paget’s Ds. , Synovial Chondromatosis
• Radiation is a risk factor

35. • PATHO:
• Gross- types
• Central Chondrosarcoma : Lobulated , Translucent, Bluish cartilaginous mass
within medullary cavity.
Endosteal aspect of cortex is eroded
Tumor contains yellow-white specks of calcification and occasional area of
mucoid cavities.
Tumor speads throughout medullary cavity
• Peripheral Chondrosarcoma : Pedicle origined from previously benign
exostosis

36. • Clinical Features:
• Pain & Swelling
• Central type remains asymptomatic until it erodes & penetrates the cortex
and cause pathological #
• Afterwards it present as swelling over affected bone. Pain is not prominent
feature
• Neurological Involvement
• Being asymptomatic it is ignored initially and pelvic tumors may present with
dysfunction of sciatic, femoral or lumbosacral plexus.

37. • X ray
• Extension of medullary portion of bone
• Thickening of cortex
• Different types of calcification
• Popcorn like
• Comma shaped
• Arc like
• Annular type

38. • Treatment – Surgical
• Local wide excision with reconstructive procedure
• Arthrodesis of knee reserved for vigorous young adults
• TKR
• Above Knee amputation for elderly patients

39. 5.MALIGNANT GCT
• Malignant giant cell tumor is extremely rare
• Most cases actually represents another type of malignancy arising
within GCT
• McGrath divided Malignant GCT in 3 types
1. Primary : GCT malignant from onset
2. Evolutionary : Malignant transformation after multiple resection or
after long latency period
3. Secondary : Develops after radiation therapy
• Diagnosis : Histological
• Treatment : Wide Excision with reconstructive procedure
• Poor Prognosis

40. 6. FIBROSARCOMA
• Arise from Fibrous layer of periosteum
• Age : over 30yrs
• Site : Long Bones (Most common- Femur), Ribs, Skull, Vertebrae,
mandible
• Position : Subperiosteal area of diaphysis or metaphysis
• Clinical Feature :
• Pain & Swelling – Gradually increasing, Smooth,Firm,Rubbery
textured swelling
• Tumor infiltrates overlying soft tissue and ROM is restricted
• Pathological #

41. • Xray
• Soft tissue shadow denser than muscles
• Single, Extra-osseous, Adjacent to cortex,
• Beneath the tumor there is saucer shaped cortical erosion of varying
depth

42. • Gross Appearance –
• Well encapsulated, firm, white, fibrous, glistering mass beneath the
periosteum
• Treatment :
• Surgical - Amputation

43. 7. HISTIOCYTIC LYMPHOMA
• Arises from marrow reticular cells
• Age : 20-50yrs
• Site : Long Bones
• Position : In Medulla, Epiphysis or metaphysis
• Clinical Features
• Insidious onset pain ( Mild to Moderate – Never Severe )
• Soft Swelling
• No Fever
• Pathological #

44. • Xray –
• Area of decreased density appears in medulla which spreads to
cortex and then invades soft tissue

45. • Gross appearance
• Grayish , soft to firm
• Vascular with small areas of hemorrhage
• Treatment :
• Radiotherapy if tumor is unifocal
• Multifocal : Chemo + Radio therapy

46. 8.LIPOSARCOMA
• Resembles FIBROSARCOMA in appearance but histologically it shows
origin from fat cells
• Site : Long Bones
• Position : Metaphysis , Epiphysis
Gross Appearance : Soft grayish yellow, lobulated mass
Treatment :
Tumor is Radiosensitive
En block resection with chemotherapy
Amputation suggested if massive wound contamination

47. 9. ADAMANTINOMA
• Also called ameloblastoma.
• Histologically resembles benign but is local invasive.
• Arise from odontogenic epithelium embedded in fibrous stroma.
• Age : 10-35 yrs
• Site : Long Bones ( Tibia Most Common)
• Tumor is slowly progressive and locally invasive. It rarely metastases.
• Pain, swelling, tenderness And Pathological # are presenting
symptoms.

48. • Gross Appearance :
• Yellow, Gray to grayish white, flesfy or firm
• Treatment :
• En Block Excision
• If Recurrence after en block excision then - Amputation

49. 10. CHORDOMA
• Rare neoplasm of cranium and spine.
• Derived from embryological remenant of notochord.
• Site : Skull ( Spheno-Occipital region) , Sacrococcygeal region
• Clinical Features :
• Pain : First it occurs in anal and rectal region. Mild & Intermittent
• Constipation & Urinary difficulty
• Motor and sensory disturbance in lower limb may occur in late stage
• Swelling : Over posterior of anterior aspect of sacrum. Tender, soft,
fixed.

51. • Xray
• Well Circumscribed osteolytic expansile defect over lower sacrum
• Rounded soft tissue shadow extends anteriorly of posteriorly.
• If vertebrae involved their arches are collapsed

52. • Treatment :
• Radiotherapy – only use full in children
• Surgery – Wide excision – Recurrence is common

53. THANK YOU