1. Benign bone tumors are more common than malignant bone tumors, though malignant tumors account for 5% of childhood cancers. The most common benign tumor is osteochondroma, while the most common primary malignant tumor is multiple myeloma and the most common bone tumor overall is metastatic carcinoma. 2. Pain and swelling are the most common presentations of bone tumors. Diagnostic evaluation begins with plain x-rays of the affected bone and surrounding area. Further imaging such as CT, bone scan and MRI are used if malignancy is suspected. 3. Biopsy is only performed after imaging to determine the appropriate surgical treatment, which is typically limb salvage rather than amputation. Adjuvant chemotherapy and radiotherapy are

1. Introduction to
Musculoskeletal
Tumors
Dr. Ahmed Youssef
MD Orthopedics
Mubarak Alkabeer Hospital
Kuwait

2. EPIDEMIOLOGY
The vast majority of primary bone tumors are
benign and many are detected incidentally at
radiographic examinations for other reasons.
Primary malignant bone tumors are very rare. The
most common genuine primary bone malignancies
account for only 0.2% of all malignancies in the UK
and USA.
However, in children (< 15 years) malignant bone
tumors account for approximately 5% of all
malignancies.

3. EPIDEMIOLOGY
The most common Benign bone Tumor is
osteochondrma.
The most common Primary Malignant Bone
tumor is Multiple Myeloma.
The most common Malignant bone tumor is
Metastatic Bone Carcinoma.

4. PRESENTATION
Pain: Most common, Not constant ,Worse at night,
Activity Related, Later— constant at rest.
Swelling
Pathological Fractures: Bone cancer can weaken
the bone it develops in.
Constitutional Symptoms: Weight loss, fatigue, etc.
Others: Pressure on nerves, leading to numbness
and tingling or even weakness.

5. EXAMINATION
Look For
Swelling: Site, size, …etc.
Adenopathy
General Musculoskeletal Exam
Metastasis: Examine thyroid, abdomen,
prostate, breasts

6. PLAIN X-RAYS
PLAIN X-Rays is the GOLD standard
diagnostic tool
X-rays (two views) of the whole bone including
joint above and below it
Don’t accept bad quality X-rays

7. PLAIN X-RAYS
Comment on:
1. Site
2. Osteolytic or Osteosclerotic margin
3. Pattern of bone destruction
4. Expansion
5. Periosteal Reaction
6. Soft tissue extension
7. Lesional Matrix
8. Additional clues

8. PLAIN X-RAYS
Site
Areas of Greatest Bone Growth:
1. PROXIMAL FEMUR
2.DISTAL FEMUR
3.PROXIMAL TIBIA
4.PROXIMAL HUMERUS
5.DISTAL RADIUS

9. PLAIN X-RAYS
Site

10. PLAIN X-RAYS
Site
A. Centric in long
bone
B. Eccentric in long
bone
C. Cortical
D. Juxtacortical

11. Osteolytic or Osteosclerotic ?
Osteolytic Osteosclerotic

12. Pattern of Bone Destruction
Well defined Border Ill defined border

13. Expansile or Localized
Expansile Localized

14. Periosteal Reaction

15. Benign Solid Periosteal Reaction

16. Aggressive Periosteal Reaction
Lamellated Speculated Codman Triangle

17. Soft Tissue Extension or not
Soft Tissue Extension No Soft Tissue Extension

18. Lesional Matrix(Calcification)
Chondroid matrix Osteoid Matrix

19. Any additional clues?
Ground Glass Appearance Punched out Lesion(skull)

20. The BIG FIVE Lesions that can look like
anything in X-rays
1. Metastatic Carcinoma
2. Cartilage Lesions
3. Fibrous Dysplasia
4. Infection
5. Eosinophilic
Granuloma

21. OTHER IMAGING STUDIES
When Suspicion of Malignant Lesion
Skeletal survey: In Multiple Myeloma
Chest XR/ Chest Abdomen & Pelvis CT Scan:
Suspected malignant lesions
Whole Body Bone Scan: To search for occult or
multiple lesions
MRI Scan: Extent of lesion, soft tissue mass, screen
for spine mets, skip lesions.

22. LABORATORY STUDIES
Usually non-specific, but may help in the
diagnosis of the unknown lesions.
CBC, ESR, CRP, to exclude infection
Urine Protein Electrophoresis for Multiple
Myeloma
Tumor Markers: PSA, Alphafetoproien etc.

23. CURRENT TRENDS IN DIAGNOSIS
Molecular Biology of Sarcomas is a big area
of research and interest.
Tumor Suppressor Genes
Oncogenes
Chromosomal Translocations

24. HISTOLOGY OF BONE LESIONS
Overall Cellularity of the lesion
Nuclear to Cytoplasmic Ratio
Cellular Atypia
Pleomorphism
Presence or absence of Necrosis

25. HISTOPATHOLOGICAL EXAMINATION OF THE BIOPSYHistopathology of
Low Grade
Malignancy
Well differentiated
Few mitotic figures
Moderate cellular
atypia
Moderate nuclear
atypia
Histopathology of
High Grade
Malignancy
Dedifferentiated
Abundant mitotic
figures
Abundant cellular
atypia
Abundant nuclear

26. HISTOLOGY OF BONE TUMORS
Benign Bone Tumor Malignant Bone Tumor

27. IS IT BENIGN OR MALIGNANT?
(Enneking) Staging System
Benign: Arabic Numbers

28. Malignant:
Roman
Numbers

29. OSTEOGENIC LESIONS
Osteoid Osteoma Osteoblastoma

30. OSTEOGENIC LESIONS
Intramedullary Osteosarcoma

31. CHONDROGENIC LESIONS
Enchondroma Ollier’s disease Maffucci Syndrome

32. CHONDROGENIC LESIONS
Chondrosarcoma

33. OSTEOCHONDROGENIC LESIONS
Osteochondroma Multiple Hereditary Exostosis

34. HEMATOPOIETIC BONY LESIONS
Multiple Myeloma

35. HEMATOPOIETIC BONY LESIONS
Lymphoma

36. CYSTIC BONY LESIONS
Simple Bone Cyst Aneurysmal Bone Cyst

37. UNKNOWN ORIGIN BONY LESIONS
Giant Cell Tumor Ewing’s Sarcoma

38. METASTATIC BONY LESIONS

39. BONE BIOPSY
DON’T DO
THIS UNLESS
YOU ARE
GOING TO
TAKE CARE
OF THE
PATIENT
Performed
AFTER the
imaging
evaluation is

40. THE BIOPSY
• Types of Biopsies:
Fine Needle Aspiration: (70-75% accurate)
Core needle Biopsy: (85% accurate)
Open Biopsy: (96-98% accurate)
1. Incisional
2. Excisional

41. SURGICAL TREATMENT
REMOVE THE LESION WITH MINIMAL RISK
OF LOCAL RECURRENCE
Limb Salvage is today’s standard.
Salvaged limb must be functional (compare
to amputation).
Local recurrence may be associated with
presence of Metastasis but generally worse
prognosis.

42. SURGICAL TREATMENT

43. SURGICAL TREATMENT
Surgical Defect Prosthetic Reconstruction

44. SURGICAL TREATMENT
Biopsy Site Resection of the lesion

45. SURGICAL TREATMENT
Allograft Reconstruction Composite Reconstruction

46. ADJUVANT CHEMOTHERAPY
Multiagent chemotherapy is a reason that
patients survive malignant bone lesions.
Usually given pre-op. (neo-adjuvant) and
post-op (adjuvant) for several months.
Has led to 5 yr survival rates of 60% - 70% in
osteosarcoma versus 11% in non-chemo
patients.

47. ADJUVANT CHEMOTHERAPY
Common Agents for Osteosarcoma
1. High-dose Methotrexate
2. Doxorubicin
3. Vincristine
4. Cyclophosphamide

48. COMPLICATIONS OF CHEMOTHERAPY
Nausea & Vomiting
Allergic reaction (including anaphylaxis)
Bone Marrow Depression
Extravasation
Nephrotoxicity

49. ADJUVANT RADIOTHERAPY
Dose measured in grays (Gy)
l rad = l centigray (cGy)
1,000 rads = l0Gy
Mechanism: Oxygenation of H2O, free
radical release -DNA injury
Dose: 180-200 cGy/day, 5 days a week

50. COMPLICATIONS OF RADIOTHERAPY
Nausea & Vomiting
Skin Ulceration& Alopecia
Lung Fibrosis
Cardiomyopathy
Infertility
Post irradiation Sarcoma

51. TAKE HOME MESSAGES
The most common Benign bone Tumor is
osteochondrma.
The most common Malignant bone tumor is
Metastatic Bone Carcinoma.
Pain and Swelling are the most common
presentation of bone tumors.
Plain X-ray is the Gold standard diagnostic tool for
benign bone tumors.

52. TAKE HOME MESSAGES
When you suspect Malignant bone tumor, CT
chest abdomen and pelvis, Bone Scan and
MRI should be done searching for primary
lesion.
Don’t Do Biopsy UNLESS You are going to
treat the patient.
Limb Salvage is today’s standard surgical
treatment for bone tumors