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- 1. OSTEOSARCOMA & CHONDROSARCOMA Presenter: Dr.U. Karthikeyan Moderator: Dr. K. Sivaprasad, Professor
- 2. BONE TUMOURS Tissue oforigin Benign Malignant Bone forming Osteoma Osteoid osteoma Osteoblastoma Osteosarcoma Cartilage forming Chondroma Osteochondroma Chondroblastoma Chondrosarcoma Fibrous tissue Fibroma Fibrosarcoma Giant-cell tumor Benign Osteoclastoma Malignant Osteoclastoma Marrow tumors Ewings sarcoma Myeloma Vascular Hemangioma Hemangiosarcoma Other connective tissue Fibrous histiocytoma Lipoma Malignant fi brous histiocytoma Liposarcoma Other tumors Neuro fi broma Adamantoma
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- 5. Primary malignant tumourof bone which produce malignant osteoid It is the m/c primary malignant tumour of bone Incidence is m/c in 2nd decade of life and second peak in 5th decade In younger population there is increased predisposition of males that decreases with age (3:2) Occurs in region of rapid bone turnover ie metaphysis Mc location distal femur > proximal tibia > proximal humerus
- 6. ETIOLOGY Previous radiation exposure Pagetsdisease Heriditary retinoblastoma Li fraumeni syndrome Bloom syndrome
- 7. CLASSIFICATION Conventional classic osteosarcoma TelengectaticOS Small cell OS High grade surface OS Periosteal chongrogenic type Low grade parosteal
- 8. CLINICAL FEATURES Pain withor without swelling Rest paint which worsens with activity Local warmth, telangiectasia, dilated veins, skin stretched thin glossy, Decreased range of motion of adjacent joint Sudden increase in pain indicates haemorrhage in tumor, rapid growth, pathological fracture Respiratory fi nding with late stage mets
- 9. INVESTIGATIONS X-RAY MRI Bone scan CT scan LABS.Sr. ALP Biopsy
- 10. RADIOLOGICAL FEATURES X-RAY The radiologicchanges maybe sclerotic(30%), osteolytic(25%), mixed(45%)
- 11. RADIOLOGICAL FEATURES X-RAY Classical isintermedullary combined lytic and sclerotic lesion Usually seen around the metaphysis Eccentric and outgrowing from medullary canal Permeative growth, indistinctive margins and cortex erosion are signs of aggressive growth Sunburst appearance, Colman’s triangle Amorphous fl u ff y bone formation in soft tissue is hallmark
- 12. RADIOLOGICAL FEATURES X-RAY Codman’s triangleBone in soft tissue Sunburst appearance
- 13. RADIOLOGICAL FEATURES MRI &PET scan MRI is good for determining marrow extend thus helpful in deciding level of resection A post contrast image is used to di ff rentiate tumor from edema Involvment of epiphysis and penetration of physeal cartilage can be seen Also to see if disease is extended to capsule or ligaments nearby Pre and post chemo MRI for analysing response and plan resection Pet scan is used to identi fi cation of metastasis and prognosis of chemotherapy
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- 15. GROSS APPEARANCE Consistency variesfrom soft and gritty to bony hard While epiphyseal plate is intact doesnt extend into epiphysis. After closure may extend to epiphysis but articular cartilage stops extension into joints Color re fl ects its components fi brous - white osseous - yellowish white cartilagenous - bluish white Some have large vascular channels and hemorrage Necrotic foci and area of disintegration cause cyst like cavity indicative of rapid growing tumor
- 16. HISTOPATH The characteristic ofosteosarcoma is osteoid which is dense pink amorphous material Pleomorphic cells mostly with a combination of cell types
- 17. INVESTIGATIONS Decrease of ALPand LDH have good prognostic signi fi cance A NCCT chest is taken as lungs is m/c site of mets A whole body bone scan to screen for bone metastasis which is 2nd m/c PET CT occasionaly in heterogenous lesion for targetting a biopsy or staging with lymph nodes and atypical mets sites
- 18. TREATMENT For high gradesurgical exision of primary tumor with chemotherapy Mulitangent chemotherapy Doxorubicin, cisplatin high dose methotreate, etoposide, ifosfamide Neoadjuvant phase f/b surgey f/b adjuvant chemotherapy
- 19. Surgical procedures Resection andarthrodesis ± bone lengthening Mettalic endoprosthesis Wide excision and autoclaved bone graft reconstruction
- 20. Resection and arthrodesis± bone lengthening
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- 22. Wide excision andautoclaved bonegraft reconstruction
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- 24. Malignant bone tumorwhere neoplastic cells produce hyaline cartilage It presents with diverse morphological features as myxoid calci fi cation or ossi fi cation It occurs in population more than 20 years of age peak incidence from 50-70 years of age Usually sporadic also malignant transformation of osteochondroma and enchondroma
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- 27. A malignant tumorarising centrally in a previously normal bone 3rd m/c primary malignancy of bone 90 % of chondrosarcomas are primary chondrosarcoma IDH 1 &IDH2 mutations common in central chondrosarcomas Age group is after 2nd decade of life peak incidence from 5th to 7th decades Male to female ratio is 3:2 Pelvis>prox femur>prox humerus>Distal femur
- 28. CLINICAL FEATURES Pain isthe mc and mostly only presentation of patients Pathologic fractures are rare its incidence increase with higher grades Pain at rest
- 29. RADIOLOGICAL FEATURES X-RAY Expansion ofmedullary portion and thickening of cortex is seen Periosteal reaction is scant or absent Shows endosteal scalloping annular punctate or comma shapes stippled calci fi cation Enchondroma also shows similar features ddx by degree of these features Endosteal scalloping >2/3 of the cortical thickness is s/o aggressive lesion Cortical expansion and thickening adaptive signs Cortical disruption and soft tissue masses are aggressive signs
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- 32. RADIOLOGICAL FEATURES MRI Presence ofedema in post contrast mri in marrow and soft tissue predict chondrosarcoma Localization of size > 5cm in axial skeleton predictor of malignancy Appearance of lysis within previous calci fi ed area suggests tumor progression Aggressive features of tubular bone of hand is an exception coz it is benign enchondroma Margins of lesions which are lobulated and intramedullary extent can be seen with MRI
- 33. RADIOLOGICAL FEATURES MRI &CT NCCT shows rings and arc classi fi cation wothout any associated periosteal reaction MRI of humerus shows a corresponding well-de fi ned lobulated lesion internal hypointesities (Blue Arrow), consistent with regions of calci fi cations within the chondroid matrix.
- 34. RADIOLOGY CT & BONESCAN Ct may be helpful in detection and characterisation of lesions in anatomically complex regions such a s sacrum and spine Bone scan uptake is graded 1 to 3 1 being uptake less than asis 2 equal to that of asis and 3 indicating uptake greater than asis Even though enchondromas show some activity on bone scan a grade 3uptake is m/c indicates chondrosarcoma
- 35. INVESTIGATIONS Laboratory fi ndings are mostlynon speci fi c In high grade a ncct chest is acquired to rule out mets A whole body scintiography screens for mets but its role is limited Diagnosis of grade 2 and 3 can be done by cytologic and histologic features Grade 1 fi ndings are similar to those of enchondromas so anatomical location, clinical behaviour and radiological fi ndings must be correlated
- 36. GROSS APPEARANCE Tumor isa glistening translucent blue grey or blue white on cut surface with nodular growth pattern Cystic myxoid changes to chalky white calci fi cations can be seen
- 37. MICROSCOPIC APPEARANCE Composed ofirregular lobules of cartilage permeating bony trabeculae Has a hyaline cartilaginous matrix Chondrocytes present in lacunae with nuclear atypic
- 38. Treatment These tumor isgenerally not sensitive to chemo or radio therapy Surgery is only reliable treatment A wide resection is done for grade 3 and grade 2 chondrosarcomas Cartilagenous lesions of pelvis and sacrum recur after intralesional excision even if histologic appearance is beningn so wide excision recommended Radiotherapy though doesnt have a signi fi cant role has some use in unresectable lesions and incomplete resections as palliative care
- 39. Treatment Grade 1 withaggressive features wide resection is preferable but extended intralesional curretage without in reading risk of recurrence or mets can be done
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