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Lecture 1: Presentation and staging msk tumour
This document discusses the radiological presentation and staging of musculoskeletal tumors. It covers: 1. The importance of plain radiographs and MRI in assessing bone and soft tissue tumors. 2. A 6-point system for radiographic evaluation of bone lesions including location, pattern of bone destruction, periosteal reaction, lesion matrix, number of lesions, and age. 3. Examples of benign and malignant patterns of bone destruction, periosteal reactions, and lesion matrices. 4. Staging studies like CT, MRI, bone scan and chest CT to determine tumor type, prognosis, treatment and presence of metastases. 5. Staging systems for benign and malignant bone tumors as well as soft
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Lecture 1: Presentation and staging msk tumour
- 1. Radiological presentation and stagingof MSK tumours Nor Azman MZ
- 2. Radiological presentation • Plainradiograph very important for bone tumours • For soft tissue tumour radiographs are useful to identify osseous or mineralising lesions and what is the tumour effect on bone • MRI is superior in the assessment of a soft tissue mass.
- 3. RADIOGRAPHIC EVALUATION 1. Whatis the age? 2. Where is the lesion? location 3. What is the lesion doing to the bone? Pattern of destruction 4. How is the bone responding? Periosteal Reaction 5. What is in the lesion? Matrix 6. How many lesions?
- 4. What is theage?
- 6. Where is thelesion? location
- 7. Location Location can providesclues to its identity – Medullary – Medullary eccenteric – Cortical – Juxtacortical LOCATION BENIGN BONE TUMOR JUXTACORTICAL TUMOR
- 8. Location • Epiphyseal :PGCAT – PVNS – GCT – Chondroblastoma – ABC – Tuberculous & other infections • Metaphyseal – NOF, UBC, OSC, CSC • Diaphyseal – ES, EG, Osteoid Osteoma – metastasis
- 9. OSTEOID OSTEOMAOSTEOCHONDROMA Location :Juxtacortical
- 10. RADIOGRAPHIC EVALUATION 1. Whatis the age? 2. Where is the lesion? location 3. What is the lesion doing to the bone? Pattern of destruction 4. How is the bone responding? Periosteal Reaction 5. What is in the lesion? Matrix 6. How many lesions?
- 11. What is thelesion doing to the bone? • Pattern of destruction – Geographic – Moth-eaten – Permeative
- 12. Geographic Bone Destruction •Destructive lesion with sharply defined border • Implies a less-aggressive, more slow-growing, benign process • Narrow transition zone e.g – Non-ossifying fibroma – Chondromyxoid fibroma – Eosinophilic granuloma
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- 14. Moth-eaten Appearance • Areasof destruction with ragged borders • Implies more rapid growth • Probably a malignancy e.g Myeloma Metastasis Lymphoma Ewing sarcoma
- 15. Permeative Pattern • Ill-definedlesion with multiple “worm-holes” • Spreads through marrow space • Wide transition zone • Implies an aggressive malignancy – Round-cell lesions Leukemia Lymphoma, leukemia Ewing’s Sarcoma Myeloma Osteomyelitis Neuroblastoma
- 16. Less malignant Moremalignant
- 17. RADIOGRAPHIC EVALUATION 1. Whatis the age? 2. Where is the lesion? location 3. What is the lesion doing to the bone? Pattern of destruction 4. How is the bone responding? Periosteal Reaction 5. What is in the lesion? Matrix 6. How many lesions?
- 18. How is thebone responding ? Periosteal reaction – Benign • None • Solid – Malignant • Lamellated • Sunburst • Codman’s triangle
- 19. SUNBURST CODMANS LAMELLATED /ONION PEEL Periosteal Reaction SOLID Lessmalignant More malignant
- 20. RADIOGRAPHIC EVALUATION 1. Whatis the age? 2. Where is the lesion? location 3. What is the lesion doing to the bone? Pattern of destruction 4. How is the bone responding? Periosteal Reaction 5. What is in the lesion? Matrix 6. How many lesions?
- 21. WHAT IS THELESION ? MATRIX • Osteoblastic – Fluffy, cotton-like or cloud- like densities Osteosarcoma • Cartilaginous – Comma-shaped, punctate, annular, popcorn-like Enchondroma, chondrosarcoma, chondromyxoid fibroma • Ground glass appearance – Fibrous dysplasia
- 22. RADIOGRAPHIC EVALUATION 1. Whatis the age? 2. Where is the lesion? location 3. What is the lesion doing to the bone? Pattern of destruction 4. How is the bone responding? Periosteal Reaction 5. What is in the lesion? Matrix 6. How many lesions?
- 23. How many lesions? •Multiple bony lesion
- 24. DD for holesin the bone • FOGMACHINE – Fibrous dysplasia – Osteoid osteoma, osteoblastoma, osteosarcoma – Giant cell tumour – Myeloma – Aneurysmal Bone Cyst, adamantimoma – Chondromyxoid fibroma, chondroblastoma, chondrosarcoma – Hystiocytosis – Infection – Nonossifying fibroma – Enchondroma, Ewing sarcoma
- 25.
- 28. Staging Purpose • Determine tumortype • Determine prognosis • Guide treatment • Compare results between study groups • Delineate extent of local and distant disease
- 29. Staging Studies • PlainRadiograph • MRI • CT scan • Chest CT • Bone Scan
- 30. Plain Radiographs Evaluate: • Rateof tumor growth • Tumor interaction with surrounding non- neoplastic tissue • Internal composition of tumor
- 31. MRI Visualize entire boneand adjacent joint Best test for intraosseous extent and soft tissue extent Identify skip metastases Tumor proximity to neurovascular structures Occasionally helpful in diagnosis of bone or soft tissue tumors (experienced radiologist)
- 34. CT • Good forevaluating cortical details and destruction • Subtle cortical erosions (endosteal;periosteal) • not detectable on plain x-ray or MRI • Subtle calcifications / ossification (Visible tumor matrix mineralization)
- 36. Chest CT • Presenceof metastatic disease
- 37. Bone Scan • Wholebody bone scan • Sites of bony mets • Active lesion??
- 40. Staging • Benign StagingSystem • Stage 1: Latent – Grow slowly with growth of individual and then stop; tendency to heal spontaneously (ex. NOF; UBC) • Stage 2: Active Progressive growth • Stage 3: Aggressive
- 41. Grading G1 G2 LG ChondrosarcomaHigh Grade Chondrosarcoma Secondary Chondrosarc Conventional Osteosarcoma Parosteal Osteosarcoma Ewing’s Sarcoma/PNET Adamantinoma MFH Angiosarcoma
- 42. Staging Soft Tissue Sarcomas •Important Prognostic Characteristics –Tumor Size (>5cm, worse prognosis) –Tumor Depth (Deep, worse prognosis) –Grade (High grade, worse prognosis) –Presence of Mets
- 43. Grading Soft Tissue Sarcomas(Biological Behavior) • Tumors that are definitionally high grade – Ewing’s Sarcoma – PNET – Rhabdomyosarcoma – Angiosarcoma – Pleomorphic Liposarcoma – Soft Tissue Osteosarcoma – Mesenchymal Chondrosarcoma
- 44. Grading Soft Tissue Sarcomas(Biological Behavior) – Tumors that are definitionally low grade • Well Differentiated Liposarcoma • Dermatofibrosarcoma Protuberans • Infantile Fibrosarcoma • Angiomatoid MFH
- 45. Evaluating response tochemoRx