This document provides an overview of osseous bone tumors, including benign and malignant types. It discusses key benign tumors like osteoid osteoma, osteoblastoma, and bone islands. It also covers osteosarcoma in depth, describing its various subtypes, characteristics, diagnosis involving imaging and biopsy, Enneking staging system, and treatment approaches including chemotherapy, surgery, and prognosis factors. The summary focuses on key details about classification and management of important osseous bone tumors.

1. INTRODUCTION,SYMPTOMS,SIGNS,
MANAGEMENT AND COMPLICATIONS
OF OSSEOUS BONE TUMORS.
DR. MEERAVALI SHAIK
2ND YR PG
ASRAM , ELURU,AP.

2. INTRODUCTION
 Bone tumors may be chondrogenic, osteogenic, fibrogenic,
vascular, myelogenic and other mesenchymal derivatives.
 Bone tumors forming osteoid matrix are known as osseous
bone tumors.
 They are divided into Benign & Malignant.

3. BENIGN MALIGNANT
1. OSTEOID OSTEOMA.
2. OSTEOBLASTOMA.
A. BENIGN,
B. AGGRESSIVE.
3. OSTEOMA.
4. BONE ISLAND
(ENOSTOSIS).
1. OSTEOSARCOMA (O.S).
A. INTRAMEDULARY O.S
(CONVENTIONAL,TELANGIECTATIC
& WELL DIFFERENTIATED)
B. INTRACORTICAL O.S
C. SURFACE O.S
(PERI;PRA;&HIGHGRADE)
D. SECONDARY O.S
E. EXTRA SKELETAL O.S.
F. O.S ASSO; WITH SYNDROMES.
OSSEOUS BONE TUMORS

4. BENIGN OSTEOBLASTIC BONE TUMORS :

5. OSTEOID OSTEOMA
 It is a well-demarcated osteoblastic mass
(NIDUS) surrounded by a zone of reactive
bone sclerosis,(<1.5 cm).
 10% to 12% of all benign bone tumors.
 Age – 2nd / 3rd decade (M/F-2:1).
 Location – 50% cases involve femur & tibia.
(M.C. femoral neck, never in craniofacial
bones).

6.  Pain is worst at night and relieved by aspirin or NSAIDS.
 Swelling , stiffness if joints involved.
 Painful Scoliosis, if vertebra is involved.
 Significant length discrepancy in young patients with open
growth plates may produce.
 PG-E2, PROSTACYCLIN & COX-2.
CLINICAL FEATURES:

7. DIAGNOSIS:
Radiograph :- A well-demarcated
lytic lesion (nidus) surrounded by a
distinct zone of sclerosis.
CT :- Shows cortically based nidus
surrounded by sclerosis more clearly.
MRI:- Demonstrate extensive
surrounding edema.
Bone scan:- Increased uptake on
Tc99 bone scans.

8. Microscopy:-
 Immature bony trabeculae that are rimmed by prominent
osteoblasts.
 It is similar to osteoblastoma with the exception that
osteoblastomas are larger.
 No nuclear atypia or aggressive features.

9. TREATMENT:
 Spontaneous healing within 3-4 yrs.
 NSAIDS (30-40MONTHS).
 Curettage or Wide en-bloc resection along
with sclerotic rim with bone grafting.
 Percutaneous radiofrequency ablation.
 MRgFUS ablation is a new technique
(non invasive &radiation free).
BURR DOWN PROCEDURE
RADIO FREQUENCY ABLATION

10. OSTEOBLASTOMA
 These are benign tumor, usually >1.5cm, closely related to
osteoid osteoma.
 They differs from osteoid osteoma showing,
1. Higher growth potential,
2. Lacks distinct nocturnal pain which relieved by Aspirin,
3. Peripheral sclerosis may be minimal or absent.

11.  Age: 5-45 yrs (2nd & 3rd decade).
 M:F is 2:1.
 Incidence : <1% of all primary bone tumor.
 M.C location -Axial skeleton(>40%).
 2nd M.C - jaw bone craniofacial bones
 Osteoblastomas:-
1. Benign osteoblastomas(1.5-4cm),
2. Aggressive osteoblastomas(>4cm).
[CEMENTOBLASTOMA]

12.  Dull, aching, nocturnal pain not relieved by aspirin.
 Posterior elements of spine are M.C. involved.
 In spine-neurologic deficit & painful scoliosis.
 If Thoracic spine involved- cord compression is M.C.
 Slow growing tumor Symptoms may be present for 1 to 2 years
before the diagnosis is made.
CLINICAL FEATURES:

13. DIAGNOSIS:
Radiography:-
 More often, features are similar to
osteoid osteoma.
 Shows a round or oval, well-
demarcated metaphyseal lytic
defect surrounded by a zone of
reactive sclerosis. PEDICLE

14. CT:- Helps in better localization of
lesion.
MRI:- Helps in extension & soft tissue
involvement by tumor.

15. Microscopy:-
 Tumor is composed of woven bone spicules which are
arranged haphazardly.
 Prominent rimming osteoblasts and multinucleated
osteoclast-like giant cells are present.
 Rich vascularity.
 Osteoblast may have mitosis but not atypical.
 Secondary ABC like changes may be seen.

16. TREATMENT:
 Extended curettage.
 Wide resection, +/- bone grafting.
 In spine , instrumentation may be required for stability.
 Adjuvant radiation can be tried in spinal lesions.
 Sarcomatous degeneration is seen if treated previously with
radiation.

17.  These are benign, slow-growing, dysplastic, sclerotic bony
lesions. They are divided into :
(1) Calvarial and mandibular ivory exostoses.
(2) Sino-orbital osteomas.
(3) Surface (juxta-cortical) osteomas of long bones.
(4) Enostoses or Bone islands.
 Age group - Adolescents
OSTEOMAS

18. CINICOPATHOLOGICAL VARIENTS OF OSTEOMAS:

19. CLINICAL FEATURES:
 External tumors are asymptomatic.
 Internal tumors are symptomatic.
 Intra-cranial osteomas cause seizures and headache.
 Intra-orbital osteomas cause exophthalmos.
 Intra-nasal tumors cause epistaxis.
 O/E – painless rocky hard fixed mass is palpated.

20. IVORY EXOSTOSIS
(PAROSTEAL
OSTEOMA) OF SKULL
SINOORBITAL OSTEOMA SURFACE OSTEOMA
OF FIBULA
(No cartilage cap)
DIAGNOSIS
Radiography:-

21. Microscopy:-
 Shows dense compact bone with prominent haversian
systems covered by a fibrous tissue capsule continuous with
periosteum.

22. TREATMENT:
 Once the osteoma reaches a certain size, it remains stationary.
 It does not undergo malignant change.
 Excision is indicated for diagnostic or cosmetic or symptomatic
cases.

23. BONE ISLAND (ENOSTOSIS)
 Dense foci of compact bone within cancellous bone.
 Measure from 0.1 to 2.0 cm.
 Any bone can be involved ,(M.C. Pelvis & Femur).
 OSTEOPOIKILOSIS (Spotted Bone Disease ) multiple bony
islands through out the skeleton.
 C/F:- Asymptomatic usually and found incidentally.

24. DIAGNOSIS:
Radiograph :-
 They are dense ovoid, with the long axis parallel to the
cortex of the affected bone.
 The characteristic feature :Presence of radiating spicules or
pseudopodia at the periphery.
Bone scan :- Mildly increased uptake.

25. CT :- Dense bone with
thickened trabeculae that
merge with surrounding bone.
MRI :- Well defined dark lesions on
both T1 & T2 images.
Histology:- Thickened trabeculae
that merge with normal bone.
No sclerotic rim.

26. TREATMENT:-
 Observation.
 If patient experiences pain or if lesion grows,
biopsy is indicated to rule out aggressive lesions (sclerosing
osteosarcoma, blastic metastasis or sclerotic myeloma).

27.  Defined as a malignant tumor of bone in which malignant
mesenchymal tumor cells produce osteoid or immature bone.
 M.C non hematological primary malignancy of bone(20%).
 2nd M.C. primary malignant bone tumor.
OSTEOSARCOMA

28.  Bimodal distribution (M.C.2nd decade &>50yrs).
 The sex ratio1.3 : 1 to 1.6 : 1 (M>F).
 50%cases are located in the knee region.
 The distal femoral>proximal tibia>proximal
humerus.

29. OSTEOSARCOMAS

30. O.S. AGE/SEX SITE FEATURES PROGNOSIS
Conventional
OS ( M C)
2nd decade
M>F
Metaphysis
(91%)of long
bones.
Pain, swelling,
path #
ALP
High grade
If untreated
fatal
Telangiectatic
OS (<4%)
2nd decade
M>F
Metaphysis of
long bones
Pain,swelling
path #, blood
filled spaces
divided by
septae. ALP
As above
Small cell
OS(1.5%)
2nd decade,
slightly mc in
female
>50%
metaphysis of
long bones
Pain, swelling
HPE – blue
cells similar to
Ewings.
High grade,
Slightly worse
than
conventional
Well-
differentiated
OS(1-2%)
2nd-3rd ,
M=F
80% in long
bones
Benign course,
irregularly
aranged
trabeculae with
atypical spindle
cells.
Excellent
INTRA MEDULLARY O.S.:-

31. AGE/SEX SITE C/F PROGNOSIS
Periosteal
OS,<2%
2nd decade
M>F
Dia-meta
region of long
bones.
tibia>femur
Painless
swelling
initially, later
pain. spindle
cells radiating
b/w lobules of
cartilage
Intermediate
grade,
Excellent.
Parosteal OS.
(3%)
3rd &4th
decade,
F>M.
Long bones Lobulated
ossified mass in
posterior aspect
of distal femur.
Excellent.
High grade
surface OS
(least
common)
2nd decade
M>F
Long bones Mass &/or pain
highly invasive,
associated with
medullary
involvement
Depend upon
response to
chemotherapy
SURFACE OSTEOSARCOMAS:-

33. AGE/SEX SITE C/F PROGNOSIS
Post-radiation
OS.(3.4%-5%)
older Any bone,
unusual sites
– skull, spine
pelvis &
shoulder
region
Pain, swelling 5yr survival
rate for
extremity
lesion is
68.2% & axial
lesion 27.3%.
OS sec. to
paget’s dis;
65yr
M>F,2:1
Mc - pelvis,
skull.
Pain, swelling,
path#
Poor.
OTHER O.S.:-

34. DIAGNOSIS:
 Radiographically, lesions
can be predominantly lytic or
sclerotic, but usually mixed
features.
 Associated cortical destruction
with soft tissue extension
 Codman’s triangle.
 Sunburst / hair on end
appearance.
 Onion peel appearance.
PERIOSTEAL REACTIONS

35. MRI:-
 Soft tissue extension.
 Intramedullary spread.
 Neurovascular involvement.
Bone scan:- Detect skip lesions.
Ct chest : Detect metastasis.

36. ENNEKING STAGING:

38. TREATMENT:
HIGH GRADE LESIONS:-
Neoadjuvant chemotherapy (x 2-3months)
Limb-sparing surgery
Adjuvant chemotherapy (x 6-12 months)
LOW GRADE LESIONS:-
Can be treated with wide resection / amputation with or
without chemotherapy.

39. CHEMOTHERAPY :-
Given as single drug or multiple drug regimen in two forms.
 Neo adjuvant chemotherapy:
High dose Methotrexate(8-12gm/m2 4 cycles every 3wks)
(Rosen T-10 protocol).
Muramyl-transpeptidase,
Adriamycin,
Cisplatin.
 Adjuvant chemo: Same regimen as preop , usually 4-6 cycles.
Note :- After neo adjuvant tt, if tissue necrosis >90% good prog;
<90%bad prog;.

40. limb salvage:- Tumor excision
Intra capsular, marginal, wide & Radical
Excision.
• Custom made megaprosthesis, after limb
salvage.
• ECIR(ExtraCorporeal Irradiated & Reimplantation):-
(Emerging limb salvage surgery).
Radiotherapy:-
 Only for palliation.

41. PROGNOSIS:
 Depends upon
Extent of disease at the time of diagnosis:-
Patients with pulmonary metastases and skip
metastases have poor prognosis.
Grade of the lesion:-
High grade – poor prognosis .
Low grade – good prognosis .
Size:- Large tumor- worse prognosis.
Skeletal location :- More proximal tumors have worse
prognosis since they are larger at the time of diagnosis.

42. REFERENCES :
1. DORFMAN & CZERNIAK’S BONE TUMORS 2ND EDI;
2. CAMPBELL’S 13TH EDI;
3. APLEY’S 9TH EDI;
4. PUBMED;

43. THANK YOU…