- Bone tumors can be benign, intermediate, or malignant lesions. They are classified based on factors like aggressiveness, metastatic potential, and histological grade.
- Imaging tools like x-rays, CT, MRI, and radionuclide scanning are used to evaluate bone tumors and detect any metastases. Biopsy is the gold standard for diagnosis.
- Treatment depends on the type and stage of the bone tumor. It may involve surgery, radiation therapy, chemotherapy, or a combination. The goal is to make the patient disease-free while preserving function and limb salvage when possible.
2. Epidemiology
• Bone and soft tissue sarcoma – derived from mesenchymal origin
• Bone sarcoma – 0.2%
• Male > Female
• Age – male >85 years , female- 50-60 years
9. General approach
• History- patient information, Pain , Mass
• Examination
• Investigation
• Imaging ( X rays , CT , MRI , Radionuclide scanning)
• Systemic evaluation ( in case of secondaries)
• PSA, Bence- Jones protein, Serum Calcium, ALP
• ESR , CRP
• Biopsy – gold standard
10.
11.
12. Clinical Presentation
• Asymptomatic
• Pain
• Swelling/mass
All superficial soft tissue lesions measuring >5cm and all deep seated lesions
should be considered a sarcoma until proven otherwise
• Pathological fractures
• Systemic findings
23. Lesions of the Spine
Older than 40 Years
• Metastases
Vertebral body, pelvis
Proximal femur, proximal humerus
skull
• Multiple myeloma
• Hemangioma
• Chordoma (in sacrum)
Younger than 30 Years
Vertebral body
• Histiocytosis
• Hemangioma
Posterior elements
• Osteoid osteoma
• Osteoblastoma
• Aneurysmal bone cyst
25. Sclerotic metastasis
• Prostatic Ca
• Breast Ca
• Transitional Cell Ca
• Carcinoid
• Mucinous Adeno Ca
Lytic bone metastasis
• Lung Ca
• Renal Cell Ca
• Thyroid Ca
• Adrenal gland Ca
• Uterine Ca
• Melanoma
26. • Computed tomography
• Shows accurately intraosseous and extraosseous extension
• Great for cortical bone evaluation
• Helps in staging
• MRI
• Defines local extent of lesion , tissue characterization
• Useful in assessing soft tissue tumor and cartilaginous tumor
• Radionuclide scanning
• 99mTcMDP – non specific reactive changes – reveal site of small
tumor (osteoid osteoma)
• Detecting skip lesions , evidence of metastatic disease
27. Enneking staging system
• Based on:
• Tumor grade
• Metastasis
• Confinement in compartment
• A compartment, for the purposes of this system, is defined as an
enclosed tissue space, such as a bone, a joint space or a muscle group
confined by its fascial envelope
28. Enneking staging system
Malignant
Stage Grade Site Metastasis
IA Low Grade Intra-
compartmental
No metastasis
IB Low Grade Extra-
compartmental
No metastasis
IIA High Grade Intra-
compartmental
No metastasis
IIB High Grade Extra-
compartmental
No metastasis
III Any Any Metastases
Benign
1. Latent—low biologic activity; well
marginated; often incidental findings (i.e.,
nonossifying fibroma)
2. Active—symptomatic; limited bone
destruction; may present with pathologic
fracture (i.e., aneurysmal bone cyst)
3. Aggressive—aggressive; bone
destruction/soft-tissue extension(i.e., giant
cell tumor)
33. Biopsy-Principles
• Referred to the institution where definitive treatment will take place.
• Should be done after clinical, lab and radiographic examinations
• Planned placement of biopsy incision
• biopsy track should be considered contaminated with tumor cells
• biopsy track needs to be excised en bloc with the tumor
• The surgeon performing the biopsy should be familiar with incisions
for limb salvage surgery and standard and nonstandard amputation
flaps
34. Biopsy- Principles
• If a tourniquet is used, the limb elevated before inflation but should
not be exsanguinated by compression to prevent “squeezing” the
tumor’s cells into the systemic circulation
• Transverse incisions should be avoided
• The deep incision should go through single muscle compartment
• Avoid major neurovascular structure
• Soft tissue extension of bone lesion should be sampled
35. Biopsy- Principles
• hole in the bone should be round
or oval
• Frozen section should be sent
intraoperatively to ensure that
diagnostic tissue has been
obtained
• meticulous hemostasis ensured
before closure
• Drain should exit in line with the
incision
• Wound should be closed tightly in
layers
36. Biopsy- Principles
• Sample should be sent for microbiology as well as histology
• The pathologist reporting biopsy must have an appropriate level of
experience
• If risk of fracture following biopsy, bone must be splinted
40. Management
• Primary Goal with primary malignancy- make patient disease free
• Goal of treatment of patient with metastatic carcinoma to bone:
Minimize pain
Preserve function
Optimal treatment of tumor :
Surgery
Radiation therapy
Chemotherapy
41. Radiation therapy
• Blue cell tumor
• Multiple myeloma
• Lymphoma
• Ewings sarcoma
• Secondaries (Except – RCC)
• Reduce local recurrence of malignant soft tissue tumor
Bone sarcoma – 0.2% of all new cancers diagnosed UK , Appleys
Age-specific incidence rates (ASIR) for soft-tissue sarcomas and primary sarcomas of bone (a) Softtissue sarcomas in the UK 1996–2010; (b) primary bone sarcomas in the UK for the same period (National Cancer Intelligence Network (NICN) data).
bone sarcomas demonstrate a bimodal distribution in both males and females, with peaks of incidence seen in both teenage/adolescent years and the elderly
Benign – doesn’t invade and spread surrounding tissue, non destructive , surgical resection – curative
Osteoblastoma – infiltrative and locally destructive growth pattern – en bloc resection – curative
Higher grade tumor have > 25% chance of local recurrence and distant spread
Low grade lesion< 25 % chance of local recurrence and mets
IF tumors are analyzed, there is preferential sites of origin within each bone. A particular tumor of given cell type usually arises in the field where homologous normal cells are most active . Eg GCT
Age , Sex (GCT: F>M), Race , Hereditary – Multiple hereditary exostosis AD
Katanoda, K., Shibata, A., Matsuda, T., Hori, M., Nakata, K., Narita, Y., … Nishimoto, H. (2017). Childhood, adolescent and young adult cancer incidence in Japan in 2009–2011. Japanese Journal of Clinical Oncology, 47(8), 762–771
CMF = Chondromyxoid fibroma
SBC = Simple Bone Cyst
EG = Eosinophilic Granuloma
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
Pain – night pain referred pain
Pathological fractures – 5-12% osteosarcoma , 21% in chondrosarcoma
s/c # of femur in children, avulsion # of L/T in adults – bone tumors
Very little trabecular bone in the diaphysis to provide an interface to allow the lesion to be seen
Simple Bone Cyst /unicameral bone cyst
If diaphyseal lesion is on radiograph cortex is involved , large medullary cavity diaphyseal lesion may be invisible d/t little trabecular bone in diaphysis to provide interface to allow lesion to be seen
Osteoid osteoma
99mTcMDP – methyl diphosphonate
aid in treatment decision making, provide some determination of prognosis, and allow meaningful comparisons of treatment methods.
A compartment, for the purposes of this system, is defined as an enclosed tissue space, such as a bone, a joint space or a muscle group confined by its fascial envelope
Low grade : well differentiated , few mitoses and exibit moderate cytological atypia , risk of mets<25%
High grade : high cell to matrix ratio
A: well defined anatomical compartment (cortex, joint capsule , fascial septa)
Tumor node metastasis staging- applied to primary sarcomas of bone
AJCC System – based on prognostic variables
Stage I- low grade , II high grade
Skip metastasis – discontinuous lesion within the same bone
Since the patient with non pulmonary metastasis from osteosarcoma and ewings sarcoma have worse prognosis than with pulmonary mets
Raw area is covered with bone wax or methylmethacrylate cement to reduce bleeding , contamination from cut bone edge
because they are extremely difficult or impossible to excise with the specimen
single muscle compartment rather than contaminating an intermuscular plane
round or oval to minimize stress concentration and prevent a subsequent fracture
The hole should be plugged with methacrylate to limit hematoma formation.
meticulous hemostasis ensured before closure, because a hematoma would be contaminated with tumor cells
Drain should exit in line with the incision so that the drain track also can be easily excised en bloc with the tumor
Complications : infection , bleeding/hematoma , pathological fracture , tumor contamination and seeding
FNAC : 90% accurate in dx malignancy
Core needle biopsy : accuracy 84-98%
Excisional biopsy : <3cm , sc mass , unlikely malignant – osteoid osteoma , osteochondroma
Painful lesion in proximal fibula and distal ulna
Large opacification on medial thigh separate from femur
Osteopetrosis – Marble bone disease- confused with sclerotic metastates from breasr and prostate ca , Pagets disease
Osteopoikilosis- AD sclerosing bone dysplasia formation of multiple bone island
Melorheostosis- mesenchymal dysplasia – widening and sclerosing of cortices in sclerotomal distribution
Adjuvant chemotherapy refers to chemotherapy administered postoperatively to treat presumed micrometastases.
Neoadjuvant chemotherapy refers to chemotherapy administered
before surgical resection of the primary tumor
