BONE TUMORS FOR UG LEVEL

1. BONE TUMOURS
DR.SUNIL KUMAR
ASST.PROFESSOR
DEPT.OF GEN.SURGERY
MNR MEDICAL COLLEGE
18-12-2018

2. • Benign tumours
• Tumour-like conditions of bone
• Osteoclastoma (GCT)
• Osteochondroma
• Primary malignant tumours
• Aneurysmal bone cyst
• Some uncommon malignant tumours
• Fibrous dysplasia
• Metastasis in bone

3. • The term ‘bone tumour’ is a broad term used
for benign and malignant neoplasms, as well
as ‘tumour-like conditions’ of the bone (e.g.,
osteochondroma).
• Metastatic deposits in the bone are commoner than
primary bone tumours of the primary bone
malignancies, multiple myeloma is the commonest.

4. • Osteochondroma is the commonest benign
tumour of the bone.
• Most primary malignant bone tumours occur
in children and young adults; in whom these
constitute one of the common malignant
tumours.
• The nature of a bone tumour can be
suspected based on the type of destruction
seen on an X-ray ( Table–28.1).

6. BENIGN TUMOURS
OSTEOMA
• This is a benign tumour composed of sclerotic, well
formed bone protruding from the cortical surface of a
bone.
• The bones involved most often are the skull and facial
bones.
• Generally, the tumour is of no clinical significance
except that it may produce visible swelling.
Treatment:
No treatment is generally required except for cosmetic
reasons, where a simple excision is sufficient.

7. OSTEOID OSTEOMA
• It is the commonest true benign tumour of the bone.
Clinical presentation:
• 5-25 years.
• Tibia being the commonest.
• The tumour is generally located in the diaphysis of long
bones.
• Posterior elements of the vertebrae are a common site.
• The presenting complaint is a nagging pain, worst at
night, and is relieved by salicylates.

8. Diagnosis:
It is generally confirmed on X-ray.
• The tumour is visible as a zone of sclerosis
surrounding a radiolucent nidus, usually less
than 1 cm in size (Fig-28.1a).
• In some cases, the nidus may not be seen on a
plain X-ray because of extensive surrounding
sclerosis, and may be detected on a CT scan.

11. Treatment:
• Complete excision of the nidus along with the
sclerotic bone is done.
• Prognosis is good.
• It is not a pre-malignant condition.

12. UNCOMMON BENIGN TUMOURS OF THE
BONE
OSTEOBLASTOMA:
• This is a benign tumour consisting of vascular osteoid
and new bone.
• It occurs in the jaw and the spine.
• It occurs in 2nd decade of life.
• The patient presents with an aching pain.
Radiologically,
• It is a well-defined radiolucent expansile bone lesion 2-
12 cm in size.
• There is minimal reactive new bone formation.
Treatment is by curettage.

13. CHONDROBLASTOMA:
• This is a cartilaginous tumour containing characteristic
multiple calcium deposits.
• It occurs in young adults, and is located around the
epiphyseal plate.
• Bones around the knee are commonly affected.
Radiologically,
• Well-defined lytic lesion surrounded by a zone of sclerosis.
• Areas of calcification within the tumour substance give rise
to a mottled appearance (Fig-28.1b).
• Treatment is by curettage and bone grafting.

15. Haemangioma of the bone
• This is a benign tumour of angiomatous origin,
commonly affecting the vertebrae and the skull.
• It occurs in young adults.
• Common presenting symptoms are persistent pain
and features of cord compression.
• Typically, one of the lumbar vertebrae is affected.

16. • Radiologically, it appears as loss of horizontal
striations and prominence of vertical striations
of the affected vertebral body.
• The importance of this tumour lies in
differentiating it from commoner diseases like
TB spine or metastatic bone disease of the
spine.
• Treatment is by radiotherapy.

17. ADAMANTINOMA
• It is a common tumour of the jaw bone; also
sometimes occurring in the tibia in its lower-half.
• 10-35 years of age.
• Minimal pain, and it increases in size gradually.
• Typically, it appears as a honeycomb-like, loculated
lesion on X-ray.
• Local recurrence is common.
• Treatment is by resection.

18. CHORDOMA
• This is a locally malignant, sometimes actually
malignant tumour supposedly originating from the
remnants of notochord.
• Sacrum and cervical spine are common sites.
• Persistent pain and swelling,
• Bone destruction is the only hallmark feature of this
tumour.
• Treatment, wherever possible, is complete excision.
• If complete excision is not possible, radiotherapy is
done.

19. OSTEOCLASTOMA (GIANT CELL TUMOUR)
• Giant cell tumour (GCT) is a common bone tumour
with variable growth potential.
PATHOLOGY
• The cell of origin is uncertain.
• Microscopically, the tumour consists of
undifferentiated spindle cells,profusely interspersed
with multi-nucleate giant cells.

20. • The tumour stroma is highly vascular.
• These giant cells were mistaken as osteoclasts in the
past, hence the name osteoclastoma.
CLINICAL FEATURES
• Age group of 20-40 years i.e., after epiphyseal fusion.
• Around the knee i.e.lower-end of the femur and upper-
end of the tibia.
• Lower-end of the radius is another common site.
• Presenting complaints are swelling and vague pain.

21. EXAMINATION
• Bony swelling eccentrically located at the end of the
bone.
• Surface of the swelling is smooth.
• There may be tenderness on firm palpation.
• A characteristic ‘egg-shell crackling’ is often not
elicited..

22. DIAGNOSIS
• GCT is one of the common cause of a solitary lytic
lesion of the bone, and must be differentiated from
other such lesions (Table–28.3).
RADIOLOGICAL FEATURES
• A solitary, may be loculated, lytic lesion.Eccentric
location, often subchondral.
• Expansion of the overlying cortex (expansile lesion).

26. • ‘Soap-bubble’ appearance – the tumour is
homogeneously lytic with trabeculae of the
remnants of bone traversing it, giving rise to a
loculated appearance.
• No calcification within the tumour.
• None or minimal reactive sclerosis around the
tumour.

27. TREATMENT
• Wherever possible, excision of the tumour is the best
treatment.
• For sites like the spine, where excision is sometimes
technically not possible, radiotherapy is done.
Following treatment
methods are commonly used:
a) Excision: This is the treatment of choice when
the tumour affects a bone whose removal does not
hamper with functions e.g., the fibula, lower-end of
the ulna etc.

28. b) Excision with reconstruction:
• For example, in tumours affecting the lower-end of
femur, the affected part is excised en bloc, and the
defect thus created made up by one of the following
methods:
• Arthrodesis by the Turn-o-Plasty procedure (Fig-
28.3a):

30. • Arthrodesis by bridging the gap by double fibulae
(Fig-28.3b), one taken from same extremity and the
other from the opposite leg (Yadav, 1990).
• Arthroplasty: In this procedure, the tumour
is excised, and an attempt is made to reconstruct the
joint in some way.

31. c) Curettage with or without supplementary
procedures:
• Curettage performed alone has the disadvantage of a
high recurrence rate.
• Cryotherapy, where liquid nitrogen is used to
produce a freezing effect and thus kill the residual
cells, and thermal burning of the residual cells using
cauterization of the walls of the tumour are popular.
• ‘bone cement’, which by the heat it produces while
setting, ‘kills’ the residual cells.

32. d) Amputation: For more aggressive tumours, or
following recurrence, amputation may be necessary.
e) Radiotherapy: It is the preferred treatment method
for GCT affecting the vertebrae.

33. PROGNOSIS
• Recurrence following treatment is a serious
problem.
• With every subsequent recurrence, the
tumour becomes more aggressive.

34. PRIMARY MALIGNANT TUMOURS
OSTEOSARCOMA (OSTEOGENIC SARCOMA)
• Osteosarcoma is the second most common, and a
highly malignant primary bone tumour.
Pathology:
• An osteosarcoma can be defined as a malignant
tumour of the mesenchymal cells, characterised by
formation of osteoid or bone by the tumour cells.

35. Clinical features
• Pain is usually the first symptom, soon
followed by swelling.
• Patient presents with a pathological fracture.

37. Examination:
• The swelling is in the region of the metaphysis.
Skin over the swelling is shiny with prominent
veins.
• The swelling is warm and tender.
• Margins of the swelling are not well defined.
• Movement at the adjacent joint may be limited
• Regional lymph nodes may be enlarged.

38. Radiological examination:
X-ray shows the following features (Fig-28.4):
• An area of irregular destruction in the
metaphysis, sometimes overshadowed by the
new bone formation.
• The cortex overlying the lesion is eroded.
• There is new bone formation in the matrix of
the tumour.

40. Codman’s triangle:
• A triangular area of subperiosteal new bone is
seen at the tumour-host cortex junction at the
ends of the tumour.
• Sun-ray appearance: New bone is laid down
along the blood vessels within the tumour
growing centrifugally, giving rise to a ‘sun-ray
appearance’ on the X-ray.

41. Serum alkaline phosphatase (SAP):
• It is generally elevated, follow up of a case of
osteosarcoma.
• A rise of SAP after an initial fall after tumour
removal is taken as an indicator of recurrence or
metastasis.
Biopsy:
• An open biopsy is performed to confirm
the diagnosis.

42. Treatment
a) Confirmation of the diagnosis
• Histologically, tumour new bone formation is
pathognomonic of osteosarcoma.
b) Evaluation of spread of tumour.
• Lung is the earliest site for metastasis.

43. • To plan amputation surgery: Complete removal
of local tumour
• To plan a limb saving operation: In cases presenting
early, a radical excision of the tumour is being
performed these days (limb saving surgery), thus
avoiding amputation.
Methods used for precise evaluation of spread of the
tumour locally are:
• Bone scan for finding the intra-medullary spread
(‘skip’ lesions),
• CT and MRI scans for finding the soft tissue spread.

44. c) Treatment of the tumour
Local control:
• This is achieved by surgical ablation.
• Amputation remains thTable–28.5 gives the
recommended levels of amputation in osteosarcoma
at common sites.

46. Role Of Radiotherapy:
• Radiotherapy is used for local control of the
disease for tumours occurring at surgically
inaccessible sites, or in patients refusing
surgery.
Control of distant macro or micro-metastasis.
• These are effectively controlled by adjuvant
chemotherapy, immunotherapy etc.
• A solitary lung metastasis -excision.

47. Role of Chemotherapy:
• Chemotherapy has revolutionised the
treatment of osteosarcoma.
• The drugs used are high dose Methotrexate,
Citrovorum factor, Endoxan, and sometimes
Cisplatinum.
• These drugs are highly toxic and should be
given in centres where their side effects can
be effectively managed.

48. Role of Immunotherapy:
• This is a new concept not yet practiced widely.
• In this technique, a portion of the tumour is
implanted into a sarcoma survivor and is removed
after 14 days.
• The sensitised lymphocytes from the survivor are
infused into the patient.
• These cells then selectively kill the cancer cells.
d) Follow up: The patient is checked up every 6-8
weeks. Flow chart-28.1.

50. Prognosis:
• Without treatment, death occurs within 2 years,
usually within 6 months of detection ofmetastasis.
• 5-year survival with surgery alone is 20 per cent.
• With surgery and adjuvant chemotherapy a 5-year
disease free period is reported to be as high as 70
per cent.
• A primarily lytic type (telangiectatic) osteosarcoma
has the worst prognosis.

51. SECONDARY OSTEOSARCOMA
• This is an osteosarcoma developing in a bone
affected by a pre-malignant disease.
• Treatment is along the lines of the
conventional osteosarcoma.

52. PAROSTEAL OSTEOSARCOMA
• This is a type of osteosarcoma, arising in the region
of the periosteum.
• It is a slower growing tumour, seen in adults.
• The common site is lower-end of the femur.
• Treatment is on the lines of osteosarcoma.
• Prognosis is better.

53. EWING’S SARCOMA
• This is highly malignant tumour occurring between
the age of 10-20 years, sometimes up to 30 years.
Bones affected:
• It commonly occurs in long bones (in two-third
cases), mainly in the femur and tibia.
• About one-third of cases occur in flat bones, usually
in the pelvis and calcaneum.

54. Site: The tumour may begin anywhere, but
diaphysis of the long bone is the most common
site.
Clinical features:
• The tumour occurs between 10-20 years of age.
• The patient presents with painand swelling.
• There may be a history of trauma
• Fever

55. Examination:
Swelling is usually located in the diaphysis and
has features suggesting a malignant swelling.
Radiological features:
• In a typical case, there is a lytic lesion in the
medullary zone of the midshaft of a long
bone, with cortical destruction and new bone
formation in layers – onion-peel appearance
(Fig- 28.5).

57. Differential diagnosis:
• Ewing’s sarcoma can be differentiated from other
bone tumours.
• From chronic osteomyelitis, it can be differentiated
by the following features in the former:
• Sequestrum
• Well-defined cloacae and a rather smooth periosteal
reaction located at metaphysis.

59. Treatment:
• This is a highly radio-sensitive tumour,melts
quickly but recurs.
• Treatment consists of control of local tumour by
radiotherapy (6000 rads), and control of
metastasis by chemotherapy.
• Chemotherapy consists of Vincristine,
Cyclophosphamide, and Adriamycin in cycles,
repeated every 3-4 weeks for about 12- 18 cycles.
.

60. Prognosis:
• It is very poor.
• Bone to bone secondaries are very common.
• 5-year survival (which was only 10%), has
now improved to 30-40%

61. MULTIPLE MYELOMA
• It is a malignant neoplasm derived from plasma cells.
Clinical features:
• 40 years of age.
• Men >women.
• Common presenting complaint is increasingly severe
pain in the lumbar and thoracic spine.
• Pathological fractures, especially of the vertebrae
and ribs may result in acute symptoms.

62. • Neurological symptoms may result if the tumour
presses on the spinal cord or the nerves in the spinal
canal.
• There is local tenderness over the affected bones.
Radiological examination
• Characteristic radiological features are as follows (Fig-
28.6):
• Multiple punched out lesions in the skull and other flat
bones.
• Pathological wedge collapse of the vertebra, usually
more than one, commonly in the thoracic spine.

64. Other investigations
• Blood: Low haemoglobin, high ESR (usually very
high), increased total protein, A/G ratio reversed,
increased serum calcium, normal alkaline
phosphatase.
• Urine: Bence Jones proteins are found in 30 per
cent of cases.
• Serum electrophoresis: Abnormal spike in the
region of gamma globulin (myeloma spike is
present in 90 per cent of cases.
• Sternal puncture: Myeloma cells may be seen.

65. • Bone biopsy from the iliac crest, or a CT guided
needle biopsy from the vertebral lesion may
show features suggestive of multiple
myeloma.
• Bone scan:
• Open biopsy

66. TREATMENT
It consists of control of the tumour by
chemotherapy and splintage to the diseased
part by PoP, brace etc.
• Radiotherapy plays a useful role in cases with
neurological compression, localised painful
lesions, fractures and soft tissue masses.
• Complications like pathological fractures must
be prevented by splinting the affected part.

67. Chemotherapy:
• Melphalan is the drug of choice.
• It is given in combination with Vincristine,
Prednisolone, and Cyclophosphamide.
• The cycles are repeated every 3-4 weeks for 6-
12 cycles.

68. SOME UNCOMMON MALIGNANT
TUMOURS
CHONDROSARCOMA
• This is a malignant bone tumour arising from
cartilage cells.
• It may arise in any bone but is common in flat bones
such as scapula, pelvis and ribs.

69. Diagnosis
• It occurs commonly in adults between 30-60 years of
age, and is rare in children.
• Metastasis occurs through the blood vessels,
commonly to the lungs.
• Presenting symptoms are pain and swelling
• X-ray shows erosion of the cortex and bone
destruction.
• The tumour matrix may have mottled calcification,
typical of a cartilaginous tumour (Fig-28.7).
• Diagnosis is confirmed by a biopsy.

71. Treatment
• Depends upon the behaviour of the tumour.
• Amputation is necessary for most tumours.
• In some low grade tumours, after proper
assessment, wide resection of the tumour is
done (limb saving surgery).

72. SYNOVIAL SARCOMA
• This is a malignant tumour, histologically a
combination of synovial cells and fibroblasts.
• It occurs most commonly around the knee.
• The tumour spreads via the blood vessels,
lymphatics, and along the soft tissue planes.
• Treatment is by amputation
• Prognosis is poor.

73. METASTASIS IN BONE
• Metastatic tumours in the bone are commoner than
the primary bone tumours.
• The tumours most commonly metastasising to bone
are carcinoma of the lung in the male and carcinoma of
the breast in the female.
• Other malignancies metastasising to the bone are
carcinoma of prostrate, carcinoma of thyroid etc.
CLINICAL FEATURES
• A patient with secondaries in the bone may present in
the following ways:

74. • a(i) bone pain – in the spine (commonest site), ribs or
extremities; and
(ii) pathological fracture – commonly in the spine.
• b) It may be a patient, not a known case of primary
malignancy, who presents with:
(i) bone pain
(ii) a pathological fracture through an area of bone
weakened by such a lesion.
• Malignancies which are known to present first time
with secondaries (with silent primary) are carcinoma of
thyroid, renal cell carcinoma, carcinoma of the bladder
etc.

75. INVESTIGATIONS
• A case of secondaries in the bone can be
investigated as follows:
a) In a case with known primary, a complaint of
bone pain may be due to metastatic lesion of
the bone.
b) On plain X-rays, 20-25 % or more of
metastatic deposits are missed. (Fig-28.8).
c) PET scan is the most recent imaging modality
for early detection of metastasis.

77. • b) In a case presenting first time with bony
secondaries, a systematic investigation
programme is required to detect the primary.

78. Radiological examination
• Majority of bone secondaries are osteolytic,
but a few are osteoblastic.
• Carcinoma of the prostate in males and
carcinoma of the breast in females are the
commonest tumours to give rise to sclerotic
secondaries in the bone.

79. Blood:
• A high ESR, and an elevated serum calcium are
indications of bony secondaries in a suspected
case.
Other investigations:
• These depend upon the site suspected on clinical
examination.
• In a secondary without a known primary, useful
investigations are an abdominal ultrasound, Ba
studies, IVP, thyroid scan etc.

80. Treatment:
• It consists of symptomatic relief of pain,
prevention of any pathological fracture, and
control of secondaries by chemotherapy or
radiotherapy, depending upon the nature of
the primary tumour.
• Role of surgery is limited, mostly to the
management of pathological fractures.

81. TUMOUR-LIKE CONDITIONS OF THE BONE
OSTEOCHONDROMA
• This is the commonest benign “tumour” of the
bone.
• It is a result of an aberration at the growth
plate, where a few cells from the plate grow
centrifugally as a separate lump of bone.

83. Clinical presentation:
• The patient, usually aroundadolescence,
presents with a painless swelling around a
joint, usually around the knee.
• There may be similar swellings in other parts
of the body in case of multiple exostosis .

84. Treatment:
• When necessary, the tumour should be
excised.
• The excision includes the periosteum over the
exostosis; since leaving it may result in leaving
a few cartilage cells, which will grow again and
cause recurrence of the swelling.

85. MAFFUCCI SYNDROME
• This is a hereditary disorder where multiple
enchondromas and cavernous haemangiomas
occur together.

86. SIMPLE BONE CYST
• This is the only true cyst of the bone, different
from other lesions, which though appear clear
‘cyst-like’ on X-ray, are actually osteolytic,
some-times solid lesions.

88. Treatment:
• The cyst is known to undergo spontaneous
healing, particularly after a fracture.
• One or two injections of methylprednisolone
into the cyst results in healing.
• Some cases need curettage and bone
grafting.

89. FIBROUS DYSPLASIA
• This is a disorder in which the normal bone is
replaced by fibrous tissue – hence its name.
• The mass of fibrous tissue thus formed grows
inside the bone and erodes the cortices of the
bone from within.
• A thin layer of sub-periosteal bone forms
around the mass, so that the bone appears
expanded.

91. • Treatment is curettage and bone grafting.

96. THANK YOU