Teleconference Ext.กานติมา 9 ส.ค. 61

1. TELECONFERANCE
Ext.Kantima Imchai

2. Patient Profile
• ผู้ป่วยเด็กชายไทยอายุ 13 ปี ศึกษาอยู่ชั้นมัธยมศึกษาปีที่ 1 ภูมิลาเนาจังหวัดนครราชสีมา
นับถือศาสนาพุทธ

3. Chief Complaint
• 3 mo PTA ปวดเข่าข้างขวา

4. Present Illness
• 3 mo PTA ผู้ป่วยรู้สึกปวดเข่าข้างขวาบริเวณด้านข้างและหลังข้อเข่า ไม่ร้าวไปไหน อาการปวดเป็นตลอดเวลา บางครั้งปวดจนตื่นจากการ
นอนหลับ ไม่มีอาการชา ไม่มีอ่อนแรง เดินได้ยืดงอเข้าได้ปกติ ไม่มีไข้ไม่มีเบื่ออาหาร ไม่มีน้าหนักลด ไม่มีเหงื่ออกกลางคืน ไม่เคยกระทบ
กระแทกบริเวณดังกล่าวมาก่อน ผู้ป่วยสังเกตว่าบริเวณด้านข้างเข่าด้านขวาคลาได้ก้อนแข็งขึ้นเทียบกับอีกข้าง

5. Past History
ปฏิเสธประวัติอุบัติเหตุและการกระทบกระแทก
ปฏิเสธประวัติประวัติโรคประจาตัว
ปฎิเสธประวัติมะเร็งในครอบครัว
ปฏิเสธประวัติดื่มสุราและสูบบุหรี่
ปฎิเธประวัติการผ่าตัด
ปฏิเสธประวัติยาที่รับประทานเป็นประจา
ปฎิเสธประวัติแพ้ยาแพ้อาหาร
ปฎิเสะประวัติสัมผัสผู้ป่วยวัณโรค

6. Physical Examination
GA: Alert, good conscious, antalgic gait
Vital sign : BP 130/97 mmHg PR 90 bpm BT 37 C RR 20 /mins
Heart : normal S1 S2, no murmur
Lung : breath sound equal both lungs
Abdomen : soft, not tender

7. Physical Examination
Extremities : tender at Right fibular head, no stepping, full ROM ,anterior drawer
negative posterior drawer negative valgus/varus stress test negative ballotment
negative
Neurovascular : sensory intact, motor gradeV all, capillary refill < 2 sec, palpable full
pulse at popliteal area, Posterior tibial artery, dorsalis pedis artery

10. Initial management
• Film Right knee AP, Lateral

12. Initial management
• Hemoculture no.1 and no.2 – No bacterial growth after 5 day
• CBC
WBC 11300 uL NE 73.7 % LYM 11.6 % MO 9.9 % EO 4.4 % BA 0.4 %
HBG 14.5 g/dL HCT 43.8 %
• ESR 42 mm/hour
• CRP 3.49 mg/L
• Eletrolyte Na 137.2 mmol/L Cl 97.4 mmol/L K 4.04 mmol/L CO2 25.2 mmol/L
Calcium 9.7 mg/dL
• BUN 8.3 mg/dL Cr 0.53 mg/dL

13. Initial management
• LFT
AST 23 U/L ALT 16 U2L ALP 191 U/LTP 8.2 g/dL Globu 4.2 g/dL DB 0.1 mg/dLTB 0.4
mg/dL Chol 191 mg/dL

14. Differential diagnosis
- Bone tumor
- Infection

15. Initial management
• CXR

16. Further Investigation
• MRI

17. Further Investigation
• MRI

18. • Finding :There is bone destruction with intraosseous lesion of fibular head, which
there is cortical breakthrough in posterior cortex. Size 2.9*3.7*3.4 cm.
• Impression : Intraosseous lesion of fibular head is concerning for primary bone
tumor
• DDx : Chondroblastoma, Giant cell tumor, Osteosacroma

19. Management
• Biopsy for tissue Pathology

20. Bone tumor
• Bone tumors develop when cells within a bone divide uncontrolably, forming a
lump or mass of abnormal tissue
• Most bone tumors are Benign

21. Type
• Primary bone tumor
• Secondary bone tumor

22. Primary bone tumor
Bone-Forming tumors Fibrous-Forming tumors
- Osteoma - Fibrous dysplasia
- Osteoid osteoma and osteoblastoma - Osteofibrous dysplasia
- Osteosarcoma - Nonossifying fibroma
Cartilage-Forming tumors - Desmoplastic fibroma
- Chondroma (Enchondroma) Miscellaneous tumors/tumor-like lesion
- Osteochondroma - Ewing’s sarcoma
- Chondrosacroma - Giant cell tumor of bone
- UBC / ABC

23. Diagnosis
• Chief complaint
• History talking
• Physical examination
• Radiography and other investigation
• Biopsy

24. Chief complaint
pain :
resting pain
night pain
progressive pain
uncontrolled pain

25. mass

26. pathologic fracture

27. deformity

28. • History talking
Age and sex
Time
Location
symptom
family history

32. • Physical examination
Affected part examination
Systematic examination

33. • การตรวจทางรังสี
X-ray
ENNEKING’S QUESTIONS
Where is the lesions?
What is the lesion?
What is the lesion act to bone?
What is the bone act to the lesion?
Skip lesion

35. Where is the lesions?

37. What is the lesion?
Lytic bone lesion

38. What is the lesion?
Lytic bone lesion

39. What is the lesion?
Lytic bone lesion

40. What is the lesion?
• Blastic bone lesion

41. What is the lesion?
• Blastic bone lesion

42. What is the lesion?
• mixed bone lesion

44. What is the lesion?
• Pattern of bone destruction
Geographic bone destruction
Moth eaten bone destruction
Permeative bone destruction

49. What is the lesion act to bone?
• Tumor matrix
Osseous
(Cloud-like)

50. What is the lesion act to bone?
• Tumor matrix
Chondroid
( Ring&arcs )

51. What is the lesion act to bone?
• Tumor matrix
Fibrous
(Ground-grass)

52. What is the lesion act to bone?
• Tumor matrix
non : lytic

53. What is the bone act to the lesion?
• Periosteal reaction

59. CXR
Other : bone scan MRI CT scan
• Laboratory investigation

60. • Tissue biopsy
Closed biopsy technique
Open biopsy technique

61. Bone tumor staging
• Surgical staging system (SSS) by Musculoskeletal Tumor Society (Enneking’s system)
Benign bone tumor staging
Malignant bone tumor staging

64. Treatment
• Surgery
• Chemotherapy
• Radiation therapy

65. Chondroblastoma
• Rare type of benign tumor
• Tumors grows at the ends of the long bone, close to joint : femur, tibia or humerus
• Typically occur in children and young adults
• A growing tumor can destroy the surrounding bone, making it painful to move the
nearby joint.
• Film : well define osteolytic lesion at epiphysis of long bone

67. Giant cell tumor
• Benign bone tumor
• The tumor grows at the ends of the long bone : lower end of femur, upper end of
the tibia around the knee, distal radius
• Most common bone tumor in aged 25 -40 year old
• Film : well-defined or ill-defined osteolytic lesion eccentric in epiphysis
• Clinical : Slowly progressive painful and swelling, pathologic fracture

69. Osteosarcoma
• Bone forming tumor
• Most common primary malignant bone tumor
• Common in 10-20 year old or 40-50 year old up who present with a painful mass
• Most common site is Metaphysis bone
- around knee
- proximal humerus
• Film : lytic or mixed lesion, osteoid matrix, cod man, sun burst, onion-skin
• CMT is adjuvant and neoadjuvant therapy for this tumor

71. Other common bone tumor
• OO
• Osteosarcoma
• Osteochondroma
• Enchondroma
• Chondrosacroma
• FD
• Ewing
• MM
• UBC ABC GCT

72. Osteoid osteoma
• Bone forming tumor
• Common in 15 – 30 year old
• Most common site is Metaphysis to diaphysis bone
– Anteromedial proximal femur
– post spine
• Film : intracortical ,lytic, sclerotic border, size <2 cm ( >
2cm : osteoblastoma)
• Presentation by night pain and the pain always response to NSAIDs

73. Osteochondroma
• Cartilage-forming tumor
• Common in 10-30 year old
• Most common site is Metaphysis bone
- around knee
- proximal humerus
• Clinical presentation : pain , mass, irritate
• Film and CT : Cartilage cap, sessile2pedunculate, continued meddullary canal

74. Chondrosacroma
• Cartilage-forming tumor
• Common in 40-70 year old
• Most common site is pelvis, acetabulum, proximal humerus, femur
• Film : permeative lytic, Flocculent, Extra-cortical expansion

75. Enchondroma
• Cartilage-forming tumor
• Common in 10-50 year old
• Most common site is hand/foot
• Clinical presentation : Pathological fracture
• Film : lytic, Endosteal scalloping

76. Fibrous dysplasia
• Common in child to adolescent
• Most common site is metaphysis to diaphysis
- proximal femur
- tibia
- rib
• Monoostotic/Polyostotic
• Film : ground glass, endosteal scalloping, Shephred’s crook deformity

77. Ewing
• Common in 5-15 year old
• Most common site is Diaphysis
- humerus
- femur
- pelvis
• Film : Permeadtive, lytic, codman, onion skin
• CMT is adjuvant and neoadjuvant therapy for this tumor

78. Multiple myeloma
• Common in 5-15 year old
• Multiple lesion
• CRAB
• Serum eletrophroresis, urin Bence Jones
• Film : Punch out lesion at skull
• Chemotherapy is definite treatment except fracture

79. Reference
• www.radiologyassistant.com
• เอกสารประกอบการสอนเรื่อง เนื้องอกกระดูก โดยนายแพทย์อดิศักดิ์ นารถธนะรุ่ง

80. Thank you