Aggressive & malignant bone tumours an overview

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  • Aggressive & malignant bone tumours an overview

    1. 1. NTRU PG CME- Gandhi Med.Col. Secunderabad 27-5- 2012Aggressive & Malignant Bone Tumours An Overview Prof. A. Srinivasa Rao M.S.(Ortho); Fellow Ortho. Path.(USA) EMERITUS PROFESSOR Gandhi Medical College, Secunderabad Consultant, KIMS, Secunderabad Honorary Fellow, IOA
    2. 2. Bone TumoursAggressive Malignant Giant Cell Tumour  Osteosarcoma Aggressive  Chondrosarcoma Chondromyxoid  Ewing’s sarcoma Fibroma  Multiple Myeloma Aggressive Osteoblastoma
    3. 3. ClinicalAge
    4. 4. AgeOsteosarcoma  Immature SkeletonEwing’s sarcomaChondromyxoid Osteosarcoma fibroma Bimodal IncidenceOsteoblastoma Adolescents & > 65 yrs  Mature SkeletonGiant cell tumourChondrosarcomaMultiple Myeloma
    5. 5. AgeEwing’sSarcoma NEUROBLASTO LYMPHOMA MA
    6. 6. AgeGiant CellTumour  If a diagnosis of GCT is to be made in an immature skeleton – think several times  Lichtenstein
    7. 7. ClinicalSymptoms & Signs
    8. 8. SymptomsLocalised Swelling Generalised body aches GCT  Multiple Myeloma Osteosarcoma - Symtoms ignored for quite sometime Chondrosarcoma - Can be mistaken for Ewing’s sarcoma many other conditions with generalised body aches Osteoporosis/Osteomal acia, FMS etc.
    9. 9. Swelling May not be obvious Especially if the tumour is deep REST PAIN
    10. 10. Wasting of Muscles Disproportionate to Duration of disease Tuberculosis Malignancy Rheumatoid Disease
    11. 11. RadiologyUtility ofPlain Radiograph Dimension – View in–Third of CT MRI ExtentIn Diagnosis Lesion Intra/Extra Compartmental STAGING Isotope Scan – Lesions elewhere
    12. 12. IMAGINGPLAIN Enneking`s four questionsRADIOGRAPHY 1. Where is the lesion? 2. What is the lesion doing to bone? Transition zone 3. How is the tissue responding to lesion? Reactive zone 4. Does anything suggest histology? Calcification, Ossification, Ground glass appearance Etc.
    13. 13. ALTRMCPS Age of Skeleton – - Mature or Immature Location Transitional zone Reactive zone Matrix Cortex Periosteal reaction Soft tissue swelling
    14. 14. Location ALTRMCPS Which Bone? Which Part of the Bone? - Epiphysis - Metaphysis - Diaphysis Eccentric or Concentric?
    15. 15. Zones of Transition A LT R M C P S Narrow - Sharp Sclerotic BENIGN - Sharp Lytic Wide - Ill-defined or hazy AGGRESSIVE / - Moth eaten MALIGNANT - permeative
    16. 16. Zone of Transition ALTRMCPS Narrow Non-ossifying Fibroma Sharp Sclerotic
    17. 17. Zone of Transition Narrow Giant Cell Tumour Sharp Lytic
    18. 18. Zone of Transition Wide Aggressive GCT Ill-defined or hazy
    19. 19. Zone of Transition Wide NH L Met Ca. Breast Moth eaten
    20. 20. Zone of Transition Wide Permeative Malignant Tumour
    21. 21. ALTR MCZone of Reaction PSLocalised Sclerotic Wide ScleroticBrodie’s Abscess Ost.Osteoma
    22. 22. Matrix ALTRMCPS Calcification -Ground Glass – Fib.Dys. Chondrosarc
    23. 23. Matrix“Cloud” like Ossific densities inBone = Osteosarcoma
    24. 24. Cortex ALTRMCPSIntact orBroken Wide Zone of Transition and Broken Cortex could be signs of Aggressiveness / Malignancy
    25. 25. Periosteal Reaction ALTR MC P S
    26. 26. Periosteal Reaction Sun Burstappearance Codman’s Triangle
    27. 27. ALTR MC PSSoft Tissue Enormous soft tissueseen in Ewing’s Sarcoma
    28. 28. Radiographic differences between Benign& Malignant TumoursIGNANTR BENIGN MALIGNANT
    29. 29. Early DiagnosisMANDATORYTO INCREASE SURVIVAL RATE
    30. 30. OS – Early diagnosis Suspect OS : * Minor injury – disproportionate duration of pain or increasing pain * Pain associated with sclerosis or erosions in the metaphysis without fever
    31. 31. AYESHA 14 yrsPain without injury 2 weeks 3 wks Later 2 mths Later
    32. 32. Mankin – Biological behavior Criteria Score____________________0_________1____ Size Small Big Margination Present Absent Cortex Intact Destroyed Soft tissue mass Absent Present_________________________________ Score 0-1 Benign 2 Aggressive 3-4 Malignant
    33. 33. Diagnosis of Bone Tumours  IMAGINGProblem - Not seen on plain Radiographss - Mistaken Diagnosis - MRI - Edema mistaken for tumour
    34. 34. Problem – Imaging 1Not seenon plainRadiograph
    35. 35. Problem – Imaging 2MistakenDiagnosis Stress fracture Osteoid Osteoma ABC Tel. OS
    36. 36. Problem – Imaging 3MRIEdemamistakenFor Tumour Histology NO Tumour In this area
    37. 37. Histopathology
    38. 38. Diagnosis of Bone Tumours  BIOPSYProblem - FNAC vs WBNABs - Sampling Error
    39. 39. Problem – Biopsy 1FNAC vs  Cytology – cellsWBNAB  Biopsy – Tissue Group of cells – identified by matrix produced by cells
    40. 40. Problem – Biopsy 2SamplingError A A B B
    41. 41. Diagnosis of Bone Tumours  HISTOLOGYProblem - Heterogenous nature ofs Osteosarcoma - Round cell Tumours - Giant cell variants - Reactive conditions mistaken for tumours - Benign vs Malignant - Path. Fr. Mistaken for Tumour - Primary or Mets - Tumour vs Infection
    42. 42. ProblemsHistology - 1 Osteosarco ma Heterogeneity Osteoblastic Chondroblastic Fibroblastic GC rich Telangiectatic Small cell OS Fibrous Histiocytoma- like
    43. 43. Problem – Histology 2Ewing’s sarcoma Round Cell Tumours of Bone  Ewing’s sarcoma  Primary Lymphoma of bone  Metastatic Neuroblastoma  Embryonal Rhabdomyosarcoma  Small cell Osteosarcoma  Mesenchymal cell Chondrosarcoma  Metastatic small cell
    44. 44. Problems – Histology 3GCT Giant Cell Variants • Chondroblastoma • Chondromyxoid Fibroma • Simple Bone Cyst • ABC • Brown Tumour of Hyperparathyroid • Nonossifying Fibroma • Ossifying Fibroma
    45. 45. Problem – Histology 4ReactiveConditionsmistakenfor Tumour- Exuberant callus -Organisinghematoma- Myositisossificans
    46. 46. Problem – Histology 4Reactive CALLUSConditionsmistakenfor Tumour-Exuberant callus -Organisinghematoma OS- Myositis
    47. 47. Problem – Histology 4ReactiveConditionsmistakenforTumours- Exuberant callus- Organisinghematoma- Myositisossificans
    48. 48. Problem – Histology 5Benign vsMalignant  Secondary Chondrosarcoma arising from osteochondromatosis - Histology may be misleading – appears benign  Aggressive Chondromyxoid Fibroma can be mistaken for low grade Chondrosarcoma  Aggressive Osteoblastoma borderlines on Osteosarcoma Clinical picture & Radiology help to a great extent to differentiate
    49. 49. Problem – Histology 6Pathologicalfr. MistakenforTumour Needle Biopsy - Chondrosarco - Open Biopsy maTuberculosis
    50. 50. Problem – Histology 7Primary vs  Met. Neuroblastoma orMetastases carcinoma vs Ewing’s – immunohistochemistry
    51. 51. Problem – Histology 8Tumour vsInfectionRadiology –Ewing’s SarcomaHistology –Plasmacytes -Plasmacytomawith path #Clinical –Osteomyelitis Plasmacytic Osteomyelitis
    52. 52. Problem – Histology 8Tumour vsInfectionOSTEOMYELITISLow GradeINTRAMEDULLARYOSTEOSARCOMA
    53. 53. Problem – Histology 8Tumour vsInfection * Ewing’s Sarcoma & Osteomyelitis are confused with each other Clinically, Radiologically and even Histologically * “Culture a tumour & Biopsy an Infection”
    54. 54. “The gross anatomy asrevealed in radiographs isoften a safer guide to correctclinical conception thanvariable and uncertainnature of a small piece of 1922 EWINGtissue” Importance of Correlation of Histology & Radiology
    55. 55. Diagnosis of Bone Tumours Final Diagnosis CLINICAL IMAGEOLOGY PATHOLOGY (Radiology)
    56. 56. Prof. Dr. Walter PutscherOrthopedic Pathologist, Boston, USA“No Pathologist shall ever sign out a report without seeing the Radiograph
    57. 57. Prof. Peter G BulloughProfessor of Orthopedic PathologyHospital for Special Surgery,Cornell University,NEW YORK “If I were you, I will run to the Radiology department and get the x-ray films and make them available before the Histology slides are studied”
    58. 58. DICTUMThe Pathologist should receive the Clinical &Radiological findings while dealing with thediagnosis of Bone Tumours
    59. 59. Thank YouThank YouThank YouThank You  For YourThank YouThank You  Patient HearingThank YouThank YouThank YouThank YouThank YouThank YouThank YouThank You

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