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NTRU PG CME- Gandhi                                                     Med.Col.                                          ...
Bone TumoursAggressive            Malignant Giant Cell Tumour    Osteosarcoma Aggressive           Chondrosarcoma  Cho...
ClinicalAge
AgeOsteosarcoma         Immature SkeletonEwing’s sarcomaChondromyxoid              Osteosarcoma       fibroma            ...
AgeEwing’sSarcoma          NEUROBLASTO                        LYMPHOMA              MA
AgeGiant CellTumour              If a diagnosis of GCT is to be made              in an immature skeleton – think        ...
ClinicalSymptoms & Signs
SymptomsLocalised Swelling   Generalised body aches GCT                 Multiple Myeloma Osteosarcoma        - Symtoms ...
Swelling May not be obvious Especially if the tumour is deep                  REST PAIN
Wasting of Muscles Disproportionate to  Duration of disease            Tuberculosis             Malignancy            Rhe...
RadiologyUtility ofPlain Radiograph Dimension – View in–Third of                         CT                               ...
IMAGINGPLAIN         Enneking`s four questionsRADIOGRAPHY               1. Where is the lesion?               2. What is t...
ALTRMCPS Age of Skeleton –  - Mature or Immature Location Transitional zone Reactive zone Matrix Cortex Periosteal ...
Location                     ALTRMCPS Which Bone? Which Part of the Bone?     - Epiphysis     - Metaphysis     - Diaphys...
Zones of Transition                  A LT R M C P S Narrow   - Sharp Sclerotic                           BENIGN   - Sharp...
Zone of Transition         ALTRMCPS  Narrow             Non-ossifying Fibroma   Sharp Sclerotic
Zone of Transition    Narrow           Giant Cell Tumour    Sharp Lytic
Zone of Transition  Wide                    Aggressive GCT    Ill-defined or hazy
Zone of Transition   Wide          NH L   Met Ca. Breast   Moth eaten
Zone of Transition   Wide   Permeative        Malignant Tumour
ALTR MCZone of Reaction         PSLocalised Sclerotic   Wide ScleroticBrodie’s Abscess      Ost.Osteoma
Matrix                                  ALTRMCPS                          Calcification -Ground Glass – Fib.Dys.   Chondro...
Matrix“Cloud” like Ossific densities inBone =                              Osteosarcoma
Cortex                ALTRMCPSIntact orBroken   Wide Zone of   Transition and   Broken Cortex  could be signs of Aggressiv...
Periosteal Reaction   ALTR MC P S
Periosteal Reaction  Sun Burstappearance            Codman’s Triangle
ALTR MC PSSoft Tissue Enormous soft tissueseen                    in Ewing’s Sarcoma
Radiographic differences between    Benign& Malignant TumoursIGNANTR   BENIGN                  MALIGNANT
Early DiagnosisMANDATORYTO INCREASE SURVIVAL RATE
OS – Early diagnosis Suspect OS : * Minor injury – disproportionate duration of pain                                   or...
AYESHA 14 yrsPain without injury     2 weeks        3 wks Later     2 mths Later
Mankin – Biological behavior      Criteria                  Score____________________0_________1____   Size              ...
Diagnosis of Bone Tumours           IMAGINGProblem    - Not seen on plain Radiographss          - Mistaken Diagnosis     ...
Problem – Imaging 1Not seenon plainRadiograph
Problem – Imaging 2MistakenDiagnosis            Stress fracture   Osteoid Osteoma            ABC                  Tel.    ...
Problem – Imaging 3MRIEdemamistakenFor Tumour                      Histology                      NO Tumour               ...
Histopathology
Diagnosis of Bone Tumours           BIOPSYProblem    - FNAC vs WBNABs          - Sampling Error
Problem – Biopsy 1FNAC vs    Cytology – cellsWBNAB      Biopsy – Tissue             Group of cells – identified by      ...
Problem – Biopsy 2SamplingError          A     A           B                     B
Diagnosis of Bone Tumours           HISTOLOGYProblem     - Heterogenous nature ofs          Osteosarcoma            - Rou...
ProblemsHistology - 1  Osteosarco  ma  Heterogeneity  Osteoblastic  Chondroblastic  Fibroblastic  GC rich  Telangiectatic ...
Problem – Histology 2Ewing’s sarcoma   Round Cell Tumours of Bone                   Ewing’s sarcoma                   Pr...
Problems – Histology 3GCT           Giant Cell Variants              • Chondroblastoma              • Chondromyxoid       ...
Problem – Histology 4ReactiveConditionsmistakenfor Tumour- Exuberant      callus        -Organisinghematoma- Myositisossif...
Problem – Histology 4Reactive                CALLUSConditionsmistakenfor Tumour-Exuberant     callus        -Organisinghem...
Problem – Histology 4ReactiveConditionsmistakenforTumours- Exuberant      callus- Organisinghematoma- Myositisossificans
Problem – Histology 5Benign vsMalignant    Secondary Chondrosarcoma arising              from osteochondromatosis -      ...
Problem – Histology 6Pathologicalfr. MistakenforTumour        Needle        Biopsy -        Chondrosarco -        Open Bio...
Problem – Histology 7Primary vs    Met. Neuroblastoma orMetastases              carcinoma vs Ewing’s –              immun...
Problem – Histology 8Tumour vsInfectionRadiology –Ewing’s SarcomaHistology –Plasmacytes -Plasmacytomawith path #Clinical –...
Problem – Histology 8Tumour vsInfectionOSTEOMYELITISLow GradeINTRAMEDULLARYOSTEOSARCOMA
Problem – Histology 8Tumour vsInfection            * Ewing’s Sarcoma &            Osteomyelitis are                 confus...
“The gross anatomy asrevealed in radiographs isoften a safer guide to correctclinical conception thanvariable and uncertai...
Diagnosis of Bone Tumours             Final Diagnosis                     CLINICAL     IMAGEOLOGY                         ...
Prof. Dr. Walter PutscherOrthopedic Pathologist, Boston, USA“No Pathologist shall ever sign out a report without seeing th...
Prof. Peter G BulloughProfessor of Orthopedic PathologyHospital for Special Surgery,Cornell University,NEW YORK “If I were...
DICTUMThe Pathologist should receive the Clinical &Radiological findings while dealing with thediagnosis of Bone Tumours
Thank YouThank YouThank YouThank You    For YourThank YouThank You    Patient HearingThank YouThank YouThank YouThank Yo...
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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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