Bone tumor

بسم الله الرحمن الرحيم

1
12 December 2015

Bone tumor

2
12 December 2015

Benign

Source of origin

malignant
Osteoma
Arise from bone


osteosarcoma

Osteoid osteoma

Osteoblastoma

Giant cell tumor

Enchondroma
Arising from cartilage

chondrosarcoma

Osteochondroma

Chondromyxoid fibroma

chondroblastoma

3
12 December 2015

Fibrous cortical defect

From fibrous tissue

Malignant fibrous histiocytoma (MFH)

Non-ossifying fibroma

Fibrous dysplasia

Simple bone cyst
Uncertain origin

Ewing's sarcoma

Aneurysmal bone cyst

admantinoma

4
12 December 2015


QUESTIONS TO ASK WHEN STUDYING ANX-RAY
5
12 December 2015

is the lesion solitary or are there multiple lesions?

What type of bone is involved?

Where is the lesion in the bone?

Are the margins of the lesion well- or ill-defined?

6
12 December 2015

Are there flecks of calcification in the lesion?

is the cortex eroded or destroyed?

is there any periosteal new-bone

formation?


Does the tumour extend into the soft tissues?

7
12 December 2015

8
12 December 2015




9
12 December 2015

This is a benign circumscribed lesion that may arise from the cortex of long bones or occasionally from the cancellous bone of the spine.
Affect young patients 10-35 years.
3 times common in males than females.
Osteoid osteoma
10
12 December 2015


The characeristic features is the formation of a small nidus of osteoid tissue usually less than 0.5cm diameter, surrounded by a reactive zone of dense sclerotic new bone formation.
Pathology


11
12 December 2015

Usually present with increasingly sever but well - localised ,deep aching pain and sometimes local bone tenderness.
Pain worse at night.
Eased by aspirin or NSAIDS.
( Diagnostic features) .
Clinical features
12
12 December 2015

Plain x-ray

Show local sclerotic thickening of the shaft that may obscure the small central nidus within the area of rarefaction.
The nidus is best seen on a fine cut CT scan

Intense uptake on an isotope bone scan.

Imaging



13
12 December 2015

C T scan

14
12 December 2015

May resolve spontaneously after several months.

Most require surgery
Removal of the nidus alone produce dramatic relieve and this done by,
Surgical exscion,
curettage.
CT guided needle can be inserted into the nidus and the lesion ablated with radiofrequency coagulation.
Treatment
15
12 December 2015









16
12 December 2015




17
12 December 2015

OSTEOCHONDROMA (CARTILAGE-CAPPEDEXOSTOSIS)

18
12 December 2015


This, one of the commonest ‘tumours’ of bone, is a developmental lesion which starts as a small over-growth of cartilage at the edge of the physeal plate.

And develops by endochondral ossification into a bony pro-tuberance still covered by the cap of cartilage.
19
12 December 2015

commonest sites are the fast-growing ends of long bone.

and the crest of the ilium.

20
12 December 2015

The patient is usually a teenager or young adult

when the lump is first discovered.
Occasionally there is pain due to an overlying bursa or impingement on soft tissues,
or, rarely, paraesthesia due to stretching of an adjacent nerve.
Clinical features
21
12 December 2015


22
12 December 2015

23
12 December 2015

the cartilage cap is seen surmounting a narrow base or pedicle of bone.

The cap consists of simple hyaline cartilage;
in a growing exostosis the deeper cartilage cells are arranged in
columns, giving rise to the formation of endochondral new bone.
Pathology


24
12 December 2015

is pathognomonic. There is a

well-defined exostosis emerging from the metaphysis,
its base co-extensive with the parent bone.


It looks smaller than it feels because the cartilage cap is usually invisible on x-ray.
The x-ray appearance
25
12 December 2015




26
12 December 2015




27
12 December 2015




28
12 December 2015


Multiple lesions may develop as part of a heritable disorder – hereditary multiple exostosis .
Ollier disease
29
12 December 2015

Large lesions may have a ‘cauliflower’

appearance, with degeneration and calcification in the Centre of the cartilage cap.

30
12 December 2015

The incidence of malignant transformation is difficult to assess .

Complications
31
12 December 2015

If the tumour causes symptoms it should

be excised; if, in an adult, it has recently become bigger or painful then operation is urgent.
Treatment
32
12 December 2015





33
12 December 2015

GIANT-CELL TUMOURosteoclastoma

34
12 December 2015

Giant-cell tumour, which represents 5 per cent of all primary bone tumours.

most commonly in the
distal femur,
proximal tibia,
proximal humerus .
and distal radius.
though other bones also may be affected.

Pathology

35
12 December 2015


It is hardly ever seen before closure of the nearby physis .

and 10% behaves as malignant .

characteristically it extends right up to the subarticular bone plate.

Rarely, there are multiple lesions.

36
12 December 2015

Tumor consist abundant of mononuclear stromal cells profusely interspersed with giant cell.
Histologically
37
12 December 2015




38
12 December 2015


The patient is usually a young adult 20-40 years who complains pain at the end of a long bone;

sometimes there is slight swelling.

A history of trauma is not uncommon.

Some time the patient is made suddenly aware of some thing wrong.

Clinical features
39
12 December 2015




40
12 December 2015




41
12 December 2015


show a radiolucent area situated eccentrically at the end of a long bone and bounded by the sub- chondral bone plate.

The endosteal margin may be quite obvious, but in aggressive lesions it is ill-defined.

X-rays


42
12 December 2015

The Centre sometimes has a soap-bubble appearance.

The cortex is thin and sometimes ballooned. aggressive lesions extend into the soft tissue.



43
12 December 2015

The appearance of a ‘cystic’ lesion in mature bone, extending right up to the subchondral plate, is so characteristic




44
12 December 2015

blood calcium, phosphate and alkaline phosphatase concentrations so as exclude an

unusual ‘brown tumour’ associated with hyper parathyroidism.
Other investigations
45
12 December 2015

CT scans and MRI will reveal the extent of the tumour, both within the bone and beyond.

46
12 December 2015

Is essential. This can be done either as a

frozen section before proceeding with operative treatment or


(especially if a more extensive operation is contemplated) as a separate procedure
Biopsy
47
12 December 2015

Well-confined, slow-growing lesions with benign histology can safely be treated by thorough curettage and ‘stripping’ of the cavity with burrs and gouges,
followed by swabbing with hydrogen peroxide or by the application of liquid nitrogen;

the cavity is then packed with bone chips.

Recurrence about 20-25%
Treatment
48
12 December 2015

Some time the cavity occupied with bone cement (methyl methacrylate)which

is acting through its exothermic action and
mechanical supports to the subchondral bone and cartilage.
49
12 December 2015


More aggressive tumours, and recurrent lesions, should be treated by excision followed,
if necessary, by bone grafting or

prosthetic replacement.

50
12 December 2015




51
12 December 2015

Tumours in awkward sites

(e.g. the spine) may be difficult to eradicate; supplementary radiotherapy is sometimes recommended.

52
12 December 2015

but it carries a significant risk of causing malignant transformation

53
12 December 2015




54
12 December 2015

ANEURYSMAL BONE CYST

aneurysmal bone cyst may be encountered at any age and in almost any bone, though more often in young adults.
Below 20 years age in 75%.
25% in spine.
20% long bones.
in the long-bone metaphysis.

Usually it arises spontaneously but it may appear after degeneration or haemorrhage in some other lesion.
55
12 December 2015


With expanding lesions, patients may complain of pain.

Occasionally, a large cyst may cause a visible or palpable swelling of the bone.

56
12 December 2015

Histology

Characteristic findings
• cavernous space
• blood-filled spaces without endothelial lining
• cavity lining
• numerous benign giant cells
• spindle cells
• thin strands of bone present in fibrous tissue of septae
12 December 2015
57

X-rays

show a well-defined radiolucent cyst, often trabeculated and eccentrically placed.


In a growing tubular bone it is always situated in the metaphysis
and therefore may resemble a simple cyst or one of the other cyst-like lesions.


58
12 December 2015

•MRI or CT scan ◦will show multiple fluid lines

•Bone scan ◦is warm to hot

12 December 2015

59

Occasional sites include vertebrae.

and the flat bones.
In an adult an aneurysmal bone cyst may be mistaken
for a giant-cell tumour
Chondroblastoma
Osteoblastoma
osteosarcoma


60
12 December 2015

Pathology

When the cyst is opened it is found to contain clotted blood, and during curettage there may be
considerable bleeding from the fleshy lining membrane.

61
12 December 2015

the lining consists of fibrous tissue with vascular spaces, deposits of haemosiderin and multinucleated giant cells.
Occasionally the appearances so closely resemble those of giant-cell tumour

Histologically

62
12 December 2015

Treatment

The cyst should be carefully opened, thoroughly curetted and then packed with bone grafts.

Sometimes the graft is resorbed and the cyst recurs

necessitating a second or third operation.


In these cases, packing with methyl methacrylate cement may be more effective.

63
12 December 2015

OSTEOSARCOMA}

12 December 2015
64

Osteosarcoma

highly malignant tumour arising within the bone and
spreading rapidly outwards to the periosteum and surrounding soft tissues. It is said to occur predominantly
in children and adolescents, 10-25 years

may affect any bone but most commonly involves the

long-bone metaphysis, especially around the knee and
at the proximal end of the humerus.

The tumour extends

Within the medulla and across the physeal plate.
Obvious spread into the soft tissues with ossification at the periosteal margins and streaks of new
Bone extending into the extraosseous mass.
Pathology

Pain is usually the first symptom; it is constant,

Worse at night and gradually increases in severity.
Sometimes the patient presents with a lump.
Pathological fracture is rare.
CLINICAL FEATURES

On examination

there may be little to find
except local tenderness.
In later cases there is a palpable mass and the overlying tissues may appear swollen and inflamed.
The over lying skin warmer than normal because of its vascularity.
The skin also shiny and stretched.

INVESTIGATIONS

The ESR is usually raised and there may be
an increase in serum alkaline phosphatase.

X-rays

variable hazy osteolytic .

areas may alternate with unusually dense Osteoblastic areas.
The endosteal margin is poorly defined. often
The cortex is breached .

The tumour extends into the adjacent tissues; when this happens.

Streaks of new bone appear, radiating outwards from the cortex – the so-called ‘sunburst’ effect.
Reactive new bone forms at the angles of periosteal elevation (Codman’s triangle).










MRI


Allow accurate delination of the tumor size and the extent of invasion to the near soft tissue.

Radioactive isotops

Increased uptake.

And the extension in to the medullary canal (skipped lesion).


CT and chest radiograph is mandatory for preoperative staging

Treatment

The patient is admitted to a special center for biopsy.
The lesion will probably be graded IIA or IIB.
Multi-agent neoadjuvant chemotherapy is given for 8–12 weeks and then.




Provided the tumor is resectable and there are no skip lesions, a wide resection is carried.

Replace that segment of bone with either a large bone graft or a custom-made implant;

in some cases an amputation may be

more appropriate.

The specimen is examined to assess the response to preoperative chemotherapy.

If tumour necrosis is marked (more than 90 per cent),
Chemotherapy is continued for another 6–12 months;
If the response is poor, a different chemotherapeutic regime is substituted.

EWING SARCOMA

12 December 2015
89

Ewing’s sarcoma

is believed to arise from endothelial cells in the bone marrow.
It occurs most commonly
between the ages of 10 and 20 years.
usually in a tubular bone and especially in the
tibia, fibula or
clavicle.


Pathology
Macroscopically the tumour is lobulated.
It may look grey (like brain) or red
(like redcurrant jelly) if haemorrhage has occurred into it.

Microscopically, sheets of small dark polyhedral cells with no regular arrangement and no ground substance are seen.

CLINICAL FEATURES

The patient presents with pain – often throbbing in character .

swelling.
Generalized illness .
pyrexia, together with
a warm, tender swelling and.
a raised ESR, may suggest a diagnosis of osteomyelitis.

X-rays usually show an area of bone destruction

in the mid-diaphysis.
New bone formation may appears as fusiform layers of bone around the lesion – the so-called ‘onion-peel’ effect.

Imaging

Infiltration into the surrounding soft tissues, with radiating streaks of ossification and reactive periosteal bone at the proximal and distal margins. These features (the‘sunray’ appearance and Codman’s triangles)

CT and MRI reveal the large extra osseous component.

Radioisotope scans may show multiple areas of activity in the skeleton.

Diagnosis
The condition which should be excluded as rapidly as possible is:
bone infection.
reticulum-cell sarcoma .
and metastatic neuroblastoma.


Treatment
Radiotherapy has a dramatic effect.
Chemotherapy is much more effective,5-year survival rate of about 50 %.

The best results are achieved by a combination of

all three methods.
a course of preoperative neoadjuvant chemotherapy; then wide excision .

or radiotherapy followed by local excision if it is less accessible; and then a further course of chemotherapy for 1 year.

SIMPLE BONE CYST

also known as a solitary cyst or unicameral bone cyst) appears during childhood, typically in the
metaphysis of one of the long bones and most commonly in the proximal humerus or femur.

Pathology

The lining membrane consists of flimsy fibrous tissue, often containing giant cells. In an
actively growing cyst, there is osteoclastic resorption of the adjacent bone.


Clinical features
The condition is usually discovered after a pathological fracture or as an incidental finding on x-ray.

it tends to heal spontaneously and it is seldom seen in adults.

X-rays

show a well-demarcated radiolucent area in

the metaphysis, often extending up to the physeal plate.
the cortex may be thinned and the bone expanded.

DD
Non-osteogenic fibroma,
fibrous dysplasia .
benign cartilage tumours are solid and merely look cystic on x-ray.

Treatment

Treatment depends on whether the cyst is
symptomatic,
actively growing or involved in a fracture.
Asymptomatic lesions in older children can be left alone.


Active’ cysts
usually abutting against the physeal plate and obviously enlarging in sequential x-rays.
should be treated, in the first instance, by aspiration of fluid and injection of 80–160 mg of methylprednisolone.
or autogenous bone marrow.
This often stops further enlargement and leads to healing of the cyst.

If the cyst goes on enlarging or if there is a pathological fracture.

the cavity should be thoroughly cleaned by curettage and then packed with bone chips.

METASTATIC BONE DISEASE

The skeleton is one of the commonest sites of secondary cancer;
in patients over 50 years bone metastases are seen more frequently than all primary malignant bone tumours together.






The commonest source
is carcinoma of the breast;
prostate,
kidney,
lung,
thyroid,
bladder and
gastrointestinal tract.
In about 10 per cent of cases no primary tumour is found.

For bone metastases are thecommonest sites

Vertebrae,
pelvis,
proximal half of the femur and
humerus.
Spread is usually via the blood stream;
occasionally, visceral tumours spread directly to adjacent bones (e.g. the pelvis or ribs).

Metastases are usually osteolytic,

and pathological fractures are common.
Bone resorption is due either to the direct action of tumour cells or to tumour-derived factors that stimulate osteoclastic activity.


Osteoblastic lesions are uncommon; they usually occur in prostatic carcinoma.

Clinical features

The patient is usually aged
50–70 years;
with any destructive bone lesion in this age group, the differential diagnosis must include metastasis.

Pain is the commonest – and often the only – clinical feature.

The sudden appearance of backache or

high pain in an elderly person (especially some one to have been treated for carcinoma in the past). always suspicious. If x-rays do not show anything.

Some deposits remain clinically silent and are

discovered incidentally on x-ray examination or bone scanning.

or after a pathological fracture. Sudden collapse of a vertebral body .

or a fracture of the mid-shaft of a long bone in an elderly person are ominous signs;


Symptoms of hypercalcaemia may occur .
often missed in patients with skeletal metastases
These include anorexia, nausea, thirst, polyuria

In children under 6 years of age, metastatic lesions are most commonly from adrenal neuroblastoma.

The child presents with bone pain and fever;

Examination reveals the abdominal mass.

Imaging

Most skeletal deposits are osteolytic and appear as rarified areas in the medulla
or
produce a moth-eaten appearance in the cortex.
sometimes there is marked bone destruction, with or without a pathological fracture.

Osteoblastic deposits suggest a prostatic carcinoma; the pelvis may show a mottled increase in density which has to be distinguished from
Paget’s disease
Or
lymphoma.

Radioscintigraphy

Bone scans with 99mTc-MDP are the
most sensitive method of detecting ‘silent’ metastatic
deposits in bone; areas of increased activity are selected for x-ray examination.

Special investigations

The ESR may be increased and the
haemoglobin con- centration is usually low.
The serum alkaline phosphatase concentration is often increased, and in
acid phosphatase also is elevated.
Patients with breast cancer can be screened by measuring blood levels of tumour-associated antigen markers.


Treatment
By the time a patient has developed secondary deposits the prognosis for survival is poor.

Occasionally, radical treatment (combined chemotherapy radiotherapy and surgery).

hormonal manipulation.

شكرا لصبركم