Bone and soft tissue tumors, Tumors of the musculo-skeletal system

incidence, age, malignancy:

Primary bone tumors :0,5%-0,7% of all tumors
Soft tissue tumours:1,5-3% of total nr. of tumors
Age: mostly young
Degree of malignancy: most of malignant bone
tumors have a high
degree of malignancy
Secondary bone tumors (metastases) much more frequent, than primary
Age: mostly young in primary musculo-skeletal tumors
Degree of malignancy: most of malignant bone tumors have a high degree of
malignancy
Signs of malignancy:
tendency to grow rapidly,
aggressive infiltration of surrounding tissues,
rapid spread in form of metastases

Symptoms, signs:
Palpable swelling
Pain
feels warm
Limitation of movements, if tu. is near to joint (due to reactive synovitis)
SOFT TISSUE TU.: hidden for a long time nagging , unremittamt pain in
muscles
Osteochondroma- benigng bone tumor
Clinical manifestation: painfree swelling

Bone tumor may be incidental finding

Pathological fracture first sign of metastatic tu.
Fracture through bone cyst
Pathological fracure of humerus
breast cancer metastasis

Pathological fracure of humerus benign

bone cyst

Clinical physical-examination
Palpable swelling
Skin above tumor mobile or fixed to tumor
Skin temperature
Thick, swollen veins compression of veins
Swollen regional lymph nodes
Radiological imaging examination
Typical radiological manifestation in most bone tumors
Soft tissue tu.: increased soft tissue shadow on plain x-rax
MRI: shows H (hydrogen) ion content of tissues
- in soft tissue tumors highest diagnostic value
- in bone tumors shows penetration of tumor into surroundung soft tissues
(sign of invasivity higher
malignancy)
Angiography: importance
Vascularity of tumor highly or poorly vascularized
Supplying arteries possibility of catheteric embolization
Possibility of intraarterial chemotherapy
Osteosarcoma of fibula highly vascularized

Ultrasound sonography: in soft tissue tumors

Tumor of the nerve sheath in the brachial plexus

Isotope scintigraphy:
shows sites of increased osteoblast activity (not specific inflamation also
causes increased isotope
uptake)
main role: revealing metastases
Multiple metastases of ribs and vertebrae

Bone tumor -diagnostics

HISTOLOGY:
- operative exploration + biopsy - necessary in most cases
- needle biopsy in soft tissue tumors (ultrasound guided biopsy)
Histological classification:
Osteogenic tumors: benign ( osteoid osteoma), malignant (osteosarcoma)
Chondrogenic tumors: benign (osteochondroma), malignant
(chondrosarcoma)
Giant cell tumors osteoclastoma semimalignant or malignant

Tumors from hemopoetic tissue (malignant)

Ewing sarcoma,
Multiple myeloma
Angiogenic tumors originating from blood vessels (benign or malignant)
Tumors originating from fibrous tissue (fibroma), muscles (myoma) , fat
(lipoma) nerves (neuroma) - they can be benign, or malignant

X-ray features of benign and

malignant bone tumors:
Benign:
thin protruding cortex
sclerotic border, sharp
demarcation from normal bone
Malignant:
Codmans triangle (3) reactive
new bone formation
Periosteal reaction sunburst effect(4)
Destroyed cortical bone (6)
Infiltration of surrounding soft tissues (7)

Value of angiography in bone

tumors:
Osteosarcoma, penetrating the cortical
bone of the femur, and dislocating the
femoral artery

Isotope scan scintigraphy in

bone tumors:
See increased uptake of isotopes in left
proximal femur
(Ewings sarcoma)

Ultrasound sonography - - in bone

tumors:
Chondrosarcoma of femur , white spots
in the vastus muscle

Incidence and localisation of

chondrosarcoma

Most frequent localisations of tumor

metastases in bone

Incidence and localisation of

osteosarcoma most frequent in distal
femur

Bone tumors: surgical management

Surgical procedure depends on
degree of malignancy
local characteristics of tumor
presence or absence of metastases
Classification that helps to decide type of op.:
ENNEKING CLASSIFICATION:
G degree of malignancy (G1- low, G2 high)
T inside capsule(T0), inside compartement (T1), outside compartement (in
surrounding tissues T2)
M metastases ( M0 no, M1 yes)
Surgical procedure:
Excochleation removing the tumor tissue alone only in benign bone
tumors
Resection- removal of tumor together with surrounding soft tissue envelope
Segment resection removal of tumor together with the surrounding bone
or muscle segment
Amputation or exarticulation if tumor penetrates into surrounding tissues
and involves nerves and blood vessels too (role of angiography!)

Operative interventions according to radicality of the procedure:

1. Radical procedure amputation or exarticulation
2. Wide resection, removing healthy tissues as well
3. marginal resection, removing only the surrounging bone
4. excochleation removing only the tumor
Surgical procedure:
Prosthetic replacement of whole bone with two joints:
femur with
knee and hip replacement
(in osteosarcoma of femur)
Osteosarcoma of distal femur: tumor penetrating into soft tissues, with typical
spicules (bony spikes)
Treatment: resection of distal femur and proximal tibia replacement with tumor
prosthesis
Chemotherapy: Only in certain bone tumors as an adjuvant therapy to
operation
Ewings tumor
Central osteosarcoma
Aim: prevent lung metastasis, prevent local recurrence of tumor
Radiotherapy:
Irradiation as adjuvant therapy to operation in Ewings tumor
Principle of chemo- and radiotherapy:
-Strict protocoll of chemo- and radiotherapy, depending on histological finding
-Preoperative chemotherapy for max. 6 weeks, postop. chemo- and radiotherapy
according to degree of malignancy and sensitivity
Malignant bone and soft tissue tumors examples:
Chondrosarcoma of the os ilei
pelvis:
Radiolucent area (more radiation is
penetrating) with an area of
calcification

a./Osteosarcoma (parosteal
osteosarcoma) at the distal metaphysis
of femur
b./ cross section of bone that was
removed at operation tumor is on the
cortex (not penetrating)
c./ CT: tumor on the outside of femural
cortex

Hypernephroma (kidney tumor)

metastasis in lumbar vertebra
destruction of the vertebral body

Osteogenic metastasis of prostate

cancer, in the pelvis- see dense, white
areas showing new bone formation

(Periosteal) osteosarcoma of tibia

cross section of tumor, removed at
operation

Osteochondroma (benign) at the

proximal end of fibula (large growth,
looking like cawliflower)

Chondrosarcoma at the proximal end of

humerus: destruction!

Metastasis of mamma cancer, causing

pathological fracture of humerus

Ewing sarcoma of the fibula

typical onion like appearance

Malignant soft tissue tumor

fibrosarcoma of the leg. Angiography
shows hypervascularity, that is typical
in aggressive malignant tumors.

Multiple myeloma metastasis in L 4

vertebra
(multiple myeloma is tumor of the bone
originating from haemopoetic tissue)

Value of MR in the diagnosis of soft

tissue tumors: malignant soft tissue
tumor (histiocytoma) in the rectus
femoris muscle

Malignant soft tissue of the thigh: huge

liposarcoma see necrotic areas (black
areas in the tumor mass) that are
typical changes in malignant tumors

Large swelling in the left arm: MR shows

the presence of an aggressive tumor,
that penetrates into the surrounding
muscle : synovial sarcoma, originating
from the elbow joint

Benign soft tissue and bone tumors : examples

a. Round osteolytic lesion in the
distal femoral epiphysis
(chondroblastoma benign)
b. MRI of the same knee: size and
extent of tumor is better visible

Giant cell tumor of proximal tibia,

extending to fibula.
Aggressive, destructive, but not
malignant

Same patient see large tumor in the

head of tibia

Giant cell tumor in the head of 2nd

metacarpal.
Operation: tumor was removed, and the
defect was filled up with bone graft from
the iliac crest

Benign bone tumor:

Osteoid osteoma in the metaphysis of
right femur
See nidus small radiolucent area,
surrounded by dense bone

Benign tumor (non- ossifying fibroma)

in distal femur and proximal tibia
round shaped changes , clearly visible
borders between osteolytic area and
normal bone

Pathological fracture due to bone cyst

(juvenile bone cyst) causing fracture
(often fracture is the first sign of bone
cyst in children)

Bone cyst pathological fracture of

distal radius

Destruction (osteolytic lesion) of the

proximal and middle phalanges of index
finger of left hand enchondroma
(benign)

Tumor of vascular origin aneurysmal

bone cyst,
large cystic bone tumor, that may cause
pathological fracture, or may cause
pain, due to its size and localisation

Tumor like condition:

myositis ossificans at the proximal
femur (calcification in the adductor
muscle)
Precise diagnosis : only by histology
(specinmen must be taken - biopsy!)

Osteoid osteoma femoral neck, vertebral arch

See NIDUS (dense area in the middle of tumor)
Symptom: pain at night, aspirin releives the pain

Take home message:

Bone and soft tissue tumors:
Early identification is essential
Painfree swelling at any part of the body is suspicious of tumor
Value of different imaging techniques must be known
Therapy is different in malignant (radical removal) and benign
tumors( excochleation or simple resection)
Aim of treatment:
Survival of patient
Maintaining extremity, if possible
Prevent recurrence of tumor

Ask:
-where is the lesion?
-is it solitary or multiple?
-does it look like a cyst?
-is the centre calcified?
-are the margins well defined? or poorly defined?
-is there cortical destruction? Or periosteal reaction?