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BONE TUMORS

The term Tumour is usually applied to an abnormal growth of tissue which may be benign or malignant.
The musculoskeletal system may develop tumours , either as a primary from this system itself or as a secondary from
a distant primary location.
Secondary bone tumours ( Metastatic deposits) are commoner than primary bone tumours.
Primary bone tumours may be begin or malignant.
Osteochondroma is the commonest benign tumour of the bone , where as Multiple Myeloma is highly malignant
tumour affecting adults above 40 years of age.

Benign tumor Malignant tumor

-Slow growing -Rapidly growing


-Well circumscribed -Not well circumscribed
-Non- invading - Invading
-Do not matastasise -Metastasises
-No or very few -Associated with pain and
symptoms disability
-X-rays- lesions confined to - X-rays- ill defined borders,
the bone mottled appearance,
breakage of the cortex.
-Do not cause death of the -May cause death of the
patients patients

Classification
Various classifications have been proposed for bone tumours like Dahlins classification, Mercers
classification , Tureks classification etc.
These classifications are mainly based on the recognisation of the dominant tissue in the various lesions.

A classification of the bone tumours


General principles of tumours
A proper understanding of the general principles of # Special investigations
tumours is essential to make correct diagnosis, and to
choose the correct line of treatment to minimize the 1. X-rays- Plain x-rays are still the most useful imaging
recurrence rate and to improve the survival rate. technique.
There are certain parameters of general principles of Look carefully for any abnormality in the bone like-
tumours. cyst, cortical thickening , any ill defined destruction
etc.
History Also note that :-
Clinical Examination Is lesion solitary or multiple?
Investigations Where is the lesion in the bone?
What type of bone is involved?
A:- History Is there any cortical destruction , any bony reaction
Most of the time the history is prolonged , resulting in etc?.
delay in obtaining proper treatment.
1.Age 2. X-rays chest- for evidence of secondaries.
Many benign tumours and some malignant tumours
like- Ewings sarcoma and Osteosarcoma are present 3. CT scan-
in childhood and adolescence. -It show more accurately the intra- osseous and extra-
Chondrosarcoma and Fibrosarcoma do occur in 4th to osseous extension of the tumour.
6th decades. -It may reveal lesions in inaccessible sites like the
Matastasis is more common in elderly patients over pelvis and the spine.
70 years of age than the primary tumours. -It is reliable method of detecting pulmonary
metastases even the size of 2 mm ( as X-rays do so
2. Pain- is a common complaint and may be caused by at 2 cm size) could be picked up.
rapid expansion of the tumour with the stretching of
surrounding tissue , central haemorrhage, 4. Radionuclide scanning with 99 Tc HDP(
degeneration in the tumour, or a pathological Technetium labelled hydroxymethyline
fracture. diphosphonate) - helps to detect the extend of spread
3.Onset- it is acute in malignant tumours and of bone tumour to other areas of skeletal system and
insidious in benign tumours. also to detect occult bone metastasis.
4. Anorexia, weight loss , fever- more pronounced in
malignant tumours. 5. MRI- provides further information the spread of the
tumour:-
B. Clinical Examination Within the bone
.General examination:- for evidence of anaemia, Into a near by joint
cachexia, lymphadenopathy etc. Into the soft tissues

.Local examination- to know the plane , extend ,


presence of pathological fractures etc. 6. Arteriography- to determine the spread of the
tumour to the vessel.
.Joint examination- to know the involvement of the 7. Ultrasonography- helpful in some situations , but
joint or any mechanical effects. has a limited role.
8. Biopsy- This is the ultimate diagnostic technique in
.Neurological examination- assess any damage to the diagnosing bone tumours.
peripheral nerves due to the spread of the tumour. Close:- needle and aspiration
Assessment- of the status of arterial and or venous Open:- incision and excision
circulation.
It is to be noted that all the above
C. Investigations investigations help to stage the bone
# Routine laboratory investigations- tumour. Staging helps in detecting the type
Hb%, total WBC count and DD count , of surgical procedures needed for local
ESR control of the tumour.
Serum calcium and phosphorous
Serum alkaline phosphatase in osteosarcoma.
Serum acid phosphatase in matastatic tumours.
Ennekings Staging - 1980 1.Benign, asymptomatic lesions- ( e.g.- a small
It is based histological grading, anatomical site and osteochondroma) no treatment is required.
presence or absence of distant metastasis. The
surgical staging system classified the bone sarcomas 2. Benign, symptomatic tumours- painful tumour
into three stages:- continuing to enlarge requires biopsy and diagnosis.
They are generally treated by local (marginal )
I. Low- grade tumours excision or by curettage ( as in benign cyst).
II. High- grade tumours
III. Low or high with presence of metastases. 3. Suspected malignant tumours- A patient with a
primary malignant tumour is admitted for more
Each group may be subdivided into:- detailed examination, blood tests, chest x-rays , CT
A- Intracompartmental lesions scanning or MRI for the confirmation of the diagnosis
B- Extra compartmental lesions and staging.

Finally the treatment options fall between


Stage Grade Site Metastasis amputation, limb sparing operations with different
kinds of adjuvant therapy with the patients fully
IA Low Intra.Comt. None informed about the outcomes of the results.
IB Low Extra Comt. None
II A High Intra. Comt. None Methods of treatment
II B High Extra.Comt. None 1 . Tumour excision- More aggressive the lesion ,
III A Low or high Intra. Comt. more widely it needs to be excised.
III B Low or high Extra.Comt. Present or high.
# Intracapsular excision and curettage

# Marginal excision

Differential diagnosis # Wide excision


Clinically or radiologically many conditions mimic a
tumour and it is important not to misled by the # Radical excision
common dissemblers.
2. Multi-agent Chemotherapy-
1 . Haematoma- proper history, rapid onset of the
symptoms. !. Now is preferred adjuvant treatment for malignant
2. Myositis ossificans- tender swelling following an bone and soft tissue tumours.
injury. Newly formed bone more defined , less painful
and well demarked unlike a malignant tumour. !!. The modern chemotherapy regimes reduce the size
of the lesion, prevent metastatic seeding and improve
3. Stress Fractures- Occurs in normal bone of a the chances of survival.
healthy patient and is caused not by a specific !!!. The drugs commonly used are- Methotrexate,
traumatic incident but by repetitive stresses. Adriamycin, Cyclophosphamide, Vincristine and
4. Tendon avulsion injuries- Children and adolescents Cisplatin.
engaged in vigorous sports are prone to avulsion !!!!- Pre-operatively the treatment is given for 8-12
injuries. weeks with the maintenance dose for another 6-12
5. Infection- Usually children or young adults are weeks.
affected.
6. Gout- Usually a large gouty tophus causes a painful 3. Radiotherapy
swelling at one of the bone ends . !. High Irradiation is used to destroy for highly
7. Other bone lesions- Fibrous cortical defects, sensitive tumour such as Ewings sarcoma as an
medullary infracts mimic for tumours. alternative to amputation.
!!. It is also used in combined form with chemotherapy
for tumours in inaccessible sites, for inoperable
Principles of management tumour because of size or local spread, metastatic
A consultation and co-operation between the deposits, myeloma and malignant lyphoma.
Orthopaedic Surgeons, Radiologists, Pathologists , !!!. Dose- it is given in divided doses up to 6000 cGy in
Oncologists, Prosthetic Designer is required in proper 4 weeks time.
managing a bone tumour.
Common Benign Tumours
Osteochondroma:- Ostoid Osteoma
It is the most common benign tumour and is NOT a
true neoplasm since its growth stops with the fusion of
epiphyseal plate. It is a peculiar small benign bone tumour , first
1.Age- It is common during the growth period described by Jaffe in 1935.
Age- Common in young adults between 10 to 25 years
. of age.
2.Sex- has a male preponderance. Sex- males are more affected (M:F=2:1)

3.Origin- Few cells from the growth plate start Pathology- The typical feature is the formation of a
growing centrifugally as a separate lump of the nidus , less than 1 cm in diameter , usually in the
bone. Eventually the tumour gets left behind and cortex of the long bone, the tibia being the
comes to lie at the metaphysis. commonest site.

4. Site- Any bone that develops in cartilage involved. Clinical features- The only symptom is a severe ill
Fast growing ends of long bone and the crest of the localised deep boring pain , worst at night. The
ilium are the commonest site. pain is eased by aspirin or its derivatives.

5. Clinical features- X-rays- The tumour is visible as a zone os sclerosis


# Symptoms- Usually symptomless , but patient may surrounded by a radiolucent nidus less than 1 cm in
complain of pain, swelling, once the complications like size.
bursitis, malignant change or fracture have developed. Tomography or CT scanning- likely to show the central
lesion more clearly.
# Signs- A firm non-tender swelling fixed to the bone
around the joints is most common finding. Bone scanning- shows a well localised area of
!!- Joint movement may be decreased due to markedly increased isotope uptake.
mechanical block of the tumour rather than its
extension into the joint. Treatment- Complete excision of the nidus together
with a margin of surrounding bone. This operation
7. X-rays- gives dramatic relief of pain .
# Well- defined exostosis emerging from the
metaphysis.
# The tumour is composed of cortical and medullary
portions which are continuous with the main bone.
# It looks smaller than it feels because the cartilage
cap is not seen on x-rays.
Multiple lesions may develop as a part of heritable
disorder Hereditary multiple exostosis.

8. Treatment
Usually it requires no treatment , but complete
surgical excision is indicated if:-
# If the tumour is large and obstructing the joint
movements.
# Painful bursitis
# Fracture of the bony stack
# Malignant change ( 1-2%)
# Pressure on the neighbouring vessels and nerves.
etc.
Giant Cell Tumour
Giant cell tumour is a benign , locally aggressive lesion Treatment:-
arising from the epiphysis. 1. Slow-growing benign lesion- curettage and stripping
of the cavity with burrs and gouses, swabbing with
Sex- more common in female than the males. hydrogen peroxide or with liquid nitrogen then the
Age- Seen commonly in age group of 20- 40 years cavity packed with bone chips.
after epiphyseal fusion. 2. More aggressive tumours, recurrent lesions- Excision
Bones affected- the lower end of femur, upper end of of the tumour followed by bone grafting or custom
tibia, the lower end of radius. made prosthesis.
Types:- Benign GTC
Intermediate GTC
Malignant t GTC

Pathology Treatment of GTC at common site


Gross-
# The tumour had a reddish, fleshy appearance and site Treatment of choice
comes out easily when curetted.
# Epiphyseal end of the bone is distorted. Lower end of femur Excision with turn-o-plasty
# Joint extension is rare Upper end of tibia Excision with turn-o-plasty
# No evidence of periosteal reaction Lower end of radius Excision with fibular grafting
Lower end of ulna Excision
Microscopic- presence of abundant large multi Upper end of fibula Excision
nucleated giant cells.

Clinical Features:-

# Pain at the site of tumour and a gradually increasing


swelling.
# History of trauma not uncommon with pathological
fracture in 10- 15 % of the cases.
# Local examination- reveals a bony swelling , tender
on firm palpation.

Radiology
- An eccentrically osteolytic lesion near the epiphysis.
-The cortex is thin and sometimes ballooned .
-No periosteal new bone formation (unless there is
pathological fracture)
-Soap- bubble appearance due to ridging of the
surrounding bone
-No calcification within the tumour
-The cortex may be disrupted at places.
-The tumour usually does not enter the adjacent joint

Campanaccis Radiological Classification of Giant cell


Tumour of Bone
Radiographic Criteria
grade
I Quiescent , small,intraosseous
II Active, aggressive but periosteum intact
III Aggressive , soft tissue invasion