Bone tumors

Prof: Mahmood Abed Aljumaily

‫المحاضرة الثالثة‬
Bone tumors

Chondrosarcoma:
Chondrosarcoma is primary malignant tumor of cartilage forming cells. It may be primary and
arise from remnant of cartilage in the bone. It may be secondary and arise from previous lesions
like cartilage capped osteochondroma or chondroma. Metastases usually present late. The
patient's age is usually more than 40 years. Pain, swelling, swelling and pain over previous
cartilage capped osteochondroma or chondroma or pathological fractures are the common
presenting feature. X-Ray shows ill-define medullary osteolytic lesion with flecks of
calcifications or large exostosis with ill-define margin with flecks of calcifications in cartilage
cap (Fig 5. 18). CT, MRI, Radioisotope scanning used to establish extent of lesion and to plan
treatment. Treatment is by wide local resection applied when possible, amputation, radiotherapy
and chemotherapy are other alternative.

{A} {B}

{C} {D}
Figure 5. 18. A: X-Ray shows ill-define medullary osteolytic lesion with flecks of calcifications
of the upper end of the humerus, B: MRI shows clear central changes of the humerus, C: X-ray
of the shoulder with extensive flecks of calcifications and soft tissue swelling, D: diagram shows
malignant changes either in the central anatomical region of the bone or at previous
osteochondroma.

Adamantinoma:
It is a rare tumor of shaft of tibia affect young adult, presented as pain and swelling. The lesion
formed of epithelial like cell in dense stromal cell. X-ray show multilocular osteolytic lesion of
tibial cortex (fig 5. 19). It is a low grade malignant tumor rarely metastasized. Treated by
excision with an adequate margin of normal bone.

Figure 5. 19 X-ray show multilocular osteolytic lesion mid shaft of tibia cortex.

Fibrosarcoma and malignant fibrous histeocytoma:

Both rare tumors affect adults and old patients, pain and pathological fractures are common
presentation. X-ray shows ill-defined osteolytic lesion in bone. Both treated by wide resection
and chemotherapy

Multiple myeloma:
Malignant disorder of B cell of lymphoproliferative tissue of bone marrow, stimulate osteoclastic
activity result in osteoporosis and multiple small osteolytic lesion (fig 5. 20). The presentation is
usually pain and pathological fractures. Sometime the lesion is solitary named solitary myeloma.
Treatment is by chemotherapy.
 {A} {B}
Figure 5. 20 A&B X-ray of the skull shows extensive multiple osteolytic lesions across whole
blade of the skull even there is involvement of the lower mandible.

Secondary metastases in bone:

The commonest bone tumors are secondary metastases. The skeleton is one of the commonest
sites of secondary tumors in patients over 50 years. It has bad prognosis. It arises from one of
these organs with the primary tumor; breast, prostate, lung, kidney, thyroid and gastrointestinal
tract. Sometimes no primary tumor can be found even after meticulous search. Metastases
usually appear in central skeleton (bone contain red marrow) like vertebra, pelvis, ribs, and
proximal end of femur and humerus. Most metastases are osteolytic caused by replacing bone
following their gradual expansion and by stimulating active bone resorption, pathological
fractures are common. Rarely metastases are osteoblastic (prostate carcinoma).
Clinical features: The common age is 50-70 years, any destructive bone lesion in this age
group; the differential diagnosis must include metastasis. The common symptom is local pain,
back ache, pathological fracture or local pressure may occur, high pain in an elderly person
(especially someone who have been treated for carcinoma in the past) always suspicious. The
primary tumor might be obvious; some deposits remain clinically silent and are discovered
incidentally on x-ray examination or bone scanning. Sudden collapse of a vertebral body or a
fracture of the mid-shaft of a long bone in an elderly person is an ominous signs. Symptoms of
hypercalcaemia may occur, this often is missed in patients with skeletal metastases, and these
symptoms include anorexia, nausea, thirst, and polyuria. Detailed clinical examination including
neck, breast, axillae, abdomen, chest, genitalia and (rectal and vaginal examination) are essential.

Investigations: X-ray of chest and urogenital tract is essential. CBP, ESR, protein
electrophoresis, serum alkaline phosphatases, serum acid phosphatases, and measuring blood
levels of tumor-associated antigen markers are indicated. Local X- ray commonly shows ill-
defined moth-eaten osteolytic lesion, (fig 5. 21). Sometimes there are osteoblastic deposits,
which should be differentiated from lymphoma and Paget's disease. Radioisotope scanning may
reveal increased activity of other unsuspected lesion and in of detecting ‘silent’ metastases.
 {A} {B}
Figure 5. 21 A: X-ray of the pelvis with rounded, ill-defined margin osteolytic lesion involving
upper third of the diaphysis of the femur, B: X-ray of the shoulder revealed extensive humeral
head resorption due to secondary metastasis.
Treatment:
The treatment are mainly palliative, by the time a patient has developed secondary deposits the
prognosis for survival is poor. Quality of life can be improved by careful management.
Pathological fractures, large osteolytic lesion or neurological compression need surgical fixation.
Radiotherapy chemotherapy, hormone therapy and analgesia were used also. Prophylactic
internal fixation may be used. Following a fracture, fixation or artificial joint replacement, is
indicated, when possible.

Synovial sarcoma:
It is a rare malignant tumor of joint or tendon sheath synovial tissue in adult and adolescent.
Patients usually complain of painful swelling related to large joints or related to tendon sheath.