Malignant

Bone Tumor
Common
malignant bone
tumor
Multiple myeloma
Osteosarcoma
Ewing sarcoma
Chondrosarcoma
 • Definition: Osteosarcoma is a highly
OSTEOSARCOMA (aggressive) malignant primary bone
tumor characterized by the production of
neoplastic osteoid by malignant cells‚
directly from the multipotential
mesenchymal tissue.
Incidence:
• 2nd most common primary malignant tumor of the bone ‚ next to multiple
myeloma. Ewing’s sarcoma 4th common (6-8%)

• - 20% of primary malignant tumor of bone.

• - Age:
• o Primary high grade Osteosarcoma- 2nd decade of life ( 10-20 years of
age)
• o Secondary variety – more than 5th decade ( older age group)
• - Sex: Male > Female
 • Most common- metaphysis of long
Sites bone
• Sites are:
- Around the knee 60% Distal femur (50%)
- Around the hip 15% Proximal tibia (20%)
- Around the shoulder 10% Proximal humerous (10%)
• Others ( less commonly)
Upper end of fibula
Vertebrae
Iliac bone
Jaw bone ( aged person)
 • Clinical features:
Clinical features: • - Pain
o Usually first symptom
o Constant
o Worse at night
o Gradually increases in severity
• - Swelling: Usually osteosarcoma diagnosed
in stage IIB. So swelling may be the first
symptom.

• - Limping gait- if weight bearing bone is

involved

• - Pathological fracture/ deformity: Rare

• - Constitutional and metastatic feature ( 10%
early metastasis in lung)
X ray of the
• Hazy osteolytic area may alternate with
affected part: unusually dense osteoblastic area
• Enlarged margin – poorly defined ‚ moth
eaten appearance
• Cortex- breached and tumor extends
into adjacent tissues
• Sun- ray appearance: steaks of new
bone appear radiating outwards from
cortex. Along the arrangement of blood
vessels.
• Codman’s triangle: reactive new bone
formation at angle of periosteal elevation
• Pathological fracture at the osteolytic
lesion.
Treatment
modalities:
• Neo- adjuvant chemotherapy:
- Surgery given for
- Chemotherapy a. 8-12 weeks before
neo-adjuvant operation
adjuvant
b. 3 weeks interval
- Radiotherapy
c. 3 cycles
d. 3 weeks gap before
operation
EWING’S
SARCOMA
It is the primary malignant
tumor of bone arises from
reticuloendothelial cells of
medullary cavity/
endothelial cells in bone
marrow.
• Incidence:
- 4th most common primary
malignant tumor of bone (6-
8% )
- 2nd most common before the
age of 30
- Most common between 10-
20
years ( less than 10 years)
- (6-8% ) of all primary
malignant
tumor
Predisposing
factor:
Age: less than 10 years –
most
common
Sex: Male: Female = 1.5:1
Site:
- Diaphysis of skeletally
immature long bone
 • Clinical features:
Clinical features: • Pain ( E.S swelling then pain but in O.S
Pain then swelling)
o Throbbing
o Worse at night
• - Swelling :
o warm‚ tender (suggestive of
osteomyelitis)
• Dilated veins over the skin ‚ firm in
consistency‚ fixed with underlying bone
• Generalized illness
• Pyrexia ( constitutional symptoms)
• Metastatic features of lung may present.
X ray of the
affected part: • Area of bone destruction‚
predominant in mid-diaphysis
• Onion peel affect: new bone
formation extend along the shaft
and it appears as fusiform layers
of bone around the lesion
• Often extend into surrounding
soft tissues ‚ with radiating
streaks of ossification ( sunray
appearance) and reactive
periosteal bone at proximal and
distal margins ( Codman’s
triangle)
Treatment of • Best result is achieved by
Ewing’s sarcoma: combination of radiotherapy‚
chemotherapy and surgery
• For accessible site:
• - Neo-adjuvant chemotherapy +
• - Surgery ( wide local excision/
amputation/ disarticulation) +
• - Adjuvant chemotherapy for 1
year.
Chondrosarcom
a • Incidence:
• - Chondrosarcoma constitutes about
Site of involvement: 9% of primary malignancies of bone
- Proximal femur • These are slow growing tumor
- Pelvis usually present for months before
- Proximal humerus
being discovered.
- Distal femur • Age: Adult; 3rd to 8th decade with a
peak 40 and 70 years.
- Scapula
- Proximal tibia
Chondrosarcom
a
X ray finding: • Large, intraosseous , osteolytic tumors
with a narrow zone of transition.
• Irregular, granular calcifications within
the matrix described as ‘honeycomb’ or
‘popcorn’.
• Endosteal scalloping of the cortex
• Eventual cortical destruction
• There may be a faint periosteal
reaction
Treatment:
Chondrosarcoma is
resistant to both
chemotherapy and
radiation, making surgical
excision the only treatment.
High grade lesion:
Only wide excision margins
are oncologically
acceptable to minimize
local recurrence

MULTIPLE
MYELOMA
Definition: Multiple
myeloma is a malignancy
of plasma cells
(monoclonal neoplastic
proliferation of plasma
cells) characterized by the
replacement of bone
marrow ‚ destruction of
bone and formation of
paraprotein.
• Predisposing factor:
• Age:
• - 45-65 years ( in 90% cases)
• - Peakincidence in 8th decade
• - M:F = 2:1
• Site: Skull‚ vertebral body‚ ribs‚ pelvis‚
sternum‚ clavicle‚ proximal part of long
bone
• Clinical features:
• - Bone pain
• - Backache
• - Weakness
X ray of the
• Generalized osteoporosis
affected part:
• Classical lesions are-
Multiple punched out defects sharply
demarcated without any surrounding
reactive sclerosis
• Commonly seen in skull‚ pelvis‚
proximal femur‚ crushed vertebra
• Marked expansion of cortex: give rise
to ballooned appearance
• Vertebral compression fracture may be
seen.
• Pathological fracture may be seen
Laboratory investigation:

• - ↓ Hb% - anaemia ( normochromic normocytic)

• - ↑↑↑ ESR ( Sky high)
• - Hypercalcaemia
• - ↓S. Alkaline phosphatase – despite of extensive bone destruction
• - B. Urea and S. Creatinine to see renal function
• - S. Globulin ↑
• - A:G Ratio↑ ( normal A:G= 1.7:1)
• - S. Protein electrophoresis - ↑level of monoclonal immunoglobulin ( M Protein)
• o Either Ig G – 60%
• o Ig A – 25%
• o Light chain inly: 15%
• - Urine: Bence Jones protein is absent ( 30% cases)
• - Bone marrow biopsy from sternum – shows abnormal plasma cells with myeloma cells
Treatment:

• 1. Specific treatment: • 3. For localized lesion:

chemotherapy
• a. Radiotherapy
• 2. For generalized lesion: • b. Surgery:
• Autologus stem cell transplantation less
than 60 years patient. • i. Pathological fracture →internal
• Correction of anaemia – blood
fixation with bone cement
transfusion • ii. Compression fracture→
• Aggressive treatment for hypercalcaemia stabilization with or without
( due to bone resorption↑) decompression
• a. Avoid immobilization
• b. Correction of fluid balance
• c. Bisphophonate-
• d. Chemotherapy – VAD
• e. To control pain: Radiotherapy ‚
corticosteroid