BONE TUMORS

BONE TUMORS

Dr.Ankit Gujarathi
DNB resident,DMH
 INITIAL EVALUATION
• Carried out in 4 phases –
• 1st phase – involves
 High index of suspicion for tumors
 Routine X-rays
 Routine lab facilities
 Meticulous history
 Thorough physical examination
• 2nd phase – is prebiopsy regional evaluation, to determine size,
location and type of tissue .
• 3rd phase – is the actual biopsy.
• 4th phase – is undertaken if presumptive clinical & path evidence
suggestive of malignancy, search for mets is done, using CT scan
of lung & Tc-99 bone scan.
 PRESENTING SYMPTOMS
 Pain
 Mass
 An abnormal radiographic finding detected during evaluation of
unrelated problem
PAIN:- is most frequent symptom
-deep constant pain, poorly localised, worse at night.
MASS:- rate of enlargement is important.
 HISTORY OF THE PATIENT
• AGE:- most imp information, because of their presentation in specific
age group.
 1st decade- usually ABC ,SBC
 2nd decade-Chondroblastoma,osteochondroma,osteosarcoma,Ewings
 3rd decade- GCT
 4th decade- chondrosarcoma
 5th decade- Multiple myeloma
• SEX:- less imp than age
 Some tumors like GCT are more in females
• RACE:- little imp, Ewings rare in African descent
• H/O any exposure to radiation.
• carcinogens- methylcholanthrene, zinc beryllium silicate, beryllium
oxide.
 PHYSICAL EXAMINATION
• Evaluation of patient’s general health
• TUMOR MASS should be measured & its location, shape,
consistency,mobility,tenderness,local temp & change with
position should be noted.
• SKIN & SUBCUTANEOUS TISSUE :
 Small dilated superficial veins overlying the mass are produced by
large tumors
 Café-au-lait spots & subcutaneous neurofibromas indicate Von
Recklinghausen’s disease
 A venous malformation on the same of body as the cartilaginous
tumor is an indicator of Maffucci Syndrome
 REGIONAL LYMPH NODES: sign of metastatic disease.
 OTHER TESTS

• Hemoglobin
• CBC
• ESR
• CRP
• Serum alkaline phosphatase, sr.ca
• Electrophoresis & urinary Bence Jones protein
 INVESTIGATIONS
• X-RAY
• CT SCAN
• MRI
• TECHNETIUM BONE SCAN-This type of scan uses a
very low radioactive material (diphosphonate) to see
whether or not the cancer has spread to other bones
and the damage suffered by the bone.
• PET- Positron Emission Tomography uses radioactive
glucose to locate cancer. This glucose contains a
radioactive atom that is absorbed by the cancerous
cells and then detected by a special camera.
 What to see in X rays
• What is the precise location of the lesion?- cortex or medulla;
epiphysis, metaphysis or diaphysis)?
• Is there any evidence of underlying bone abnormality ?
• Is the lesion multifocal?
• Does the tumour have a well-defined margin? Is there a rim of
sclerotic bone? The presence of a well-defined margin and a
sclerotic rim strongly suggests a benign non-growing lesion.
• Is there evidence of significant cortical expansion or
destruction? These findings are seen with locally aggressive or
malignant tumours.
• Is there an associated periosteal reaction and, if so, of what
type?
• Is there a soft tissue mass?
PATTERNS OF GROWTH and BONE
DESTRUCTION

• Geographic
• Moth-eaten
• Permeative
 TYPES OF PERIOSTEAL REACTION
Benign
• None
• Solid
More aggressive or malignant
• Lamellated or onion-skinning
• Sunburst
• Codman’s triangle
 BIOPSY
• According to the tumor size and type (malignant or benign)
and the biopsy's purpose (to remove the entire tumor or only a
small tissue sample), there are two types of biopsies used in
bone cancer diagnosis. These are: needle biopsy and incisional
biopsy.
• 1. Needle biopsy: During this procedure, a small hole is made
in the affected bone and a tissue sample from the tumor is
removed.
• There are two types of needle biopsies:
• Fine needle aspiration: During this procedure, the tissue
sample is removed with a thin needle attached to a syringe.
• Core needle aspiration: During this procedure, the surgeon
removes a small cylinder of tissue sample from the tumor with
a rotating knife like device.
• 2. Incisional biopsy: During this procedure, the surgeon cuts
into the tumor and removes a tissue sample.
 Principals of biopsy
• Should be done after all investigation done.
• Surgeon should be familiar with incisions for limb salvage surgery. 
• If Tourniquet is used, the limb is elevated before inflation but
should not be exsanguinated by compression.
• Avoid transverse incisions.
• Enter thru single compartment(single muscle belly).
• Minimal retraction.
• Drain thru same incision.
• Biopsy from periphery of lesion.
 STAGING
Enneking described the most widely used staging system for benign
bone tumors .
Many benign bone tumors have the potential to present at, and
progress through, various stages during their disease course.
Stage 1-LATENT, it do not have any characteristics of growth or
progressive change, may resolve spontaneously.
Stage 2-ACTIVE, lesion deform the host bone but remain contained in
bone, require intralesional curettage.
Stage 3-AGGRESSIVE , tumor extend beyond the bone, require
complete work-up and a removal with wide margins to avoid possible
local recurrence.
• The staging system for malignant tumors adopted by the
Musculoskeletal Tumor Society, and originally developed by
Enneking is based on the histological grade, the local extent, and
the presence or absence of metastasis.
Stage Grade Local Extent Metastasis
1A low intracompartmental -
1B low extracompartmental -
2A high intracompartmental -
2B high extracompartmental -
3 any any +
Grade is determined by histological parameters. Low-grade tumors
generally have few mitotic figures, little if any cellular atypia, and
have a relatively non-infiltrative growth pattern. High-grade tumors
tend to have marked cellular atypia, hyperchromatism, and nuclear
pleomorphism. They often demonstrate an infiltrative growth
pattern
 Musculoskeletal Tumour Society
staging
(surgical margins)
• Radical- Normal tissue extracompartmental
• Wide -Beyond reactive zone through normal
tissue within compartment
• Marginal- Within reactive zone-extracapsular
• Intralesional -Within lesion
Site of bone involvement
 WHO CLASSIFICATION
1.Bone Forming Tumors-
• Osteoid Osteoma
• Osteoblastoma
2. Cartilage forming Tumors-
• Osteochondroma
• enchondroma
• Chondroblastoma
• Chondromyxoid fibroma
3. Giant Cell Tumor   5. Benign vascular tumors
4.Other-
• Solitary bone cyst
• Aneurysmal bone cyst
• Metaphyseal fibrous
defect
• Fibrous dysphasia
• Osteofibrous Dysplasia
• Myositis ossificans
tumors .
 1.OSTEOCHONDROMA
• solitary osteochondroma (exostosis) or multiple
osteochondromatosis .
• Solitary Osteochondroma is a developmental abnormality
of bone. When a stalk is present, the structure is called
pedunculated. When no stalk is present, it is called sessile.
• An osteochondroma growth usually stops at maturity.
• Solitary osteochondromas-most common benign bone
tumor.
• It is seen in patients aged 10 to 30. It occurs equally in
males and females.It is thought to arise during skeletal
growth when bone grows away from the growth plate
instead of in line with it.
 SYMPTOMS
• The most common symptom of an osteochondroma is a
painless mass near the joints.
• Most common skeletal sites include metadiaphyses of the
femur and tibia at the knee (35%), proximal femur and
humerus, pelvis and scapula.
 DIAGNOSIS

• A plain X-ray will show

the bony growth.
• MRI scan may be used
to look for cartilage on
the surface of the bony
growth.
• CT scan may also be
used.
 TREATMENT
Nonsurgical Treatment
Most of the time, solitary osteochondroma is not removed surgically.
Observe it & take regular X-rays to keep track of any changes.

Surgical Treatment
When surgery is recommended, it is best to wait until growth
complete (a mature skeleton by X-ray evaluation) before removing a
solitary osteochondroma. This decreases the chance of the tumor
growing back.
Surgery may be considered if the osteochondroma:
Is causing pain with activity
Puts pressure on a nerve or blood vessel
Has a large cap of cartilage
The osteochondroma is removed at the level of the normal bone.
 Discussion
• This tumor does not occur in bones with membranous type
of ossification.
• Multiple osteochondromas represent an autosomal dominant
hereditary disorder and are associated with bone deformities.
• Recurrence may develop when a portion of cartilage cap is
left behind.
• Malignant transformation is more often seen in multiple
hereditary osteochondromas. Most common secondary
malignancy is chondrosarcoma. (The earliest pathologic sign
of malignant transformation to a low-grade chondrosarcoma
is increased thickness of the cartilage cap, cap thickness will
exceed 2cm)
 MULTIPLE OSTEOCHONDROMATOSIS

• Multiple osteochondromatosis is also called multiple

osteocartilaginous exostosis, multiple hereditary exostosis
(MHE), familial osteochondromatosis, multiple hereditary
osteochondromatosis, or Diaphyseal aclasia.
• It affects males more often than females. It usually happens
within the first three decades of life.
• Alterations in genes called EXT genes are thought to be the
cause of this disease. There is increased risk of malignant
transformation.
 SYMPTOMS
• Symptoms are the same as solitary osteochondroma. The
number and location of osteochondromas varies. A patient
may have deformities of the forearms, a short stature, and
knock-knees and ankles. This is caused by abnormal growth
in the bones affected by the osteochondromas.
• Symptoms and signs of a tumor becoming cancerous are:
Growth of an osteochondroma after puberty
Pain at the site of an osteochondroma
A cartilage cap >2cm
 2.ENCHONDROMA
• Benign cartilage tumor.
• They are often found in patients between 10 and 20 years
of age.
• very common in the small bones of the hand and feet
• In rare cases, multiple tumors can appear as part of a
syndrome.
• These syndromes are Ollier's disease and Maffucci's
syndrome.
• Ollier’s disease-multiple enchromatosis
• Maffucci’s disease-multiple haemangiomas
+enchondromas
 SYMPTOMS

• Enchondromas are usually painless, found during an X-ray

evaluation of another problem in the same area. When
these tumors appear in the hands or feet, or in multiple
lesions, they can deform the bone, lead to pathologic
fracture.
• The deformities in patients with Ollier's disease and
Maffucci's syndrome can be quite severe.
 Diagnosis

• They are appear as

small (less than 5 cm)
lobe-shaped white
tumors in the middle of
the bone, white areas
of the tumor usually
show a pattern of rings
and arcs that indicates
the tumor contains
cartilage.
 Characteristics of a more
aggressive tumor or malignant
chondrosarcoma include:
Scalloping of the inner surface of the bone
Thickening of the bone cortex
Destruction of the bone by the tumor
Soft-tissue mass
Bone erosion that is growing
Erosion surrounded by reactive bone
• CT or MRI scan give a more complete picture of the bone
around the tumor. .
• Under the microscope, enchondromas have islands of
cartilage that surrounds them. Usually, cartilage is not
found in the center of bones. However, these tumors in the
hand and foot or in Ollier's disease or Maffucci's syndrome
may contain more odd-looking cartilage.
• Low-grade chondrosarcomas (cancers) look more cellular
under a microscope than enchondromas and there is less
normal bone in the tumor.
 TREATMENT
Nonsurgical Treatment
• Most enchondromas require no treatment at all. When
needed, treatment for enchondroma can vary due to the
difficulty in determining the aggressiveness of the lesion.
• Stage 1 latent lesions - that show no symptoms can be
watched with regular X-rays to ensure the tumor is not
growing.
 Surgical Treatment
• Scraping out and filling of the cavity with bone graft or
other filling substances back.
• Tumors that cause pathologic fractures are usually treated
by allowing the fracture to heal. Then, the tumor is scraped
out to prevent another fracture.
• Malignant tumors are either scraped out or the entire bone
around the lesion must be removed. This decision is made
depending on the grade of the tumor. The grade of the
tumor is determined by imaging studies and biopsy.
 3.CHONDROBLASTOMA
• Sometimes called Codman's tumor, a chondroblastoma is a
rare type of benign bone tumor that originates from
cartilage. Chondroblastoma most often affects the ends of
the long bones in the arms and legs at the hip, shoulder,
and knee.
• Chondroblastoma is a rare bone tumor that can affect
people of all ages, most common between the ages of 10
and 20 years. This type of tumor is also more common in
males than females.
Originates from immature cartilage producing cells called
chondroblasts.
 SYMPTOMS
• Symptoms of chondroblastoma may vary depending on
the location of the tumor. Symptoms may include:
pain in the knee, hip, and shoulder joint.
withered or shrunken appearance of the muscle near the
affected bone
impaired mobility of the adjacent joint
fluid accumulation in the joint adjacent to the affected
bone
 DIAGNOSIS
• X-RAY : The diagnosis of chondroblastoma can usually be
made by radiograph.The most common site for
chondroblastoma is the epiphysis. The lesion is lytic with
well defined margins and can be from 1-6cm in size.
Scalloping or expansion of cortical bone may be present.
Fine calcifications, either punctate or in rings, may be
visible.
• MRI & CT : Cysts are present about 20% of the time and
both MRI and CT can define the fluid levels. CT is also
useful for defining the relationship of the tumor to the
joint, integrity of the cortex, and intralesional calcifications.
Diagnosis
• Epiphyseal location of
the tumor above the
open
• growth plate, and
"benign" radiological
features (good
demarcation and a
• sclerotic rim).
 Histology
• uniform, polygonal cells that
are closely packed. These
primitive cells are derived
from the epiphyseal cartilage
plate and have abundant
cytoplasm. A scant chondroid
matrix may be superimposed
by a pericellular deposit of
calcification that appears like
"chicken-wire".
 TREATMENT
• The goal for treatment of chondroblastoma is to remove
the tumor and prevent damage to the end of the affected
bone.
• Treatment may include:
 Surgical removal of the tumor -
Biopsy and curettage with possible use of  adjuvant liquid
nitrogen or phenol, or a mechanical burr.
 Bone grafting.
 4.OSTEOID OSTEOMA
•  Osteoid Osteoma is a benign bone lesion with a nidus of <2 cm
surrounded by a zone of reactive bone.
• Second decade,M>F
• The proximal femur is the most common location followed by the
tibia, posterior elements of the spine, and the humerus.It is found in
the diaphysis or the metaphysis of the proximal end of the bone.
SYMPTOMS :-
• It has a distinct clinical picture of dull pain that is worse at night and
disappears within 20 to 30 minutes of treatment with non-steroidal
anti-inflammatory medication.
• Joint pain may be present with a periarticular lesion and synovitis
can occur secondary to an intraarticular lesion.
 DIAGNOSIS
• radiolucent nidus surrounded
by a dramatic reactive sclerosis
in the cortex of the bone
• diagnostic features include
(1) a sharp round or oval lesion
that is
(2) less than 2 cm in diameter,
(3) has a homogeneous dense
center.
• CT is the preferred method of
evaluation.
• Radiologic D/D includes
osteoblastoma, osteomyelitis,
arthritis, stress fracture and
enostosis
 TREATMENT
• Osteoid osteoma will resolve without treatment.
• If the patient does not wish to endure the pain and
prolonged use of non-steroidal anti-inflammatory
medications, surgical removal or percutaneous
ablation of the nucleus is indicated.
 5.Osteoblastoma
• Osteoblastoma is a rare bone-producing neoplasm that
closely resembles osteoid osteoma on microscopic
examination.
• By definition, all osteoblastomas are larger than 1.5cm.
• Osteoblastomas tend to arise in the axial skeleton,
involving the spine and the sacrum.
• Osteoblastomas do not produce
prostaglandin/prostocyclin .
• Peak incidence is in the second and third decades of life.
 6.UNICAMERAL BONE CYST
• A unicameral (simple) bone cyst is a cavity found
within a bone that is filled with straw-colored fluid. It
is a benign condition.
• UBC are usually found in patients younger than 20
years.
• Location-proximal humerus or proximal femur. Less
common locations include the pelvis, ankle (talus), or
heel (calcaneus).
• There is no known cause.
 SYMPTOMS

• Most unicameral bone cysts have no symptoms.

Some are discovered incidentally. Other unicameral
bone cysts are not noticed at all.
• If a unicameral bone cyst is thinning the bone, there
may be pain with weightbearing activities.
• If there is a pathologic fracture through the cyst, the
affected arm or leg may have pain, swelling, and
deformity.
 DIAGNOSIS

• plain X-rays to show a

hollow cavity in the
metaphyseal portion of
the bone.
• There is no associated
bone expansion. A well-
defined cortical rim can
be seen.
• Fallen leaf sign-path
gnomic of #.
 TREATMENT
Nonsurgical Treatment
• A unicameral bone cyst without pain or other symptoms
can be watched with repeated X-rays
Surgical Treatment
• Only unicameral bone cysts at risk of a pathologic fracture
need treatment.
• If the unicameral bone cyst is painful, growing larger, or in
a location that may fracture, may be treated by aspiration
and injecting it with a steroid or with demineralized bone
from the bone bank.
• A unicameral bone cyst in a structurally compromising
location may need surgery and fixation.
 7.Aneurysmal bone cyst
• locally destructive, blood-filled reactive lesions of
bone and are not considered to be true neoplasm's.
• Any bone may be involved, but the most common
locations include the proximal humerus, distal femur,
proximal tibia and spine.
• F>M
 DIAGNOSIS
• circumscribed,loculated
• Radiolucent lesion
producing Blowout
expansion of the bone.
• Double-density fluid
level and intralesional
septations usually
indicates an
aneurysmal bone cyst.
 Treatment
• Extended curettage and grafting with a bone graft
substitute. Because the lesion may produce heavy
bleeding, tourniquet control is advised. Marginal
resection sometimes is indicated for lesions in
expendable bones.
• Arterial embolization.
 8.GIANT CELL TUMOR
• Benign/aggressive tumor.
• Ages of 20 and 40 years.
• F>M
• Giant cell tumors are named for the way they look under
the microscope. Many "giant cells" are seen.
• Giant cell tumor of bone occurs almost exclusively in the
end portion of long bones next to the joints (epiphysis)-
distal femur,proximal tibia, distal radius .
• In rare cases, this tumor may spread to the lungs.
Giant Cell Tumor Osteoclastoma of Bone in Rib
"Soap Bubble" appearance on X-ray
 SYMPTOMS
• The bone involved is generally tender. There may be
swelling in the area around it.
• The first symptom is pain in the area of the tumor. There
may be pain with movement of a nearby joint. Pain
generally increases with activity and decreases with rest.
Pain is usually mild initially, but it progressively increases.
Occasionally the bone weakened by the tumor may break
and cause sudden onset of severe pain.
 DIAGNOSIS
• Giant cell tumors appear on X-rays as destructive (lytic)
lesions next to a joint. Occasionally, the involved area of
bone can be surrounded by a thin rim of white bone that
may be complete or incomplete. The bone in the area of
the tumor is sometimes expanded.
• MRI and CT scans better evaluate the area of involvement.
• bone scan generally shows a "hot spot" in the bone where
the tumor is. An X-ray or CT scan of the chest will often be
done to look for possible spread to the lungs.
 Treatment
• If not treated, these tumors will continue to grow and
destroy bone. Surgery has proven to be the most effective
treatment for giant cell tumors.
Nonsurgical Treatment
• Radiation therapy.
• Embolization- a process where the blood vessels supplying
the tumor are occluded by means of a catheter threaded
through the main arteries. Blocking the blood supply to the
tumor can cause it to shrink and even disappear because
the tumor loses its source of nutrition.
• Interferon
 Surgical Treatment
• If treatment is limited to curettage and bone grafting alone,
the tumor may come back (recur) up to 45 percent of the
time.
• Scooping out the tumor (curettage) is generally performed.
This techniques cause a window in the bone that can be
filled with a bone graft.
• Enhancing the curettage with a high-speed burr or with the
use of agents such as liquid nitrogen, hydrogen peroxide, or
phenol, followed by placement of bone cement decreases
the recurrence rate to 10 percent to 29 percent.
• In the rare cases where the tumor has spread to the lungs,
surgical removal of the tumor in the lungs results in cure 75
percent of the time.
Thank you