BONE TUMORS

Dr M.O.Okunola ,FWACS
Definition.
-Neoplastic growth of tissues in bone

Aetiology
- unknown

Predisposing factors
-high dose of external radiation therapy
-chemotherapy
-hereditary-retinoblastoma
-metal implants
-bone disease e.g.Paget’s disease
Classification
-Primary bone tumors
-Secondary /metastatic bone tumors- from
-thyroid
-lungs
-breast
-colorectal ca
-prostate
-cervix
Primary bone tumors
- originate from bone or bone derived cells /tissue

Benign-non cancerous
-slowly growing
-non invasive
-non metastatic

Malignant –cancerous
-aggressive
-invasive
-metastatic
Cell type Benign` Malignant
Bone Osteoid osteosarcoma
osteoma Ewing’s
Osteoma sarcoma
osteoblastoma

Cartilage Chondroma chondrosarcoma

Osteochondroma
chondroblastoma
Cell type Benign Malignant
Fibrous Fibroma fibrosarcoma
Fibrous dysplasia

Marrow Haemangioma Angiosarcoma

Myeloma

Uncertain Giant Cell tumor Malignant Giant

Simple bone cyst cell tumor
Aneurismal bone
cyst
Non ossifying
fibroma
Clinical Presentation
Age
-benign tumors present in childhood and
adolescence
-4th -6th decade of life-chondrosarcoma
` -fibrosarcoma
-myeloma-commonest primary malignant bone
tumor -6th decade
>70years-metastatic tumors are commonest
Age Most common Most common
group benign lesions malignant
tumors
0-10 simple bone cyst Ewing's sarcoma
eosinophilic leukemia
granuloma metastatic
neuroblastoma

10-20 non-ossifying fibroma osteosarcoma,

fibrous dysplasia Ewing's sarcoma,
simple bone cyst
aneurysmal bone cyst adamantinoma
Age group Most common Most common
benign lesions malignant
tumors
10-20 osteochondroma
(exostosis)
osteoid osteoma
osteoblastoma
chondroblastoma
chondromyxoid
fibroma
20-40 enchondroma chondrosarcoma
giant cell tumor
Age Most common Most common
group benign lesions malignant tumors

40 & osteoma metastatic tumors

above myeloma
leukemia
chondrosarcoma
osteosarcoma
(Paget's associated)
Clinical Presentation contd
-Asymptomatic
-benign lesion
-accidental X-ray findings
-slow growing malignant tumors.

Pain
-common complaint- dull, achy
-cause -rapid expansion with pressure
on / stretching of surrounding tissues

-central haemorrage/degeneration
Clinical Presentation contd
Swelling /lump
-painful
-enlarging rapidly/slowly
-ulceration.

Trauma
-may be a red herring
-may cause a pathologic fracture

Neurological symptoms
-paraesthesia ,numbness
Clinical presentation contd
Pathologic fracture
-may be the 1st clinical symptom
-slight injury
- unexpected site
Symptoms of metastasis

Clinical Examination.
-general examination
-pallor
-weight loss/ cachexia ,fever
Specific examination
Lump/swelling
-site
-discrete/ill-defined/diffuse
-soft/hard
-tenderness
-pulsatile
-overlying skin—warm,and inflammed
-ulceration
Neighbouring joint
-effusion ,limitation of movement
Neurologic and vascular examination of the limb
Investigations
Imaging
Plain X-rays
-most useful-some appearances
are pathognomonic
-the type of bone involved
--the site of the lesion in the bone
-bone end –GCT
-metaphysis
-diaphysis
Imaging contd
-the type of lesion
-discrete,well defined edges-benign
-edges ill-defined--invasive
-cortical thickening,bone reaction
-cortical destruction
-solitary /multiple
-calcified centre-chondrosarcoma
-soft tissue invasion-malignant
-soap bobble appearance—GCT
- sun ray appearance-osteosarcoma
 CXR
Angiography
-embolectomy
-neo-adjuvant chemotherapy
Bone scan/radionuclide scanning
-Tc-99
-reveals site of small tumor e.g osteoid
osteoma
-detects skip lesions
-detect silent secondary deposits
Computerised Tomography /CAT scan
-serial X-ray linked to computer
-excellent for cortical erosion or fractures
-intraoseous and extraoseous extensions
-reveals suspected lesions in inaccessible sites
e.g.spine,pelvis
-most reliable for pulmonary metastasis
MRI-magnetic resonance imaging
-use powerful magnetic field linked to computer
-greater value in assessing
- soft tissue involvement –muscles and
neurovascular bundles
-intramedullary spread of the tumor
important in assessing a limb for salvage surgery
PET-positron emission tomography scan
-uses radioactive glucose and a scanner linked to computer.

Laboratory Investigation
-FBC –PCV ,WBC, differentials
-blood film
- ESR
-Alkaline Phosphatase
-Protein electrophoresis-abnormal gama globulin
- Serum acid phosphatase,PSA-Ca prostate
-Urine-Bens Jones protein –multiple myeloma
-Serum E&U
-G&M blood
Tissue Biopsy
-essential for accurate diagnosis and planning of
treatment
Needy biopsy-FNAC /Trucut biopsy
-quick ,inepensive,under local anaesthesia
-best for sampling inaccesible tumor-under
image guidance
-insufficient/unrepresentative samples for
accurate diagnosis sometimes.
Open biopsy
Open biopsy
-tissue sample is taken through open surgery
-more reliable-adequate and represntative tissue
-more technical, high risks of complications
-haemorrage
-wound infection
-wound breakdown
-pathological fracture
-tumor cells desemination

1.Excisional biopsy-entire lesion is removed

-for benign lesion
2.Incision biopsy-a representative part of the tumor is removed
-for malignant lesion
Differential Diagnosis
-soft tissue /subperiostal haematoma
-myositis ossificans(heterotropic calcification)
-chronic osteomyelitis
-stress fractures

Staging
-tells of the likelyhood of spread and recurrence
after surgical removal
-for planning treatment and prognosticate
• Enneking’s classification –for sarcoma
Stage I -low grade sarcoma
A-intracompartment
( confined to an enclosed tissue
space –bone,joint cavity,muscle
group within its fascial envelope)
B-extracompartmental
(extend into interfascial or
extralfascial planes)
Stage II –high grade lesion
A-intracompartmental
B-extralcompartmental

Stage III –Metastatic lesion

Treatment
Principle of management.
-for all but the simplest and most obvious
benign tumors,treatment is- multidisciplinary
-orthopaedic surgeon
-radiologist
-pathologost
-oncologist
-prothetic designer
-rehabilitation therapist
A. Benign-asymptomatic lesions
1.where diagnosis is beyond doubt e.g non
ossifying fibroma,osteochondroma
-temporize
-treatment may never be needed
-lesion may remain quiscent or disappear
-monitor patient regularly

2.Where appearance is not pathognomonic

-a biopsy is advisable-excision or curettage
-send sample for histology.
B. Benign-symptomatic-painful,enlarging tumor
-biopsy to confirm diagnosis
-surgery –local(marginal excision)
-or curettage for benign cyst

C. Suspected malignant tumors

-admit patient
-investigate
-biopsy
-counsel for treatment
Treatment for malignant bone tumors.
1.Surgery-main stay of treatment
-local/marginal excision-dissection goes just
beyond the tumor
-wide excision-dissection carried well clear of
the tumor through normal tissue.
-radical excision-the compartment is removed
en-bloc .
-limb sparing
-amputation above the compartment.
Adjuvant therapy
- multiagent chemotherapy
-radiotherapy