Bone Tumor

A tumor may be defined as an abnormal mass in the

tissue the growth of which exceed and incoordinated
with surrounding normal tissue and remain in the
same excessive manner even after the cessation of
stimuli which evoked the change.

Neoplasm

It may be defined as the new growth from

preexisting tissue which is autonomous and not
guided by the principle of natural growth and not
serve any useful purpose and having an unknown
etiology.

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 CLASSIFICATION OF BONE TUMOURS
(W.H.O. 1972)

WHO classification:

a. Primary Bone Tumors

1. Bone forming Tumor: They synthesize Osteoid

matrix that becomes mineralized.

I. Benign:
a. Osteoma
b. Osteotastoma
c. Perosted ossifying fibroma.

II. Malignant:
a. osteogenic sarcoma

III. Indeterminate:
a. Aggressive osteobtastoma.

2. Cartilage forming tumor:

a. Benign:
1. Osteochondroma
2. Enchondroma
3. Chondroblastoma
4. Chondromyxoid fibroma

b. Malignant:
1. Chondroamasarcoma

2
 3. Giant cell tumor: containing various types of
giant cells of unknown origin and may be
a. Benign
b. Indeterminate
c. Malignant

4. Marrow tumors: Arise from bone marrow.

a. Malignant:

1. Ewing’s sarcoma
2. Multiple myeloma
3. Chodoma or leukaemia of bone
4. Histiocytic Lymphoma

5.Vascular tumors of bone:

1. Benign: 2. malignant
• Haemangioama • Angiosarcoma
• Glomangioma

6.Other tumors of bone:

a. Benign b. Malignant:
• Neurilemmoma • Malignant
• Neurofibroma fibrous
histocytoma
• Liposarcoma
• Undifferentiated
sarcoma
• Adamantinoma

3
 B. Secondary tumors of bone :

75% bone tumors are secondary. Any bone tumors

above the age 40 years are considered a
secondary unless prove otherwise.

1. Metastatic:
From the tumor of other organ or tissue to bone
from bone.
From other organs or tissue to bones
a. Breast
b. Prostate
c. Thyroid
d. Lung
e. Kidney
f. Gastrointestinal tract

2. by invasion or inclusion.

a. Chordoma: Neoplasm of the embryonic

remnants of the notochord persist in the nucleus
palposus of intervertreval disc.

b. Angioma , angiosarcoma

c. Fibroma, fibrosarcoma

d. Myosarcoma

e. Synovioma

4
 C. Tumor like Lesion of Bone

1. Bone cysts:
a. Unicameral bone cyst
b. Aneurysmal bone cyst
c. Ganglion cyst of bone
d. Epidermoid cyst

2. Fibrous lesions of bone:

a. Fibrous cortical defect

b. Non ossifying fibroma
c. Fibrous dysplasia
d. osteofibrous dysplasia / ossifying fibroma

3. Reparative giant cell granuloma

4. Eosinopilic granuloma

5. Diffuse osteitis fibrosa cystica.

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Biological behavior of bone tumor.

A tumor may remain intracapsular or become extra

capsular similarly it may remain within the
compartment or may erode or destroy the bone
cortex become extra compartmental

Advanced trauma or excision may cause in

compartmental lesion to spread outside the
compartment of origin.

Benign tumors:

Behaviorally they are 3 categories

a. Inactive benign tumor: (remain static or

latent. )

• completely intracapsular
• Reactive zone minimum.
• Histologically benign, well differentiated.
• No hyperchromasia , Anaplasia or
pleomorphism
• Usually asymphtomatic.

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b. Active benign tumor:
• Remain encapsulated with a fibrous tissue or
trabecular ring
• But continue higher and inner side of the
capsule may be irregular and the tumor
becomes tabulated.

c. Aggressive benign:
• Invasive in character

• Slowly penetrates the normal tissue with finger

like projections.

• Reactive zone forms pseudocapular but unable

to prevent distribution or penetration into
adjacent bone or compartment.

• They have high cell to cell matrix ratio clearly

differentiated bone matrix.

• Cytological feature offer symptomatic and cause

pathological fracture.

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Malignant tumors:
Ability to metastasis at a distal sides and form new
foci. Behavior varies widely. Some are characterized
by indolent local growth low incidence of metastasis
and a protracted interval between primary tumors
and metastasis.

The other exhibit as aggressive destructive local

growth, high indicidence of metastasis, and the
primary tumor and metastasis recognize
simultaneously.

Aggressive behavior usually demonstrated by the

• Tumors histological activity

• Degree of cellular differentiation
• Degree of tissue necrosis.

This histological grade best reflects the biologic

activity of tumor and best option for treatment and
the ultimate prognosis.

Assessment of histological type and grade is tem the

key to successful treatment whether surgical or non
surgical to alter the course of the disease.

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Behaviorally malignant tumor are-

1. Low grade sarcoma

• Slowly growing locally invasive low risk of
metastasis.
• Anaplasia
• Plemorphism
• Hyperchromatism
• Modest number of mitosis
• Usually remain asymptomatic

2.High grade sarcoma

• Rapidly growing wide reactive zone but no
psudocapsutation uninhibited by natural barriers
and rapidly extends into adjacent tissues by
destroying anatomical and compartmental
barriers.

• Satellite nodules occur in the reactive tissue and

“Skip” metastasis (Tumor nodules in ostensibly
uninvolved areas of some bone) are found well
outside the reactive zone usually in medullary
canal.
Histologic features:

• High cell to cell matrix ratio

• Poor differentiation of immature matrixes
• Anaplasia
• Plemorphism
• Dyperchonmsia
• High atypical mylosis

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Staging of bone tumors:

TNM system

TNM staging system is Tumor,Node & Metastasis staging

designed by American Joint Commission on Cancer (AJCC) &
adapted by International Union Against Cancer (IUAC) in
1987 for intramedullary tumor.

T for Tumor:
TX Cannot be assessed
T1 Tumor confined with in the cortex.
T2-Extend beyond the cortex.

N- For lymph node

NX- Can’t be assessed.
N1 – Designates presence of metastasis.

M for metastasis:
MX- Indicates an unknown stratus of metastasis.
M0- Indicates the absence of detectable distance
metastasis.
M1- Designates the presence of distant metastasis.

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Enneking’s system was proposed in 1986 & adapted by
AJCC & task force of bone tumors.

This system may be applied to both bone & soft tissue

tumors & based on the assessment of

Biological aggressive ness & local extent of the disease

based on the compartmentation concept of bone & soft
tissue.
The biologic & clinical aggressiveness is a combination of
histologic grading & specific histologic types.

The designation of this parameters

G0- Benign lesions

G1- Locally aggressive, low potential of metastasis

e.g. Giant cell tumor of bone,Perosteal & periosteal
osteosarcoma , Grade I & II osteosarcoma.

G2- Aggressive with high metastatic potential

Conventional osteosarcoma,Ewing’s sarcoma, Grade III
Chondrosarcoma,,Malignant fibrous histocytoma.T1 – Tumor
involves only one compartment.
T2- Tumor extend beyond the cortex, into adjacent soft
tissue, joint or another bone.

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TNM staging for Osseous neoplasm
Stage Grade Tumor Node Metastases
Stage I A Grade T1 N0 M0
Stage Grade T2 N0 M0
Stage Grade T1 N0 M0
Stage Grade T2 N0 M0
Stage Not - - -
defined
Stage Any Any N1 M0
Tumor
Grade
Stage Any Any Any Node M1
Tumor
Grade

Enneking’s staging system:

Stage Grade Site

Stage IA G1 –Low T1
Stage IB G1 –Low T1
Stage II A G2 – High T1
Stage II B G2- High T2
Stage III Metastasis

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 Osteoma

Benign tumour forming mature bone;

Commonly seen in adults and common sites are
Mandible and Paranasal Sinuses.

OSTEOID OSTEOMA:

Def. A Benign Osteoblastic Lesion that occurs in

Adolescents and Young Adults and affects the Long
Bones.

• Excruciating pain is the obvious Feature.

Etiology:

• Unknown
• Incidence: 10% of benign bone tumors.
• M : F: 2:1
• Peak age 5 - 25 years (85% in this range)
• Rare >40 years
• Only occurs in bones formed by endochondral
ossification

Clinical features:

• Conspicuous pain often worse at night and

relieved by aspirin.
• 10% occur in the spine and may -> scoliosis
• Other sites may -> joint effusion, LLD, synovitis

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• Runs a self limiting course but usually -> surgery
for pain relief
• Pain usually decreases as the lesion matures
lasting 18 - 30 months
• Lesion heals by 3 - 7 years

Radiology
 Lytic nidus surrounded by sclerotic bone (which may mask the
nidus)
 Tomograms are useful
 Hot spot on bone scan

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Radiology:

• Lytic nidus surrounded by sclerotic bone (which

may mask the nidus)
• Tomograms are useful

Histopathology:

Nidus- composed of vascular fibrous tissue in which

there are small, irregular, but connected trabeculae
of woven bone, demonstrating both prominent
osteoblasts and prominent osteoclasts .

Differential Diagnosis:

1. Idiopathic cortical sclerosis.

2. Brodies abscess
3. Benign bone cyst
4. Ch. Osteomyelitis with annular sequestrum

Treatment:

• NSAIDs for pain relieve ( Salicylic acid)

• Surgical:

Nidus excision -> no recurrence (need only intact

rim of reactive bone around the nidus to ensure
complete excision).

• Intraoperative localization
bonescan,Tetracycline, CT

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 • Percutaneous radiofrequency coagulation

OSTEOSARCOMA

The presence of malignant cells producing osteoid or

bone identifies a neoplasia as an
osteosarcoma.

Origin:

Multipotential mesenchymal tissue.

Histological type:

1. Osteogenic: osteoid tissue is

predominant .
2.Collagenic
3.Chondrogenic.

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Etiological Classification:

a. Primary Osteosarcoma (70%)

1. Sclerosing type – Abundant tumor bone

formation.

2. Fibromatous type.

3. Chondromatous type.

4. Telangiectatic type or osteolytic type.

5. Periosteal type (arising from outer cortex).

6. Parosteal type (juxtacortical soft tissue).

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b. Secondary Osteosarcoma

1. Paget’s disease.
2. Radiation induced.
3. Osteochondroma.
4. Fibrous dysplasia.

C. On basis of dominant histopathology

1. Osteoblastic or sclerosing Osteosarcoma

2. Chondroblastic
3. Tetangiectatic
4. Fibroblastic

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Etiology
Etiology exact unknown;

1. Predisposing factors:
a. Age- peak incidence between 10-20 years rare
below 10 years.
b. Sex- male : female= 2:1
c. Race- white and black same ratio.
d. Anatomical site

90% occurs in metaphysis of long bone.

Deceasing order of frequency

 Lower end of femur
 upper end of tibia
 Upper end of humerus
 upper end of femur
 pelvis

2. Exciting factors:
a. Virus
* RNA virus: eg Meloney mouse sarcoma
virus
* DNA virus- eg polyoma virus

b. Radiation:
o Localized irradiation above 2000 rads can
produce osteosarcoma
o Radio nucleotide that localized in bone can
produce tumor.

c. Chemicals:
• 20- methylrcholanthrene
• Beryllium compounds.

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20
CLINICAL PICTURE:
1. Age- Common second decade.

2. Location -- Metaphyseal region of long bones.

3. Sex -- More in males.

4. Onset- Gradual & Spontaneous.

5. Symptoms -- Pain
-- Swelling

6. Signs -- Tenderness
- Consistency – soft to hard.

● Lab findings :

• Hb% ↓
• ESR ↑
• Serum Alkaline phosphatase ↑.

● Radiological finding:

1. Both osteoblastic & osteolytic lesion.

2. Destructive changes are represented by -

a) Irregular, poorly defined areas of
radiolucency.
b) Inner margin of cortex is eroded giving
Moth-eaten appearance.

3. Sun-ray appearance.

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 4. Codman’s triangle – due to reactive sub
periosteal new bone formation.

Common variants are:

• Osteoblastic
• Osteolytic
• Telengiectatic
• Fibroblastic and Anaplastic types

Osteosarcoma - Histopathology
• Parosteal Osteosarcoma

A rare osteosarcoma arising from the external

surface of bone. It has better prognosis than the
usual osteosarcoma.

• Telangiectatic Osteosarcoma

Pathology
Irregularly distributed
Gross appearance: 90% situated in the
Pleomorphic cellsmetaphysis
with 2 or
pleomorphic malignant tumour
of long bone and 70% of knee tumor isMitotic
conventional
more nuclei. figures
cells with islands of osteoid
or medullary. In the metaphyseal region
and osteiod seenit appears as
tissue
a large tumor with destruction of inner cortex as it
extends into subperiosteal space. Macroscopically

Fibrous osteosarcoma- white

Osseous - yellowish white
Cortilanous – bluish white

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Periosteum act as a barrier and lifted away from the
parent bone as the tumor tissue accumulate large
amount within subperiosteal space the newly formed
neoplastic bone becomes oriented perpendicularly to
the surface of the cortex producing characteristic
sunray appearance seen in roentgenograme.
Reactive subperiosteal bone which is laid down is
most pronounced at the proximal and distal osteo
periosteal attachment producing codman's angles
seen in roentogenous rarely it produce lamellar
appearance under periosteum. Periosteum is
penetrated as the tumor extends into the
surrounding soft tissues.

During active growth period when the epiphyseal

plate is still intact act as a barrier to extend into
epiphysis but after epiphyseal closure tumor reach
epiphysis where articular cartilage act as a barrier to
enter into the joint.

Metastasis is early and haematogenous producing

pulmonary deposit or to other bone suggest multi
focal origin.

Macroscopic appearance:
Absolute - diagnostic criteria for osteogenic sarcoma
are

1. sarcomatous stroma
2. Direct formation of neoplastic bone .

Osteoid bone formed by the malignant connective

tissue

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There fore the tumor which contain neoplastic osteo
blastic area are qualified as osteogenic sarcoma.
Sometimes malignant cartilage and fibrous tissue
present in variable amount even may predominate .
But the findings of minute foci of neoplastic osteoid
and bone directly formed the anaplastic cellular
stroma categories the tumor as an osteosarcoma

The stromal cells are large resemble osteoblast and

their malignant characteristics include.

b. Anisocytosis( Variable size)

c. Poikilocytosis ( Variable shape)
d. Nuclear pyknosis
e. Pleomorphism
f. Polyhadral contours tending toward a
spindle shape
g. Frequent mitosis

Central portion of the tumor is sclerotic with

neoplastic bone. As the anaplastic cells become
enclosed in new bone , they become smaller rounded
and unsuitable for diagnosis. So the peripheral zones
are most satisfactory for diagnosis.

Sclerosing osteosarcoma

Grayish white tumor central portion continue

neoplastic bone, peripheral part contain cell and
stroma so consistency soft.

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Develop in metaphysic, erode the inner cortex and
spread through medullary canal, not reach epiphysis
except epiphyseal union. Advanced stage erode the
outer cortex & cause periosteal elevation,
subperiosteal new bone formation . Late stage
invades the surrounding soft tissue Metastasis is
through haematogenous route.

Microscopically-

Extensive irregular sheet of new osteoid and bone.

Peripherally hypercellular stroma with direct
formation of osteoid from the anaplastic cells.
Biopsy should performed from the peripherally of
the tumor.

Osteolytic osteosarcoma

Destructive tumor arise in central metaphysic usually

cause pathological fracture.

Grosssly- tumor consists of soft friable bloody tissue

interspersed with fibrous tissue that enclose the
necrotic haemorrhagic cavities

Macroscopically- blood containing cavities without

indothelial living composed mainly abundant spindle
cells and anaplastic osteoblastic hypochromatic
nucleus and frequent mitoses. Slow growing tumor
contain foreign body giant cell and rapid growing
tumor contain tumor giant cells.

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Differential diagnosis finding of osteosarcoma

Osteosarcoma contain any one or all the three

element of osteogenesis

1. osteoblast
2. osteoid (neoplastic )
3. bone (neoplastic )
4. calcifying cartilage which eventually replace by
bone

Osteosarcoma varies in appearance depending upon

the predominating component. The osteoblast is
analplastic characterised by large size large
hyperchromatic nuclei, frequent mitosis.
Osteoid irregular bone intermingled with partially
absorbed bone trabeculi and cortical lamella .

The main criteria for diagnosis of osteosarcoma is-

1. Sarcomatous stroma
2. Formating of neoplastic osteo.. and bone by
the sarcomatous stroma.

CLINICAL FEATURE

Symptoms:
1. Children adolescent or young adult male or
female present with a gradual or spontaneous
onset of pain in the metaphyseal region of long
bone , that at first become intermittent and
latter become continuous & incapacitating the

26
 pain is due to increased tension or
neurovascular compression.
2. Swelling may present for several months.
3. Constitutional symptoms present.

Local examination:
1. Early stage : A tender palpable mass at the
end of a long bone, soft to free or hard in
consisting with normal overlying skin, rapid
growing tumor becomes lobular.
2. Letter stage: The overlying tissue become
immobile , skin stretched, thin & glossy &
exhibit distended nevus, but never ulcerates.
Involvement of joint cause limitation of
motion.

General examination:
1. Weight loss in children
2. Moderate anemia

Cause:
80% case develop progressive pulmonary metastasis
in early stage but remain undetected before months
. The process usually total within 2 years.

Treatment:

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 Before treatment is instituted the first
consideration is to establish a definite diagnosis.
This can only be ascertained by biopsy.

To prevent metastasis the biopsy a frozen section,

and the ablative surgery should be carried out at the
same time. After diagnosis has established we are to
find out whether the patient can any pulmonary
deposit or not.

By the time the patient seen medical attention. Local

tumor extension and haemoatogenous metastasis
spread, usually to the long have already occurred in
most instances . Although at the early date tumor
micro emboli are not demonstrable but must be
considered in the treatment protocol.

The principles of treatment are-

1. complete control of primary tumor: by early and

radical amputation.
2. Prevention of metastasis or their control.

Once they are established : this can be accomplished

locally by preoperative moderate and post operative
chemotherapy as some possible after ablation of
primary tumor not before healing of amputation
stump otherwise interfering with soft tissue healing.

Level of amputation:

a. Tumor upper and of tibia- above knee

amputation.
b. Tumor distal end of femur-

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* Disarticulation of Hip
* 7 cm above the area of increased uptake seen in
bone scan if modern chemotherapy & `
megavoltage irradiation instituted earlier.
c. Tumor of the midshaft of femur-
* Disarticulation of hip
* 7cm above the maximum …of dye if stump size
is 10cm
d. Tumor at the upper end of femur or of
innominate bone – hind quarter amputation.
* But done after local growth control has been
established by radiotherapy and adjuvant
chemotherapy along.

a. Tumor upper end of the humerus -- fore

quarter amputation.

3. Treatment of pulmonary metastasis:

During diagnosis micro emboli in lung are present

in most of the areas. But opacities of solitary or
multiple ling metastasis not become radiologically
apparent for several months or year when the
patient treated with chemotherapy.

When large masses developed in the ling can be

removed by lobectomy or wedge resection.

After ablation of primary tumor whole lung

tomogram are taking every 3 months as
appearance of metastasis require early pulmonary
resection.

Contra indication of pulmonary resection:

29
1. Wide spread metaststic disease beyond the lung
2. Extensive pulmonary involvement
3. Inability of the patient to tolerate such surgery.

4. Megavoltage Radiotherapy

• Chemotherapy &Radiotherapy
• Methotrexate -> 80% response.
• T10 regimen (methotrexate, vincristine,
adriamycin)-> 60-75% survival .
• Regimen continued post operatively or changed
to cisplatin depending on histology -> 92%
disease free at 2 years
• Chemotherapy continues for 12 months in 4/52
cycles
• Intra-arterial chemotherapy used in some
centres -> increased dose to the site of the
lesion but no evidence that this changes the
outcome as if multiple feeding vessels some of
tumour may be missed.

Radiotherapy –

• palliation of local pain and to treat surgically

inaccessible lesions and painful metastatic
deposits.
• Relatively radio-resistant tumour but
radiotherapy may also be used pre-

30
 operatively to decrease the size and
vascularity of the tumour.
• Prophylactic irradiation of the chest has not
been shown to be effective

Survival beyond 10 years = cure

Surgery:

• Wide resection / Amputation

• Limb salvage requires ability to:

1. Preserve nerves.
2. Preserve or reconstruct vessels
3. Preserve sufficient muscle for functional
motor power & soft tissue coverage
4. Achieve safe, tumour-free margins
(wide)

Reconstruction options:

1. Allografts
2. Endoprosthesis
3. Expendable bone (fibula, ilium)

Prognosis –

Typical OS.

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 • Untreated -> 95% death in 2 years.
• 10% have macro-metastases at presentation;
90% have micro-metastases
• Even with metastatic (Stage 3) disease 5 year
survival rate is now 30 - 40%.

Prognostic Factors:

1. Age - adults do worse ,Location (proximal worse

than distal)
2. Type -Parosteal - tend to be more low grade
tumours , Intra osseous (classical)
osteosarcoma -> good prognosis
3. Stage
4. Origin of tumour in pre-existing lesion -> worse
prognosis

Response to chemotherapy

• 80 - 90% 5 year disease free survival in good

response patients.
• 60% 5 year disease free survival in patients with
poor response.
• more than 16 metastatic deposits -> poor
prognosis
• Pathological fracture does not affect prognosis

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Biopsy of Bone Tumours-Principles

• Should know probable diagnosis and stage of

tumour before biopsy - last step in the staging.
• Performed by the surgeon who will perform the
definitive surgery
• Biopsy tract orientation & location is critical
• Meticulous haemostasis
• Microbiological analysis

Open Biopsy

• Aim for excisional biopsy when possible .

• Incisional biopsy preferable in malignant lesions.
• After consultation with the pathologist and
radiologist.
• Longitudinal incision
• Incision through muscle not between muscle
planes.
• Windows in bone - small and oval to avoid stress
risers and pathological fracture .
• Haemostasis

33
 • Close with a subcutaneous stitch.
• Drains should come out through the wound
• If proceed following biopsy -> new instruments
and drapes to stop seeding

Needle Biopsy

• Place the biopsy tract where it can be excised

• Fine needle biopsy: accuracy = 65 to 95% .

Core needle biopsy:

• Accuracy = 75 to 95%
• allows for immuno-histochemical analysis.

Disadvantage of needle biopsy

• Tissue obtained may be from necrotic portion of

tumor and therefore not suitable for diagnosis,
or tissue may be reactive in nature and not
representative of actual tumor. Frozen section
may benefit.

• Frozen section- Can determine if specimen is

adequate or representative,needs culture,any
more tests required, immediate diagnosis & can
proceed to definitive surgery.

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ADJUVANT CHEMOTHERAPY Neo-adjuvant
chemotherapy

• Immediate action against tumour.

• Reduces mass and vascularity of the tumour
prior to definitive surgery
• Buys time for operative planning
• Want 90% kill rate and if < 90% -> change
agents
• Commence adjuvant treatment once the wound
has healed
• May persist for 2 months to 2 years depending
on the response
• Localised disease = 60-70% long-term disease-
free survival

SURGICAL PROCEDURES
Principles of surgical management:

The surgical procedure for removing the tumor is

classified by the type of surrounding tissue removed
with the tumor .Therefore basic surgical margins
are for definitive surgery.

1. Intracapsular ( Intralesional ) margin

2. Marginal margin
3. Wide margin

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 4. Radical margin

1. Intracapsular margin:
The surgical dissection extents the reactive zone
and psudocapsule or capsule into the tumor itself.
Surgical procedures can be done are-

1. Incisional biopsy
2. Debulking of the tumor
3. Curettage
4. Piece meal removal
5. Intracapsular excision. Amputation.

Surgical procedure through this margin is not good

procedure. 100% chance of recurrence due to
incomplete removal, disturbing or dissimination of
tumor.

1. Marginal margin ( excisoinal margin):

Recurrence rate 25- 50 %.

Here the flame of dissection is through the
reactive zone …… at side the pseudocapsule or
capsular. It is also not a ideal procedure but has
some indications such as-

1. Benign tumor with no chance or very title

chance or propensity to recurrence.This
procedure is not suitable for –

1. Benign tumor with chance of

reccurence
2. Benign tumor with recurrence
3. Potentially malignant tumor

36
 4. Frankly malignant tumor
5. Frank malignant tumor metastasis.

3. Wide margin :
The plane of dissection is through normal tissue
outside the reactive zone. The tumor and its reactive
zone are removed enblci along with an intact “cuff”
of normal tissue surgical procedure done or,

a. wide excision or
b. wide amputation

But this is not a suitable procedure becomes of

micrometastasis or skipped metastasis.
Recurrence rate > 10%
The procedure is indicated –

1. Benign tumor
2. Benign tumor with propensity to recurrence
3. Potentially malignant tumor
4. Some malignant tumor.

Actually this level is 7cm above the maximum

concentration of dye seen in radioisotopic scanning.

5. Radical margin: The tumor and the enteric

bone or muscle compartment that contained it
are removed. Procedure named as-

h. Radical excision or
i. Radical amputation.

Radical excision or radical margin achieved in two

ways-

37
 j. Ablative type- wide excision with removal
of whole limb
k. Non ablative type- wide excision without
removing normal foot tissue.

Compartmental excision an also be done. But the

extent of tumor is determined by sophisticated
invation eg. CT. For this reason there must be
sufficient scope and the surgeon must be experience.

ADJUVANT THERAPY

1. Chemotherapy
2. Radiation therapy

Antineoplastic

1. Antimetabolities : ad by inter……..

l. Methotieatel
m. 6- mercaptopureni
n. 6- Thioguanine
o. 5- Fluroural
p. Cytosine arabinoside
q. Azathioprine

2. Alkylothing agents: act by …….

* Nitrogen mustard
*Cyclophosphomide
*Chloranmbual
* Busulphan

38
* Melphalan
* Iphosphamide

3. Plant alkatoids:
* Vincristen
*Vin blastin
* Vincrintine
* Vp – 16-213
* VM- 26

4. Antibiotics:
* Doxorubicin
* Actinomycin- D
* Mitomycin-C

Radiation therapy

This necrotizes primary tumor therapy facilities limb

salvage stage I and II malignant tumors and selected
stage 3 benign lesions responds well to radiation
therapy . It is most effective in controlling tumor that
originate from bone marrow. Tumors of connective
tissue origin do not respond as well.

Complication of chemotherapy
1. Aplastic anaemia
2. Bone marrow depression
3. Alopecia

During chemotherapy
1. Blood count

39
 2. Platedls count
3. Alkaline phosphatase
4. Bone marrow examination

Limb Salvage.

Criteria for limb salvage:

• local control of the lesion.

• Saved limb must be functional.

Types of osseous resection

• Inter calary (between joints)

• Intra articular (one side of joint)
• Extra articular (both sides of the joint) .

Various methods of salvage eg,

endoprosthesis, allograft, composite, arthrodesis

(allograft).

Relative contraindications

• Pathological fractures
• Skeletal immaturity
• The presence of distal metastasis is not a
contraindication.

40
41