General principles of bone tumors

Classification of Neoplasm-like Lesions of Bone

A. Osteogenic
1. Osteoma (ivory exostosis)
2. Single osteochondroma (osteocartilaginous exostosis)
3. Multiple osteochondromata (multiplehereditary exostoses)
4. Osteoid osteoma
5. Benign osteoblastoma (giant osteoidosteoma)
B. Chondrogenic
1. Enchondroma
2. Multiple enchondromata (Ollier's dyschondroplasia)
C. Fibrogenic
1. Subperiosteal cortical defect (metaphyseal fibrous defect)
2. Nonosteogenic fibroma (nonossifying fibroma)
3. Monostotic fibrous dysplasia
4. Polyostotic fibrous dysplasia
5. Osteofibrous dysplasia (Campanacci syndrome)
6. "Brown tumor" (hyperparathyroid ism)
D. Angiogenic
1. Angioma of bone (hemangioma and lymphangioma)
2. Aneurysmal bone cyst (ABC)
E. Uncertain origin
1. Simple bone cyst (unicameral bonecyst) (UBC)

Classification of True Primary Neoplasms of Bone

A. Osteogenic
1. Osteosarcoma (osteogenic sarcoma)
2. Surface osteosarcoma (parosteal sarcoma; periosteal sarcoma)
B. Chondrogenic
1. Benign chondroblastoma
2. Chondromyxoid fibroma
3. Chondrosarcoma
C. Fibrogenic
1. Fibrosarcoma of bone
2. Malignant fibrous histiocytoma bone
D. Angiogenic
1. Angiosarcoma of bone
E. Myelogenic
1. Myeloma of bone (multiple myeloma)
2. Ewing's sarcoma (Ewing's tumor)
3. Hodgkin's lymphoma of bone
4. Non-Hodgkin's lymphoma (reticulum cell sarcoma)
5. Skeletal reticuloses (Langerhans' cell histiocytoses)
6. Leukemia
F. Uncertain origin
1. Giant cell tumor of bone (osteoclastoma)
General Considerations

Incidence
 Age incidence
-. Childhood and adulthood ( Osteosarcoma )
-. Adolescence and young adult ( Ewing’s Tumor )
-. Middle adult ( Chondrosarcoma / Fibrosarcoma )
-. Older adults ( Multiple Myeloma )
 Sex incidence
-. Male
-. Female
 Site incidence / anatomical site

Diagnosis
 Complete history physical examination
 Diagnostic Imaging
 Laboratory investigation
 Staging of the neoplasm
 Biopsy

Clinical Feature
 History of local trauma
 Slowly growing
 Pain
  Local swelling and lump
 Function of the limb ( usually in joint region )

Diagnostic Imaging and Correlation with Pathology

 Plain radiography:
-. Location and size
-. Resorption of bone
-. Margin of the lesion
-. Reaction of the bone to the lesion
-. Effect of the lesion on the cortex
 Computed Tomography
 Magnetic Resonance Imaging
 Bone Scan ( Technectium-99 )
 Laboratory Investigation
-. Complete blood count, white blood cell differential
-. Erythrocyte Sedimentation Rate (↑ Ewing’s Sarcoma )
-. Serum Calcium (↑ Multiple Myeloma and metastatic )
-. Serum Phosphorus (↓ Hyperparathyroidisme with Brown
Tumor )
-. Serum Alkaline Phosphatase (↑ Osteosarcoma and Paget’s
disease )
-. Serum Acid Phosphatase
-. Prostatic Specific Antigen (PSA)
-. Urinary Bence-Jones (↑ Multiple Myeloma )
Staging of Benign, Potentially Malignant and Malignant Neoplasms of
Bone

The required methods of assessment for staging of a suspected malignant

neoplasm include:
-. Plain radiography
-. CT scan
-. MRI
-. Bone scan
The factors involved in assessing the staging of a given lesion include:
-. The histological grade of the lesion
-. The size of the lesion (limited to the one compartment or has
extended into one or more compartments)
-. The lesion has metastasized

For Malignant, the staging :

I. Low Grade Malignancy
A. Intracompartmental
B. Extracompartmental
II. High Grade Malignancy
A. Intracompartmental
B. Extracompartmental
III. Metastases
Biopsy
 Frozen Section is helpful in determining that the biopsy specimen is
representatives.
 The surgical incision for biopsy should be longitudinal and Transgress
the minimum number of compartment to avoid contamination.
 The samples must be adequate in size and must represent of the
lesion.
 Open biopsy is more accurate.

Treatment
Principles of Surgical Treatment
 Intralesional margin ( benign lesions )
 Marginal zone of resection ( 25-50% for the malignant tumors )
 Wide surgical resection
 Radical surgical margin

Principles of Adjuvant Therapy

 The appropriate utilization of the multi agent chemotherapy has
allowed smaller margins of tumor resection while reducing the rate of
local tumor recurrence.
 Improved the prospect limb-salvage and disease free survival
  Neoadjuvant chemotherapy for 8 – 12 weeks followed by
postoperative maintenance chemotherapy for up to 1 year.
 Radiation Therapy has a role in the treatment of all soft tissue
sarcomas.
 Postirradiation sarcoma and pathologic stress fractures are the
complications.
Reference:
1. Salter RB, Neoplasms of Musculoskeletal Tissues in Textbook of
Disorders and Injuries of the Musculoskeletal System, 3rd edition,
William&Wilkins, 1999; Chapter 14: 379-416
2. Lonner JH, Kenan S, General Principles in Orthopaedic a Study
Guide, Jeffrey M. Spivak, MD.,et al eds, Int’l Edition, McGraw-Hill,
1999; Chapter 38: 229-41.