BONE TUMOURS

-JEFFREY PRADEEP RAJ

OBJECTIVES
Classification of bone tumours
Evaluation of bone tumours
Clinical presentation
Blood, radiological and bone scan
CLASSIFICATION OF BONE TUMOURS
Osteogenic tumours
Chondrogenic tumours
Haematopoetic tumours
Giant cell tumours
Vascular tumours
Fibrous tumours
Other tumours of the bone
Tumour like lesions of the bone
Osteogenic tumours
Benign- osteoid osteoma, osteoma, osteoblastoma
Intermediate-aggressive osteoblastoma
Malignant-osteosarcoma , parosteal ostealsarcoma,
periosteal ostealsarcoma, dedifferentiated
osteosarcoma.
Chondrogenic tumours
Benign-osteochondroma(exostosis),
enchondroma(chondroma), periosteal enchondroma,
chondromyxoid fibroma,chondroblastoma
Malignant-chondrosarcoma, mesenchymal
chondrosarcoma, dedifferentiated chondrosarcoma,
myxoid chondrosarcoma, clear cell chondrosarcoma
Haematopoetic tumours
Malignant-ewing’s sarcoma, plasma cell tumour,
multiple myeloma, lymphoma, peripheral
neuroepithelioma.
Giant cell tumours(GCT)
Benign gct
Intermediate gct
Malignant gct
Vascular tumours
Benign-haemangioma, globangioma
Malignant- hemangiopericytoma,
hemangioendothelioma, angiosarcoma
Fibrous tumours
Benign- nonossifying fibroma, fibrous dysplasia,
desmoplastic fibroma.
Malignant- fibrosarcoma.
Other tumours of the bone
Benign- neurilemmoma, neurofibroma
Malignant- malignant fibrous histiocytoma,
liposarcoma, undifferentiated sarcoma , malignant
mesenchymoma, chordoma, adamantinoma,
parachordoma
Tumour like lesions
Bone cysts-simple or aneurysmal
Fibrous dysplasia-mono or polyostotic
Reparative giant cell carcinoma
Fibrous cortical defect
Eosinophilic granuloma
 HISTORY
Pain, mass and disability are the usual presenting symptoms
Pain- benign tumours rarely cause pain unless there is a stress
reaction or a pathological fracture.malignant tumours cause
continuous unremitting unresponsive to oral analgesic and nocturnal
pain.
Onset is acute in malignant tumours an insiduous in benign tumours
Duration: benign tumours- years. Malignant tumours- months
age: certain tumours have predilection to age groups. E.g ewing’s
sarcoma has a predilcction for children
Anorexia, weight loss and fever are more pronounced in malignant
tumours
 EXAMINATION
GENERAL EXAMINATION: anaemia, cachexia,
lymphadenopathy, oedema, etc
LOCAL EXAMINATION: to know the extent, plane of
tumour, presence of pathological fractures, etc
JOINT EXAMINATION: to know the involvement of joints,
mechanical effects, etc
NEUROLOGICAL EXAMINATION: to asses the damage to
the peripheral nerves due to spread of tumour and its
infiltration
VASCULAR EXAMINATION: assessment of the arterial
and/or the venous circulation
DISABILITY HISTORY
 INVESTIGATIONS
Routine laboratory investigations
Radiological examination of the affected site
Chest radiographs to check for secondaries
CT scan
MRI
Bone scans
biopsy
Ateriograpy to determine the spread of tumour to the vessel
Ultrasonograpy may help in some situations but is of
limited use
Routine Laboratory Investigation
Hb percentage is decreased
Total WBC count and differential count are increased
or decreased.
ESR is increased
Serum phosphorous and calcium is increased
Serum ALP is increased in tumours like osteogenic
sarcoma
Serum acid phophotase is increased in metastses
urianalysis
 RADIOGRAPHY
majority of bone tumours seen in
plain x-ray
Beningn tumours show evidence
of chronicity including sclerosis
at the margins of the tumour and
surrounding bone, there may be
matrix formation and periosteal
new bone formation.
Malignant tumours are
characterised by destruction of
bone, permeation of bone and a
poor transition zone between the
tumour and surrounding tissue.
Nuclear medicine
The most common radioisotope used is
technitium-99m labelled methyl
diphosphonate.
It demonstrates increased local turnover
of bone.
It gets incorporated into newly developed
osteoid.
Metastates is indicated by multiple lesions on
the bone scan.
Used to determine the extent of a bone tumour
and to check for prognosis of the patient during
oncological follow up.
 Computerised Tomography
It is an excellent
method for cross
sectional examination
of bone tumours.
The image of cortical
and trabecular bone
may be constructed
which can clearly
delineate bone
destruction
Magnetic Resonance Imaging
MRI provides an unsurpassed soft
tissue contrast and is therefore essential
for delineating a tumour
It is also an excellent modality for
demonstrating tumour spread without
intramedullary spread because of the
high contrast provided by the
intramedullary fat
Its routine use is not advocated.
However it is mandatory for the
investigation of primary bone tumours
Functional Nuclear Scanning
Investigations like positron emission
tomography(PET) and thallium scans provide
information about the biological activity of the tumour
It may also indirectly help in determining the grade of
the tumour and areas of tumour that are particularly
active, necrotic or represent recurrent disease.
 BENIGN TUMOURS
Osteoma-Seen in adolescents and
young adults. It is of 2 varieties
namely cancellous (exostosis)and
compact(ivory exostosis) osteoma
*cancellous osteoma-conical
lump of bone with a cap of cartilage
arising from the metaphysis of the
long bone.
*compact osteoma-the
membrane bones are affected and
the tumour is sessile. commomnly
seen from the outer surface of the
skull but occasionally can be seen
from the inner surface also.
osteoid osteoma-
children and
adolescent are usually
affected. starts with
pain and an x-ray
reveals a radiolucent
area which may or
may not contain a tiny
dense opacity(nidus)
Osteoblastoma- a larger more aggressive counterpart of
osteiod osteoma commonly occuring in spine
Osteochondroma-benign
cartilage capped bony
projection originating
from the physis and
growing away from the
point towards the
diaphysial region of the
bone. Usually solitary
OLIER’S DISEASE
Enchondroma- asymptomatic
benign cartilaginious neoplasm
within the intramedullary cavity of
the bone. Commonest in the hand.
* Olier’s disease-developmental
conditions
characterised by multiple
MAFUCCI SYNDROME
enchondromas
* Maffucci syndrome-multiple
enchondromas associated with
multiple angiomas.
Chondroblastoma- cartilage
producing tumour with
calcification occuring in
the epiphysis of
children.extremely
painful.common around the
knee
Chondromyxoid fibroma-
has both cartilagenous and
fibrous components. Seen
in the age group of 10-30
years.
Fibroma-the tumour is
an island of fibrous
tissue in the
bone.commonly seen in
adolescents.x-ray
reveals an oval gap in
the cortex of the
metaphysis of the long
bone
Haemangioma-benign tumour of haemangiomatous
origin affecting the vertebrae and the skull. Presents
with dull boring pain and features of cord
compression.
Osteoclastoma(GCT)-benign aggressive tumour with large
oteoclast like giant cells. seen in the age group of 20-45
years. It typically affects the epiphysis of long bones
especially around the knee proximal humerous and distal
radius.
 MALIGNANT TUMOURS
Osteosarcoma-the tumour arises from the medulla of the
metaphysis. Gradually the cortex is eroded and the
periosteum is first pushed away from the shaft. There is
new bone formation along with the new periosteal blood
vessels. Haematogenous spread
Chondrosarcoma-a
malignant tumour with
cartilage differentiation.
Long standing symptom
of pain and/or swelling.
Haematogenous spread
and comparatively less
metastatic.
Fibrosarcoma- the tumour
contains spindle shaped
fibroblasts. It may
originate in the medullary
cavity or periosteally. The
patients are usually 30-50
years of age and present
with pain swelling and
even pathological
fracture. This produces
blood-bone pulmonary
metastasis.
Synovial sarcoma- extremely
malignant histologically
comprising of both synovial and
malignant fibroblasts. It arises
close to a major joint like knee
or wrist and metastasis is by
blood, lymphatics or migration
through tissue planes.
Multiple myeloma- arises from the plasma cells of the
bone marrow. Involves the bone containing the red
marrow.(pelvis ribs vertebrae and skull). Characteristic
features are urinary excretion of bence-jones proteins,
abnormal spike in the region of gamma globulin in
electrophoretic pattern, reversal of AG ratio, myeloma
cells in sternal marrow puncture and punched out lesions
in the skull and other flat bones on radiological
examination.
Plasmacytoma- a solitary myeloma with the similar above
said clinical presentation. The patient presents with pain
swelling or a pathological fracture. Radiologically an area
of translucency is observed at the site of tumour.
Ewing’s sarcoma- the tumour
arises from the reticulam
cells of the medullary
cavityof the diaphysis of long
bones. It may gradually lift
the periosteum and deposit
layers of bone giving a
characterisitc onion
appearance in x-ray. common
in males of age group of 10-
20. Poor prognosis. Patient
presents with throbbing pain
worsening in the night.
Malignant fibrous histiocytoma-histiocytic origin.it
occurs in the ends of long bones.it is characterised by
osteolytic lesions with hazy border.
Secondary carcinoma of the bone
Occurs mainly by haematogenous spread.
Primary sites are mainly the thyroid, breast, prostate,
kidney, bronchus,uterus, GI tract and testes
Sites affected are vertebrae ,ribs, sternum, pelvis and
upper end of humerous and femur.
X-ray shows osteolytic(when primary carcinoma is in
viscus)...osteoblastic change( in prostate carcinoma)
Bone scan shows metastatic lesion much earlier than
skiagraphy.
REFERENCES
TEXTBOOK OF SURGERY, BAILEY AND LOVE
MANUEL ON SURGICAL EXAMINATION, S.DAS
TEXTBOOK OF ORTHOPAEDICS, EBENEZER
APLEY’S TEXTBOOK OF ORTHOPAEDICS
INTERNET-PUBMED