Tumor Musculoskeletal

Definitions

• Primary Bone / Soft tissue tumors

• Mesenchymally derived tumors (Mesodermal)

• Benign or Malignant (Sarcoma)

• Sarcoma
ability to metastasize systemically
 and invade locally
• Based on tissue of origin
– Bone
– Cartilage
– Fibrous tissue
– Bone marrow
– Blood vessels
– Mixed
– Uncertain origin
 Evaluation
• History

• Physical examination

• Investigations; labs, imaging

• Biopsy
Analytic approach to evaluation of the
bone neoplasm
 Evaluation; history
• Age
• Symptomatology
– Pain
– Swelling
– History of trauma
– Neurological sympts
– Deformities
– Regional nodes

• Pathological fracture
 Evaluation; imaging
• Plain radiograph
• CT scan
• MRI
• Radionuclide scanning
• PET
 Radiography
• Information yielded by radiography includes :
– Site of the Lesion
– Borders of the lesion/zone of transition
– Type of bone destruction
– Periosteal reaction
– Matrix of the lesion
– Nature and extent of soft tissue involvement
Radiographic features of bone tumors
Parosteal Site of the lesion.
osteosarcoma Adamantinoma
Chondroblastoma
 Site of the lesion.
Distribution of various lesions Distribution of various lesions in a
in a long tubular bone in a long tubular bone after skeletal
growing skeleton maturity
 Site of the lesion.
Location of epicenter of lesion usually determines site of its origin
(medullary, cortical, periosteal, soft tissue, or in the joint)
 Distribution of various lesions in a vertebra.
Malignant lesions are seen Benign lesions predominate in its
predominantly in its anterior posterior elements.
part (body)
 Borders/margins of the Lesion
Margins determined by GRate hence benign or malignant
 Three types of lesion margins are encountered:
Sharp demarcation by sclerosis (IA margin),
 sharp demarcation without sclerosis (IB margin)
Ill-defined margin (IC margin)
Slow-growing lesions -sharp sclerotic borders;
usually indicates that a tumor is benign
E.g nonossifying fibroma, simple bone cyst
Indistinct borders- typical of malignant or aggressive
lesions
Post- Radio- or chemo of malignant bone tumors
Can exhibit sclerosis and a narrow zone of transition
 Borders of the lesion
determine its growth rate.
sharp sclerotic sharp lytic ill-defined.
 Borders of the lesion.
A: Sclerotic border B: A wide zone of transition
typifies a benign lesion e.g typifies an aggressive or
nonossifying fibroma in the malignant lesion e.g
distal femur. plasmacytoma involving the pubic
bone and supraacetabular portion
of the right ilium
 Patterns of bone destruction.
geographic permeative type
moth-eaten
a uniformly affected characteristic of
rapidly growing round cell tumors
area within sharply infiltrating lesions
defined borders

giant cell tumor. myeloma Ewing sarcoma

 Periosteal Response
 the pattern of periosteal reaction is an indicator of the biologic activity
of a lesion .
 periosteal reactionsthat can be categorized as;
 uninterrupted (continuous) or I
 nterrupted (discontinuous).
 Any widening and irregularity of bone contour may represent
periosteal activity.

 An uninterrupted periosteal reaction indicates a long-standing (slow-

growing), usually indolent, benign process.
 There are several types of solid periosteal reaction:
 a solid buttress e.g aneurysmal bone cyst and chondromyxoid fibroma;
 a solid smooth or elliptical layer e.gosteoid osteoma and osteoblastoma;
 a single lamellar reaction, such as accompanies Langerhans cell
histiocytosis
 Sunburst (“hair-on-end”) or onion-skin (lamellated) pattern .
 Codman triangle
 Types of periosteal reaction.

An uninterrupted periosteal reaction usually indicates a benign process, whereas an

interrupted reaction indicates a malignant or aggressive nonmalignant process
Examples of Nonneoplastic and Neoplastic Processes
Categorized by Type of Periosteal Reaction
 Interrupted type of periosteal reaction

lamellated or Ewing sarcoma -

sunburst onion-skin lamellated type
pattern - type in ewing
sarcoma
osteosarcoma

Codman
triangle
(arrow)
 Soft Tissue Mass
• A bone lesion associated with a soft tissue
mass should prompt the question of which
came first.

• Is the soft tissue lesion an extension of a

primary bone tumor, or is it a primary soft
tissue tumor invading bone?
Radiographic features differentiating primary soft tissue tumor
invading bone from primary bone tumor invading soft tissues.
 Benign Versus Malignant Nature
 clusters of features that can be gathered from radiographs
can help in favoring one designation over the other .
 Benign lesions usually have
well-defined sclerotic borders
exhibit a geographic type of bone destruction
the periosteal reaction is solid and uninterrupted, and
there is no soft tissue mass.
 Malignant tumors often
exhibit poorly defined borders with a wide zone of transition;
bone destruction appears in a moth-eaten or permeative pattern,
and
 the periosteum shows an interrupted, sunburst, or onion-skin
reaction with an adjacent soft tissue mass.

 NB-benign lesions may also exhibit aggressive features

Radiographic features that may help differentiate
benign from malignant lesions
 Grading of bone sarcomas
 Criteria for grading
 Cellularity
 Nuclear features
 Mitotic figures
 necrosis
 Correlates with prognosis in some tumors
 E.g chondrosarcoma, malig vascular tumors
 Some not amenable to histological grading e.g monomorphic
tumors
 Ewing, MM, lymphoma
 Some always high grade
 Sometimes not useful in predicting prognosis
 Adamantinoma, chordoma
 Staging of bone tumors
Benign tumors (Enneking staging of benign tumors)
Stage 1 - latent
Stage 2 - active
Stage 3 - aggressive
Malignant tumors
TNM staging
AJCC staging system
Musculoskeletal tumor society staging system(enneking)
 Surgical staging
Note
Benign tumors - classified using Arabic numerals(1,2,3)
Malignant tumors - classified using roman numerals(I,II,III)
 Staging of bone tumors
Benign tumors (Enneking staging of benign tumors)
Stage 1 - latent
Stage 2 - active
Stage 3 - aggressive
Malignant tumors
TNM staging
AJCC staging system
Musculoskeletal tumor society staging system(enneking)
 Surgical staging
Note
Benign tumors - classified using Arabic numerals(1,2,3)
Malignant tumors - classified using roman numerals(I,II,III)
 Benign tumors - not aggressive
• Bone-forming tumors
– Osteoid osteoma
– Bone island
• Cartilage lesions
– Chondroma
– Osteochondroma
• Fibrous lesions
– Nonossifying fibroma
– Cortical desmoid
– Benign fibrous histiocytoma
– Fibrous dysplasia
– Osteofibrous dysplasia
– Desmoplastic fibroma
• Cystic lesions
– Unicameral bone cyst
– Aneurysmal bone cyst
– Intraosseous ganglion cyst
– Epidermoid cyst
• Fatty tumors
– Lipoma
• Vascular tumors
– Hemangioma
• Other nonneoplastic lesions
– Paget disease
– Brown tumor-hyperparathyroidism
– Bone infarct
– Osteomyelitis
–
 Aggressive benign tumors
• Giant cell tumor
• Chondroblastoma
• Chondromyxoid fibroma
• Osteoblastoma
• Langerhans cell histiocytosis
 Bone biopsy
Options
Needle biopsy
 90% accuracy at determining malignancy
 Accuracy at determining specific tumor much lower
 Absence of malignant cells less re-assuring than incisional biopsy
Core biopsy
 Provides accurate diagnosis in 90% of cases
incisional biopsy
Primary resection instead of biopsy can be done in;
Small(<3cm) subc mass- marginally resected if likely malignant
Characteristic radiographic appearance of benign lesion
Painful lesion in an expendable bone e.g prox fibula, distal ulna
 Malignant Tumors of Bone
Osteosarcoma
Chondrosarcoma
Ewing sarcoma
Chordoma
Adamantinoma
Malignant vascular tumors
Malignant fibrous histiocytoma and fibrosarcoma
Multiple myeloma and plasmacytoma
 Lymphoma
Metastatic carcinoma
Osteosarcoma
Chondrosarcoma
 TREATMENT

• Surgery
- direct primary excision : size < 3 cm, superficial
- radical resection : tumour en bloc + normal tissue at least 2 cm

Inadequate surgery  clearance margins show evidence of residual

macroscopic tumour  re-resection entire contaminated area
If re-resection is not possible  radiotherapy
• Radiation
Indication :
- after plan non radical resection
- resection margin < 1 cm after fixation
- incomplete resection of the original surgical area

Patient with limited tumour process, post operative adjuvant

radiotherapy reduce the risk of a local recurrence.

In this combined therapy  pre-operative

 post-operative
In all other cases post-operative radiotherapy indicated by the result of
surgery :
- After non-radical surgery
- After reoperation because of non-radical surgery
- After marginal radical surgery ( < 2 cm )
- Tumour contamination during surgery
 Soft tissue
tumors
Plain Film

MRI
Lipoma Probable hemangioma/ Other
IM lipoma

Doppler US

Biopsy Arteriography/ MR
angio
“Triple
Diagnosis”
Clinical
Findings

Radiology Pathology