BONE TUMORS

Basic

NITIN BANSAL
Plain X rays
SEVEN
1. Where is the lesion – what bone and what part
of the bone
2. Age & size of the lesion?
3. What is the lesion doing to bone?
4. What is the bone doing in response?
5. Is the lesion making matrix?
6. Is the cortex eroded?
7. Is a soft tissue mass evident?
How are bone tumours

Like Real Estate ?

LOCATION !

LOCATION !

LOCATION !
 LOCATION
1. In the transverse plane:
a) Central – Enchondroma
b) Eccentric -GCT, osteosarcoma,
chondromyxoid fibroma
c) Cortical - Non-ossifying fibroma,
osteoid osteoma
d) Parosteal - Parosteal osteosarcoma,
osteochondroma
2. In the longitudinal plane:
Diaphyseal: Ewings, Osteoid Osteoma, Mets,
Adamantinoma, Fibrous Dysplasia
Epiphyseal: Chondroblastoma,GCT, Ganglion of Bone.
Metaphyseal: Everything!!!!!!
 Characteristic Location
Some tumors almost exclusively occur at specific sites

Chondroblastoma - Epiphyses
Giant Cell tumor - Epiphyses
Simple bone cyst - Proximal
Adamantinoma humerus
Chordoma - Tibia
Osteoblastoma - Sacrum
Chondrosarcom - Posterio
a r
element
of spine
 Characteristic Locations

Epiphysis Spine, posterior

• Chondroblastoma • Osteoblastoma
 Tibia

Sacrum, clivus

Adamantinoma

• Chordoma
 Epiphyses

• Giant Cell tumor

Proximal humerus

• Simple bone cyst

 Age of the patient

• 20>…..Osteogenic Sarcoma, Ewings. simple bone

cysts and chondroblastomas

• 40……GCT, Chondrosarcoma, MFH, Lymphoma,

Mets.

• 60……Mets, Myeloma, Chondrosarcoma, MFH

– Late Osteogenic, Fibrosarcoma.
Size
In general The larger the lesion the more
likely it is to be aggressive or malignant

(some exceptions i.e.

fibrous dysplasia)

The bigger the uglier

What is the bone doing to the tumor ?

Bone reacts in two ways -- either by removing

some of itself or by creating more of itself.

If the disorder is rapidly progressive, there may

only be time for retreat (defense).

If the process is slow growing, then the bone

may have time to mount an offense and try to
form a sclerotic area around the offender.
 Periostitis
A periosteal reaction will occur whenever the
periosteum is irritated.
This may occur due to a malignant
tumor, benign tumor, infection or trauma.
Two types Benign or Aggressive.

• Benign Aggressive or malignant

– None – Lamellated or onion peel
– Solid – Sunburst
– Codman’s triangle
Benign

Solid Aggressive

Lamellated
V . Aggressive

Spiculated
Codman's
 Solid Periosteal Response
Slow-growing tumors provoke focal cortical thickening
A continuous layer of new bone that attaches to outer cortical
surface

Related to a slow form of

irritation osteoid osteoma
 Unilamellated periosteal reaction

Single layer of reactive periosteum. … thick

unilamellated periosteal reaction. Smooth
and continuous

H
y
p
e
 Aggressive Periostitis

Layered, onion-skin, lamellated

• Alternating layers of opaque and
lucent densities
• Can be seen with slow growing
and aggressive tumors and
infections

appearance of aggressive
growth spurt.
periostitis in Ewing’s sarcoma
Spiculated periosteal reaction.
Osteosarcoma

Perpendicular, brushed whiskers, hair-on-end, Fine linear

spiculations of new bone oriented perpendicular to the cortex
or radiating from a point source indicative of very aggressive
bone tumors
 “sunburst”
This is a very aggressive process
Bone is formed in a disorganized fashion
Process may destroy spicules of bone as they are being
formed
Codman's triangle

Too fast growth for periosteum to respond

only the edges of raised periosteum will ossify
forming a small angle with the surface of bone.

seen in malignant bone tumors and in

rapidly growing lesions .. aneurysmal bone
cyst, subperiosteal hematoma.
 Periosteal Reactions

Solid onion-peel Sunburst Codman’

s
triangle
Less malignant More malignant
 Zone of Transition

Most reliable indicator for benign versus malignant lesions.

“Narrow”, if it is so well defined that it can be drawn

with a fine-point pen.

“Wide”, if it is imperceptible and can not be drawn at all.

An aggressive process should be considered, although
not necessarily a malignant lesion.
 ZONE OF TRANSITION

NARROW ZONE WIDE ZONE

Three Patterns of Bone Destruction

• Geographic Pattern
• Moth-Eaten Pattern
• Permeative Pattern

Result from the degree of aggressiveness of

the lesion
Typ 1 a Geographic Lesion.
e

Well-defined lucency
with sclerotic rim.

Intra osseous lipoma

with a sclerotic
rim .
 Type 1 b Geographic Lesion

well-defined lucent lesion

without sclerotic rim.

Well-defined geographic lytic focus without

sclerotic rim , Endosteal scalloping seen.

myeloma
 Type 1 c Geographic Lesion

ill-defined lytic lesion

Large ill-defined lytic lesion , Codman’s triangle

Periosteal interruption, Tumor-induced new osteosarcoma
bone .

.
 Margins: 1A, 1B, 1C
IA: GEOGRAPHIC DESTRUCTION
WELL – DEFINED WITH SCLEROSIS
IN MARGIN

IB: GEOGRAPHIC DESTRUCTION

WELL – DEFINED BUT NO SCLEROSIS
IN MARGIN

IC : GEOGRAPHIC DESTRUCTION
WITH ILL DEFINED MARGIN

increasing aggressiveness
Type 2 Moth-eaten Appearance

Areas of destruction with

ragged borders

Implies more rapid growth

Probably a malignancy

osteosarcoma
Type 3. Permeative Pattern

ill-defined lesion
with multiple “worm-holes”
Spreads through marrow space
Wide transition zone
Implies aggressive
malignancy

Round-cell lesions

Leukemia

Ewing sarcoma.
 Patterns of Bone Destruction

Geographic Moth-eaten Permeative

Less malignant More Malignant

Is the Cortex Eroded?

Cortical erosion is hallmark of active, aggressive, or

malignant tumors.

High-grade malignant tumors may erode through cortex

with ineffective periosteal response to erosion

In general, low grade tumors will produce endosteal

erosion with orderly response; high grade tumors will
erode through the endosteal surface without adequate
response, increasing surface risk of fracture
 Osteosarcoma Ewings sarcoma
Complete destruction may be seen in high-grade malignant
lesions, but also in locally aggressive benign lesions like EG and
osteomyelitis.
 "Cortical Erosion"
destruction of cortex by a
lytic or sclerotic process.

Cortical erosion

"Endosteal Scalloping"
Thinning of the cortex by an
intraosseous process
Giant cell tumor.

Malignant
 Cortical destruction

In tumors like Ewing's sarcoma, lymphoma and small cell

osteosarcoma, cortex may appear normal radiographically, while there is
permeative growth throughout Haversian channels.
These tumors may be accompanied by a large soft tissue mass while
there is almost no visible bone destruction.
 Cortical Destruction

• The presence of cortical destruction is not a

reliable indicator of whether the lesion is a
malignant process or a benign process.

• Other radiographic findings must also be

examined.
Is the lesion making matrix?
Matrix is the dominant internal extracellular substance
of a lesion.

Most tumor have soft tissue matrix-Radiolucent (lytic)

on X-ray

Chondroid matrix -Calcified rings, arcs, dots

Osteoid matrix- Bone forming

 Clear Matrix

"Clear Matrix" refers to lesions which are clear or mostly clear.

A radiolucent lesion with few undestroyed trabeculae is
considered to have a clear matrix.
 Patterns of mineralization of
cartilaginous tumor matrix
Stippled

Flocculent

Ring and arc

 Punctate and arc like mineralization

Chondrosarcoma

Enchondroma
 Chondral-type matrix mineralization
and endosteal scalloping .

chondrosarcoma
 Patterns of mineralization of osseous matrix

Solid
Cloudlike Ivory-like
opacity
 Let’s turn from
spectators
into
participants.

‘ What I hear, I forget ;

what I see, I remember ;
what I do, I understand. ’
AGE 13 Y

AGE
Location
Margins
Periosteal reaction

Matrix
other
DX
AGE 13
Location Metadiaphysis
Margins 1A-1B
Periosteal reaction none

Matrix None
other Trabecular struts
DX UBC
ADUL
T AGE
Location
Margins
Periosteal reaction

Matrix
other
DX
Age Adult

Location metaphysis

Margin 1B

Periosteal reaction None

Matrix None

other fx

DX ABC
13 Y/O WITH KNEE PAIN

AGE
Location
Margins
Periosteal reaction

Matrix
other
DX
AGE 13
Location Epiphyseal
Margins IB
Periosteal reaction None

Matrix None
Other DX Chondroblastoma
45 Y/O MALE

AGE
Location
Margins
Periosteal reaction

Matrix
other
DX
Age 45

Location Metaphysis

Margins 1B

Periosteal reaction None

Matrix None

Other Epi involvement

DX GCT
ELDERLY PT

AGE
Location
Margins
Periosteal reaction

Matrix
other
DX
25 Y/O WITH THIGH PAIN

Age

Location

Margin

Periosteal reaction

Matrix

Other

Dx
Age 25

Location Diaphysis

Margin 1B

Periosteal reaction Thick

Matrix faint

Other Dx Osteoid osteoma

Benign vs. Malignant
 Don’t Give Flash Diagnosis !!!!
• Think of the age of the patient.

• Think of where the abnormality is …. or

isn’t.

• Think of the tissue categories of tumors.

• Think in terms of benign, benign aggressive or

malignant.
Don’t ever look at
MRI or CT scan
Before plain X-rays
 Aggressive Lesions Non-aggressive Lesions

Poorly demarcated Well demarcated

Wide zone of transition Narrow zone of transition

Poorly marginated osteolysis
Absent or geographic osteolysis
Cortex interrupted
Cortex may be displaced, remodeled
and thin, but not broken
Interrupted irregular
periosteal reaction Solid, smooth periosteal reaction

No surrounding sclerosis +/- surrounding sclerosis

Rapid rate of change Static or slow rate of change

 INITIAL EVALUATION
⚫ Carried out in 4 phases
1 st phase –
High index of suspicion for tumors
Routine X-rays
Routine lab facilities
Meticulous history
Thorough physical examination
2nd phase -is prebiopsy regional evaluation, to determine size,location and
type of tissue involved
3 rd phase – is the actual biopsy.
4 th phase – is undertaken if presumptive clinical & pathology
evidence sugestive of malignancy, search for mets is done, using CT scan of
lung & Tc-99 bone scan
 PRESENTING SYMPTOMS
⚫ Pain
⚫ Mass
⚫ An abnormal radiographic finding detected during evaluation of unrelated
problem
⚫ PAIN:- is most frequent symptom
-deep constant pain,poorly localised,worse at night
-initially controlled by analgesics,later requires narcotics
⚫ MASS:- rate of enlargement is important
-Fluctuating mass can be cyst,ganglion or
hemangioma
-Family H/O masses near the joint may be indicator of Ollier’s
disease or Maffucci Syndrome
 PRESENTING SYMPTOMS
⚫ NEUROLOGICAL SYMPTOM:- found in few patients
such as sacral tumors & with tumors located near the nerve
causing compression of nerve,especially common in
sciatic notch ,inguinal canal & popliteal fossa

⚫ UNEXPLAINED SWELLING OF THE LOWER

EXTREMITY :- found in pelvic tumors which are
painless & without a palpable mass & cause swelling
due to compression of iliac vein
 HISTORY OF THE PATIENT
⚫ AGE:- most imp information, bcoz of their
presentaion in specific age group.
⚫ 1 st decade- usually ABC ,SBC
⚫ 2 nd decade-
Chondroblastoma,osteosarcoma,Ewings
⚫ 3 rd decade- GCT
⚫ 4 th decade- chondrosarcoma
⚫ 5 th decade- Multiple myeloma
⚫ SEX:- less imp than age
Some tumors like GCT are more in females
 HISTORY OF THE PATIENT
⚫ RACE:- little imp, Ewings rare in african descent

⚫ H/O any exposure to radiation Tt or Carcinogens- bone seeking

radionucleotide can cause sarcoma.

⚫ Various chemlcal carcinogens- methylcholanthrene,zinc beryllium

silicate, beryllium oxide.

⚫ Currently the most worrisome & controversial is Nickel

which is used in many orthopedic device
 PHYSICAL EXAMINATION
⚫ Evaluation of patient’s general health

⚫ TUMOR MASS should be measured & its location, shape, consistency,

mobility, tenderness, local temp & change with position should be noted.

⚫ SKIN & SUBCUTANEOUS TISSUE :

⚫ Small dilated superficial veins overlying the mass are produced by large tumors

⚫ REGIONAL LYMPH NODES: sign of metastatic disease

⚫ Atrophy of surrounding musculature should be recorded,also neurological

deficits & adequacy of circulation
 LABORATORY TESTS
⚫ Alkaline phosphatase test: Normally, this enzyme is present in
high levels when bone-forming cells are very active . High levels of
alkaline phosphatase can also be an indicator of bone tumors (when the
tumor creates abnormal bone tissues).
⚫ PTH test: Lower-than-normal level of parathormone can be an
indicator of bone cancer.
⚫ Serum phosphorus: Higher than normal levels of
phosphorus can be an indicator of bone cancer.
⚫ Ionized calcium and serum calcium: Higher than normal
levels of calcium can be an indicator of bone cancer.
 LABORATORY TESTS
⚫ OTHER TESTS
Hemoglobin
CBC
ESR CRP
Glucose tolerance test PSA,PAP
Electrophoresis & urinary Bence Jones protein
 INVESTIGATIONS
⚫ X-RAY
⚫ CT SCAN
⚫ MRI
⚫ TECHNETIUM BONE SCAN-This type of scan uses a very low radioactive
material (diphosphonate) to see whether or not the cancer has spread to other
bones and the damage suffered by the bone.
⚫ PET- Positron Emission Tomography uses radioactive glucose to locate cancer.
This glucose contains a radioactive atom that is absorbed by the cancerous cells
and then detected by a special camera
 BIOPSY
⚫ The biopsy is the most conclusive as it confirms if the tumor is
malignant or benign, the type (primary or secondary ), and stage
⚫ According to the tumor size and type and purpose (to
remove entire tumor or only a small tissue sample), biopsies can be
: needle biopsy , incisional biopsy , excisional
biopsy
⚫ 1. Needle biopsy: a small hole is made in the affected bone and a
tissue sample from the tumor is removed.
There are two types of needle biopsies:
Fine needle aspiration : During this procedure, the tissue
sample is removed with a thin needle attached to a syringe
Core needle aspiration :a small cylinder of tissue sample is removed
from the tumor with a rotating knife like device.
⚫ 2. Incisional biopsy : During this procedure, the surgeon
cuts into the tumor and removes a tissue sample.
 PRIINCIPLES OF BIOPSY
⚫ Biopsy should be done after clinical,
laboratory, and radiographic examinations are
complete
⚫ biopsy track should be considered contaminated
with tumor cells , biopsy track needs to be excised
en bloc with the tumor
⚫Transverse incisions avoided because they are
difficult to excise with the specimen
 PRIINCIPLES OF BIOPSY
⚫ deep incision through a single muscle compartment
not to contaminating an intermuscular plane
⚫ Major neurovascular structures be avoided

⚫ Soft tissue extension of bone lesion should be sampled because

leading edge contains most viable tumor for making diagnosis
⚫ If tourniquet used,limb elevated before inflation but not to be
exsanguinated by compression to prevent “squeezing” the tumors
cells into the systemic circulation
 PRIINCIPLES OF BIOPSY
⚫ If a hole is made in bone, should be round or oval to
minimize stress concentration and prevent a subsequent
fracture, which could preclude limb salvage surgery
⚫ The hole be plugged with methacrylate to limit
hematoma formation
⚫ sample more than just the pseudocapsule surrounding
the lesion
 PRIINCIPLES OF BIOPSY
⚫ frozen section should be sent intraoperatively to
ensure that diagnostic tissue has been obtained
⚫ If drain used, it should exit in line with incision
so that the drain track can be easily excised en
bloc with tumor
⚫ wound should be closed tightly in layers
PRIINCIPLES OF BIOPSY
 STAGING

⚫ Staging of benign bone tumours as described by Enneking

⚫ stages of benign tumors designated by Arabic numbers, and
malignant tumors by Roman numerals
⚫ stage 1, latent; stage 2, active; and stage 3, aggressive
⚫ Stage 2-
intracapsular
actively growing cause
symptoms or pathological
fracture
⚫ Radiographs-well-
defined margins expand and
thin
cortex.
thin rim of reactive bone
⚫ Treatment - extended
curettage
⚫ Stage 1 -lesions are
intracapsular,
usually asymptomatic, and
frequently incidental
findings
⚫ Radiographic features –
well-defined margin
with thick rim of reactive
bone.
no cortical destruction or
expansion.
⚫ not require treatment –
not compromise the
strength of the bone
resolve spontaneously
⚫ Stage 3 –
extracapsular
broken through
reactive bone and cortex
⚫ MRI shows soft tissue mass,
and
metastases may present
in 5% of patients
⚫ Treatment -extended
curettage
marginal or wide
resection,
⚫ local recurrences are
common.
⚫ The staging system for malignant tumors adopted by the
Musculoskeletal Tumor Society, and originally developed by
Enneking is based on the histological grade, the local extent, and
the presence or absence of metastasis
⚫ Bone sarcomas are broadly divided as follows:
⚫ • Stage I All low-grade sarcomas.
⚫ • Stage II Histologically high-grade lesions.
⚫ • Stage III Sarcomas which have metastasized
⚫ stage I-lesions are well-differentiated, have few
mitoses, and
exhibit moderate cytological atypia
⚫ risk for metastases is low (<25%)
⚫ stage II-poorly differentiated high
mitotic rate and
high cell-to-matrix ratio
⚫ Stage III-lesion that metastasized regardless of
size or grade of primary tumor

Anatomical compartments are the natural

anatomical barriers to tumor growth, such as
cortical bone, articular cartilage, fascial septa, or
joint capsules
 PRINCIPLES OF SURGERY
AMPUTATION VERSUS LIMB SALVAGE
⚫ issues to be considered whenever contemplating limb
salvage instead of an amputation
1.Would survival be affected by the treatment
choice?
2.How do the short-term and long-term morbidity
compare?
3.How would the function of a salvaged limbcompare
with that of a prosthesis?
4.Are there any psychosocial consequences?
⚫ involvement of neurovascular structures, displaced
pathological fracture, complications secondary poorly
performed biopsy preclude limb salvage procedures
⚫ choice between limb salvage and amputation made on
basis of expectations and desires of patient and family
⚫ multimodal treatment including surgery and
chemotherapy, improved long-term survival for patients.
⚫ patients with a local recurrence despite wide
margins represent aggressive or chemotherapy-
resistant disease , has poor outcomes regardless
of surgical procedure
⚫ most important aspect of surgical procedure is
attainment of a wide margin regardless of achieved
by amputation or local resection
⚫ Amputation often requires
nonstandard flaps for closure or bone
graft augmentation for a more
functional residual limb
⚫ Complications - infection, wound
dehiscence, chronically painful limb,
phantom limb pain, and bone
overgrowth requiring revision surgery
⚫ Limb salvage is associated with
greater perioperative and long-
term morbidity
⚫ Complications- greater risks of
infection, wound dehiscence, flap
necrosis, blood loss, and dvt
⚫ long term complications like
periprosthetic fractures, prosthetic
loosening or dislocation, nonunion
of the graft-host junction, allograft
fracture, leg-length discrepancy, and
late infection
⚫ more likely to need multiple future
operations for treatment of
complications including
⚫ regard to function, location of tumor is most important
issue
⚫ Resection of upper extremity lesion with limb salvage,
even sacrificing one or two major nerves, provides better
function than amputation and prosthetic fitting
⚫ resection of a proximal femoral or pelvic lesion with local
reconstruction provides better function than after hip
disarticulation or hemipelvectomy
⚫ Around ankle and foot, large sarcomas treated with
amputation and prosthetic fitting
⚫ osteosarcoma around the knee treated with wide
resection with prosthetic knee replacement or
transfemoral amputation
⚫ osteoarticular allograft reconstruction, allograft
arthrodesis, and rotationplasty are less prefered
⚫ patients with amputations had difficulty walking on steep, rough, or
slippery surfaces but active and least worried about damaging limb
⚫ Patients with arthrodesis performed most of physical work but had
difficulty with sitting, especially in back seats of cars, theaters
⚫ Patients with arthroplasty led more sedentary lives , protective of limb
but had less difficulty with activities of daily living
⚫ probability of limb survival after resection depends
on type of reconstruction and location of
tumor(most imp issue).
⚫ proximal reconstructions outlasting distal
reconstructions. ( inverse of the prognosis for
patient survival, with distal sarcomas better
prognosis than proximal ones.)
⚫ No study has shown significant difference between
amputation and limb salvage with regard to
psychological outcome or quality of life in long-
term survivors of sarcoma.
⚫ patient ultimately make the final decision in light
of long-term goals and lifestyle decisions.
 MARGINS

⚫In oncological surgical procedure, the surgical

margin must be appropriately defined
⚫orthopaedic oncology, surgical margin described
by one of four :
intralesional, marginal, wide, or radical
⚫ intralesional margin-
plane of surgical
dissection is within the
tumor
⚫ appropriate for
symptomatic benign
lesions when the
surgical alternative
would be to sacrifice
important anatomical
structures ,
or as a palliative
procedure in case of
metastatic disease
⚫ marginal margin -plane of
dissection passes through
pseudocapsule(surrounding
reactive tissue referred as
pseudocapsule)
⚫ treat most benign lesions
and some low-grade
malignancies.
⚫ marginal resection leaves
microscopic disease leading
to local recurrence in high
grade malignancies
⚫ marginal resection preferable
if alternative is more
mutilating procedure
⚫ Wide margins -plane of dissection is in
normal tissue
⚫ no specific distance , entire tumor remains
completely surrounded by rim of normal tissue
⚫ quality of margin is more important than
the quantity (thickness) of the margin
⚫ wide margins are goal of most
procedures for high-grade
malignancies
⚫ Radical margins -all
compartments containing
tumor removed en bloc
⚫ previously the procedures
of choice for most high-
grade neoplasms
⚫ amputations defined
further by any of the four
margins
 CURETTAGE

⚫ Many benign bone

tumors treated by
curettage
⚫ curettage is associated with
higher rate of local
recurrence than resection,
but allows a better
functional result
PRINCIPLES OF
CURETTAGE
⚫ done by first making large
cortical window
⚫ Next, cavity is enlarged to
normal host bone in each
direction with a power burr
⚫ Finally, cavity and wound TO
be copiously irrigated to
remove any debris and tumor
cells
⚫ Extended” curettage - use of
adjuvants, such as liquid
nitrogen, phenol, polymethyl
methacrylate, or thermal
cautery to extend destruction of
tumor cells
 filling the cavity
⚫ -through autogenous bone
graft, allograft,
demineralized bone matrix,
artificial bone graft
substitutes, or bone cement
⚫ Autogenous bone
graft must be harvested
using different set of
instruments to prevent
contamination of the donor
site
⚫ Autogenous bone graft provides most rapid
and most reliable healing rate as it is osteogenic,
osteoinductive, and osteoconductive
⚫ But is associated with morbidity harvest site, may
not available in sufficient quantity to fill a large
cavity
⚫ cancellous allograft (only
osteoinductive)incorporated easily, available
in large quantities and not involve further
operative morbidity
⚫ demineralized bone matrix used as filling
agent after curettage of benign bone tumors
⚫ is osteoconductive and osteoinductive
⚫ Artificial bone graft substitutes ( calcium
sulfate, calcium phosphate) are osteoconductive,
easy to use, and readily available
⚫ used alone or in combination with autogenous
bone graft, bone marrow aspirates, or
demineralized bone matrix
⚫bone cement is also used as a filling agent
⚫has the advantage of providing immediate
stability, makes rehabilitation easier and
lessens risk of pathological fracture
⚫ another advantage of bone cement is
detection of local recurrence
⚫recurrent tumor recognized as an expanding
lucency adjacent to bone cement