LAKI-LAKI, 16 TAHUN

• Kiriman Dari :
Poli Orthopedi
• Informasi Klinis:
Curiga Tumor Tulang
• Permintaan :
Foto Thorax Proyeksi PA
Foto Genu Kanan Kiri Proyeksi AP/Lateral
 ANAMNESA
Timeline

Mei 2023 Pasien mengeluhkan benjolan di paha kiri, awalnya berukuran kecil, sebesar bola
pingpong. Pasien tidak mengeluhkan rasa nyeri dan tidak ada keterbatasan gerak.
Pasien masih aktif bermain seperti biasa.
Juni 2023 Benjolan semakin membesar menjadi sebesar telur, nyeri mulai muncul pada sendi
lutut namun hilang timbul. Untuk mengatasi nyeri pasien dibawa oleh keluarga
untuk berobat ke klinik dokter umum terdekat diberikan paracetamol tablet 3x1.
Selain berobat pasien juga dibawa ke tukang urut.
Juli 2023 Pasien mengalami jatuh saat bermain sepak bola dengan tumpuan kaki terjatuh
adalah kaki kiri yang terdapat benjolan. Benjolan kaki tersebut semakin bengkak
berwarna kemerahan, nyeri hebat dan kulit terasa tegang. Pasien dibawa berobat
tradisional urut. Namun karena keluhan tidak membaik, pasien berobat ke klinik.
Dari klinik pasien dirujuk ke RSUD Sidoarjo. Di RSUD Siodarjo pasien dirujuk ke RSUD
Dr. Soetomo.
Agustus 2023 Di RSUD Dr. Soetomo pasien dirujuk ke bagian radiologi untuk dilakukan
pemeriksaan Genu kanan kiri proyeksi AP/Lateral dan foto thorax proyeksi PA
FOTO KLINIS
HASIL LABORATORIUM
FOTO THORAKS PROYEKSI PA
FOTO GENU KANAN KIRI PROYEKSI AP
FOTO GENU KANAN KIRI PROYEKSI LATERAL
Thank You
 BONE
TUMOR
 SYSTEMATIC APPROACH

– Morphology
– Age
– Transitional Zone

– Periosteal Reaction
– Cortical destruction
– Location
– Matrix calcification
– Polycistic or Multiple lession
AGE
 MORPHOLOGY - AGE

• Osteolytic
• Well-
defined
• Ill-defined
• Osteoblas
tic
(Sclerotic)
TRANSITIONAL ZONE

NARROW

WIDE
PERIOSTEAL REACTION
ERIOSTEAL REACTION (2) Onion skin/multilamellated PR

interrupted PR
(bone is continually
Codman Triangle PR
trying to wall of
but can not

Periosteal Perpendicucular PR
Reaction (Spiculated/Hair on end/Sun burst PR)

(PR)

Uninterrupted PR
Solid/unilamellated PR
(slow growing)
 PERIOSTEAL REACTION (3)
BENIGN MALIGNANT

- Malignant lesions never cause a benign periosteal reaction

- aggressive periostitis the periosteum does not have time to consolidate
- Solid Periosteal reaction (left picture blue arrow)
- Codman’s triangle (yellow arrow)
- Lamellated and focally interrupted periosteal reaction (right blue arrow)
- Infection with a multilayered periosteal reaction (red arrow)
 CORTICAL DESTRUCTION
Endosteal scalloping

Arise within cortex Balooning lytic lession :

Expansile
Soap buble

Destroyed/breached the
cortex (aggressive)

Cortical
destruction

saucerization

Arise outside cortex Buttressed appearance

(+ periosteal reaction)
 CORTICAL DESTRUCTION (2)

A benign, well-defined, A locally aggressive lesion with

irregular cortical Endosteal scalloping cortical destruction, expansion and a
destruction (destroyed) cortical destruction expansile lesion with regular thin, interrupted peripheral layer of
destruction of cortical bone new bone.
and a peripheral layer of Notice the wide zone of transition
towards the marrow cavity, which is
new bone a sign of aggressive behavior.
TUMOR LOCATION
 TUMOR LOCATION (2)

ECCENTRIC:
-ABC
-GCT
-Osteomyelitis
-Osteoblastoma
-Osteosarcoma

CORTICAL:
-Stress fracture*
-Adamantinoma
-Osteoid osteoma
-Non-ossifying fibroma
-Chronic Osteomyelitis
CALCIFICATION OF TUMOR
MATRIX

•Punctate
chondoid/ •Flocculent
chondroblastic •Comma shaped
•Ring like

•Fluffy
osteoid/ •Amorphous
osteoblastic •Cloudlike
CALCIFICATION OF TUMOR
MATRIX (2)

•Fluffy
osteoid/ •Amorphous
osteoblastic •Cloudlike

Calcification = mineralization=matrix
 SOFT TISSUE COMPONENT

Surrounding
Destruction of the cortex
tissue

Displace adjacent
Harvesian chanel Fat planes

e.g. : Osteosarcome; Ewing Sarcoma; Lymphoma

OSTEOSARCOMA
 INTRODUCTION

• One of the most common primary malignant bone tumors, approximately 20% of all primary bone

malignancies.
• The majority of osteosarcomas are of unknown cause and can therefore be referred to as idiopathic, or

primary
• Conventional osteosarcoma is the most common type, having its highest incidence in patients in their

second decade, affecting males slightly more often than females. It has a predilection for the knee

region (distal femur and proximal tibia), whereas the second most common site is the proximal humerus.

Patients usually present with bone pain, occasionally accompanied by a soft-tissue mass or swelling. At

times, the first symptoms are related to pathologic fracture

• Physical examination findings

- Mass - A palpable mass may or may not be present; the mass may be tender and

warm, though these signs are indistinguishable from osteomyelitis

- increased skin vascularity over the mass may be discernible

- Decreased range of motion

- Lymphadenopathy - Involvement of local or regional lymph nodes is unusual

- Respiratory findings
 INTRODUCTION
IMAGING

• Osteosarcoma lesions can be

purely osteolytic (30%), purely
osteoblastic (45%), or a
mixture of both
• Elevation of the periosteum
may appear as the
characteristic Codman
triangle
• Extension of the tumor
through the periosteum may
result in a so-called sunburst
appearance (60%)
• Telangiectatic osteosarcomas
are often very cystic and can
be mistaken for an
aneurysmal bone cyst
EWING SARCOMA
 INTRODUCTION

• Highly malignant neoplasm

• Originates from bone marrow cells
• Clinically presented as a localized painful mass/swelling or with
systemic symptomps
- Type of destruction : Moth eaten and Permeative
- Transitional zone : Wide zone of transistion
- Periosteal reaction : Laminated onion skin
(codman and sunray pattern may also occur)
- Matrix calcification : None
- Cortical involvement : Cortical thickening and violation,
saucerization is an early sign
- Soft tissue involvement : associated with large soft-tissue
component. However, calcification in soft tissue is described as
uncommon findings seen in 7%–9%
 Ewing Sarcoma

• Almost always metadiaphyseal or

diaphyseal with Metadiaphysis > diaphysis
• Usually solitary at presentation (90%)

• lower limb: 45%

femur most common (25%) followed by tibia: 11%
• pelvis: 20%
• upper limb: 13%, humerus: 10%
• spine and ribs: 13% sacrococcygeal region
most common
• skull/face: 2%
 DD

• Osteomyelitis : Clinical symptoms of inflammation,

cortical and soft tissue involvement is not as large

• Osteosarcoma : Matrix calcification osteoid, soft tissue

involvement is not as large, dapat diikuti dengan
peningkatan nilai ALP

• Malignant Lymphoma : older group, soft tissue

involvement is not as large
THANK YOU
• Anshul Sobti, et al. 2016. Giant Cell
Tumor : An Overview. Arch Bone Jt Surg
• Setiawati, R. 2021. Bone Tumor
Powerpoint
• Rahardjo, P. 2021

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