Bone Tumors and Tumor-like Conditions
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Transcript of Bone Tumors and Tumor-like Conditions
Prof. Mamoun KremliAlMaarefa College
Bone Tumors andTumor-like Conditions
ObjectivesBone tumors:
Primary:Benign – Malignant
Secondaries in bone
Tumor-like conditionsBone cysts
How to read x-ray of a bone lesion
Classification – predominant tissueTissue of Origin Benign MalignantBone forming Osteoma
Osteoid OsteomaOsteoblastoma
Osteosarcoma
Cartilage forming ChondromaOsteochondromaChondroblastoma
Chondrosarcoma
Fibrous tissue Fibroma FibrosarcomaGiant-cell tumor Benign
OsteoclastomaMalignant Osteoclastoma
Marrow tumors Ewing’s SarcomaMyeloma
Vascular Haemangioma HaemangiosarcomaOther connective tissue
Fibrous histocytomaLipoma
Malignant fibrous histocytomaLiposarcoma
Other tumors Neurofibroma Adamantoma
Clinical presentation - historyProlonged history:
In most benign lesionsSome malignant: slow growing / in pelvis (expandable)
Age:Childhood and adolescence
Most benign, and some malignant (e.g. Ewings sarcoma)4th – 5th decade:
Chondrosarcoma and fibrosarcomaSixth decade:
Myeloma (the commonest primary malignant bone tumor)Over 70 yrs:
Metastatic lesions are the commonest
Clinical presentation - historyPain:
In both malignant and benign May be caused by:
Rapid expansion – stretching of tissuesCentral hemorrhage or degenerationInsipient pathological fractureTense encapsulation in bone (e.g. osteoid osteoma)
Swelling
H/O Trauma
Neurological symptoms Pressure on nerve / stretching the nerve
Pathological fracture
Clinical examinationA mass (lump)
LocationDiscrete or ill-definedTendernessWarmPulsatileMobility….etc
Range of motion
LN, pelvis, abdomen, chest, spine
Imaging – x-raysWhich bone, and which site in bone?
Solitary or multiple?
Bone forming or bone eating?
Margins: well-defined or ill-defined?
Calcifications in the lesion?
Is cortex eroded or destroyed?
Is there periosteal new bone formation?
Soft tissue extension?
Location
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Radiographic features
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The Border
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The Matrix
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Type of Bone Destruction
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Type of Periosteal Reaction
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Soft Tissue Extension
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Benign Vs. malignant
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Other imagingBone scan (Tc99):
Shows the site of lesion / and skip lesions
CT: Intraosseous and extraosseous structure and extensionGood in deep bones (pelvis, spine)
MRI:Tumor spread
Within bone, into joints, into soft tissueRelation to vesselsSoft tissue and cartilage tumors
Lab, investigationsLook for infection
Look fro metabolic disease (brown tumor)
Anemia, raised ESR
S. Alkaline phosphatase
Bence Jones protein in urine: myeloma
S. Acid phosphatase: prostatic carcinoma
Raised s Calcium in metastasis
BiopsyDiagnostic
Needle biopsy:CT- guided In the line of further surgical incisionRepresentative sample
? frozen section confirmation of a good sample
Open biopsy:After all imaging techniques completedMore reliable – significant morbiditySite considering further surgeryFrom boundariesExcision biopsy for almost certainly benign tumors
Differential diagnosis Soft tissue hamartomas
Myositis ossificans
Stress fracture: Histopath. may be confused with osteosarcoma?
Tendon avulsion injuries Near hip and knee (e.g. Osgood-Schlatter)
Infection
Gout: Large gouty typhus
Other bone lesions: Cortical defects, bone infarcts, “bone islands”
StagingHow does the tumor behave?
Aggressiveness
How far has it spread?Extent
Staging – benign tumorsType
(Staging))Description
Latent Well-defined marginGrows slowly and then stopsRemains static / heals spontaneously(e.g. Osteoid osteoma)
Active Progressive growth limited by natural barriersNot self-limiting. Tendency to recur(e.g. Aneurysmal bone cyst)
Aggressive Growth not limited by natural barriers(e.g. Giant cell tumor)
Staging – malignant tumorsStage I Low-grade sarcomasStage II Histologically high-grade lesionsStage III Distant Metastasis
Site DiscriptionIntracompartmental Confined within an enclosed tissue
space (e.g. a bone, a joint, a muscle group within the fascial coverage
Extracompartmenta;
No natural barrierExtends across interfascial planes
Tumor ExcisionIntracpsular
Marginal
Wide local
Radical
Amputation
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Benign bone lesionsNon-ossifying fibroma
Fibrous dysplasia
Osteoid osteoma / osteoblastoma
Chondroma / chondroblastoma
Osteochondroma
Simple bone Cyst
Aneurysmal bone cyst
Giant cell tumor
Non-ossifying fibromaAnother name:
Fibrous cortical defect
The commonest benign lesion of bone
Asymptomatic Incidentally discovered
Children: Disappears later
Common site: Metaphysis of long bones
Treatment: Observation Surgery if v large
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Non-ossifying fibroma
Non-ossifying fibroma ……..………Fibrous cortical defect
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Fibrous DysplasiaDevelopmental disorder
Trabecular bone replaced by fibrous tissue
Types:MonstaticMonomelicPolystatic
Site:Prox. Femur:
Shepherd’s crookTibia, humerus. Ribs, cranio-facial
Deformity of bone
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Polystotic Fibrous Dysplasia
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Osteoid osteomaSmall tumor (<1 cm)
Young adults
Pain, pain, pain Relieved by Salicylates
Sites: Femur, tibia, spine
X-ray: Small radiolucent “nidus” Surrounded by sclerotic bone
CT: Shows “nidus” better
Tc scan: hot
Treatment: surgical excision, or thermal ablation
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Osteoid osteomaSmall tumor (<1 cm)
Young adults
Pain, pain, pain Relieved by Salicylates
Sites: Femur, tibia, spine
X-ray: Small radiolucent “nidus” Surrounded by sclerotic bone
CT: Shows “nidus” better
Tc scan: hot
Treatment: surgical excision, or thermal ablation
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Osteoid Osteoma7 year old boy
Osteoid Osteoma
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OsteoblastomaA giant ostoid osteoma
Spine and flat bones
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Chondroma (Enchondroma)Incidentally discovered
Young age
Tubular bones of hands and feet
X-ray:Well-defined, central lesionAt junction of metaphysis with diaphysisFlake of calcification are characteristic
Malignant transformationRare in solitary30% in multiple (Ollier’s disease)
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Chondroma (Enchondroma)Incidentally discovered
Young age
Tubular bones of hands and feet
X-ray:Well-defined, central lesionAt junction of metaphysis with diaphysisFlake of calcification are characteristic
Malignant transformationRare in solitary30% in multiple (Ollier’s disease)
Slide Atlas of Orthop Pathology, P Bullough. Gower Med P
Chondroma (Enchondroma)
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Enchondromatosis (Ollier’s)Many lesions
Malignant transformation: 30%
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Enchondromatosis (Ollier’s)Many lesions
Malignant transformation: 30%
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ChondroblastomaIn epiphysis
Proximal humerus, femur, tibia
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Osteochndroma (Exostosis)A common lesion
Ends of long bone
Bony overgrowthAway from epiph. LateCovered by cartilage
Growth:Stops when epiphysis closeIf continues later:
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Osteochndroma (Exostosis)
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Multiple ExostosisMany lesions
Causes growth disturbance
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Simple bone cystSolitary – unicameral
Children
MetaphysisProx. Humerus and Femur
Not a tumorNot seen in adultsHeals spontaneously
Pathological fracture / incidental
Aspirate is clear straw-coloredOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
Simple bone cystSolitary – unicameral
Children
MetaphysisProx. Humerus and Femur
Not a tumorNot seen in adultsHeals spontaneously
Pathological fracture / incidental
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Simple bone cystTreatment:
Small, reducing: leave aloneIncreasing in size, active
Multiple bone marrow injectionsPathological fracture
Treat fractureCyst might heal
Recurrent / injection failed:Surgical curettage and bone grafting
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Aneurysmal bone cystYoung adults
Metaph. of long bone
X-ray:Well-defined cystTrabeculatedEccentrically placedBallooning
Bloody content
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Giant-Cell TumorUnknown origin
Giant cells abundant
Behavior:One third benignOne third locally aggressiveOne third (less) with distant metastasis
Young adults
Common sites:Around kneeProximal humerusDistal radius
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Giant-Cell TumorUnknown origin
Giant cells abundant
Behavior:One third benignOne third locally aggressiveOne third (less) with distant metastasis
Young adults
Common sites:Around kneeProximal humerusDistal radius
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Giant-Cell TumorEccentric lesion
RadiolucentSoap bubbleAbuts against the jointThin cortex
Margins may be clear / unclearDepends on aggressiveness
TreatmentCurettage & bone graftingMore wide excision in recurrent and aggressive lesions
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Giant-Cell Tumor
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Giant-Cell Tumor
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Giant-Cell Tumor
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Cyst-like lesions in bone
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Simple bone cyst Aneurysmal bone cyst Giant-cell tumor
• Fills medullary cavity• Does not expand bone
• At metaphyseal side of physis
• Expansile
• After fusion of physis• Extend to sub-
articular
Cyst-like Lesions
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Primary malignant bone tumorsChondrosarcoma
Osteosarcoma
Ewings sarcoma
Multiple myeloma
ChondrosarcomaMales: 4th – 5th decade
Slow growing
Common sites:Metaphysis of long bonePelvic girdle
Types:Central: in medullaPeripheral: out from cortex
In pre-existing osteochondromaChange in pain / size
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ChondrosarcomaX-rays:
ExpandedSomewhat radiolucentFlakes of calcification
More fluffiness: more aggressive
Treatment:Surgical wide excision / radicalNot sensitive to:
chemotherapy, nor radiotherapyWhy?
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Chondrosarcoma
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Chondrosarcoma
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Chondrosarcoma
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OsteosarcomaUsually highly malignant
(10% already lung metastasis)
Children - adolescents
Presentation:PainMass
Sight:Metaphysis of long bones
PathologyBone forming: osteoblasticWith chondroblastic areas
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OsteosarcomaUsually highly malignant
(10% already lung metastasis)
Children - adolescents
Presentation:Pain – mass
Sight:Metaphysis of long bones
PathologyBone forming: osteoblasticWith chondroblastic areas
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OsteosarcomaX-ray:
Radiolucency and sclerosisPoorly defined marginsExtends into soft tissuePeriosteal reaction:
Sunburst (sun-ray) appearanceCodman’s triangle
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Osteosarcoma
Slide Atlas of Orthop Pathology, P Bullough. Gower Med P
OsteosarcomaTypes:
Medullary: usualParostealPeriostealPaget’s sarcoma
old age
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OsteosarcomaTreatment:
Look for metastasisBiopsy a must
Well planned incisionChemotherapySurgery:
Wide resectionAmputation
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Osteosarcoma - case
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Osteosarcoma - case
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Osteosarcoma - case
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Ewing’s SarcomaFrom bone marrow cells
A round-cell tumor
Age: 10-20 yrs.
Tubular boneTibia, fibula, clavicle
Presentation:Throbbing painSwellingTendernessHotnessESR raised
Osteomyelitis ?
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Ewing’s SarcomaX-ray:
DiaphysealBone destructionNew bone formation
Along the bone“Onion-peel” layers? “Sunray”? Codman’s triangle
Secondaries – in skeleton Apley’s System of Orthop. And Fractures
Ewing’s SarcomaX-ray:
DiaphysealBone destructionNew bone formation
Along the bone“Onion-peel” layers? “Sunray”? Codman’s triangle
Secondaries – in skeleton
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Ewing’s SarcomaTreatment
Poor prognosis – a killing tumorRadiotherapyChemotherapy – multiple drugs
Multiple MyelomaB-Cells of bone marrow
Plasma cells mainly
Age: 45-65 yrs
Bone pains
Increases s. Calcium
Bence Jones protein in urine
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Multiple MyelomaX-ray:
OsteoporosisVertebral compression fracture
If both present in a male >45: ? MyelomaMultiple punched-out lesionsCommon sites:Skull, Prox. Femur, vertebrae
Bone marrow biopsy
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Multiple Myeloma
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Multiple Myeloma
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Metastatic bone diseaseCommon in skeleton
In patients >50 yrs.:metastasis more common than all primary
tumors together
Primary from:Prostate, Kidney, Lung, Thyroid, Bladder,
GIT
Common sites:Vertebrae, pelvis, Proximal femur and
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Metastatic bone diseaseClinical features:
Age 50-70 yrs.Pain – may be silentH.O CarcinomaHypercalcaemia
X-ray:Osteolytic, moth-eatenOsteoblastic in ca prostate
Bone scan
Anemia, raised ESR
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Metastatic - Prostate
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Metastatic bone disease
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Which lesion?
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Which lesion?
http://www.radiologyassistant.nl/
SummaryBone is a common site of tumors
Primary bone tumors:Benign tumorsTumor-like: CystsMalignant
Secondary metastatic
Features, bone, site, age, and X-ray shape characteristic for each tumor
Keep an open mind