Bone Tumors2006

Musculoskeletal tumors
Bao Heng
Department of Orthopaedic Surgery
The First Affiliated Hospital
Classification
 Primary
 Metastatic
Main complaints
 Pain
 Mass
 Abnormal roentgenogram
Enneking system
 T0: intracapsular
 T1: extracapsular intracompartmental
 T2: extracompartmental
 G0: benign
 G1: low grade malignant
 G2: high grade malignant
 M0: metastases are absent
 M1: metastases are present

 Anatomical compartments are
determined by the natural anatomical
barriers to tumor growth such as
cortical bone,articular cartilage,fascial
septa, or joint capsules
 Tumor grades are based on a
combination of histological
,roentgenographic,and clinical
characteristics
Biopsy
 Biopsy is the ultimate diagnostic technique for

evaluating neoplasma
 Closed
Percutanous needle aspiration or core biopsy
 Open
Incisional biopsy:removing a small sample of the
lesion
Excisional biopsy:removing the entire mass
Core needle biopsy
instruments commonly used
for bony specimens
Surgical techniques
Curettage
 Many benign bone tumors can be treated

satisfactorily by curettage.
 If the aggressive tumors(such as giant cell
tumors) are curetted, the tumor margins
should be treated with cryotherapy,PMMA
cementage
 Recurrence of an aggressive tumor is
likely with curettage alone
 Grafting using allograft or autograft with

or without internal fixation for
preventing fracture
Surgical techniques
 limb-sparing resection or amputation ?
 Surgery radiotherapy chemotherapy
 Individualization of treatment rather than

rigid adherence to protocol is advisable
Benign tumors of bone
Osteochondroma
Aneurysmal bone cyst

Osteochondroma
 the most common of the benign bone

tumors
 probably developmental malformation
rather than true neoplasms
 Their growth usually ceases when
skeletal maturity is reached.
Osteochondroma
 About 90% of patients have only a

single lesion
 They are usually found on the
metaphysis of a long bone near the
physis
 Distal femur the proximal tibia
proximal humerus
Osteochondroma
 Many of these lesions cause no symptoms and are
discovered incidentally
 some cause pain by irritating the surrounding structures
 the physical finding usually is a palpable mass

Indications for treatment
 The lesion is large enough to be

unsightly or produce symptoms from
pressure on surrounding structures
 Roentgenographic features suggest

malignancy or when rapid growth has
occurred recently
Treatment
 Excision or observation
 If possible the excision should consists

of and en bloc resection of the
osteochondroma, a rim of normal bone
surrounding its base of stalk, and the
entire overlying busra
Aneurysmal bone cyst
 An aneurysmal bone cyst (ABC) is a solitary,

expansile and erosive lesion of bone.
 It is found most commonly during the second

decade and the ratio of female to male is 2:1.
Aneurysmal bone cyst
 The most common location is the metaphysis of

the lower extremity long bones.
 ABC's are thought to be a reactive process

secondary to trauma or vascular disturbance.
Clinical presentation
 Swelling, tenderness and pain.
 Occasionally there is limited range of motion

due to joint obstruction.
 Spinal lesions can cause neurological
symptoms secondary to cord compression.
 Pathological fractures are rare due to the
eccentric location of the lesion.
X ray
 On plain film, an ABC is normally placed

eccentrically in the metaphysis and
appears osteolytic.
 The periosteum is elevated and the cortex

is eroded to a thin margin.
CT and MRI
 CT scan can narrow the differential

diagnosis of ABC by demonstrating
multiple fluid-fluid levels within the
cystic spaces.
 MRI can also confirm the multiple fluid-

fluid levels
Treatment
 Most lesions can be treated with

currettage
 Recurrence was statistically related to

young age and open growth plates, and
may be less likely following wide
excision than following intralesional
treatment by currettage.
Benign (occasionally malignant)
tumors of bone
 Giant cell tumor

 Chondroblastoma
 Chondromyxoid fibroma
 Osteoblastoma
 Histiocytosis X
Giant cell tumor
 Giant cell tumor mostly occurs in young

adults
 More than half of the tumors occur

about the knee
 Most patients have pain or disability or

both about the involved joint
 The lesion is often located eccentriclly to the
long axis of the bone
 the center is most lucent with increasing
density towards the periphery
 these tumors often thin the cortex,and may
expand into the soft tissues surrounding the
bone
Treatment
 Currettage with or without bone grafing

has a reported recurrence rate of 15%
to 60%.
 Cryotherapy with liquid nitrogen
 Polymethymethacrylate cementation
Malignant tumors of bone
 Malignancy is determined by the ability

of a neoplasm to spread beyond its site
of origin and disseminate to distant
parts of the body
Osteosarcoma
 It is the most common primary malignancy

of bone
 Occurs most commonly in boys and
young men in their teenage or young adult
age
 The most common sites are the distal
femur and proximal tibia
Diagnosis
 Pain and a palpable mass are usually

present
 Local temperature rises
 Venous engorgement
 Roentgenograms shows a metaphyseal
lesion both producing and destroying bone
impressive swelling throughout deltoid region as well
as disuse atrophy of pectoral musculature
Note radiodense matrix of the intramedullary portion of
the lesion as well as soft-tissue extension and aggressive
periosteal reaction
Note dramatic tumor extension into adjacent soft tissue regions
Codman trigone and sunlight
Malignant
cells
Osteoid
matrix
Treatment
 Open biopsy

 Chemotherapy

 Limb-sparing resection

 Wide amputation
 Amputation
Ewing Sarcoma
 It is relatively rare primary malignant tumor

of bone
 This tumor occurs most frequently in males

in the second decade
 Usually the long bones of the lower

extremity are involved
Diagnosis
 Pain and a mass

 Fever and malaise
 Routine roentgenograms commonly

show a diaphyseal lesion with irregular
destruction,periosteal new bone
formation,and a permeative margin
Ewings: uniform round clear cells.
Treatment
 A combination of local radiotherapy

and systemic chemotherapy
 Amputation
Metastatic tumors of bone
 Bone is the third most common site of

metastatic disease.
 Cancers most likely to metastasize to
bone include breast, lung, prostate,
thyroid and kidney.
 The ribs, pelvis and spine are normally
the first bones involved
Diagnosis
 Pain is the most common symptom found in

70% of patients
 Pathological fractures are most common in
breast cancer due to the lytic nature of the
lesions. They are uncommon in lung cancer
due to short life span
 Paraplegia
CT and MRI
 CT is more specific than bone scan and

can distinguish between osteolytic and
osteoblastic lesions.
 MRI is the most sensitive method of
detection bone metastases because
cells can spotted before local bone
reaction has occurred.
 Metastatic bone lesions can be described as
osteolytic, osteoblastic and mixed.
 New treatments with medicines that may

block bone lysis by tumor cells are currently
in clinical trials (Diphosphate)
ECT
Treatment
 Treatment for bone metastasis is normally

palliative.
 Lesions that are regarded as a risk for pathologic
fracture should be surgically stabilized before a
fracture occurs. The goals of surgery are to
preserve stability and function of the
musculoskeletal system as well as alleviate pain.
 Emergency surgery is done for spinal metastasis
in the hope of preserving neurological function.

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Musculoskeletal tumors

 M1: metastases are present

 Biopsy is the ultimate diagnostic technique for

 Many benign bone tumors can be treated

 Grafting using allograft or autograft with

 limb-sparing resection or amputation ?

 Surgery radiotherapy chemotherapy

 Individualization of treatment rather than

Aneurysmal bone cyst

 the most common of the benign bone

 About 90% of patients have only a

 some cause pain by irritating the surrounding structures

 the physical finding usually is a palpable mass

 The lesion is large enough to be

 Roentgenographic features suggest

 If possible the excision should consists

 An aneurysmal bone cyst (ABC) is a solitary,

 It is found most commonly during the second

 The most common location is the metaphysis of

 ABC's are thought to be a reactive process

 Swelling, tenderness and pain.

 Occasionally there is limited range of motion

 On plain film, an ABC is normally placed

 The periosteum is elevated and the cortex

 CT scan can narrow the differential

 MRI can also confirm the multiple fluid-

 Most lesions can be treated with

 Recurrence was statistically related to

 Giant cell tumor

 Giant cell tumor mostly occurs in young

 More than half of the tumors occur

 Most patients have pain or disability or

 Currettage with or without bone grafing

 Cryotherapy with liquid nitrogen

 Malignancy is determined by the ability

 It is the most common primary malignancy

 Pain and a palpable mass are usually

 It is relatively rare primary malignant tumor

 This tumor occurs most frequently in males

 Usually the long bones of the lower

 Pain and a mass

 Routine roentgenograms commonly

 A combination of local radiotherapy

 Bone is the third most common site of

 Pain is the most common symptom found in

 CT is more specific than bone scan and

 New treatments with medicines that may

 Treatment for bone metastasis is normally

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