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

Orthopedic Radiolgy. A Greenspan. Lippincott-Raven

Radiographic features

The Border

The Matrix

Type of Bone Destruction

Type of Periosteal Reaction

Soft Tissue Extension

Benign Vs. malignant

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

Apley’s System of Orthop. And Fractures

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

Non-ossifying fibroma

Non-ossifying fibroma ……..………Fibrous cortical defect

Fibrous DysplasiaDevelopmental disorder

Trabecular bone replaced by fibrous tissue

Types:MonstaticMonomelicPolystatic

Site:Prox. Femur:

Shepherd’s crookTibia, humerus. Ribs, cranio-facial

Deformity of bone

Polystotic Fibrous Dysplasia

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

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

Osteoid Osteoma7 year old boy

Osteoid Osteoma

OsteoblastomaA giant ostoid osteoma

Spine and flat bones

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)

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)

Enchondromatosis (Ollier’s)Many lesions

Malignant transformation: 30%

Enchondromatosis (Ollier’s)Many lesions

Malignant transformation: 30%

ChondroblastomaIn epiphysis

Proximal humerus, femur, tibia

Osteochndroma (Exostosis)A common lesion

Ends of long bone

Bony overgrowthAway from epiph. LateCovered by cartilage

Growth:Stops when epiphysis closeIf continues later:

? Malignant transformationOrthopedic Radiolgy. A Greenspan. Lippincott-Raven

Osteochndroma (Exostosis)

Multiple ExostosisMany lesions

Causes growth disturbance

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

Aspirate is clear straw-coloredOrthopedic Radiolgy. A Greenspan. Lippincott-Raven

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

Aneurysmal bone cystYoung adults

Metaph. of long bone

X-ray:Well-defined cystTrabeculatedEccentrically placedBallooning

Bloody content

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

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

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

Giant-Cell Tumor

Cyst-like lesions in bone

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

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

ChondrosarcomaX-rays:

ExpandedSomewhat radiolucentFlakes of calcification

More fluffiness: more aggressive

Treatment:Surgical wide excision / radicalNot sensitive to:

chemotherapy, nor radiotherapyWhy?

Chondrosarcoma

OsteosarcomaUsually highly malignant

(10% already lung metastasis)

Children - adolescents

Presentation:PainMass

Sight:Metaphysis of long bones

PathologyBone forming: osteoblasticWith chondroblastic areas

OsteosarcomaUsually highly malignant

(10% already lung metastasis)

Children - adolescents

Presentation:Pain – mass

Sight:Metaphysis of long bones

PathologyBone forming: osteoblasticWith chondroblastic areas

OsteosarcomaX-ray:

Radiolucency and sclerosisPoorly defined marginsExtends into soft tissuePeriosteal reaction:

Sunburst (sun-ray) appearanceCodman’s triangle

Osteosarcoma

Slide Atlas of Orthop Pathology, P Bullough. Gower Med P

OsteosarcomaTypes:

Medullary: usualParostealPeriostealPaget’s sarcoma

old age

OsteosarcomaTreatment:

Look for metastasisBiopsy a must

Well planned incisionChemotherapySurgery:

Wide resectionAmputation

Osteosarcoma - case

Ewing’s SarcomaFrom bone marrow cells

A round-cell tumor

Age: 10-20 yrs.

Tubular boneTibia, fibula, clavicle

Presentation:Throbbing painSwellingTendernessHotnessESR raised

Osteomyelitis ?

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

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

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

Multiple Myeloma

Metastatic bone diseaseCommon in skeleton

In patients >50 yrs.:metastasis more common than all primary

tumors together

Primary from:Prostate, Kidney, Lung, Thyroid, Bladder,

Common sites:Vertebrae, pelvis, Proximal femur and

humerusOrthopedic Radiolgy. A Greenspan. Lippincott-Raven

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

Antigen markers of tumorsOrthopedic Radiolgy. A Greenspan. Lippincott-Raven

Metastatic - Prostate

Metastatic bone disease

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

bone tumors and tumor-like conditions

malignant orthopedic

bone eating

location orthopedic

tumor spreadwithin bone

periosteal new bone

spineimaging xrayswhich

benign lesionssome malignant

benign malignantsecondaries

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