1) Bone tumours can be benign or malignant and are classified based on features seen on imaging such as location within the bone, pattern of bone destruction, and presence of a periosteal reaction. 2) Imaging plays an important role in evaluating bone tumours and includes plain radiographs, CT, MRI, and bone scans. Biopsy is also important to determine the specific diagnosis. 3) Treatment depends on whether the tumour is benign or malignant but may include surgery, chemotherapy, and radiation therapy. The surgical margin taken is a key factor in oncology outcomes.

1. BONE TUMOURSBONE TUMOURS
Dr. SidharthYadav
Orthopaedic Dept.
N.K.P.SIMS

2. IntroductionIntroduction
Bone tumours are very diverse in morphology and
biological potential.
Most bone tumours are benign lesions
Most benign lesions are seen <30 years of age
Benign lesions typically present as incidental finding.

3. ApproachApproach
Age of the patient :- mature or immature skeleton.
Location of tumour :- Epi/Meta/Diaphyseal
Number of lesion :- solitary/multiple
Nature of lesion :- lytic/sclerotic/mixed
Matrix :- osteoid/chondroid/fatty
Zone of transition
Peiosteal reaction

4. 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.
Metaphyseal: Osteosarcoma ,Osteochondroma

5. • < 20 yrs - Osteogenic Sarcoma, Ewings. simple bone
cysts and chondroblastomas
• 20-40 yrs - GCT, Chondrosarcoma, MFH,
Lymphoma, Mets.
• >40 yrs - Mets, Myeloma, Chondrosarcoma, MFH
– Late Osteogenic, Fibrosarcoma.
Age of the patient

6. Clinical featuresClinical features
 Pain
- deep & consistant.
- may be present from a week to as long as 3-4 yrs.
- poorly localized.
- may be associated with antalgic limp with muscle waisting.
- night cries.
 Mass
 Pathological fractures due to excessive bone replacement by
tumour.
 Generalised weakness.
 Neurological symptoms such as paraesthesia.
 Deformity

7. InvestigationsInvestigations
Blood investigation
X-rays
Bone scan
Ct scan
MRI
Arteriography
Biopsy

8. Laboratory investigationsLaboratory investigations
Complete blood count.
ESR
C-reactive protein (CRP)
Urine for bence jones protein.
Serum electrophoresis.
Acid phosphatase.
Alkaline phosphatase.

9. RadiographsRadiographs
Exact location of the tumour
Borders of the tumour
Pattern of bone destruction
Matrix formation
Periosteal reaction

10. Pattern of bone destructionPattern of bone destruction
Bone destruction is due to osteoclastic resorptive
activity on both trabecular & cortical level.
2 stages :-
 Removal of mineral content
 Followed with enzymatic digestion.
3 types of bone destruction
 Geographic
 Moth eaten
 Permeative

11. Geographic bone destructionGeographic bone destruction
Seen as a well circumscribed hole in the
bone with a narrow zone of transition.
Divided into 3 types :-
A – with sclerotic margins
B – with out sclerotic margins
C – with ill defined margins

12. Type 1 a Geographic Lesion.
Eg. – unicameral bone
cyst, enchondroma.
Well-defined lucency with sclerotic rim.
Associated with benign / slow growing
Disorders.

13. Well-defined geographic lytic focus without
sclerotic rim , Endosteal scalloping seen.
Type 1 b Geographic Lesion
well-defined lucent lesion
without sclerotic rim.
myeloma

14. Large ill-defined lytic lesion , Codman’s triangle
Periosteal interruption, Tumor-induced new
bone .
.
Type 1 c Geographic Lesion
ill-defined lytic lesion.
Focally destructive & locally
Invasive.
Wider zone of transition.
osteosarcoma

15. 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
Margins: 1A, 1B, 1C

16. Type 2 Moth-eaten Appearance
Aggressive pattern.
Areas of destruction with
ragged borders
Implies more rapid growth
Presents as multiple scattered
hole vary in shape & size
These scattered hole coalesce
to form large defect.
osteosarcoma

17. Type 3. Permeative Pattern
Ewing sarcoma.
ill-defined lesion
with multiple “worm-holes”
Wide transition zone
Total penetration of cortex is
assumed.
Eg. Round cell tumours,
fibrosarcoma.
Leukemia

18. Patterns of Bone DestructionPatterns of Bone Destruction
Geographic Moth-eaten Permeative
Less malignant More Malignant

19. Periosteal reactionPeriosteal reaction
Periosteum of adult is minimally cellular & mainly fibrous in
inactive stage.
Reaction must mineralize to become visible on
radiographs.
Usually take 10 days – 3 wks.
Classified as :-
 Solid
 Interrupted
Ragsdale (1981) expanded this classification by adding
subclasses.

20. SolidSolid
Is further divided as :-
Smooth shell
Lobulated
Ridged

21. Solid Periosteal ResponseSolid Periosteal Response
Related to a slow form of
irritation osteoid osteoma
Slow-growing tumors provoke focal cortical thickening
A continuous layer of new bone that attaches to outer cortical surface

22. Single layer of reactive periosteum.
thick unilamellated periosteal reaction.
Smooth and continuous
Unilamellated periosteal reaction
Hypertrophic osteoarthropathy

23. Aggressive PeriostitisAggressive Periostitis
appearance of aggressive
periostitis in Ewing’s sarcoma
Layered, onion-skin, lamellated
• Alternating layers of opaque and
lucent densities
• Can be seen with aggressive
tumors and infections
growth spurt.

24. Spiculated periosteal reaction.
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
Osteosarcoma

25. Bone is formed in a disorganized fashion
Process may destroy spicules of bone as they are being
formed
This is a very aggressive process
Sunburst

26. Too fast growth for periosteum to respond
only the edges of raised periosteum will ossify
forming a small angle with the surface of bone.
Codman's triangle
seen in malignant bone tumors and in
rapidly growing lesions , aneurysmal bone
cyst, subperiosteal hematoma.

27. Solid onion-peel Sunburst Codman’s
triangle
Less malignant More malignant
Periosteal reaction

28. Matrix mineralizationMatrix mineralization
Matrix refers to acellular /intracellular substance
produced by mesenchymal cell.
Types :-
 Osteoid
 Chondroid :-

29. Solid
Patterns of mineralization of osseous matrix
Ivory-like
opacityCloud like
Osteoid tissue mineralise in a confluent manner that result in
radiographic density Ranging from hazy ground glass to ivory like
pattern.

30. Patterns of mineralization of cartilaginous tumour
matrix
Stippled Flocculent Ring and arc

31. CT ScanCT Scan
Very useful in early diagnosis
Determine intra/extramedullary extension.
More accqurate in demonstrating integrity of cortex in a area
contaning tumour.
Also demonstrate matrix mineralization.
Differentiate between solid & lytic lesion.
Early detection of pulmonary secondaries
Exact measurement for limb salvage procecures
(Prosthesis/allograft)

32. MRIMRI
Intra medullary extension
Soft tissue extension
Defines the relationship to the nearby major blood
vessels
T1 – differentiate tumour from fat.
T2 – differentiate tumour from surrounding muscle

33. Radio nuclide bone scanningRadio nuclide bone scanning
For pre biopsy staging
Dissemination of
tumour
Silent secondaries and
skip lesions

34. ArteriogramArteriogram
Planning limb sparing
surgery
Therapeutic
embolization
To assess vascularity of
tumour

35. BiopsyBiopsy
Closed biopsy
FNAC
Needle biopsy
Open biopsy
Incisional biopsy
Excisional biopsy

36. TreatmentTreatment
Chemotherapy
Radiotherapy
Surgical resection

37. RadiotherapyRadiotherapy
Radiation cause cell death by inducing formation
of free radicles that cause DNA damage.
Sensitivity of cell depends upon :-
 Cell’s position in cell cycle.
 Tissue oxygenation
 Cell’s ability to repair DNA damage or its inability to
undergo apoptosis.

38. Primary bone tumour’s are resistant to
radiotherapy except marrow cell tumour.
CarcinomaMetastatic to bone except renal cell
carcinoma are sensitive to radiation.
Radiation therapy is associated with
acute(erythema anorexia) & chronic
complications(oedema,fibrosis).
Rarely used for benign conditions.

39. Conventional external beam radiation can be
delivered by brachytherapy.
Hollow catheters are implanted in tumour bed at
the time of resection.
This techinique allow high dose of radiation to be
delivered to target cell.

40. ChemotherapyChemotherapy
With the use of new chemo protocol the 5 yrs survival
rate is approx 70% for osteosarcoma.
Similar rates has been noted for other maligant
conditions.
Chemotherapy is not useful for cartilagenous lesions &
other low grade malignancies.
Pre operative chemotherapy may decrease the spread of
tumour cells at the time of surgery.

41. 2 types :-
 Adjuvant chemotherapy.
Administered post operatively to treat metastases.
 Neoadjuvant chemotherapy.
Administered before surgical resection of primary tumour.
Preoperatively chemo regress the primary tumour .
Drugs used in chemotherapy are more effective when they are
used against a small lesion.
They are more effective when used in combination rather then
single drug.

42. SurgerySurgery
In orthopaedic oncology surgical margins are
defined by :-
 Intralesional
 Marginal
 Wide
 Radical

43. Intralesional marginIntralesional margin
 Plane of surgical resection is with in the
tumour.
 This is a/k/a debulking because it leaves
behind gross residual mass.
 Procedure may be appropriate for
benign tumours when only option is to
sacrifice important anatomical
structures.

44. Marginal marginMarginal margin
 Tumours suppress the surrounding
tissue & appears to become
encapsulated .
 This surrounding is k/as pseudocapsule.
 A marginal margine is achieved when
the plane of dissection passes through
pseudocapsule.
 In high grade malignancy
pseudocapsule may contain satellite
lesion.

45. Wide & Radical marginWide & Radical margin
 Wide resection is acchieved when the
plane of resection is in normal tissue.
 If the plane of dissection touches the
pseudocapsule at any point then it
would be defined as marginal margin.
 Radical margine are achieved when all
the compartment that contain tumour
are removed en bloc.

46. CurettageCurettage
Many benign lesion can be treated adequately by curettage.
Local recurrence rate is high in curettage as compared to
resection.
Allows better functional results.
Curretage is first done by creating a large cortical window
over the lesion , atleast the size of lesion.
Bulk is removed with curets.

47. Cavity is enlarged by 1-2 cm in each
direction.
Cavity is filled with bone graft / cement.

48. THANK
YOU…