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Similar a approach to bone tumors.pptx
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approach to bone tumors.pptx
- 1. Approach to bone tumors Dr Madhuri parija
- 2. Epidemiology • Benign bone tumors are 5 times more common than malignant • Most common bone malignancy is metastasis • Most common primary bone malignancy is multiple myeloma • bone sarcomas account for 0.2% of all malignancies • bimodal distribution - first peak occurring in the second decade - second peak occurring in patients >60 • overall 5-year relative survival for 2001–2007 was 66.3%
- 11. Prognosis in primary bone tumors • Stage of disease • Presence of metastasis • Skip lesions within same bone • Histological grade • Tumor size
- 13. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 14. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 15. Clinical workup - history • Age • Swelling (duration , progression, associated skin changes, associated pain ) • Pain (Typical night pain relieved with salicylates – 0steoid osteoma) • Fracture ( trivial trauma , +/-preceeding pain) • Systemic complaints ( loss of appetite, loss of weight , fever ) • History of preexisting bone lesions • Previous radiotherapy • Personal / family history
- 19. • Ollier’s disease • Maffucci syndrome • Familial retinoblastoma syndrome • Rothmund Thompson syndrome • multiple osteochondromas • Paget’s disease • radiation osteitis • fibrous dysplasia, bone infarct, chronic osteomyelitis, prosthetic implants, osteogenesis imperfecta, giant cell tumor, osteoblastoma and chondroblastoma
- 20. Clinical workup - examination • Swelling ( site, size, plane, consistency, pulsatility, overlying skin tethering) • Draining lymph nodes • Involvement of adjacent joints and NV structures • Scars • If suspecting malignancy then work up for primary
- 22. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 23. Plain radiography- pattern analysis • Where is the lesion ? • How extensive is the lesion? Size, single /multiple, skip lesions • What is the lesion doing to the bone? • What is the bone doing to the lesion? • Is the lesion making matrix? • Is the cortex eroded? • Is there a soft tissue mass
- 24. Q1- Where is the lesion ? • Vertical axis - diaphyseal - metaphyseal - metadiaphyseal - epiphyseal • Horizontal axis - cortical - medullary
- 29. Q2. What is lesion doing to bone ? Lodwick classification of margin • Lytic - Type 1 : geographical (A,B,C) - Type 2 : moth eaten - Type 3 : permeative • Sclerotic
- 31. Type IA : well defined, sclerotic margin • Fibrous dysplasia • SBC • Non ossifying fibroma
- 32. Type 1B – well defined , non sclerotic • GCT • Enchondroma • Chondroblastoma • Chondromyxoid fibroma • MFH
- 33. Type IC margin – ill defined • Chondrosarcoma • Osteosarcoma • GCT • lymphoma
- 34. Moth eaten • Multiple myeloma • Metastasis • lymphoma
- 35. Permeative lesions • Ewing sarcoma • Osteosarcoma • Infection • Eosinophilic granuloma
- 37. Q3 – what does the bone do to the tumor ? • Periosteal reaction - less specific than other radiographic sign - Highly aggressive tumors often result in interrupted or multilaminar periosteal reactions - Less-aggressive processes typically produce a unilaminar periosteal reaction
- 40. Lamellar / onion peel periosteal reaction
- 43. Cortical expansion • most commonly seen with benign tumors that grow slowly enough to allow the cortex to remain completely or partially intact. • malignancies are more likely to progress rapidly and destroy rather than expand the cortex. • Lesions that produce a larger degree of cortical expansion are more likely to predispose to pathologic fracture and local bone deformity
- 45. Pathological fracture Limb deformity
- 48. Endosteal scalloping : cartilaginous tumors
- 49. matrix • Osteoid matrix – cloud like densities, ivory dense • Chondroid matrix – stippled, flocculent, rings and arc • Fibrous tissue – ground glass appearance
- 51. Stippled calcification Popcorn calcification
- 52. Osteoid osteoma • Diaphyseal • Eccentric (cortical) • Type 1 B margin • Solid smooth periosteal reaction
- 53. Simple bone cyst • First decade • Metaphyseal • Centric • Proximal humerus
- 54. GCT • Adult bone • Epimetaphyseal • Eccentric • Distal femur
- 55. osteosarcoma • Metaphyseal • Central • Permeative • Sunburst periosteal reaction • Codman triangle
- 56. Parosteal osteosarcoma • 3rd- 4th decade • Metaphyseal • Eccentric • Distal femur – posterior cortex • Solid periosteal reaction • Dense matrix
- 58. Blood tests • To rule out differentials such as infection • When investigating bone secondaries • PAC • Weak prognostic marker
- 60. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 61. MRI -Indicated when lesion is indeterminate or shows s/o aggressiveness -Even when a specific diagnosis cannot be made, the differential diagnosis can be narrowed • To detect lesions not apparent or indeterminate on Xray • To help in local staging • Detects skip lesions • Helps in surgical planning by assessing the degree of intramedullary extension and invasion of the adjacent physeal plates, joints, muscle compartments and neurovascular bundles • used in assessing response to neoadjuvant therapy
- 64. CT scan • Complementary role in diagnosis • local staging of bone tumor – CT chest • Percutaneous biopsy
- 69. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 70. Biopsy • Biopsy planning is important as all tissues contaminated by biopsy track must be removed during definitive surgery • Should be performed after discussion with MDT • Culture the biopsy ( and biopsy the culture)
- 77. Types of biopsy • Percutaneous biopsy - fine needle aspiration (FNAC) - core needle biopsy • Incisonal /open biopsy - should be performed only if enough tissue is not obtained in percutaneous biopsy - For open biopsy close attention must be paid to haemostasis and tissue dissection must be kept to minimum - Drain must be placed in line of incision • Excisional biopsy - entire lesion is removed - for benign lesion e.g osteochondroma
- 79. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 85. History & examination Screening radiograraphy & blood tests Advanced imaging Histopathological diagnosis Staging protocol Treatment
- 97. Surgical options • Limb salvage surgery • Amputation • Palliative surgery
- 100. Indications of limb salvage surgery • Should be intracompartmental • good preoperative chemotherapy respnonse • Skin should be free of tumor • Wide resection of affected bone with a normal muscle cuff in all direction • All previous biopsy sites and all contaminated tissues can be removed en bloc • Adequate motor reconstruction can be achieved by regional muscle transfer
- 105. Arthrodesis
- 106. Autograft