Malignant Bone Tumours - A lecture for undergraduate students and demonstrators / Tutors featuring general aspects and three common malignant bone tumours viz. Osteosarcoma, Ewing's Sarcoma and Multiple Myeloma

1. MALIGNANT BONE
TUMOURS
PROF. AJAY PANT
Prof. & Head, Orthopaedics, TMMC&RC

2. TUMOUR
• A swelling of a part of body, generally without
inflammation, possessing no physiological
function, cause by abnormal growth of tissue
whether benign or malignant.

3. BENIGN
• Benign tumour is non – progressive
• Not harmful to human health
• Does not metastasize

4. MALIGNANT
• Progressive and tend to become worse and can
potentially result in death.
• Grow fast and seek new territory.
• Spread to distant sites (metastasis).

5. METASTASIS
• Malignant tumours invade nearby cells and
spread.
• Some cells break off from the tumor and
spread to various parts of body through blood
stream or lymphatic system.
• Establish elsewhere and form new malignant
tumours.
• metastasized cells are same as original.

6. CARCINOMA
• Tumours derived from skin or tissues that line
body organs (EPITHELIAL CELLS).
• eg. Stomach, Pancreas, Prostate, Lung, Liver,
Breast, Colon.

7. SARCOMA
• Start off in connective tissue such as -
CARTILAGE, BONE, FAT, NERVES.
• Originate in the MESENCHYMAL CELLS
• Called after the cell/tissue/ structures they arise
from e.g. –
– Liposarcoma
– Fibrosarcoma
– Osteosarcoma
– Chondrosarcoma
– Angiosarcoma

8. LYMPHOMA / LEUKEMIA
• Cancer arising from blood forming or
HEMATOPOIETIC CELLS
• Originate in the marrow and mature and
generally mature in the blood or lymph nodes.

9. GERM CELL TUMOUR
• Arise from –
– GERM CELLS
– PLURIPOTENT CELLS – cells that can turn
into any kind of cells.
• Present in the OVARY or TESTICLE
• Less commonly appear in brain, abdomen or
chest.

10. BLASTOMA
• Derived from EMBRYONIC TISSUE or
IMMATURE “PRECURSOR” CELLS
• More common in children.
– Glioblastoma
– Medulloblastoma
– Retinoblastoma
– Osteoblastoma
– Neuroblastoma

11. • Common primary malignant bone tumours-
– Multiple myeloma
– Osteosarcoma
– Ewing’s sarcoma
– Chondrosarcoma

12. OSTEOSARCOMA
• Osteosarcoma is an aggressive malignant
neoplasm arising from primitive transformed
cells of mesenchymal origin (and thus a
sarcoma) that exhibit osteoblastic
differentiation and produce malignant osteoid.
• It is the most common histological form of
primary bone cancer in age 12-25yrs.

13. 13
EPIDEMIOLOGY
• Male more than female
• At any age but
• 75% of cases appear at age 12-25yrs

14. RISK FACTORS:
• Radiation exposure
• Patients who survive after taking therapy for another
Cancer.
• Retinoblastoma(malignant tumor arising from retina
of eye).

15. SITES OF PREDILECTION:
• Osteosarcoma :It originates more frequently
(90%) in the metaphyseal region of tubular
long Bones, with 42% occurring in the femur.
• Commonest sites are distal femur, proximal
tibia and proximal humerus.

16. HISTOPATHOLOGY
This tumor arises from primitive
mesenchymal cells and is diagnosed by the
presence of malignant stromal cells laying
down tumor osteoid along with areas of
hemorrhage and necrosis and spicules of
destroyed bone .Depending on the
predominant tissue-- can be chondroblastic
,fibroblastic, and telangiectatic.

17. DIAGNOSIS OF
OSTEOSARCOMA
• Clinical examiation
• Radiologic examinatiom
• Biopsy for histopathology

18. CLINICAL PRESENTATION

19. SIGNS AND SYMPTOMS
• Persistent pain, may increase at night.
• Deep, firm, fixed mass may be palpable.
• Swelling usually develops near the end of a
long bone.
• Overlying skin may be stretched, thin, glossy
with distended veins.
• Adjacent joint may be impaired.

20. PLAIN XRAY
• The area of tumor mass
may be Lytic, sclerotic
or mixed

21. IN X – RAY WE CAN SEE CODMAN’S
TRIANGLE
• Codman’s triangle is a term used to describe
the triangular area of new subperiosteal bone
that is created when a lesion, often a tumour,
raises the periosteum away from the bone.
• sun-burst" appearance on X-ray examination
due to the tumor spicules of calcified bone
radiating in right angles

22. “Codman’s triangle” of bone appears as tumor
elevates periosteum from underlying bone.
Cortical soft tissue extension may produce
radiating spicules of bone called “sunray”
appearance.

23. CODMAN’S TRIANGLE

24. OSTEOSARCOMA
Elevated periosteum described as “Codman’s Triangle”

25. OTHER LOCAL
INVESTIGATIONS
• CT
• MRI
• Angiogram

26. SYSTEMIC INVESTIGATIONS
• Bone scan
• CT Chest

27. DIFFERENTIAL DX
• Giant Cell Tumor
• Aneursymal Bone Cyst
• Ewings tumor
• Osteoblastoma
• Metastasis
• Lymphoma

28. TREATMENT
Preoperative and/or postoperative chemotherapy Drugs
used are methotrexate,adriamycin and cisplatin (MAP
regimen) in a cyclical manner)
Resection - A procedure performed for the specific
purpose of removal
Allograft replacement - the process of transplanting
tissues and organs-limb salavging procedures
Amputation is to be reserved only for late presentation

29. EWING’S SARCOMA
• Identified in 1921 by James Ewing
• Third most common primary tumour of bones
• Second most common malignant bone tumour
of late childhood and early adulthood.
• Precise cell of origin unclear.
• Thought to arise from primitive mesenchymal
cells.

30. • ETIOLOGY - More common in white
population compared to Africans & Asians.
• AGE – first two decades of life.
• SEX – M:F ratio 1.4 to 1
• SITE – occurs throughout the skeleton but
more frequently in pelvis, long bone, ribs and
vertebral column.

31. CLINICAL PICTURE
• Commonest – pain and swelling
• About 10% patients present with pathological
fracture.
• Occasionally signs and constitutional
symptoms of systemic infection (often
confused with infection).
• Diagnosis often delayed in the pelvis and other
axial sites.

32. RADIOGRAPHIC FINDINGS
• X-rays usually show an area of bone destruction
predominantly in the diaphysis.
• New bone formation may extend along the shaft
and appear as fusiform layers of bone around the
lesion – ONION PEEL APPEARANCE
• Sometimes tumour extend into surrounding soft
tissues with radiating streaks of ossifications and
reactive periosteal bone presenting with
Codman’s triangle and Sun Ray appearance.

33. • MRI is excellent for describing lesions
especially in the marrow for extent of disease.
• PET – CT scans are used for metastasis and
staging of tumours.
• Lab findings may include anaemia,
Leukocytosis, elevated ESR and Lactate
Dehydrogenase (LDH levels).
• Biopsy

34. TREATMENT
• Multidisciplinary approach –
– Systemic multiagent chemotherapy
– Surgery
– Radiation therapy
OR
Combination of the two
• Multimodality treatment gives 60-70%
survival in localized disease.

35. MULTIPLE MYELOMA

36. • Most common primary malignancy of bone
• Malignant B cell lymphoproliferative disorder of
the bone marrow.
• Characterized by presence of neoplastic plasma
cells which replace bone and marrow spaces.
• Formation of abnormal protein leads to immune
deficiency.
• Marrow cell proliferation and increased
osetoclastic activity – osteoporosis and
appearance of discrete lytic lesions in the
skeleton.

37. • Large colony of plasma cells may form a solitary
tumour – plasmacytoma
• Bone resorption Hypercalcemia
• Late features -
1) Renal dysfunction
2) Vertebral collapse -Nerve root compression or cord
3) Pathological fractures
Age:
• Older persons – 40-70 Years
• Sex – Male > Female

38. ETIOLOGY
• Genetic Cases
• Environmental / occupational (wood, leather,
Paint workers).
• Chronic Inflammation
• Radiation

39. CLINICAL PICTURE
• 30 % cases asymptomatic and detected incidentally.
• Bone pain
• Anemia
• Infection
• Weakness
• Hypercalcemia
• Pathological fracture
• Spinal cord compression
• Signs & symptoms of renal failure in late cases –
tubular blockade by myeloma proteins.

40. RADIOGRAPHIC FINDINGS
• Generated osteopenia
• Bi concave vertebral bodies
• Lytic “Punched out” bone lesions in skull,
pelvis, ribs, vertebral column, less commonly
in long bones.

43. LABORATORY FINDINGS
• Anemia
• Thrombocytopenia
• Increase blood urea
• Increase Serum Calcium
• Increase ESR
• Presence of Para proteins in –
Serum – B2 Micro globulin
Urine – Bence Jones Proteins
• ‘M’ Band is serum protein electrophoresis
• Malignant plasma cells in filtrate the bone marrow –
Histological examination of aspirate.

44. TREATMENT
• Supportive Medical therapy:
– Control of pain, Rest, Diet, Hydration
• Chemotherapy:
– Alkylating cytotoxic agents , E.g Melphelan,
Cyclophosphamide
– Corticosteroids
• Radiotherapy:
– Solitary Plasmacytoma more amenable.
– Control of pain in vertebral lesions.

45. • Surgical care:
– Internal fixation of pathological fracture s
– Decompression of Spinal cord