VIP Hyderabad Call Girls KPHB 7877925207 ₹5000 To 25K With AC Room 💚😋
Bone tumours
1.
2.
3.
4. Classification based on:
Histological grade (G)
Site (T)
Metastases (M)
ENNEKING'S SURGICAL STAGES
STAGE GRADE SITE METASTASES
1A
1B
Low(G1)
Low(G1)
Intracompartmental(T1)
Extracompartmental(T2)
None(M0)
None(M0)
2A
2B
High(G2)
High(G2)
Intracompartmental(T1)
Extracompartmental(T2)
None(M0)
None(M0)
3
Low(G1) or
High(G2)
Intracompartmental(T1)
Or
Extracompartmental(T2)
Yes(M1)
5. Clinical examination (age, sex, site and past history)
◦ Thyroid
◦ Breasts
◦ Chest
◦ Liver
◦ Kidney
◦ Rectal (prostate & rectal tumours)
Bloods
◦ FBC (leukaemic cells etc)
◦ ESR (often elevated)
◦ Biochemistry (Ca++, PO4, liver enzymes and Alkaline Phosphatase) -> mets
◦ Acid Phosphatase (prostate and increased with metastatic deposits)
◦ Thyroid function tests
◦ PSA
◦ Serum Protein Electrophoresis (Myeloma)
Urinalysis
Urine Bence-Jones (myeloma)
CXR
Abdominal ultrasound
Bone scan -> other sites
MRI -> soft tissue extent and association with nerves and vessels
CT of lesion and chest (-> staging)
Angiography -> tumour blood supply and relationship to major vessels
Biopsy
6. Should know probable diagnosis and stage of
tumour before biopsy
Performed by the surgeon who will perform the
definitive surgery
Biopsy tract orientation & location is critical - will
need to be included in the definitive surgery if
lesion is malignant.
Meticulous haemostasis to avoid tracking
haematomas
Send samples for microbiological analysis
7. Intra-lesional
◦ through the tumour
◦ leaves macroscopic tumour
◦ not therapeutic
Marginal
◦ through pseudo-capsule of tumour / reactive zone
◦ controls non-invasive benign tumours
◦ recurrence of malignant tumours = 25-50%
Wide
◦ around reactive zone, leaving a cuff of normal tissue
◦ skip lesions left
◦ recurrence of malignant tumours = < 10%
Radical
◦ removal of entire compartment or compartments
◦ distant metastases left
Amputation
◦ should be thought of as a form of reconstruction where surgical control of
the tumour precludes useful function.
14. Pattern of bone destruction
Tumour matrix
Cortical expansion/penetration
Periosteal reaction
Adjacent soft tissues
Size & shape of lesion
Trabeculation
Growth Plate
15. Benign lesion - during growth
20% of benign bone lesions
Age 5-15 years
Not found in adults
Sex m:f 3:1
The most common location is the proximal humerus
(67%) followed by the proximal femur (15%)
unusual sites (calcaneum, pelvis) in patients >17 yrs
Cysts may be Active or Latent: Active cysts are
located near the growth plate, but they move further
away as the child grows and become inactive (latent)
16. Well defined, central osteolytic area with a thin sclerotic margin
Metaphyseal in young - moves towards diaphysis with growth
It fills and slightly expands metaphysis
Pathology
Thin walled cavities - blood tinged fluid.
The lining cells are cuboidal,
17. Treatment goal is to minimise fracture risk until
the cyst heals (but this can take years)
Steroid injection
◦ 1-3 percutaneous injections repeated at 2 monthly
intervals
◦ 60-80% success rate
Curettage and bone graft - 50% recurrence
rate and possibility of damage to the growth
plate
Bone marrow aspirate has recently been used
18. Benign solitary, expansile and erosive lesion of bone
1% of benign bone lesions
Age (85% cases <20 years old)
Sex f:m is 2:1
ABC's can be found in any bone in the body
The most common location is the metaphysis of the lower extremity
long bones, more so than the upper extremity
The vertebral bodies or arches of the spine may be involved
Approximately one-half of lesions in flat bones occur in the pelvis
Presentation
Swelling, tenderness and pain
Limited range of motion due to joint obstruction
Spinal lesions - neurological symptoms
Pathological fractures are rare - eccentric location of the lesion
19. Placed eccentrically in the metaphysis and appears osteolytic
The periosteum is elevated; cortex is eroded to a thin margin
The expansile lesion - "blow-out”
CT scan -for pelvis or spine lesions
CT scan can demonstrating multiple fluid-fluid levels
MRI can also confirm the multiple fluid-fluid levels
20. A slow growing, indolent ABC has been observed
to regress spontaneously
Most lesions can be treated with curettage and
application of a high-speed burr
Recurrence was statistically related to
young age and open growth plates, and may
be less likely following wide excision than
following curettage
21. Benign, usually solitary and locally aggressive
10% of benign bone lesions
malignant transformation (5-10%)
Not seen until after the growth plate closes
Rarely metastasises (<1% to lungs)
Age 20 - 40 years
More common females
Most commonly seen in the distal femur,
proximal tibia and the distal radius
Nearly always located at the very end of a long
bone (metaphyseal / epiphyseal)
Pathological fracture occurs in 10 - 15%
Neighbouring joint often irritated (effusion)
23. Usually well defined lesion in
the epiphysis extending up
to the joint surface without
marginal sclerosis, cortex
thinned and sometimes
ballooned
soap bubble appearance
Junction with normal bone
poorly defined
Soft, friable tumour
Cut surface tan in colour, with
areas of necrosis and
haemorrhage
Numerous multinucleated giant
cells. The stromal cells are
homogenous mononuclear
round/ovoid with large nuclei
Up to 50% have soft tissue
extension
24. Intralesional excision by "extended" curettage
Curettage alone has a high local recurrence rate (50%) and the
curettage is "extended" into the bone by a few millimetres by
either using a burr, liquid nitrogen or phenol
The resulting cavity can be filled with bone graft or cement
En-bloc resection is possible if the bone is expendable e.g.
proximal fibula, proximal radius
Amputation reserved for massive local recurrence, malignant
change or infection
Radiotherapy reserved rare cases of unresectable tumours
because of increased risk of secondary malignancy
25. 10% of benign bone tumours
Male : Female 2:1
Peak age 5 - 25 years (85% in this range)
Rare over 40 years
Location:
Any bone, rarely multifocal
tibia & femur in 50%
spine - posterior elements
Only occurs in bones formed by endochondral ossification
Clinically
Pain - commonest presentation
Pain - worse at night and relieved by aspirin
10% occur in the spine
Runs a self limiting course > surgery for pain relief
Pain usually decreases as the lesion matures
Lesion healed by 3 - 7 years
26. Lytic nidus surrounded by sclerotic bone (which
may mask the nidus)
Centre of nidus may be calcified
CT or tomograms -> diagnosis
Hot spot on bone scan
Differential Diagnosis
Bone island (enostosis)
Brodie's abscess
Osteoblastoma
fatigue fracture
28. Cartilage capped bony projection / exostosis
Commonest benign tumour
Developmental abnormality of the metaphysis
Accounts for 45% of benign bone tumours
12% of all bone tumours
most become evident under 20 years
May be solitary or multiple (diaphyseal
aclasis)
Any bone developing by endochondral
ossification may be involved
29. Autosomal dominant
Disordered endochondral growth
Multiple osteochondromas
Short stature and bowing of limbs
Treat individual lesions as necessary
and observe for malignant change
Malignancy Risk = ~ 20%
overall or 0.2% per lesion
Trevor's Disease:
Osteochondroma on epiphyseal side
of the growth plate
30. x-ray hallmark is blending of tumour into
underlying metaphysis
flat, sessile lesion or a peduculated (stalk like) process
pedunculated osteochondromas are oriented in
proximal direction
Cartilaginous cap displays irregular areas of
calcification
31. Nil required unless symptomatic (persistent
irritation (from bursitis or tendon) or neurovascular
compromise)
Extra capsular marginal excision
◦ Including the cartilaginous cap & overlying perichondrium
◦ Deep bony base has minimal activity & may be removed
piecemeal
◦ The cartilaginous cap should not be traumatised during
removal
◦ Recurrence = < 5%
Decreased risk of recurrence if excised after
maturity
32. Risk of malignant change ~ 0.2% in a solitary
lesion
Risk of malignant change in diaphyseal aclasis
20%
Sarcomatous change usually ->low grade
Evidence of transformation to
Chondrosarcoma:
◦ Cartilaginous cap thicker than 1 cm in an adult (in
child may be 2-3 cm thick)
◦ Cartilage cap > 8cm diameter
◦ Fluffy outline
◦ Bone scan - Marked increase in uptake in an adult
◦ CT/MRI - soft tissue mass or displacement of a
major neurovascular bundle
33. 10% of benign bone tumours
50% occur in small bones of the hands and feet
15% femur and 12% humerus
Peak incidence 10 - 50 years
May be solitary or multiple (Olliers, Mafuccis)
Clinically
Usually metaphyseal
75% Solitary
60% present as fractures
pathological fracture, lump
incidental finding
34. X-Rays Scalloped erosions on endosteal
surface
flecks of calcification - sometimes called 'ground
glass'
enchondroma (typical appearance & site)
35. Macroscopically - bluish white well
demarcated
hypocellular; nests of mature
cartilage cells,
Ollier's disease - more cellular;
50% ->malignant transformation
Mafucci's disease - associated
with multiple haemangiomata
and associated with nearly 100%
malignant change somewhere
36. Observe - x-ray 6 months & 1 year after
presentation
Curettage and grafting if latent
Recurrence - en block excision
Prognosis
Risk of malignant change in Olliers is 50%
malignant change in Mafuccis is nearly 100%
37. 5 - 20% benign bone lesions
usually monostotic
Affects children and adolescents
Median age at onset 8 years
Male > Female (Albrights - Female > Male)
McCune - Albrights Syndrome
Polyostotic disease (unilateral usually)
Skin pigmentation
◦ cafe au lait spots with serrated borders (called "coast of Maine") that tend to stop
abruptly at the midline of the body
Precocious puberty (endocrinopathy)
usually presents earlier, may be unilateral or widespread, affecting long
bones, hands, feet & pelvis
Malignant transformation (chondrosarcoma or osteosarcoma) is about 4 %;
38. Lucent lesion in medullary space
Sclerotic margin.
Ground glass appearance
No periosteal reaction
Shepherds crook - proximal femur
expansion of cortex
Pathology
Bone replaced by firm, whitish tissue of
gritty consistency
bone trabeculae separated by fibrous
tissue.
Bone is woven rather than lamellar
39. Pagets disease
FCD
Hyperparathyroidism
osteoblastoma
osteosarcoma
Treatment
Monostotic -> curettage and grafting if symptomatic
Polyostotic -> symptomatic treatment
May require osteotomy for deformity or lengthening / shortening procedures
Prognosis
Monostotic lesions cease activity at puberty but may be reactivated by
pregnancy
Polyostotic - 85% -> pathological fracture
malignant change occurs after radiotherapy