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Aggressive & malignant bone tumours an overview
- 1. NTRU PG CME- Gandhi Med.Col. Secunderabad 27-5- 2012 Aggressive & Malignant Bone Tumours An Overview Prof. A. Srinivasa Rao M.S.(Ortho); Fellow Ortho. Path.(USA) EMERITUS PROFESSOR Gandhi Medical College, Secunderabad Consultant, KIMS, Secunderabad Honorary Fellow, IOA
- 2. Bone Tumours Aggressive Malignant Giant Cell Tumour Osteosarcoma Aggressive Chondrosarcoma Chondromyxoid Ewing’s sarcoma Fibroma Multiple Myeloma Aggressive Osteoblastoma
- 3. Clinical Age
- 4. Age Osteosarcoma Immature Skeleton Ewing’s sarcoma Chondromyxoid Osteosarcoma fibroma Bimodal Incidence Osteoblastoma Adolescents & > 65 yrs Mature Skeleton Giant cell tumour Chondrosarcoma Multiple Myeloma
- 5. Age Ewing’s Sarcoma NEUROBLASTO LYMPHOMA MA
- 6. Age Giant Cell Tumour If a diagnosis of GCT is to be made in an immature skeleton – think several times Lichtenstein
- 8. Symptoms Localised Swelling Generalised body aches GCT Multiple Myeloma Osteosarcoma - Symtoms ignored for quite sometime Chondrosarcoma - Can be mistaken for Ewing’s sarcoma many other conditions with generalised body aches Osteoporosis/Osteomal acia, FMS etc.
- 9. Swelling May not be obvious Especially if the tumour is deep REST PAIN
- 10. Wasting of Muscles Disproportionate to Duration of disease Tuberculosis Malignancy Rheumatoid Disease
- 11. Radiology Utility of Plain Radiograph Dimension – View in–Third of CT MRI Extent In Diagnosis Lesion Intra/Extra Compartmental STAGING Isotope Scan – Lesions elewhere
- 12. IMAGING PLAIN Enneking`s four questions RADIOGRAPHY 1. Where is the lesion? 2. What is the lesion doing to bone? Transition zone 3. How is the tissue responding to lesion? Reactive zone 4. Does anything suggest histology? Calcification, Ossification, Ground glass appearance Etc.
- 13. ALTRMCPS Age of Skeleton – - Mature or Immature Location Transitional zone Reactive zone Matrix Cortex Periosteal reaction Soft tissue swelling
- 14. Location ALTRMCPS Which Bone? Which Part of the Bone? - Epiphysis - Metaphysis - Diaphysis Eccentric or Concentric?
- 15. Zones of Transition A LT R M C P S Narrow - Sharp Sclerotic BENIGN - Sharp Lytic Wide - Ill-defined or hazy AGGRESSIVE / - Moth eaten MALIGNANT - permeative
- 16. Zone of Transition ALTRMCPS Narrow Non-ossifying Fibroma Sharp Sclerotic
- 17. Zone of Transition Narrow Giant Cell Tumour Sharp Lytic
- 18. Zone of Transition Wide Aggressive GCT Ill-defined or hazy
- 19. Zone of Transition Wide NH L Met Ca. Breast Moth eaten
- 20. Zone of Transition Wide Permeative Malignant Tumour
- 21. ALTR MC Zone of Reaction PS Localised Sclerotic Wide Sclerotic Brodie’s Abscess Ost.Osteoma
- 22. Matrix ALTRMC PS Calcification - Ground Glass – Fib.Dys. Chondrosarc
- 23. Matrix “Cloud” like Ossific densities in Bone = Osteosarcoma
- 24. Cortex ALTRM CPS Intact or Broken Wide Zone of Transition and Broken Cortex could be signs of Aggressiveness / Malignancy
- 25. Periosteal Reaction ALTR MC P S
- 26. Periosteal Reaction Sun Burst appearance Codman’s Triangle
- 27. ALTR MC PS Soft Tissue Enormous soft tissue seen in Ewing’s Sarcoma
- 28. Radiographic differences between Benign& Malignant Tumours IGNANTR BENIGN MALIGNANT
- 29. Early Diagnosis MANDATORY TO INCREASE SURVIVAL RATE
- 30. OS – Early diagnosis Suspect OS : * Minor injury – disproportionate duration of pain or increasing pain * Pain associated with sclerosis or erosions in the metaphysis without fever
- 31. AYESHA 14 yrs Pain without injury 2 weeks 3 wks Later 2 mths Later
- 32. Mankin – Biological behavior Criteria Score ____________________0_________1____ Size Small Big Margination Present Absent Cortex Intact Destroyed Soft tissue mass Absent Present _________________________________ Score 0-1 Benign 2 Aggressive 3-4 Malignant
- 33. Diagnosis of Bone Tumours IMAGING Problem - Not seen on plain Radiographs s - Mistaken Diagnosis - MRI - Edema mistaken for tumour
- 34. Problem – Imaging 1 Not seen on plain Radiograph
- 35. Problem – Imaging 2 Mistaken Diagnosis Stress fracture Osteoid Osteoma ABC Tel. OS
- 36. Problem – Imaging 3 MRI Edema mistaken For Tumour Histology NO Tumour In this area
- 37. Histopathology
- 38. Diagnosis of Bone Tumours BIOPSY Problem - FNAC vs WBNAB s - Sampling Error
- 39. Problem – Biopsy 1 FNAC vs Cytology – cells WBNAB Biopsy – Tissue Group of cells – identified by matrix produced by cells
- 40. Problem – Biopsy 2 Sampling Error A A B B
- 41. Diagnosis of Bone Tumours HISTOLOGY Problem - Heterogenous nature of s Osteosarcoma - Round cell Tumours - Giant cell variants - Reactive conditions mistaken for tumours - Benign vs Malignant - Path. Fr. Mistaken for Tumour - Primary or Mets - Tumour vs Infection
- 42. Problems Histology - 1 Osteosarco ma Heterogeneity Osteoblastic Chondroblastic Fibroblastic GC rich Telangiectatic Small cell OS Fibrous Histiocytoma- like
- 43. Problem – Histology 2 Ewing’s sarcoma Round Cell Tumours of Bone Ewing’s sarcoma Primary Lymphoma of bone Metastatic Neuroblastoma Embryonal Rhabdomyosarcoma Small cell Osteosarcoma Mesenchymal cell Chondrosarcoma Metastatic small cell
- 44. Problems – Histology 3 GCT Giant Cell Variants • Chondroblastoma • Chondromyxoid Fibroma • Simple Bone Cyst • ABC • Brown Tumour of Hyperparathyroid • Nonossifying Fibroma • Ossifying Fibroma
- 45. Problem – Histology 4 Reactive Conditions mistaken for Tumour - Exuberant callu s - Organising hematoma - Myositis ossificans
- 46. Problem – Histology 4 Reactive CALLUS Conditions mistaken for Tumour - Exuberant callu s - Organising hematoma OS - Myositis
- 47. Problem – Histology 4 Reactive Conditions mistaken for Tumours - Exuberant callus - Organising hematoma - Myositis ossificans
- 48. Problem – Histology 5 Benign vs Malignant Secondary Chondrosarcoma arising from osteochondromatosis - Histology may be misleading – appears benign Aggressive Chondromyxoid Fibroma can be mistaken for low grade Chondrosarcoma Aggressive Osteoblastoma borderlines on Osteosarcoma Clinical picture & Radiology help to a great extent to differentiate
- 49. Problem – Histology 6 Pathological fr. Mistaken for Tumour Needle Biopsy - Chondrosarco - Open Biopsy maTuberculosis
- 50. Problem – Histology 7 Primary vs Met. Neuroblastoma or Metastases carcinoma vs Ewing’s – immunohistochemistry
- 51. Problem – Histology 8 Tumour vs Infection Radiology – Ewing’s Sarcoma Histology – Plasmacytes - Plasmacytoma with path # Clinical – Osteomyelitis Plasmacytic Osteomyelitis
- 52. Problem – Histology 8 Tumour vs Infection OSTEOMYELITI S Low Grade INTRA MEDULLARY OSTEOSARCOM A
- 53. Problem – Histology 8 Tumour vs Infection * Ewing’s Sarcoma & Osteomyelitis are confused with each other Clinically, Radiologically and even Histologically * “Culture a tumour & Biopsy an Infection”
- 54. “The gross anatomy as revealed in radiographs is often a safer guide to correct clinical conception than variable and uncertain nature of a small piece of 1922 EWING tissue” Importance of Correlation of Histology & Radiology
- 55. Diagnosis of Bone Tumours Final Diagnosis CLINICAL IMAGEOLOGY PATHOLOGY (Radiology)
- 56. Prof. Dr. Walter Putscher Orthopedic Pathologist, Boston, USA “No Pathologist shall ever sign out a report without seeing the Radiograph
- 57. Prof. Peter G Bullough Professor of Orthopedic Pathology Hospital for Special Surgery, Cornell University, NEW YORK “If I were you, I will run to the Radiology department and get the x-ray films and make them available before the Histology slides are studied”
- 58. DICTUM The Pathologist should receive the Clinical & Radiological findings while dealing with the diagnosis of Bone Tumours
- 59. Thank You Thank You Thank You Thank You For Your Thank You Thank You Patient Hearing Thank You Thank You Thank You Thank You Thank You Thank You Thank You Thank You
Notas del editor
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