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This is a power point presentation about Tumors in my orthopedic rotation.
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TumorsKhalid Al Hamadani
OUTLINE Introduction Classification of Bone tumors Clinical Presentation Staging of Bone tumors Primary Bone tumors Case Presentation
Introduction A bone tumor is an abnormal growth of
cells within a bone. The cause of bone tumors is unknown. They often occur in areas of rapid bone
growth. Possible causes include:1.Genetic defects passed down through families2.Radiation3.InjuryMedline plus: Service of U.S national Library of Medicine http://www.nlm.nih.gov/medlineplus/ency/article/001230.htm
Introduction Cancers that start in the bones are
referred to as primary bone tumors. Cancers that start in another part of the
body (such as the breast, lungs, or colon) are called secondary or metastatic bone tumors.
Medline plus: Service of U.S national Library of Medicine http://www.nlm.nih.gov/medlineplus/ency/article/001230.htm
Classification of Bone tumors
Most classifications of bone tumors are based on the dominant tissue in the various lesions.
Classification of Bone tumors
Clinical presentation History Examination Imaging Biopsy Important differential diagnosis
History History is often prolonged, results in delay
of treatment. Patients most of the time will be completely
asymptomatic until the abnormality is discovered on X-ray.
This is more of benign lesions, common in children and rare after 30
Malignant tumors can be silent if they are slow growing and there is room for expansion like cavity of the pelvis.
History AGE: Useful clue. Many benign tumors present during
childhood and adolescence Chondrosarcoma and fibrosarcoma typically
occur in 4th and 6th decades adults. Myeloma rarely seen before 6th decade. Patients over 70 years metastatic bone
lesions are more common than primary tumors.
History PAIN: common complaint and gives little
indication of the nature of lesion. Progressive and unremitting pain is a
very important symptom though. It may be caused by:1. Rapid expansion2. Central hemorrhage or degeneration of
the tumor3. Pathological fracture.
History Swelling: Appearance of a lump, may
be alarming. Neurological symptoms: Parasthesia
and numbness may be caused by pressure or stretching of a peripheral nerve.
Progressive dysfunction is alarming and suggests invasion by an aggressive tumor.
History Pathological fracture: may be the
first and only clinical sign. In elderly people whose bones usually
fracture at the cortico-cancellous junctions, if they get mid shaft fracture it is regarded as pathological until proven otherwise.
Examination If there is a lump: Where does it arise? Is it well defined or not? Soft, hard or pulsatile? Tender? Swelling can be diffuse and the
overlying skin warm and inflamed which makes it hard to distinguish from infection and hematoma.
Examination If it is near a joint: is there any
movement limitation? Spinal lesions cause muscle spasm,
back stiffness or painful scoliosis. Examination will focus on symptomatic
part but it should include lymph nodes, pelvis, abdomen, chest and spine.
Imaging X-ray: Most useful of all imaging
techniques. There might be obvious abnormality of
the bone:1. Cotrical thickening2. Discrete lump3. Cyst4. Ill-defined destruction
Imaging Is it in the metaphysis or diaphysis? Is it solitary or multiple lesions? Margins are well or ill defined? Note: cystic lesions are not necessarily
hollow cavities: any radiolucent material may look like a cyst (e.g fibroma and chondroma)
Imaging If the boundaries of the cyst is well
defined is mostly benign. If it is hazy and diffuse it is mostly
invasive tumor. Bone surfaces: periosteal new bone
formation and extension of the tumor to the soft tissues are suggestive of a malignant tumor.
Imaging Soft tissues: are the muscle planes
distorted by the swelling? Is there any calcification?
X-ray is not a definitive diagnosis and further investigation must be done to confirm.
X-RAY
Imaging Other techniques of imaging used are
Radinuclide scanning, CT and MRI. They all help in viewing the lesions
better, view soft tissue and detect skip lesions too.
Patient must not go for biopsy if MRI or CT is planned for him as it will distort the image and appearances.
Biopsy There are three ways:1.Needle biopsy: Must be performed by experienced personal.2. Open biopsy: most reliable way of obtaining a representative sample.3. Excisional biopsy: for benign tumors.
Deferential Diagnosis
Deferential Diagnosis
Deferential Diagnosis
Deferential Diagnosis
Staging of bone tumors Staging is the process of finding out how
far the cancer may have spread. This is very important because the type
of treatment and the outlook for recovery (prognosis) depend on the stage of the cancer.
Staging of bone tumors In treating tumors we are facing two
conflicting principles:1. Lesion must be removed widely to
ensure it doesn’t recur.2. Damage must be kept minimal.
Staging of bone tumors The balance between the 2 conflicting
objectives depends on knowing:1. How the tumor behaves
(Aggressiveness)2. How far it has spread.
The answers to these two questions are embodied in the staging system of Enneking.
Tumor
Benign
Latent
Active
Aggressive
Malignant
Low Grade
High Grade
Aggressiveness
Enneking Staging system of bone tumorsBenign Tumors
Latent Well defined margin. Grows slowly and then stops.Remains static/heals spontaneously E.g Osteoid osteoma
Active Progressive growth limited by natural barriers.Not self limiting. Tendency to recur E.g Aneurysmal Bone cyst
Aggressive Growth not limited by natural Barriers E.g Gaint cell tumor
Enneking Staging system of bone tumors
Malignant Tumors
Low Grade Moderatly aggressive and takes a long time to metastasize
High Grade Very aggressive and metastasize early
Spread Assuming that there is no metastases,
the local extent of the tumor is the most important factor in deciding how much tissue to be removed.
Spread
Intracompartmental
Extracompartmental
Spread Lesions that are confined to an enclosed
space (e.g Bone cavity, joint cavity or muscle group within its fascial envelope) are called Intracompartmental.
Lesions that extend into interfascial or extrafascial with no natural barrier to proximal or distal spread are called Extracompartmental. (E.g pelvis, axilla)
Surgical stage Staging the tumor is an important step
towards selecting the best operation suited to the patient.
Bone sarcomas are divided as follows:1. Stage 1: All low grade sarcomas2. Stage 2: Histologically high grade
lesions3. Stage 3: Sarcomas which have
metastasized.
Surgical stages described by EnnekingStage Grade Site Metastases
IA Low Intracompartmental
No
IB Low Extracompartmental
No
IIA High Intracompartmental
No
IIB High Extracompartmental
No
IIIA Low Intra/extracompartmental
Yes
IIIA High Intra/extracompartmental
Yes
Management
Primary bone tumors
Divided into Benign and Malignant.
They are rare to occur and secondary bone tumors are more common.
Primary Bone tumors Benign Tumors: Osteoid Osteoma Giant cell Tumor Enchondroma
Primary Bone tumors Malignant tumors: Multiple myeloma Osteosarcoma Ewing’s sarcoma Chondrosarcoma
Osteoid Osteoma peak incidence in 2nd and 3rd decades,
M:F = 3:1 small, round radiolucent nidus (<1 cm)
surrounded by dense bone tibia and femur most common
produces severe intermittent pain, mostly at night
characteristically relieved by NSAIDs
Osteoid Osteoma
Osteochondroma 2nd and 3rd decades, M:F = 1.8:1 metaphysis of long bone
cartilage-capped bony spur on surface of bone may be multiple
higher risk of malignant change
generally asymptomatic unless impinging on neurovascular structure
malignant degeneration occurs in 1-2%
Enchondroma 2nd and 3rd decades 50% occur in the small tubular bones of the
hand and foot; others in femur, humerus, ribs benign cartilagenous growth, develops in
medullary cavity single/multiple enlarged rarefied areas in
tubular bones lytic lesion with sharp margination and central
calcification malignant degeneration occurs in 1-2%
Enchondroma
Cystic lesions includes unicameral/solitary bone cyst (most
common), fibrous cortical defect children and young adults local pain, pathological fracture or incidental
detection lytic translucent area on metaphyseal side of
growth plate cortex thinned/expanded; well defined lesion
treatment of unicameral bone cyst with steroid injections ± bone graft
Cystic lesions Treatment treatment only necessary if
symptomatic osteochondroma: resection cystic lesions: currettage and bone graft
Cystic lesions
Giant cell Tumor affects patients of skeletal maturity, peak 3rd decade distal femur, proximal tibia, distal radius, sacrum, tarsal
bones, spinal (osteoblastoma) cortex appears thinned, expanded; well-demarcated
sclerotic margin local tenderness and swelling aggressively destroy bone 15% recur within 2 years of surgery giant cell tumour occasionally metastasizes (1-2%) Treatment intralesional curettage + bone graft or cement wide local excision of expendable bones
Giant cell tumor
Osteosarcoma mostly frequently diagnosed in 2nd decade of life (60%) Mostly affects distal femur (45%), proximal tibia (20%)
and proximal humerus (15%) invasive, variable histology; frequent metastases without
treatment painful, poorly defined swelling x-ray shows
characteristic periosteal elevation and spicule formation representing tumour extension into periosteum
treatment: complete resection (limb salvage, rarely amputation), chemotherapy
survival “ 70%
Osteosarcoma
Chondrosarcoma primary
previous normal bone, patient over 40; expands into cortex to give pain, pathological fracture, flecks of calcification
secondary malignant degeneration of pre-existing cartilage
tumour such as enchondroma or osteochondroma most commonly occurs in pelvis, femur, ribs,
scapula, humerus unresponsive to chemotherapy, treat with
aggressive surgical resection + reconstruction
Chondrosarcoma
Ewing’s sarcoma most occur between 5-20 years old florid periosteal reaction in diaphysis of long
bone moth-eaten appearance with periosteal
lamellated pattern (onion-skinning) present with mild fever, anemia, leukocytosis
and increased ESR metastases frequent without treatment treatment “ resection, chemotherapy, radiation survival “ 70%
Multiple myeloma most common primary malignant tumour of bone in
adults 90% occur in people >40 years old present with anemia, anorexia, renal failure,
nephritis, increased ESR, bone pain, compression fractures, hypercalcemia
diagnosis punched-out lytic lesions on x-ray at multiple bony
sites serum/urine protein electrophoresis
treatment: chemotherapy, radiation, surgery for symptomatic lesions or impending fractures
References Medline plus: Service of U.S national Library of
Medicine http://www.nlm.nih.gov/medlineplus/ency/article/001230.htm
Apley’s system of orthopedics and fractures (Ninth Edition)
Apley’s Concise system of orthopedics and fractures (Third Edition)
American Cancer society http://www.cancer.org/Cancer/BoneCancer/OverviewGuide/bone-cancer-overview-staging
First Aid for the USMLE Step 1 2011 Toronto notes 2009
THANK YOU