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BONE TUMORS

Assoc. Prof. Melih Güven Yeditepe University Hospital Department of Orthopaedics and Traumatology. BONE TUMORS. Learning Objectives. Classification of benign bone tumors Charasteristic clinical and radiological features of most common benign bone tumors Definition of tumor like lesions

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BONE TUMORS

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  1. Assoc. Prof. Melih Güven Yeditepe University Hospital Department of Orthopaedics and Traumatology BONE TUMORS

  2. Learning Objectives • Classification of benign bone tumors • Charasteristic clinical and radiological features of most common benign bone tumors • Definition of tumor like lesions • Classification of malign bone tumors • Charasteristic clinical and radiological features of most common malign bone tumors • Charasteristic features of metastatic bone tumors • Surgical applications in benign and malign bone tumors

  3. Bone tumors • General knowledge • Benign tumors • Tumor like lesions • Malign tumors • Metastatic bone tumors

  4. General approaches • Initial referral • Pain • Deeply, sharp and increased over time • Localized sensitivity and rush • Pathologic fracture • Deformity • Incidental finding

  5. General approaches • First stage evaluation • Anamnesis • Duration and level of pain, number and duration of the lesions, age, loss in weight, fever, weakness • Physical examination • Site and size of the lesion, mobility, sensitivity,LAP • Radiological evaluation • Codman triangle, onion skin view, sunrise view • Laboratory findings • ALP, serum Ca level, ESR, LDH, protein electrophoresis

  6. General approaches • Second stage evaluation • CT • Bone scintigraphy – Tc 99m • Anjiography • MRI • PET – CT

  7. General approaches • Radiological evaluation • Definition of the radiographs • Where is the tumor? • Name of the bone, proximal-distal, metaphysis-diaphysis • What is the localisation of the tumor? • Central, medullary, cortical • How does the tumor effect the bone? • Lysis, sclerosis, destruction, deformity • Any surrounding abnormalities?

  8. General approaches • Second stage evaluation • Biopsy • Closed • Fine needle aspiration biopsy • Trochar biopsy • Needle biopsy under CT control • Open • Incisional biopsy • Excisional biopsy • Frozen section biopsy (intraoperative)

  9. Staging • Staging of benign bone tumors (Enneking) • Stage I: Latent • thick capsule, no reactive zone • can grow up in children and adolescents, no growing in adults, spontaneous healing can occur • Stage II: Active • thick capsule, adhesions between capsule and surrounding soft tissue, thick reactive zone • no spontaneous healing, rarely metastasis

  10. Grading • Staging of benign bone tumors (Enneking) • Stage III: Agressive • irregular border of the lesion, very thin capsule • thick and edematous reactive zone • Tumor grows up rapidly into the surrounding tissues, no restrictive tissues around the tumor

  11. Staging • Staging of malignant bone tumors (Enneking) • G (Grade) : G1 %10 > metastasis potency , G2 %20 < metastasis potency • T (Compartment) : intracompartmental (T1) or extracompartmental (T2) • M (Metastasis): Lymph nodule or far metastasis IA G1 T1 M0 IB G1 T2 M0 IIA G2 T1 M0 IIB G2 T2 M0 IIIA G1-G2 T1 M1 IIIB G1-G2 T2 M1

  12. General classification • Tumors with osseous origin a-Benign:  Osteoma, Osteoid osteoma, Osteoblastoma b-Malignant:   Osteosarcoma • Tumors with cartilaginous origins a- Benign : Chondroma, Osteochondroma, Chondroblastoma, Chondromixoid fibroma b- Malignant :  Chondrosarcoma

  13. General classification • Tumors with bone marrow origins Ewing sarcoma Reticulum cell carcinoma of the bone Lymphosarcoma of the bone Multiple or solitary myeloma • Gaint cell tumors Gaint cell bone tumors (osteoclastoma)

  14. General classification • Tumor like lesions (Fibrous, cystic) Solitary bone cyst (unicameral bone cyst) Aneurysmal bone cyst Non-ossifying fibroma (fibrous cortical defect) Eosinophilic granuloma Fibrous dysplasia Myositisossificans Brown tumor (hyperparathyreoidismus)

  15. Treatment • First of all, LIFE !! • Extremity preserving surgery • Usable extremity • Physical appearance of the body • Psychological compliance • Sociocultural compliance

  16. Surgical treatment 1.Intracapsular: - Benign, latent lesions 2.Marginal excision: - Excision of the lesion with reactive zone - Benign, active lesions

  17. Surgical treatment 3.Wide resection: - Resection of the tumor with surrounding healthy-normal tissues - Benign, aggressive lesions; malignant low grade lesions (with adjuvant therapies) 4.Radical resection: - Resection of the whole, entire compartment - Malignant high grade lesions 5. Amputation

  18. Adjuvanttherapies • Chemotherapy • Neoadjuvant (8-12 weeks) • Adjuvant (6-12 months) • Drugs: • metotrexate, cyclophosphamid, ifosfamide, doxorubicin, vincristine ve cis-platine • Radiotherapy • Local adjuvants: • Phenol, hydrogene peroxide, liquid nitrogen, bone cement, alcohol, coterisation, hot water (80°C)

  19. BENIGN BONE TUMORS

  20. Osteochondroma (Exostosis)

  21. Enchondroma

  22. Enchondroma • Ollier disease • Maffuci synd.

  23. Osteoid osteoma

  24. Osteoblastoma

  25. Gaint cell bone tumor (Osteoclastoma)

  26. Chondroblastoma

  27. Benign bone tumors • Osteochondroma • Multiple familial osteochondromatosis • Enchondroma • Osteoid osteoma • Osteoblastoma • Gaint cell bone tumor • Chondroblastoma

  28. TUMOR LIKE LESIONS

  29. Simple (solitary) bone cyst

  30. Aneurysmal bone cyst

  31. Eosinophilic granuloma

  32. Non-ossifying fibroma(Fibrous cortical defect)

  33. Fibrous dysplasia mlgn 5 years later

  34. Tumor like lesions • Simple (solitary) bone cyst • Aneurysmal bone cyst • Eosinophillic granuloma • Fibrous cortical defect • Fibrous dysplasia

  35. MALIGNANT BONE TUMORS

  36. Osteosarcoma Birkaç ay sonra

  37. Osteosarcoma • Classification: • Clasicosteosarcoma • Parostealosteosarcoma • Periostealosteosarcoma • Endostealosteosarcoma • Telengiectaticosteosarcoma • Small cell osteosarcoma • Intracorticalosteosarcoma • Secondary osteosarcoma • Paget, Rt, low grade Chondrosarcoma, fibrous dysplasia,bone infarct

  38. Chondrosarcoma

  39. Chondrosarcoma • Classification: • Primary • Low grade, borderline, high grade • Secondary • Multiple familial osteochondromatosis, Ollier disease, Mafucci syndrom

  40. Ewing’s sarcoma

  41. Multiple myeloma

  42. Chordoma

  43. Malignant bone tumors • Osteosarcoma • Chondrosarcoma • Ewing’s sarcoma • Multiple myeloma • Chordoma

  44. METASTATIC BONE TUMORS

  45. Metastatic bone tumors • Pain (most common), ROM limitation, pathologic fracture, cord compression, hypercalcemia • Most common; breast in females, prostate and lung in males • Breastcancer %73 • Ductal carcinoma • Prostate cancer%68 • Adeno ca • Thyroid cancer %42 • Papiller ca • Lung cancer %36 • Adeno ca • Renal carcinoma%35 • Clear cell ca • Rectum carcinoma%11

  46. Metastatic bone tumors • Metastasis; • Direct • Indirect • Lymphogenic • Hematogenic • Localisation of metastasis; - vertebra% 69 - pelvis %41 - femur % 25 - cranium %14 • Osteoblastic or osteolytic Batson vertebral venous plexus

  47. Breast metas. Renal met. Prostat met. Prostate met. ob ol Lung met.

  48. Metastatic bone tumors • Diagnosis; • Bone scintigraphy – Tc 99m • Radiography • CT • MRI • PET-CT • Biopsy Standard

  49. THANKS

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