BONE TUMOUR

Tumours found in bone are classified according to the tissue

of origin. These include:
● Metastatic carcinomas – may show histological features of
their tissue of origin;
● Haematopoietic tumours – e.g. myeloma;lymphoma
● Osteogenic tumours – [Link]-Osteoid osteoma
Osteoblastoma
osteochondroma
Malignant-Osteosarcoma
• Chondrogenic tumour:benign-osteochondroma
enchondroma-occurs within
[Link] in hands and feet.
chondroblastoma
Malignant-chondrosarcoma
• Others-simple bone cyst
aneurysmal bone cyst
Giant cell tumour- arises from osteoclast- like giant cell
Eosinophilic granuloma-arises from langerhans cell
fibrous dysplasia
Ewing’s sarcoma
 classificaiton of bone tumour according
to site
Diaphysial Metaphyisal Epiphysial

eosinophilic granuloma bone cyst Chondroblastoma

osteoid osteoma Osteosarcoma Intraarticular osteoid osteoma

fiborus dysplasia Giant cell tumour

adamantinoma chondrosarcoma

Ewing’s sarcoma
common bone tumours according to age

epiphysial tumour age

Giant cell tumour between 20 to 45 years,after physis is
closed
chondroblastoma in children

chondrosarcoma adult
Meatphysial tumour age

bone cyst in children

osteosarcoma Occurs between the ages of10 to

[Link] are mostly affected.
Diaphysial tumour age

eosiniphilic granuloma <10 years of age

Ewing’s sarcoma teen age(10 to 20)

lymphoma adult

metastatic tumour/myeloma >60 yeras

Simple bone cyst
• Simple (unicameral) bone cyst is a membrane-lined cavity filled with
serous fluid within a bone. It usually occurs in the metaphysis of
proximal long bones of children. Associated thinning of the cortex of
the bone can lead to fracture. Such fractures usually heal with
conservative treatment, but the cyst may only partially resolve.
Bone exostosis
An exostosis is an extera growth of bone that extends outward from
the existing bone.

• Simple exostosis or osteoid osteoma–

small, painful;produce dense cortical reaction. Usually, pain occurs at
night and is typically relieved by non-steroidal anti-inflammatory
medication. Osteoid osteomas usually occur in children and
adolescents. They arise in any bone, particularlythe proximal femur.
Osteohcondroma
Is a benign cartilage-capped bony projection, thought to originate
from the physis. The bony projection always grows away from the joint
towards the diaphyseal region of the bone.
types: pedunculated (with a stalk)
sessile (without a stalk).
They are usually solitary, but some patients have multiple
ostechondromas (hereditary multiple exostoses, autosomal dominant
inheritance)
clinical features:
• local irritation and pain
• complications include mechanical symptoms, nerve impingement,
vascular pseudoaneurysm, fracture and infarction.
Increasing size or pain, particularly after skeletal maturity, is
concerning and may indicate malignant transformation. The
incidence of malignant transformation is less than 1% in solitary
osteochondromas and 1–3% in patients with multiple
osteochondromas
X-ray of the affected bone:

The stalk or base is always continuous with the

intramedullary cavity of the bone, and the continuity of the cortex of
the bone into an osteochondroma is a characteristic radiological
feature.
METASTATIC CARCINOMA OF BONE
Metastatic carcinoma of bone
Most tumours which metastasise to bone are carcinomas.
Not infrequently the primary tumour is never found despite
further investigation: these patients are described as having
“carcinoma of unknown primary” .

Carcinomas usually spread to bone by the haematogenous

route: the spine is the third most common site for metastases,
after the lung and liver.
Tumour cells metastasise to the spine via Batson’s venous
plexus. These retroperitoneal veins have no valves and allow
retrograde embolic spread to the spine and proximal long
bones
• Bone metastases can be lytic, sclerotic or mixed.
• Metastases are rare in children, but bone metastases can
occur from neuroblastoma,rhabdomyosarcoma and clear
cell carcinoma of the kidney.
Osteolytic bone lesion
• The most common cancers that metastasize to form
osteolytic lesions are thyroid, lung, kidney, gastrointestinal,
malignant melanoma and breast though any cancer can
cause bone lesions. Lesions are most often found in larger
bones, such as the skull, pelvis, radius, and femur.
• Giant cell tumour
Osteolytic bone lesion
Osteosclerotic bone lesion
• Infection
chronic osteomyelitis
• Neoplasm
primary
osteoma
osteosarcoma
metastatic
prostate
breast
carcinoid tumour
ostesclerotic bone lesion
SOFT TISSUE TUMOUR
Benign-lipoma is the most common
Neurofibroma
Malignant-liposarcoma
Synovial sarcoma
pleomorphic sarcoma
evaluation and investigation of a patient with a
suspected bone or soft tissue tumour
patients with primary bone and/or soft tissue tumours requires a high
index of suspicion,
History and examination
age
pain-mechanical
nonmechanical and/or night pain
Malignancy-history of malignancy with Back pain should be considered
as metastasis until porven otherwise.
other features of metastasis-cough,hemoptysis
local examination-site of the lesion
overlying skin
consistency
one side/whole cicumferrence
General examination
systemic examination
Investigation
Local
● plain radiographs of the whole affected bone or soft tissue lesion -
Plain radiographs are usually the most useful imaging in vestigations in
determining the diagnosis of a primary bone tumour, but further
appropriate scans are usually required for confirmation and staging.
Imaging should always include the whole of the affected bone to look
for satellite lesions and skip metastases. Satellite lesions occur within,
whilst skip lesions occur beyond, the reactive zone of the tumour.
● MRI of the whole affected bone or soft tissue mass;
● Computed tomography (CT) scan may be helpful in
addition to or instead of MRI scan.
• USG scan of lesion for soft tissue tumour
Codmans triangle
Codmans triangle is a radiological sign seen most commonly on
musculoskeletal plain [Link] is the name given to a periosteal reaction
that occurs when bone lesion grows so aggressively they lift the
periosteum of the bone and do not allow the periosteum to lay down
new bone.
Causes:Osreosarcoma
Ewings sarcoma
subperiosteal abscess
sun ray appearence
Onion skin sign/onion peel
appearence
moth eaten appearence
 Distant:
● blood tests; including full blood count, ESR, urea and
electrolytes, bone profile and protein electrophoresis;
● plain radiographs or CT scan of the chest (more sensitive);
● whole body isotope bone scan (for suspected primary
or metastatic bone tumours);
● ultrasound or CT scan of abdomen (if renal metastasis
is a possibility).
BIOPSY
Staging of benign tumour
Staging of primary bone tumours
In the Enneking system, benign tumours are staged as:
● latent (e.g. osteochondroma);
● active (e.g. osteoid osteoma);
● aggressive (e.g. giant cell tumour).
Staging of malignant tumour
A tumour is extracompartmental when it has breached the cortex of
the bone. Most primary malignant bone tumours are Enneking stage
2B at diagnosis, meaning they have extended outside the bone of
origin but metastases are not detectable.
Treatment of benign tumour
treatment of malignant lesion

treatment depends upon thefollowing factor:

staging
histological ytpe
general condition of the patient
treatment options are
• surgery followed by chemotherapy
• surgery followed by radiotherapy
• neoadjuvant chemotherapy followed by surgery
• neoadjuvant radiotherapy followed by surgery
• chemotherapy and radiotherapy
• Surgery mab be limb salvage or amputation.
treatment of malignant lesion
OSTEOSARCOMA
Most common malignant bone forming tumour in children speically in
teenage group.
Types:
sclerotic
chondroblastic
telangiecatic
age incidence :10 to 30 years age group(teens are mainly )
• Site of the lesion:(arms and legs)
Distal femur
Proximal tibia
proximal humerus
distal tibia
• Clinical features:
bone pain(non mechanical,night pain)
limited limb or joint movement
swelling around the knees or other common sites
unexplained fracture of bone
investigations
Local- x ray findings-
periosteal lifting with formation of codman’s triangle
Sun burst appearence
CT or MRI of the lesion
Distant:● blood tests; including full blood count, ESR, urea and
electrolytes, bone profile and protein electrophoresis;
● plain radiographs or CT scan of the chest (more sensitive);
● whole body isotope bone scan (for suspected primary
or metastatic bone tumours);
Treatment of osteosarcoma
• Treatmen tof osteosarcoma requires multidisciplinary approach
which may include chemotherapy and radiotherapy as well as
surgery.
• Osteosarcomas are treated with neoadjuvant chemotherapy
followed by surgery.
Ewing’s tumour
Ewing’s sarcoma is a malignant round cell sarcoma in which cells usually
have a characteristic11:22 [Link] most common malignant
tumour occuring in children.

Two types:
osseous(80%)

extraosseous(20%)
Site of the lesion:
Osseous (80%): diaphysis of a long bone or
pelvis.
ribs
Extraosseous(20%):Paravetebral and thoracic soft tissue
Non skeletal primary tumour have been documented in the
retroperitoneum,oesophgus,pancreas,ileum,kidney,bladder,vagina,uterus,p
enis,adrenal gland,lung,breast
Clinical features
● Painful mass
● fever
● anaemia

Site of metastasis:
● lung
● bone
prmary
tumour

metastatic
tumour
Investigations
local:
X-ray findings:
onion peel periostel reaction
Moth eaten sign
codmans triangle
CT or MRI of the lesion
Distant:
complte blood count with ESR-
Decreaes hemoglobin
raised ESR
plain radiograph or CT scan of Chest
whole body isotope bone scan
Biopsy:poorly diffrentiated tissue with small,round blue cell with prominent nulcei
and minimal cytoplasm.
Treatment of ewings sarcoma
● Treatmen tof Ewing’s sarcoma requires multidisciplinary approach which
may include chemotherapy and radiotherapy as well as surgery.

● Treatment for Ewing sarcoma usually begins with chemotherapy. The

drugs may shrink the tumor and make it easier to remove the cancer
with surgery or target with radiation therapy. After surgery or radiation
therapy, chemotherapy treatments might continue in order to kill any
cancer cells that might remain.
what is giant cell?
Giant cell is a large cell characterized by an arc of nuclei toward the outer
membrane. The cell is formed by the fusion of epithelioid cells, which are
derived from immune cells called [Link] are multi-nucleated
large in size, and most of the times present at the site of chronic
inflammation and other granulomatous conditions.
Types of giant cell:
● Foreign body giant cell
● Langhans Giant cell
● Tuoton Giant cell
● Giant cell arteritis
● Reed-Stenberg cell
Giant cell tumour(GCT)
Giant cell tumour of are locally aggressive and rarely malignant or
metastasizing neoplasm mostly occuring in the bone(GCTB) and typically
found at the end of the long bones which is the region around the closed
growth plate extending into the epyhysis and into the joint [Link] few
percentage may arise from tendon or synovial membrane(GCTTS)

Synonym:Osteoclastoma
Epidemiology:

Only 4-10% of all primary bone tumour and 20%of all benign bon e
tumour is Giant cell tumour.

Age incidence:20-45 years age group,

A slight prediliction for female is noted.

Malignant transformation:Occurrs in <5% cases,with male

[Link] are rare.
Types
According to radiograpihc findings(CAMPANACCI et al. grading system):
● Latent
● Active
● Aggresive
Site of the lesion:

● around the knee joints-50%-65%(Distal femur and proximal tibia)

● Distal radius-10-12%
● Proximal humerus4-8%
● sacrum
● Very few may arise from tendon sheath or synovial surface(GCTTS)
Clinical features:
● Often diagnosed as an incidental case.
● Pain and swelling around joints
● Limited joint movement
● unexplined fracture
Investigations:
Local:Plain radiograph off the affected bone shows:
● Well circumscribed cyst like osteolytic lesion(single).
● soap bubble appearence(formed by multiple expanding cystic osteolytic
lesion,sorounded by a thin shell of [Link] found at the end of the
long bone.

CT or MRI of the lesion.

CBC with ESR:
May show raised ESR.

Plain radiograph or CT Scan of the chest:

To exclude distant metastasis
Biopsy folloed by histopathology.
● Multiple non neoplastic osteosclastic giant cell,with neoplstic
mononuclear cell.
Treatment
● curettage(grade 1 nd 2)
● wide resection followed by reconstruction(grade3)
● usually limb salvage operation is performed.
● recurrence after surgery is very commoon.
● new treatment options-thermocoagulation,chemical adjuvant
therapy,radiation therapy,etc.
CHONDROSARCOMA
● Chondrosarcoma is a malignant tumour with cartilage differentiation.
The biological behaviour ranges from very low-grade lesions to highly
aggressive dedifferentiated tumours.

● Patients usually present (after 50 years of age) with pain and/or swelling
and symptoms may be longstanding.
● Many chondrosarcomas arise in pre-existing lesions such as
osteochondromas or enchondromas.
● Diagnosis of a chondrosarcoma requires clinical, radiological and
pathological correlation. Clear cell chondrosarcoma is a rare form of
chondrosarcoma that occurs in the epiphysis .