BONE TUMORS

The term Tumour is usually applied to an abnormal growth of tissue which may be benign or malignant.
The musculoskeletal system may develop tumours , either as a primary from this system itself or as a secondary from
a distant primary location.
Secondary bone tumours ( Metastatic deposits) are commoner than primary bone tumours.
Primary bone tumours may be begin or malignant.
Osteochondroma is the commonest benign tumour of the bone , where as Multiple Myeloma is highly malignant
tumour affecting adults above 40 years of age.

Benign tumor Malignant tumor

-Slow growing -Rapidly growing

-Well circumscribed -Not well circumscribed
-Non- invading - Invading
-Do not matastasise -Metastasises
-No or very few -Associated with pain and
symptoms disability
-X-rays- lesions confined to - X-rays- ill defined borders,
the bone mottled appearance,
breakage of the cortex.
-Do not cause death of the -May cause death of the
patients patients

Classification
Various classifications have been proposed for bone tumours like Dahlins classification, Mercers
classification , Tureks classification etc.
These classifications are mainly based on the recognisation of the dominant tissue in the various lesions.

A classification of the bone tumours

General principles of tumours
A proper understanding of the general principles of
tumours is essential to make correct diagnosis, and to
choose the correct line of treatment to minimize the
recurrence rate and to improve the survival rate.
There are certain parameters of general principles of
tumours.
History
Clinical Examination
Investigations
A:- History
Most of the time the history is prolonged , resulting in
delay in obtaining proper treatment.
1.Age
Many benign tumours and some malignant tumours
like- Ewings sarcoma and Osteosarcoma are present
in childhood and adolescence.
Chondrosarcoma and Fibrosarcoma do occur in 4th to
6th decades.
Matastasis is more common in elderly patients over
70 years of age than the primary tumours.
2. Pain- is a common complaint and may be caused by
rapid expansion of the tumour with the stretching of
surrounding tissue , central haemorrhage,
degeneration in the tumour, or a pathological
fracture.
3.Onset- it is acute in malignant tumours and
insidious in benign tumours.
4. Anorexia, weight loss , fever- more pronounced in
malignant tumours.
B. Clinical Examination
.General examination:- for evidence of anaemia,
cachexia, lymphadenopathy etc.
.Local examination- to know the plane , extend ,
presence of pathological fractures etc.
.Joint examination- to know the involvement of the
joint or any mechanical effects.
.Neurological examination- assess any damage to the
peripheral nerves due to the spread of the tumour.
Assessment- of the status of arterial and or venous
circulation.
C. Investigations
# Routine laboratory investigations-
Hb%, total WBC count and DD count ,
ESR
Serum calcium and phosphorous
Serum alkaline phosphatase in osteosarcoma.
Serum acid phosphatase in matastatic tumours.
# Special investigations
1. X-rays- Plain x-rays are still the most useful imaging
technique.
Look carefully for any abnormality in the bone like-
cyst, cortical thickening , any ill defined destruction
etc.
Also note that :-
Is lesion solitary or multiple?
Where is the lesion in the bone?
What type of bone is involved?
Is there any cortical destruction , any bony reaction
etc?.
2. X-rays chest- for evidence of secondaries.
3. CT scan-
-It show more accurately the intra- osseous and extra-
osseous extension of the tumour.
-It may reveal lesions in inaccessible sites like the
pelvis and the spine.
-It is reliable method of detecting pulmonary
metastases even the size of 2 mm ( as X-rays do so
at 2 cm size) could be picked up.
4. Radionuclide scanning with 99 Tc HDP(
Technetium labelled hydroxymethyline
diphosphonate) - helps to detect the extend of spread
of bone tumour to other areas of skeletal system and
also to detect occult bone metastasis.
5. MRI- provides further information the spread of the
tumour:-
Within the bone
Into a near by joint
Into the soft tissues
6. Arteriography- to determine the spread of the
tumour to the vessel.
7. Ultrasonography- helpful in some situations , but
has a limited role.
8. Biopsy- This is the ultimate diagnostic technique in
diagnosing bone tumours.
Close:- needle and aspiration
Open:- incision and excision
It is to be noted that all the above
investigations help to stage the bone
tumour. Staging helps in detecting the type
of surgical procedures needed for local
control of the tumour.
Ennekings Staging - 1980
It is based histological grading, anatomical site and
presence or absence of distant metastasis. The
surgical staging system classified the bone sarcomas
into three stages:-
I. Low- grade tumours
II. High- grade tumours
III. Low or high with presence of metastases.
Each group may be subdivided into:-
A- Intracompartmental lesions
B- Extra compartmental lesions
1.Benign, asymptomatic lesions- ( e.g.- a small
osteochondroma) no treatment is required.
2. Benign, symptomatic tumours- painful tumour
continuing to enlarge requires biopsy and diagnosis.
They are generally treated by local (marginal )
excision or by curettage ( as in benign cyst).
3. Suspected malignant tumours- A patient with a
primary malignant tumour is admitted for more
detailed examination, blood tests, chest x-rays , CT
scanning or MRI for the confirmation of the diagnosis
and staging.

Finally the treatment options fall between

Stage Grade Site Metastasis amputation, limb sparing operations with different
kinds of adjuvant therapy with the patients fully
IA Low Intra.Comt. None informed about the outcomes of the results.
IB Low Extra Comt. None
II A High Intra. Comt. None Methods of treatment
II B High Extra.Comt. None 1 . Tumour excision- More aggressive the lesion ,
III A Low or high Intra. Comt. more widely it needs to be excised.
III B Low or high Extra.Comt. Present or high.
# Intracapsular excision and curettage

# Marginal excision

Differential diagnosis # Wide excision

Clinically or radiologically many conditions mimic a
tumour and it is important not to misled by the
common dissemblers.
1 . Haematoma- proper history, rapid onset of the
symptoms.
2. Myositis ossificans- tender swelling following an
injury. Newly formed bone more defined , less painful
and well demarked unlike a malignant tumour.
3. Stress Fractures- Occurs in normal bone of a
healthy patient and is caused not by a specific
traumatic incident but by repetitive stresses.
4. Tendon avulsion injuries- Children and adolescents
engaged in vigorous sports are prone to avulsion
injuries.
5. Infection- Usually children or young adults are
affected.
6. Gout- Usually a large gouty tophus causes a painful
swelling at one of the bone ends .
7. Other bone lesions- Fibrous cortical defects,
medullary infracts mimic for tumours.
Principles of management
A consultation and co-operation between the
Orthopaedic Surgeons, Radiologists, Pathologists ,
Oncologists, Prosthetic Designer is required in proper
managing a bone tumour.
# Radical excision
2. Multi-agent Chemotherapy-
!. Now is preferred adjuvant treatment for malignant
bone and soft tissue tumours.
!!. The modern chemotherapy regimes reduce the size
of the lesion, prevent metastatic seeding and improve
the chances of survival.
!!!. The drugs commonly used are- Methotrexate,
Adriamycin, Cyclophosphamide, Vincristine and
Cisplatin.
!!!!- Pre-operatively the treatment is given for 8-12
weeks with the maintenance dose for another 6-12
weeks.
3. Radiotherapy
!. High Irradiation is used to destroy for highly
sensitive tumour such as Ewings sarcoma as an
alternative to amputation.
!!. It is also used in combined form with chemotherapy
for tumours in inaccessible sites, for inoperable
tumour because of size or local spread, metastatic
deposits, myeloma and malignant lyphoma.
!!!. Dose- it is given in divided doses up to 6000 cGy in
4 weeks time.
Common Benign Tumours
Osteochondroma:- Ostoid Osteoma
It is the most common benign tumour and is NOT a
true neoplasm since its growth stops with the fusion of
epiphyseal plate. It is a peculiar small benign bone tumour , first
1.Age- It is common during the growth period described by Jaffe in 1935.
Age- Common in young adults between 10 to 25 years
. of age.
2.Sex- has a male preponderance. Sex- males are more affected (M:F=2:1)

3.Origin- Few cells from the growth plate start Pathology- The typical feature is the formation of a
growing centrifugally as a separate lump of the nidus , less than 1 cm in diameter , usually in the
bone. Eventually the tumour gets left behind and cortex of the long bone, the tibia being the
comes to lie at the metaphysis. commonest site.

4. Site- Any bone that develops in cartilage involved. Clinical features- The only symptom is a severe ill
Fast growing ends of long bone and the crest of the localised deep boring pain , worst at night. The
ilium are the commonest site. pain is eased by aspirin or its derivatives.

5. Clinical features- X-rays- The tumour is visible as a zone os sclerosis

# Symptoms- Usually symptomless , but patient may surrounded by a radiolucent nidus less than 1 cm in
complain of pain, swelling, once the complications like size.
bursitis, malignant change or fracture have developed. Tomography or CT scanning- likely to show the central
lesion more clearly.
# Signs- A firm non-tender swelling fixed to the bone
around the joints is most common finding. Bone scanning- shows a well localised area of
!!- Joint movement may be decreased due to markedly increased isotope uptake.
mechanical block of the tumour rather than its
extension into the joint. Treatment- Complete excision of the nidus together
with a margin of surrounding bone. This operation
7. X-rays- gives dramatic relief of pain .
# Well- defined exostosis emerging from the
metaphysis.
# The tumour is composed of cortical and medullary
portions which are continuous with the main bone.
# It looks smaller than it feels because the cartilage
cap is not seen on x-rays.
Multiple lesions may develop as a part of heritable
disorder Hereditary multiple exostosis.

8. Treatment
Usually it requires no treatment , but complete
surgical excision is indicated if:-
# If the tumour is large and obstructing the joint
movements.
# Painful bursitis
# Fracture of the bony stack
# Malignant change ( 1-2%)
# Pressure on the neighbouring vessels and nerves.
etc.
Giant Cell Tumour
Giant cell tumour is a benign , locally aggressive lesion Treatment:-
arising from the epiphysis. 1. Slow-growing benign lesion- curettage and stripping
of the cavity with burrs and gouses, swabbing with
Sex- more common in female than the males. hydrogen peroxide or with liquid nitrogen then the
Age- Seen commonly in age group of 20- 40 years cavity packed with bone chips.
after epiphyseal fusion. 2. More aggressive tumours, recurrent lesions- Excision
Bones affected- the lower end of femur, upper end of of the tumour followed by bone grafting or custom
tibia, the lower end of radius. made prosthesis.
Types:- Benign GTC
Intermediate GTC
Malignant t GTC

Pathology Treatment of GTC at common site

Gross-
# The tumour had a reddish, fleshy appearance and site Treatment of choice
comes out easily when curetted.
# Epiphyseal end of the bone is distorted. Lower end of femur Excision with turn-o-plasty
# Joint extension is rare Upper end of tibia Excision with turn-o-plasty
# No evidence of periosteal reaction Lower end of radius Excision with fibular grafting
Lower end of ulna Excision
Microscopic- presence of abundant large multi Upper end of fibula Excision
nucleated giant cells.

Clinical Features:-

# Pain at the site of tumour and a gradually increasing

swelling.
# History of trauma not uncommon with pathological
fracture in 10- 15 % of the cases.
# Local examination- reveals a bony swelling , tender
on firm palpation.

Radiology
- An eccentrically osteolytic lesion near the epiphysis.
-The cortex is thin and sometimes ballooned .
-No periosteal new bone formation (unless there is
pathological fracture)
-Soap- bubble appearance due to ridging of the
surrounding bone
-No calcification within the tumour
-The cortex may be disrupted at places.
-The tumour usually does not enter the adjacent joint

Campanaccis Radiological Classification of Giant cell

Tumour of Bone
Radiographic Criteria
grade
I Quiescent , small,intraosseous
II Active, aggressive but periosteum intact
III Aggressive , soft tissue invasion