BONE TUMORS

Bone tumors

 Patient
presentation:
 *Pain.
 *Swelling.
 *Pathological
fracture &
deformity.
 *Disturbance of
function.
 *Incidental
discovery.
 Bone tumors
 Clinical features &evaluation:
 1-Careful history& physical
examination beside routine X-
ray &laboratory facilities.
 2-Pre-biopsy evaluation :C T

scan and/or M R I.
 3-Actual biopsy.

 4-Search for metastatic

disease.
 DIAGNOSIS
A)-Clinical features and evaluation
B)-Investigations:
1-Imaging of musculoskeletal
neoplasm's : a) Plain
radiography
b) C T scan
c) M R I
d) Isotope bone scan
e) Arteriography
2-Laboratory studies & tumor
markers
 Simple bone cyst
 Occurs before 15 years of age.
 50% develop in the proximal end of the
humerus.
 Other common sites include: the proximal
femur , the proximal and distal tibia , iliac
wing and calcaneus.
 Common presentation : incidental
discovery when radiographs are taken for
other reasons or by pathological fracture
after minor trauma.
 Simple bone cyst
 Solitary or unicameral bone cyst:
 Expansion of bone & thinning of the
bone cortex through endosteal
erosion.
 Pathological fracture.
 Extensive bone destruction resemble
a neoplasm
 Simple bone cyst
 The cavity is filled by a serous fluid.The fluid
will be stained by hemorrhage if pathological
fracture occurred.
 Radiographically appear as symmetric well
demarcated radiolucent expansile lesions at
bone metaphyses, often extending up to the
physeal plate and the cortex may be thinned.
as the bone grows away from the cyst , the
lesion may come to lie in the diaphysis.
 When pathological fracture occurs a fragment
of thin cortex may separate and fall in the
cavity {fallen leaf sign} .
 No periosteal reaction except after stress
fracture
Simple bone cyst
Simple bone cyst
Simple bone cyst
 Simple bone cyst
 With skeletal growth and maturation,
simple bone cysts tends to spontaneous
healing.
 Most fractures of simple bone cysts heal
rapidly with closed treatment as callus
formation induces cystic healing as well
as fracture consolidation.
 Methods of treatment:
 1- observation and restriction of activity
until the cyst heals in asymptomatic
lesions .
 Aneurysmal bone cyst
 ABCs arise primarily as a skeletal
osteolytic lesion or may arise as a
reaction to hemorrhage within a pre-
existing tumoral lesion.
 The primary lesion is found mostly in the
second decade of life.
 Common sites are metadiaphysis of long
bones preferably in the lower limb bones.
 The lesion usually is eccentric
subperiosteal in origin, so pathological
fracture is unusual presentation, but it
 Aneurysmal bone cyst
 The diagnostic features are :
 Marked expansion of the involved bone,
cystic bone destruction and periosteal
new bone formation.
 The lesion rapidly destroys the original
bone cortex and is contained only by a
thin rim of periosteal new bone.
 During curettage there may be a
considerable bleeding from the fleshy
lining membrane [welling or pouring of
blood ]
 Aneurysmal bone cyst
 Radiographic features: is a well defined
radiolucent subperiosteal osteolytic lesion
elevating and inflating the periosteum
and progressively eroding the cortex,
with scarce periosteal reaction observed
as a thin shell of reactive bone at the
metaphysis of long bones [egg shell]. The
cyst initially appears as an eccentric
osteolytic area .
Aneurysmal bone cyst
Aneurysmal bone cyst
 Aneurysmal bone cyst
 Methods of treatment :
 The treatment of choice is curettage and
autogenous grafting. [during curettage
copious bleeding may be encountered ].
Aneurysmal bone cyst
 osteochondroma
 Osteocartilaginous exostoses: [cartilage
capped exostosis] the most common tumors of
bone.
 Are hamartomas and occur during skeletal
growth as a small overgrowth of cartilage at the
edge of the physeal plate and develops by
enchondral ossification into a bony
protuberance still covered by the cap of
cartilage.
 They continue to grow and mature , undergoing
enchondral ossification.
 osteochondroma
 Radiographic features are usually classic
and other studies are rarely required to make
the diagnosis.
 The pathogonomonic feature of an exostosis is
that the medullary bone is contiguous in the
stalk of the exostosis and the underlying bone.
 Lesions are usually pedunculated but can be
sessile, the lesion initially is adjacent to the
physeal mechanism and becomes more
diaphyseal as the child ages.
 Pedunculated lesions extend away from the
epiphysis of origin toward the diaphysis of the
involved bone.
osteochondroma
osteochondroma
 osteochondroma
 The exostosis is covered with a
cartilaginous cap and undergoes
enchondral ossification to from the
underlying cancellous bone.
 The thickness of the cap is variable
depending on the age of the person and
diminishes following skeletal maturity.
The cells of the cartilaginous cap are
arranged in columns similar to an
epiphyseal mechanism.
 osteochondroma
 Common problems of
osteochondromas:
 1- Fracture of the stalk in pedunculated
type.
 2- Entrapment of the adjacent
neurovascular structures.
 3- Adventitious bursa formation over the
cartilaginous cap which is liable for
bursitis.
 4- Malignant transformation to chondro –
sarcoma { more in lesions arising in the
osteochondroma
 osteochondroma
 Malignant transformation :
 Malignant transformation of a single
osteochondroma is a rare event {<1%}
and is less common than in patients with
MHE {6%}.
 Lesions arising in the pelvis, scapula, ribs
and spine are at higher risk for malignant
transformation than those in the
appendicular skeleton.
 Transformation does not occur before
skeletal maturity
 osteochondroma
 Methods of treatment :
 Surgical excision should be reserved for
lesions that cause discomfort or
deformity or are cosmetically
unappealing.
 To avoid the local recurrence, the entire
cartilaginous cap must be excised.
 osteochondroma
 Multiple Heritable Exostoses :
 MHE is a syndrome of being multiple ,heritable
and associated with skeletal deformity and
short stature, and by having a significant
frequency of transformation into secondary
peripheral chondrosarcoma.
 The ratio of solitary exostoses to MHE is at least
10:1.
 Exostoses usually are identified earlier in
persons with MHE [usually by 10 years of age]
than with solitary lesions.
 MHE are transmitted as an autosomal dominant
trait.
 osteochondroma
 Multiple Heritable Exostoses:
 The lesions tend to be diffuse and
relatively symmetric.
 The long bones are affected most
severely, with the greatest
involvement around the knee,
shoulder, hip, wrist and ankle.
 The pathogenesis and
histopathologic features are the
same as for solitary exostoses.

 osteochondroma
 Multiple Heritable Exostoses:
 Radiographically: the lesions are larger
than the solitary one and the underlying
bones are shorter than normal, with a
widened metaphysis [ due to failure of
bone remodeling as the periosteum is
tethered in all direction at the metaphysis
].
osteochondroma
 osteochondroma
 Multiple Heritable Exostoses:
 Malignant transformation occurs in
around 1-6% and central lesions [ pelvis,
scapula, ribs, and spine] are at great risk
of malignant transformation as with
solitary osteochondromas.
 Excision of one or more exostoses often is
necessary in persons with MHE because
of discomfort or for mechanical reasons
as fracture of a stalk in pedunculated
lesion or due to bursitis and pressure on
nearby vital structures.
 Enchondroma
 Enchondromas are hamartomatous
collections of mature hyaline
cartilage within bone.
 They usually present as solitary

lesions.
 Multiple lesions known as

enchondromatosis or Ollier`s
disease.
 It arise from the lack of normal

enchondral ossification below the

 Enchondroma
 They commonly involve the small tubular
bones in the hand and foot, the proximal
humerus, the femur and the ribs.
 A well defined radiolucent central lesion
within the metaphysis or diaphysis of the
involved bone, sometimes the bone is
slightly expanded.
 Calcification may be present and usually
is stippled or flecks, “smoke ring or
popcorn” ossification.
Enchondroma
Enchondroma
 Giant cell tumor
 Although benign, GCTs show a tendency
for significant bone destruction, local
recurrence, and occasionally metastasis .
 * Frequency: GCTs represent
approximately 5% of all primary bone
tumors and 18-21% of all benign bone
tumors. The most common bone tumor
in the young adults aged 25 to 40 years,
GCTs occur most commonly in the third
decade of life.
 giant cell tumors only occur after the
epiphyseal plates have closed and a
diagnosis of GCT in a patient with open
 Giant cell tumor

 Approximately 50% of GCTs are located

about the knee at the distal femur and
proximal tibia, with the proximal humerus
and distal radius representing the third
and fourth most common sites.
 Giant cell tumor
 Radiologic features:
 * The lesions are expansile, osteolytic,
radiolucent without sclerotic margins and
usually without a periosteal reaction and
eccentrically located within the bone.
 There is a well-defined defect in the
metaphysis and epiphysis, with
destruction of the medullary cavity and
adjacent cortex. The destruction may
stop just short of the joint.
Giant cell tumor
Giant cell tumor
Giant cell tumor
Giant cell tumor
 Osteosarcoma
 Osteosarcoma is the most common
primary malignant tumor of bone,
characterized by the direct formation of
bone or osteoid by tumor cells.
 The incidence of osteosarcoma peaks in
those aged 10-20 years; (maximum
period of skeletal growth).
 Osteosarcoma
 osteosarcoma occurs most commonly in
the metaphyses of long tubular bones,
particularly around the knee joint (distal
femur, proximal tibia). The proximal
humeral metaphysis is another common
site. The disease commonly extends from
the metaphysis into the adjacent
diaphysis or epiphysis.

 Osteosarcoma
 Radiographic appearances shows a
mixture of lytic and sclerotic areas. Soft
tissue extension of osteosarcoma is
common and seen on radiographs as a
soft-tissue mass.
 Cloudlike areas of sclerosis due to
malignant osteoid production and
calcification may be seen within the
mass.
 Periosteal reactions are commonly seen
once the tumor extends through the
cortex ( Codman triangles and
Osteosarcoma
Osteosarcoma
Osteosarcoma
 Chondrosarcoma
 Chondrosarcoma is a malignant tumor
that produces cartilage matrix.
 Primary chondrosarcoma is very
uncommon, arises centrally in the bone,
and is found in young adult. Secondary
chondrosarcoma arises from benign
cartilage defects such as
osteochondroma or enchondroma.
Chondrosarcoma can also be classified as
intramedullary, which generally arise
from enchondromas, and surface which
 Chondrosarcoma
 It is most common in the femur, humerus,
ribs and on the surface of the pelvis.
 chondrosarcoma is a fusiform, lucent
defect with scalloping of the inner cortex
and periosteal reaction. Extension into
the soft tissue may be present as well as
punctate or stippled calcification of the
cartilage matrix. May shows a lobulated
appearance like a cauliflower mass.
Chondrosarcoma
Chondrosarcoma
Chondrosarcoma
 Ewing's sarcoma
 Ewing's sarcoma is a highly malignant
tumor that is found in the lower extremity
more than the upper extremity, but any
long tubular bone may be affected. The
most common sites are the metaphysis
and diaphysis of the femur followed by
the tibia and humerus.
 Ewing's sarcoma is most common in the
first and second decade.
 Ewing's sarcoma
 The clinical presentation of Ewing's
sarcoma includes pain and swelling of
weeks or months duration. Erythema and
warmth of the local area are sometimes
seen. Osteomyelitis is often the initial
diagnosis based on intermittent fevers,
leukocytosis, anemia and an increased
ESR.
 Ewing's sarcoma
 Radiologically,
Ewing's sarcoma is
often associated
with a lamellated
or "onion skin"
periosteal reaction.
Ewing's sarcoma
 Multiple Myeloma
((Plasmacytoma
 Multiple myeloma is a malignant tumor of
plasma cells that causes widespread
osteolytic bone damage. Multiple
myeloma is the most common primary
tumor of bone and is found in the spine,
skull, ribs, sternum and pelvis but may
affect any bone with hematopoietic red
marrow. The average patient age is over
fifty years old.
 Monoclonal immunoglobulin is found on
serum protein electrophoresis.
 BenceJones proteins are present in urine.
 Multiple Myeloma
 The radiological appearance of multiple
myeloma is characterized by irregular
lytic defects of different sizes. These lytic
areas are often described as "punched
out" and have no periosteal reaction.
Erosion begins intramedullarly and
progresses through the cortex.
 It may causes generalized osteoporosis.
Multiple Myeloma
Multiple Myeloma
 BONE SECONDARIES
COMMONEST MALIGNANT BONE TUMOURS
SITE OF PRIMARY:
breast, prostate, thyroid, kidney, lung
2/3 come from cancer breast or prostate
16 % from thyroid, kidney, lung
17 % unknown primary
SITE OF SECONDARIES:
bones rich in cancellous bone
trunk bones e.g spine, pelvis, skull, ribs
root bones e.g upper humerus, upper femur
ROUTES :
1- Local invasion…e.g rectum invades pelvis
2- Blood born… from tumour drain via vena cava
to heart , to lung to systemic circulation to bone
3- LYMPPHATICS…
 BONE SECONDARIES

TYPES :
Osteolytic 90 %... Bone destruction ( breast )
osteosclerotic … Bone sclerosis
( prostate )
PRESENTATION:
1- Pain
2- Pathologic fracture ( fr. Spine )
3- Swelling
4- Anaemia, cachexia
TREATMENT :
Hormonal
Radio & Chemo..
Surgical . Internal fixation
. Amputation
Thank you