dr. Ronald V.

Munthe SpOT
SMF Bedah RS UKI
 ETIOLOGY
Usually no obvious cause
Ionising radiation
Predisposing conditions:
Pagets disease
fibrous dysplasia
retinoblastoma (genetic)
syndromes eg. Gardners, Olliers disease
INTRODUCTION & INCIDENCE:

Rare - 0.5% of cancer deaths.

40% Malignant.

Primary & Secondary/metastatic.

Primary in Young. (Osteosarcoma)

Secondary in the old. (Breast, Kidney, thyroid,

lung, prostate)
CLASSIFICATION

Based
on tissue of origin
Bone
Cartilage
Fibrous tissue
Bone marrow
Blood vessels
Mixed
Uncertain origin
Cell type Benign Malignant

Bone Osteoid osteoma Osteosarcoma

Cartilage Chondroma Chondrosarcoma

Osteochondroma

Fibrous tissue Fibroma Fibrosarcoma

Marrow Eosinophilic Ewings sarcoma

granuloma Myeloma

Vascular Haemangioma Angiosarcoma

Uncertain Giant-cell tumour Malignant giant-cell

tumour
EVALUATION

History : age, sex

Physical examination : location

Investigations; labs, imaging

Biopsy
Analytic approach to evaluation
of the bone neoplasm
EVALUATION: HISTORY

Age

Symptomatology

Pain
Swelling
Historyof trauma
Neurological sympts

Pathological fracture
EVALUATION: PHYSICAL
EXAMINATION

Lump/swelling

Effusion

Deformities

Regional nodes
EVALUATION: IMAGING

Plain radiograph
CT scan
MRI

Radionuclide scanning
PET
 RADIOGRAPHY
Information yielded by radiography
includes :
Siteof the Lesion
Borders of the lesion/zone of transition
Type of bone destruction
Periosteal reaction
Matrix of the lesion
Nature and extent of soft tissue involvement
Radiographic features of bone tumors
 TYPE OF BONE DESTRUCTION
Mechanisms of bone destruction
Direct effect of tumor cells
Increased osteoclastic activity

Bone destruction can be described as

geographic (type I) - benign lesions
moth-eaten (type II) and
permeative (type III) - rapidly growing infiltrating tumor
 Patterns of bone destruction.
geographic permeative type
moth-eaten
a uniformly affected characteristic of
rapidly growing
area within sharply round cell tumors
infiltrating lesions
defined borders

giant cell tumor. myeloma Ewing sarcoma

 Types of periosteal reaction.

An uninterrupted periosteal reaction usually indicates a benign

process, whereas an interrupted reaction indicates a malignant
or aggressive nonmalignant process
 Interrupted type of periosteal reaction

lamellated or Ewing sarcoma

sunburst onion-skin -lamellated type
pattern type in ewing
sarcoma
-osteosarcom
a

Codman
triangle
(arrow)
BENIGN VERSUS MALIGNANT
NATURE

Benign lesions
well-defined sclerotic borders
bone destruction : geographic type
periosteal reaction : solid and uninterrupted
no soft tissue mass.

Malignant tumors
poorly defined borders with a wide zone of transition;
bone destruction : moth-eaten or permeative
Periosteal reaction : an interrupted, sunburst, or
onion-skin reaction
soft tissue mass.
Radiographic features that may help
differentiate benign from malignant
lesions
METHODS OF TREATMENT

Tumour excision :
marginal
limb-sparing surgery
amputation

Radiotherapy

Chemotherapy
OSTEOID OSTEOMA
Benign, second decade; males (3:1)
1-2 cm lesion in cortex of femur or tibia

Painful (high prostaglandin levels in lesion)

Central nidus of vascular spaces surrounded by

interlacing reactive trabecular bone.
Therapy - Resection of nidus - bone graft.
OSTEOSARCOMA

Common primary cancer of bone

Young adults - 10 and 25 years

Rare in later age Secondary to previous irradiation

or Pagets disease
genetic (retinoblastoma gene)

Metaphysis of a long bone (Knee)

Tenderness / pain / Mass.

OSTEOSARCOMA
Malignant mesenchymal cells that produce
Irregular lace like osteoid matrix.
May or may not be calcified.

pre-operative chemotherapy with surgical

resection.
The five-year survival ~ 60%
OSTEOSARCOMA GROSS
OSTEOSARCOMA X-RAY
OSTEOCHONDROMA

Hereditary (multiple) or sporadic (single)

mushroom-shaped bony projections

Lateral aspects of cartilage joints.

Chondrosarcoma in hereditary type.

Osteochondroma
CHONDROMA (ENCHONDROMA)
Benign, Any age
Single or multiple sites

Often involves small bones of hands and feet.

Well demarcated, mature cartilage.

CHONDROMA (ENCHONDROMA)

Hereditary multiple enchondromatosis. Usually

over one side of the body. (Olliers disease).
Maffucci's syndrome - multiple bone chondromas
and hemangiomas of soft tissue
Increased risk for chondrosarcoma
CHONDROSARCOMA
Next common to Osteosarcoma.
Older adults 30 to 60 years.

Location - axial skeleton (pelvis & pectoral girdles,

ribs & spine)
Aggressive, erodes & invades soft tissue,

Metastases to lungs, liver, kidney & brain.

CHRONDROSARCOMA
Malignant cartilage with anaplastic
chondrocytes in spaces with focal enchondral
ossification and calcification
Resistant to chemo Surgical resection
Grade I tumors have 5-year survival rates of
90%, while high grade tumors have poor
prognosis.
Clear cell chondrosarcoma is a histologic
variant that is associated with a better
prognosis.
CHONDROSARCOMA - GROSS
CHONDROSARCOMA OF PELVIS

nodules of white to bluish-white cartilagenous tumor

tissue eroding and extending outward from the bone at
the lower right.
 OSTEOSARCOMA CHRONDROSARCOMA
10-25 years of age
>40 years of age
affects axial skeleton
affects long bones
not sensitive to
sensitive to
chemotherapy chemotherapy
EWINGS SARCOMA:
Rare, young, 10-20 years, Males 2:1
Diaphysis of long bones, pelvis

Histopath : sheets uniform round cells cytoplasmic

glycogen, extensive necrosis; 11/22 translocation
Prognosis: very poor, <10% 5-year survival with surgery
and radiotherapy, 40% with adjuvant chemotherapy
EWINGS SARCOMA:
MULTIPLE MYELOMA
from plasma cells of the bone marrow.

Thetumours are found wherever red

marrow occurs : the trunk bones, the skull
and the proximal ends of femur and
humerus.

Usually the lesions are multiple from the

start.

Age : 45-65 years

 The patient presents with anaemia, cachexia,
chronic nephritis, weakness, bone pain or a
pathological fracture.

The bone pain is constant and backache in

particular is common, lower limb weakness.

The usual cause of death is renal failure.

 X-ray :

may show nothing more than overall reduction in

density, myeloma is one of the commonest causes
of secondary osteoporosis and vertebral
compression fracture after the age of 45 years.
 Laboratorium :
urinalysis shows Bence-Jones protein,
electrophoretic analysis of plasma and urine
proteins, high ESR.

Treatment : Radiotherapy, chemotherapy

TERIMA KASIH