Bone Tumors Lec 1 PDF - Al-Warirth University

Al-Warirth University College of Medicine Department of Surgery BONE TUMOURS Lec 1 (2nd stage) Dr. Ali Tariq Jassim  Tumours, tumour-like lesions and cysts are considered together, partly because their clinical presentation and management are similar and partly b...

Al-Warirth University College of Medicine Department of Surgery BONE TUMOURS Lec 1 (2nd stage) Dr. Ali Tariq Jassim  Tumours, tumour-like lesions and cysts are considered together, partly because their clinical presentation and management are similar and partly because the definitive classification of bone tumours is still evolving… CLINICAL PRESENTATION  HISTORY  asymptomatic(discover accidently).  Age ;childhood and adolescence primary malignant tumours, notably Ewing’s tumour and osteosarcoma. Chondrosarcoma and fibrosarcoma typically occur in older people.  In patients over 70 years of age, metastatic bone lesions are more common than all primary tumours together.  Pain : even a tiny lesion may be very painful if it is encapsulated in dense bone (e.g. an osteoid osteoma).  Swelling, or the appearance of a lump, may be alarming.  Neurological symptoms (paraesthesiae or numbness)  EXAMINATION:  The examination will focus on the symptomatic part, but it should include the area of lymphatic drainage and, often, the pelvis, abdomen, chest and spine. IMAGING  X-RAYS QUESTIONS TO ASK WHEN STUDYING AN X-RAY :  Is the lesion solitary or are there multiple lesions?  What type of bone is involved?  Where is the lesion in the bone?  Are the margins of the lesion well- or ill-defined?  Are there flecks of calcification in the lesion?  Is the cortex eroded or destroyed?  Is there any periosteal new-bone formation?  Does the tumour extend into the soft tissues? IMAGING  RADIONUCLIDE SCANNING  COMPUTED TOMOGRAPHY  MAGNETIC RESONANCE IMAGING LABORATORY INVESTIGATIONS  Blood tests exclude other conditions, e.g. infection or metabolic bone disorders, or a ‘brown tumour’ in hyperparathyroidism.  increased ESR and elevated serum alkaline phosphatase.  Serum protein electrophoresis, urine may contain Bence Jones protein.. BIOPSY  Needle biopsy :.  Open biopsy  Note : it is important to delay the procedure until all the imaging studies have been completed. DIFFERENTIAL DIAGNOSIS.  Soft-tissue haematoma  Myositis ossificans.  Stress fracture  Bone infection  Gout (a) (b) (c) (d) (e) 9.1 Tumours – differential diagnosis (a) This huge swelling was simply a clotted haematoma. (b) Bone infection with pathological fracture. (c) Florid callus in an un-united fracture. (d) Large erosion in the calcaneum by a gouty tophus. (e) Bone infarcts. STAGING OF BONE TUMOURS  Staging of benign bone tumours as described by Enneking : Latent ,, Active,, Aggressive.  Bone sarcomas are broadly divided as follows: Stage I All low-grade sarcomas. Stage II Histologically high-grade lesions. Stage III Sarcomas which have metastasized. METHODS OF TREATMENT TUMOUR EXCISION  MULTI-AGENT CHEMOTHERAPY  RADIOTHERAPY  TUMOUR EXCISION Intracapsular (intralesional) excision  Marginal excision  Wide excision  Radical resection  MULTI-AGENT CHEMOTHERAPY  neoadjuvant and adjuvant  chemotherapy regimens effectively reduce the size of the primary lesion, prevent metastatic seeding and improve the chances of survival.. RADIOTHERAPY  Nowadays the indications are more restricted.  The main complications of this treatment are the occurrence of post-irradiation spindle-cell sarcoma and pathological fracture in weight bearing bones.  BENIGN BONE LESIONS NON-OSSIFYING FIBROMA (FIBROUS CORTICAL DEFECT) :  the commonest benign lesion of bone, is a developmental defect in which a nest of fibrous tissue appears within the bone and persists for some years before ossifying. It is asymptomatic and is almost always encountered in children as an incidental finding on x-ray. The commonest sites are the metaphyses of long bones.  FIBROUS DYSPLASIA  is a developmental disorder in which areas of trabecular bone are replaced by cellular fibrous tissue.  If the lesions are large, the bone is considerably weakened and pathological fractures or progressive deformity may occur.  Treatment depends on the extent of the defect and the presence or absence of deformities. Small lesions need no treatment. Those that are large and painful or threatening to fracture (or have fractured) can be curetted and grafted.  OSTEOID OSTEOMA  This tiny bone tumour (less than 1 cm in diameter) causes symptoms out of all proportion to its size.  Patients are usually under 30 years of age  Any bone except the skull may be affected, but over half the cases occur in the femur or tibia.  Typically the pain at night and relieved by salicylates.  The important x-ray feature is a small radiolucent area, the so-called ‘nidus.  Treatment The only effective treatment is complete removal or destruction of the nidus.  ) CHONDROMA (ENCHONDROMA)  Chondromas are usually asymptomatic and are discovered incidentally on x-ray or after a pathological fracture.  They are seen at any age and in any bone( hands and feet). Lesions may be solitary or multiple…  Treatment is not always necessary, but if the tumour appears to be enlarging, or if it presents a pathological fracture, it should be removed OSTEOCHONDROMA (CARTILAGE-CAPPED EXOSTOSIS)  This is one of the commonest ‘tumours’ of bone..  the commonest sites are the fast-growing ends of long bones and the crest of the ilium. it may go on growing but at the end of the normal growth period for that bone it stops enlarging.  Any further enlargement after the end of the growth period is suggestive of malignant transformation.  The patient is usually a teenager.  Occasionally there is pain due to an overlying bursa or impingement on soft tissues.  The x-ray appearance is pathognomonic. There is a well-defined exostosis emerging from the metaphysis, its base co-extensive with the parent bone.  Multiple lesions may develop as part of a heritable disorder – hereditary multiple exostosis –  Complications :The incidence of malignant transformation is 1 per cent for solitary lesions and 6 per cent for multiple.  Treatment If the tumour causes symptoms it should be excised; if, in an adult, it has recently become bigger or painful then operation is urgent, for these features suggest malignancy.  GIANT-CELL TUMOUR  The patient is usually a young adult who complains of pain at the end of a long bone; sometimes there is slight swelling.  X-ray, CT scan and MRI will reveal  The tumour has the potential to transform into an osteosarcoma.  treated by thorough curettage and bone grafting.  SIMPLE BONE CYST  This lesion (also known as a solitary cyst or unicameral bone cyst) appears during childhood, typically in the metaphysis of one of the long bones and most commonly in the proximal humerus or femur.  It is not a tumour, it tends to heal spontaneously and it is seldom seen in adults.  The condition is usually discovered after a pathological fracture or as an incidental finding on x-ray.  X-rays show a well-demarcated radiolucent area in the metaphysis.  Asymptomatic lesions in older children can be left alone.  Active’ cysts treated by by aspiration of fluid and injection of methylprednisolone or autogenous bone marrow or thoroughly cleaned by curettage and then packed with bone chips.. ANEURYSMAL BONE CYST  may be encountered at any age and in almost any bone, more often in young adults and in the long-bone metaphyses..  X-rays show a well-defined radiolucent cyst, often trabeculated and eccentrically placed in the metaphysis and therefore may resemble a simple cyst or one of the other cyst-like lesions..  MRI is diagnostic (fluid-fluid level ).  Treatment The cyst should be curetted and then packed with bone grafts.