Musculoskeletal Tumors for Students PDF

MUSCULOSKELETAL TUMORS adapted 1 lll Musculoskeletal-tumors for students adapted - 10 February 2023 intro to pathology 2 lll Musculoskeletal-tumors for students adapted - 10 February 2023 NEOPLASIA new growth abnormal mass of tissue unco-ordinated growth/ cell proliferation despite stimuli cessation...

MUSCULOSKELETAL TUMORS adapted 1 lll Musculoskeletal-tumors for students adapted - 10 February 2023 intro to pathology 2 lll Musculoskeletal-tumors for students adapted - 10 February 2023 NEOPLASIA new growth abnormal mass of tissue unco-ordinated growth/ cell proliferation despite stimuli cessation BOTH BENIGN vs MALIGNANT 3 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BONE TUMORS adapted The term bone tumour encompass benign & malignant neoplasms, reactive focal abnormalities, metabolic abnormalities, and miscellaneous “tumorlike” conditions 4 lll Musculoskeletal-tumors for students adapted - 10 February 2023 5 lll Musculoskeletal-tumors for students adapted - 10 February 2023 6 lll Musculoskeletal-tumors for students adapted - 10 February 2023 CLASSIFICATION OF BONE TUMORS ⦿ Origin: ⦿ Primary (except myeloma and lymphoma) ⦿ ⦿ Secondary: ⦿ mets/95%/ breast, lung, prostate, kidney and thyroid/ ⦿ ⦿ ⦿ only 0.2%of all malignancies in adults and 5% in children < 15 years STS spread/ malignant transformation preexisting benign lesions cell type: Bone! ○ Osteoma, osteosarcoma Cartilage! ○ Chondroma, Chondrosarcoma Marrow! ○ Hemangioma, angiosarcoma Fibrous tissue! ○ Fibroma, fibrosarcoma Tumor type: Benign: Osteoma/ osteochondroma Malignant:: Osteosarc/ MM/ chondrosarc/ EWINGS ⦿ 7 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Bone Tumour Classi cation (WHO) Bone-forming tumours Cartilage forming tumours Giant-cell tumour Marrow tumours Vascular tumours Other connective tissue tumours Other tumours Secondary malignant tumours of bone fi 8 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Bone-Forming Tumors 9 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Bone-Forming tumors; Tumor Type Locations Age Morphology Osteoma Facial bones, skull 40-50 Exophytic growths from bone surface; histologically resemble normal bone Osteoid osteoma Metaphysis of femur and tibia 10-20 Cortical tumors, Osteoblastoma Vertebral column 10-20 vertebral processes; histologically similar to osteoid osteoma Metaphysis of distal femur, proximal tibia, and humerus 10-20 Grow outward, lifting periosteum, and inward to the medullary cavity; microscopically malignant cells form osteoid. Femur, humerus, pelvis >40 Complications of polyostotic Paget disease; BENIGN BENIGN to INTERMEDIATE MALIGNANT Aggressive Oblastoma Primary osteosarcoma Secondary osteosarcoma 10 characterized by pain; histologically interlacing trabeculae of woven bone histologically similar to primary osteosarcoma lll Musculoskeletal-tumors for students adapted - 10 February 2023 Cartilage -Forming Tumors 11 lll Musculoskeletal-tumors for students adapted - 10 February 2023 12 lll Musculoskeletal-tumors for students adapted - 10 February 2023 13 lll Musculoskeletal-tumors for students adapted - 10 February 2023 14 lll Musculoskeletal-tumors for students adapted - 10 February 2023 15 lll Musculoskeletal-tumors for students adapted - 10 February 2023 16 lll Musculoskeletal-tumors for students adapted - 10 February 2023 17 lll Musculoskeletal-tumors for students adapted - 10 February 2023 18 lll Musculoskeletal-tumors for students adapted - 10 February 2023 19 lll Musculoskeletal-tumors for students adapted - 10 February 2023 20 lll Musculoskeletal-tumors for students adapted - 10 February 2023 21 lll Musculoskeletal-tumors for students adapted - 10 February 2023 22 lll Musculoskeletal-tumors for students adapted - 10 February 2023 23 lll Musculoskeletal-tumors for students adapted - 10 February 2023 24 lll Musculoskeletal-tumors for students adapted - 10 February 2023 25 lll Musculoskeletal-tumors for students adapted - 10 February 2023 26 lll Musculoskeletal-tumors for students adapted - 10 February 2023 27 lll Musculoskeletal-tumors for students adapted - 10 February 2023 28 lll Musculoskeletal-tumors for students adapted - 10 February 2023 29 lll Musculoskeletal-tumors for students adapted - 10 February 2023 30 lll Musculoskeletal-tumors for students adapted - 10 February 2023 31 lll Musculoskeletal-tumors for students adapted - 10 February 2023 32 lll Musculoskeletal-tumors for students adapted - 10 February 2023 33 lll Musculoskeletal-tumors for students adapted - 10 February 2023 34 lll Musculoskeletal-tumors for students adapted - 10 February 2023 35 lll Musculoskeletal-tumors for students adapted - 10 February 2023 36 lll Musculoskeletal-tumors for students adapted - 10 February 2023 37 lll Musculoskeletal-tumors for students adapted - 10 February 2023 38 lll Musculoskeletal-tumors for students adapted - 10 February 2023 39 lll Musculoskeletal-tumors for students adapted - 10 February 2023 40 lll Musculoskeletal-tumors for students adapted - 10 February 2023 SECONDARY 41 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Secondary Bone Tumours Can be further subdivided into: Metastatic tumors contiguous spread from soft tissue neoplasms malignant transformation of the pre-existing benign lesions. 42 lll Musculoskeletal-tumors for students adapted - 10 February 2023 METASTATIC NEOPLASMS Metastatic neoplasms primary origin can be in descending frequency : 1. 2. 3. 4. 5. 6. 7. 8. 9. Prostate Breast. Lung. Gastro Intestinal Tract. Kidney. Thyroid UroGenital Tract. skin bone 43 lll Musculoskeletal-tumors for students adapted - 10 February 2023 44 lll Musculoskeletal-tumors for students adapted - 10 February 2023 45 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BONE TUMOURS PRESENTATIONS?? 46 lll Musculoskeletal-tumors for students adapted - 10 February 2023 DIAGNOSIS ⦿ History and examination ⦿ Labs ⦿ IMAGING ⦿ BIOPSY 47 lll Musculoskeletal-tumors for students adapted - 10 February 2023 CLINICAL FEATURES 48 lll Musculoskeletal-tumors for students adapted - 10 February 2023 SYMPTOMS AND SIGNS ⦿ ⦿ asymptomatic discovered accidentally. Pain: initially intermittent ⤇ rest/ spread to joint/ tearing neuralgia type ⦿ may worsen at night / intolerable ⦿ may radiate (involve nerve trunks)/ SPINE: radicular/ myelopathy ⦿ ⦿ ⦿ ⦿ tumor compression on surrounding tissue hemorrhage in the tumor pathological fractures inflammation 49 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ⦿ Swelling/ mass. size/ site/ shape/ consistency/ mobility ○ Increase in size : Bleeding, malignant change ○ extra osseous component/ expansile lesion ○ skin changes/ tense shiny/ prominent veins/ livid colour/ ulceration ○ mobility/ lesion close to joint (OB/ CB/ GCT/ sarcomas)/ reactive synovitis ⦿ Local tenderness/ Warmth/ Loss of function/ Deformity ⦿ Pathological fracture: may be the first sign. ○ ○ ⦿ diaphyseal fracture in the elderly, malignancy should be ruled out Neurovascular involvement Lymph nodes regional & general General: fatigue, fever, wt. loss ○ Mets/ thyroid/ breasts/ chest/ abdomen/ prostate/ UGT/ skin ⬇︎ ⦿ 50 lll Musculoskeletal-tumors for students adapted - 10 February 2023 MALIGNANT VS. BENIGN TUMORS “Rapid growth, warmth, tenderness, and ill defined edges are suggestive of malignancy.” 51 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Age / Location TYPICAL AGE 40 TYPICAL LOCATION flat vs tubular bone epi vs meta vs dia physeal medullary centric vs medullary eccentric vs cortical vs juxtacortical 52 lll Musculoskeletal-tumors for students adapted - 10 February 2023 AGE 53 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Age TYPICAL AGE Benign 40 Malignant Metastatic disease MM/ NHL chondrosarcoma/ MFH osteosarcoma (post Pagets/ post-radiation) 56 lll Musculoskeletal-tumors for students adapted - 10 February 2023 LABS 57 lll Musculoskeletal-tumors for students adapted - 10 February 2023 LABS CBC ESR U.Es/ Creat Calcium: osteocalcin-A bone forming tumours Serum phosphorus: may indicate bone metastasis. serum proteins electrophoresis SPEP/ Bence Jones proteinuria PTH: may indicate bone metastasis. anaemia/ leukemia/ lymphoma mets/ ewing’s/ lymphoma/leukemia/ myeloma renal function/ myeloma may indicate mets/ myeloma/ hyperPTH.. may indicate hyperparathyroidism LfTs esp ALP: Paget's disease, osteoblastic cancers, ALP LDH: TUMOUR MARKERS/ serology PSA/ CEA/ AFP. ↓ sx excision ↑mets / osteomalacia and rickets. indicate poor prognosis ⬆︎ ⬆︎ ⬆︎ ⬆︎ ⬆︎ ⬇︎ ⬆︎ 58 lll Musculoskeletal-tumors for students adapted - 10 February 2023 imaging 59 lll Musculoskeletal-tumors for students adapted - 10 February 2023 60 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Xrays Benign Treat/ manage Diagnostic Dilemma ?Malignant CT scan staging exam Biopsy MRI Treat/manage 61 lll Musculoskeletal-tumors for students adapted - 10 February 2023 IMAGING X-RAY CT SCAN MRI Ultrasound Arteriogram Radionucleotide scan PET SCAN 62 lll Musculoskeletal-tumors for students adapted - 10 February 2023 PLAIN X-RAY Most useful and available Could see: ○ ○ ○ ○ mass Bone destruction Cortical thickening+ periosteal reaction Cysts Important to notice: site Number (monostotic or polyostotic) properties Effect and reaction (aggressive / non aggressive ) 63 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ENNEKING’s FOUR QUESTIONS 1. 2. 3. 4. Where is the lesion? What is the lesion doing to the bone ? What is the bone doing (endosteally and periosteally) ? What is in the lesion? 64 lll Musculoskeletal-tumors for students adapted - 10 February 2023 65 lll Musculoskeletal-tumors for students adapted - 10 February 2023 where? 66 lll Musculoskeletal-tumors for students adapted - 10 February 2023 LOCATION 67 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Where is the lesion? FLAT LONG Medullary centric Medullary eccentric dia meta cortical epi 68 juxtacortical -physeal lll Musculoskeletal-tumors for students adapted - 10 February 2023 69 lll Musculoskeletal-tumors for students adapted - 10 February 2023 70 lll Musculoskeletal-tumors for students adapted - 10 February 2023 71 lll Musculoskeletal-tumors for students adapted - 10 February 2023 72 lll Musculoskeletal-tumors for students adapted - 10 February 2023 73 lll Musculoskeletal-tumors for students adapted - 10 February 2023 74 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Location: epiphysis - metaphysis - diaphysis Epiphysis Only a few lesions In young patients either a CB or an infection. In patients 20-40, a GCT has to be included in DDx. In older patients a geode, i.e. degenerative subchondral bone cyst included DDx Look for arthrosis. Metaphysis NOF, SBC/UBC, ABC, CMF, Osteosarcoma, Chondrosarcoma, Enchondroma and infections. Diaphysis Ewing's sarcoma, SBC/UBC, ABC, Enchondroma, Fibrous dysplasia and Osteoid Osteoma/ OB. 75 lll Musculoskeletal-tumors for students adapted - 10 February 2023 76 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Location: centric - eccentric - juxtacortical Centric in long bone SBC, eosinophilic granuloma, fibrous dysplasia, ABC, enchondroma Eccentric in long bone Osteosarcoma, NOF, chondroblastoma, chondromyxoid fibroma, GCT, osteoblastoma Cortical Osteoid osteoma differentiate from osteomyelitis. Juxtacortical Osteochondroma. The cortex must extend into the stalk of the lesion. Parosteal osteosarcoma arises from the periosteum. 1. 2. 3. 4. 5. 6. SBC: central diaphyseal NOF: eccentric metaphyseal SBC: central diaphyseal Osteoid osteoma: cortical Degenerative subchondral cyst: epiphyseal ABC: centric diaphyseal 77 lll Musculoskeletal-tumors for students adapted - 10 February 2023 78 lll Musculoskeletal-tumors for students adapted - 10 February 2023 79 lll Musculoskeletal-tumors for students adapted - 10 February 2023 FOUR QUESTIONS OF ENNEKING 2. What is the lesion doing to the bone ? ○Usually causes 30-40% bone destruction before detection. ?50% ○transition zone circumscribed and localized destructive and ill-defined 80 lll Musculoskeletal-tumors for students adapted - 10 February 2023 FOUR QUESTIONS OF ENNEKING 2. What is the lesion doing to the bone ? ○erosion ○expansion ○cortical breakthrough ○fracture ○transition zone 81 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BENIGN VS. MALIGNANT 82 lll Musculoskeletal-tumors for students adapted - 10 February 2023 PATTERNS OF BONE DESTRUCTION Geographic Moth-eaten Less malignant Permeative More malignant 83 lll Musculoskeletal-tumors for students adapted - 10 February 2023 84 lll Musculoskeletal-tumors for students adapted - 10 February 2023 85 lll Musculoskeletal-tumors for students adapted - 10 February 2023 86 lll Musculoskeletal-tumors for students adapted - 10 February 2023 87 lll Musculoskeletal-tumors for students adapted - 10 February 2023 88 lll Musculoskeletal-tumors for students adapted - 10 February 2023 89 lll Musculoskeletal-tumors for students adapted - 10 February 2023 90 lll Musculoskeletal-tumors for students adapted - 10 February 2023 91 lll Musculoskeletal-tumors for students adapted - 10 February 2023 92 lll Musculoskeletal-tumors for students adapted - 10 February 2023 93 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BENIGN LESIONS WITH AGGRESSIVE FEATURES ○ Giant cell tumour ○ Chondroblastoma ○ Aneurysmal bone cyst ○ Unicameral bone cysts GCT CB ABC SBC/ UBC Aggressive GCT 94 lll Musculoskeletal-tumors for students adapted - 10 February 2023 95 lll Musculoskeletal-tumors for students adapted - 10 February 2023 96 lll Musculoskeletal-tumors for students adapted - 10 February 2023 97 lll Musculoskeletal-tumors for students adapted - 10 February 2023 FOUR QUESTIONS OF ENNEKING 3. What is the bone doing (endosteally and periosteally ) ? Clue to the biologic activity ○Smooth periosteum, benign process ○Onion-skin ( ewing’s sarcoma ) ○Sunburst reaction ( osteosarcoma ) ○Codman’s triangle 98 lll Musculoskeletal-tumors for students adapted - 10 February 2023 99 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Midshaft periosteal reaction with smooth + thick edges: this is a benign osteoma. 100 lll Musculoskeletal-tumors for students adapted - 10 February 2023 101 lll Musculoskeletal-tumors for students adapted - 10 February 2023 102 lll Musculoskeletal-tumors for students adapted - 10 February 2023 103 lll Musculoskeletal-tumors for students adapted - 10 February 2023 104 lll Musculoskeletal-tumors for students adapted - 10 February 2023 105 lll Musculoskeletal-tumors for students adapted - 10 February 2023 106 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Codman triangle a triangle of reactive bone formation found at the proximal and distal extremes of the elevated periosteum. skin” layers of reactive bone formation ○ “Onion represent a more competent response; successive waves of tumor expansion create layers of reactive bone formation. 107 lll Musculoskeletal-tumors for students adapted - 10 February 2023 108 lll Musculoskeletal-tumors for students adapted - 10 February 2023 109 lll Musculoskeletal-tumors for students adapted - 10 February 2023 110 lll Musculoskeletal-tumors for students adapted - 10 February 2023 111 lll Musculoskeletal-tumors for students adapted - 10 February 2023 SUNBURST REACTION CODMAN’S TRIANGLE 112 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ONION-SKIN 113 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Periosteal Reactions Solid Sunburst Less malignant onion-peel Codman’s triangle More malignant 114 lll Musculoskeletal-tumors for students adapted - 10 February 2023 115 lll Musculoskeletal-tumors for students adapted - 10 February 2023 FOUR QUESTIONS OF ENNEKING 4.What is in the lesion? ○ CLUES bone/ calcific soft tissue component radiolucent/ ground glass ○ MATRIX Osteoid/ forming process chondroid/ Stippled calcification myxoid Cartilaginous 116 lll Musculoskeletal-tumors for students adapted - 10 February 2023 117 lll Musculoskeletal-tumors for students adapted - 10 February 2023 FOUR QUESTIONS OF ENNEKING 4.What is in the lesion? Neo-bone formation Osteoid forming process Stippled calcification Cartilaginous 118 lll Musculoskeletal-tumors for students adapted - 10 February 2023 119 lll Musculoskeletal-tumors for students adapted - 10 February 2023 120 lll Musculoskeletal-tumors for students adapted - 10 February 2023 121 lll Musculoskeletal-tumors for students adapted - 10 February 2023 122 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Lytic Blastic 123 lll Musculoskeletal-tumors for students adapted - 10 February 2023 124 lll Musculoskeletal-tumors for students adapted - 10 February 2023 125 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Expansile Lesions Cartilaginous 126 Osteoblastic lll Musculoskeletal-tumors for students adapted - 10 February 2023 127 lll Musculoskeletal-tumors for students adapted - 10 February 2023 128 lll Musculoskeletal-tumors for students adapted - 10 February 2023 129 lll Musculoskeletal-tumors for students adapted - 10 February 2023 130 lll Musculoskeletal-tumors for students adapted - 10 February 2023 131 lll Musculoskeletal-tumors for students adapted - 10 February 2023 132 lll Musculoskeletal-tumors for students adapted - 10 February 2023 133 lll Musculoskeletal-tumors for students adapted - 10 February 2023 NUMBER 134 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Leukemia Multiple Myeloma 135 lll Musculoskeletal-tumors for students adapted - 10 February 2023 136 lll Musculoskeletal-tumors for students adapted - 10 February 2023 137 lll Musculoskeletal-tumors for students adapted - 10 February 2023 138 lll Musculoskeletal-tumors for students adapted - 10 February 2023 139 lll Musculoskeletal-tumors for students adapted - 10 February 2023 140 lll Musculoskeletal-tumors for students adapted - 10 February 2023 141 lll Musculoskeletal-tumors for students adapted - 10 February 2023 142 lll Musculoskeletal-tumors for students adapted - 10 February 2023 143 lll Musculoskeletal-tumors for students adapted - 10 February 2023 144 lll Musculoskeletal-tumors for students adapted - 10 February 2023 145 lll Musculoskeletal-tumors for students adapted - 10 February 2023 146 lll Musculoskeletal-tumors for students adapted - 10 February 2023 147 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ⦿ CT and MRI Assess the extent of the tumor Relation to surrounding structures ⦿ Radionuclide scanning: Helpful in revealing site of a small tumor Skip lesions Silent secondary deposits 148 lll Musculoskeletal-tumors for students adapted - 10 February 2023 149 lll Musculoskeletal-tumors for students adapted - 10 February 2023 150 lll Musculoskeletal-tumors for students adapted - 10 February 2023 151 lll Musculoskeletal-tumors for students adapted - 10 February 2023 152 lll Musculoskeletal-tumors for students adapted - 10 February 2023 153 lll Musculoskeletal-tumors for students adapted - 10 February 2023 154 lll Musculoskeletal-tumors for students adapted - 10 February 2023 155 lll Musculoskeletal-tumors for students adapted - 10 February 2023 156 lll Musculoskeletal-tumors for students adapted - 10 February 2023 157 lll Musculoskeletal-tumors for students adapted - 10 February 2023 158 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Multiple hot spots seen: lung cancer which has metastasized to vertebrae. 159 lll Musculoskeletal-tumors for students adapted - 10 February 2023 160 lll Musculoskeletal-tumors for students adapted - 10 February 2023 161 lll Musculoskeletal-tumors for students adapted - 10 February 2023 162 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ANGIOGRAPHY ○Diagnostic : Feeding vessels identified as well as the tumor proximity to major vessels ○Therapeutic : Embolisation of vascular tumors prior to surgery , Intra-arterial chemotherapy 163 lll Musculoskeletal-tumors for students adapted - 10 February 2023 164 lll Musculoskeletal-tumors for students adapted - 10 February 2023 165 lll Musculoskeletal-tumors for students adapted - 10 February 2023 166 lll Musculoskeletal-tumors for students adapted - 10 February 2023 167 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Xrays Benign Treat/ manage Diagnostic Dilemma ?Malignant CT scan staging exam Biopsy MRI Treat/manage 168 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BIOPSY PRINCIPLES 169 lll Musculoskeletal-tumors for students adapted - 10 February 2023 170 lll Musculoskeletal-tumors for students adapted - 10 February 2023 171 lll Musculoskeletal-tumors for students adapted - 10 February 2023 172 lll Musculoskeletal-tumors for students adapted - 10 February 2023 173 lll Musculoskeletal-tumors for students adapted - 10 February 2023 174 lll Musculoskeletal-tumors for students adapted - 10 February 2023 175 lll Musculoskeletal-tumors for students adapted - 10 February 2023 176 lll Musculoskeletal-tumors for students adapted - 10 February 2023 177 lll Musculoskeletal-tumors for students adapted - 10 February 2023 178 lll Musculoskeletal-tumors for students adapted - 10 February 2023 179 lll Musculoskeletal-tumors for students adapted - 10 February 2023 180 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BIOPSY OF BONE TUMORS ○ Should know probable diagnosis and stage of tumor before biopsy ○ Performed by the surgeon who will perform the definitive surgery do not biopsy what you are not equipped to treat. ○ Meticulous haemostasis to avoid tracking haematomas ○ Send samples for microbiological analysis ○ Longitudinal incision. ○ sharp dissection through the muscle. ○ Uninvolved compartments should not be exposed ○ Windows in bone should be oval and small ○ 181 lll Musculoskeletal-tumors for students adapted - 10 February 2023 BIOPSY ○A biopsy is performed after appropriate staging studies ○ Alternatives include Fine needle aspiration (FNA) ○ A simple procedure that can be done using local anesthesia. ○ Most helpful in diagnosing soft tissue tumors and bony tumors with homogenous cell types ○ Obtains the least amount of material. Core needle biopsy ○ May be aided by ultrasonography, fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI). ○ The surgeon obtains a core of tissue that measures 10 mm by 2 mm. open biopsy or incisional, biopsy ○ A surgical procedure that provides the largest amount and the best sampling of tissue for pathologic identification. 182 lll Musculoskeletal-tumors for students adapted - 10 February 2023 183 lll Musculoskeletal-tumors for students adapted - 10 February 2023 184 lll Musculoskeletal-tumors for students adapted - 10 February 2023 185 lll Musculoskeletal-tumors for students adapted - 10 February 2023 CT GUIDED FNA CONFIRMED… 186 lll Musculoskeletal-tumors for students adapted - 10 February 2023 187 lll Musculoskeletal-tumors for students adapted - 10 February 2023 188 lll Musculoskeletal-tumors for students adapted - 10 February 2023 STAGING PRINCIPLES 189 lll Musculoskeletal-tumors for students adapted - 10 February 2023 190 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Benign bone tumours staging ENNEKING SYSTEMIC 211 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Staging LOCAL blood radiographic 212 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Staging blood CBC/ ESR/ CRP LFT esp ALP/ LDH Ca/ PO4/ serum prot serology PSA/ CEA etc 213 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Staging Radiographic/ local Xray CT MRI 214 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Staging Radiographic/ systemic bone scintigraphy PET CXR (mets >1cm∅) CT chest (mets >2mm∅) 215 lll Musculoskeletal-tumors for students adapted - 10 February 2023 216 lll Musculoskeletal-tumors for students adapted - 10 February 2023 217 lll Musculoskeletal-tumors for students adapted - 10 February 2023 218 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ` 219 lll Musculoskeletal-tumors for students adapted - 10 February 2023 MANAGEMENT PRINCIPLES ○AIMS: safe margins, minimum recurrence, minimum morbidity 220 lll Musculoskeletal-tumors for students adapted - 10 February 2023 221 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Surgical Margins : ○1. Intra-lesional through the tumour , leaves macroscopic tumour ,,not therapeutic. 100% recurrence For benign lesions or for debulking 222 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○2. Marginal Through pseudocapsule of tumour / reactive zone controls non-invasive benign tumours recurrence of malignant tumours = 25-50% 223 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○3. Wide around reactive zone, leaving a cuff of normal tissue skip lesions left recurrence of malignant tumours = < 10% 224 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○4. Radical removal of entire compartment or compartments distant metastases left 225 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○5. Amputation should be thought of as a form of reconstruction where surgical control of the tumor precludes useful function. 226 lll Musculoskeletal-tumors for students adapted - 10 February 2023 227 lll Musculoskeletal-tumors for students adapted - 10 February 2023 228 lll Musculoskeletal-tumors for students adapted - 10 February 2023 LIMB SALVAGE ○ Criteria for limb salvage: 1. local control of the lesion must be at least equal to amputation ( no skip lesions ) 2. the saved limb must be functional 229 lll Musculoskeletal-tumors for students adapted - 10 February 2023 LIMB SALVAGE VERSUS AMPUTATION ○The surgeon must determine whether a limb salvage operation or an amputation will provide the best outcome in terms of postoperative function and local control. Amputation usually provides better postoperative function and reduced risk of recurrence for tumors located in the distal leg Limb salvage surgery should be considered for treatment of tumors in the more proximal aspect of an extremity, because an amputation at this level would be very disabling. 230 lll Musculoskeletal-tumors for students adapted - 10 February 2023 231 lll Musculoskeletal-tumors for students adapted - 10 February 2023 232 lll Musculoskeletal-tumors for students adapted - 10 February 2023 233 lll Musculoskeletal-tumors for students adapted - 10 February 2023 234 lll Musculoskeletal-tumors for students adapted - 10 February 2023 235 lll Musculoskeletal-tumors for students adapted - 10 February 2023 236 lll Musculoskeletal-tumors for students adapted - 10 February 2023 237 lll Musculoskeletal-tumors for students adapted - 10 February 2023 238 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Rotationplasty is a new solution to disfiguring surgical resections of lower limb sarcomas: 239 lll Musculoskeletal-tumors for students adapted - 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10 February 2023 Primary Bone Tumors Bone-Forming tumors ❑ Osteoma ❑ Osteoid osteoma and osteoblastoma ❑ Osteosarcoma Miscellaneous tumors − Ewing’s sarcoma ❑ Giant cell tumor of bone Cartilage-Forming tumors ❑ Chondroma (Enchondroma) ❑ Osteochondroma ❑ Chondrosarcoma 295 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Bone-Forming Tumors 296 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Bone-Forming tumors; Tumor Type Locations Age Morphology Osteoma Facial bones, skull 40-50 Exophytic growths attached to bone surface; histologically resemble normal bon Osteoid osteoma Metaphysis of femur and tibia 10-20 Cortical tumors, characterized by pain; histologically interlacing trabeculae of woven bone Osteoblastoma Vertebral column 10-20 vertebral processes; histologically similar to osteoid osteoma Metaphysis of distal femur, proximal tibia, and humerus 10-20 Primary osteosarcoma Grow outward, lifting periosteum, and inward to the medullary cavity; microscopically malignant cells form osteoid. Femur, humerus, pelvis >40 Complications of polyostotic Paget disease; histologically similar to primary osteosarcoma BENIGN MALIGNANT Secondary osteosarcoma 297 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteoma Osteoma are benign lesions of bone that in many cases represent developmental aberrations or reactive growths rather than true neoplasms. Site; Age; Gross: Histology: 298 lll Musculoskeletal-tumors for students adapted - 10 February 2023 OSTEOID OSTEOMA ○a unique and relatively common benign bone tumor ○ The typical age at presentation is 5 to 25 years, with peak incidence in the second decade. ○ M:F is 3:1 ○ Radiographs show a radiolucent zone (the nidus) surrounded by a halo of increased density ( a sclerotic zone ). 299 lll Musculoskeletal-tumors for students adapted - 10 February 2023 300 lll Musculoskeletal-tumors for students adapted - 10 February 2023 301 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Treatment options include Observation surgical excision CT-guided radiofrequency ablation (RFA) 302 lll Musculoskeletal-tumors for students adapted - 10 February 2023 PAIN ASSOCIATED WITH AN OSTEOID OSTEOMA IS FREQUENTLY WORSE AT NIGHT AND OFTEN IS DRAMATICALLY RELIEVED BY NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) 303 lll Musculoskeletal-tumors for students adapted - 10 February 2023 OSTEOBLASTOMA ○ an uncommon benign tumor with histologic and radiographic similarities to osteoid osteoma occurs in a slightly older population frequently involves the posterior elements of the vertebrae usually does not cause night pain Patients do not report the striking relief of pain with NSAIDs ○ Radiographs show a radiolucent zone and a thin margin of reactive bone. Treatment is en bloc marginal excision. 304 lll Musculoskeletal-tumors for students adapted - 10 February 2023 305 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteosarcoma Osteosarcoma is a bone-producing malignant mesenchymal tumor. 306 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteosarcoma Radiograph 307 lll Musculoskeletal-tumors for students adapted - 10 February 2023 308 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteosarcoma Incidence: Age: Sex: Site : 309 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteosarcoma Distribution 310 lll Musculoskeletal-tumors for students adapted - 10 February 2023 OSTEOSARCOMA ○Osteosarcoma represents only 0.2% of all malignancies ○The most common primary malignant bone tumor (excluding multiple myeloma) ○Usually develops during adolescence and affects males more often than females 311 lll Musculoskeletal-tumors for students adapted - 10 February 2023 312 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○May arise anywhere 70% of these lesions develop in the metaphysis of distal femur ○proximal tibia ○proximal humerus ○ 313 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Cartilage -Forming Tumors 314 lll Musculoskeletal-tumors for students adapted - 10 February 2023 315 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Cartilage-forming Tumors; Tumor Type BENIGN MALIGNANT Locations Age Morphology Metaphysis of long tubular bones 10-30 Bony excrescences with a cartilaginous cap; may be solitary or multiple and hereditary Chondroma Small bones of hands and feet 30-50 Well-circumscribed single tumors resembling normal cartilage; arise with medullary cavity of bone; uncommonly multiple and hereditary Chondrosarcoma Bones of shoulder, pelvis, proximal femur, and ribs 40-60 Arise within medullary cavity and erode cortex; microscopically well differentiated cartilage-like or anaplastic Osteochondroma 316 lll Musculoskeletal-tumors for students adapted - 10 February 2023 OSTEOCHONDROMA ○The most common benign bony tumor ○Most are located at the metaphyseal portion of long bones, particularly the distal femur and proximal tibia. ○May be solitary and idiopathic or multiple and genetic (called hereditary multiple exostosis). ○Solitary osteochondroma has a maleto-female ratio of 2:1 317 lll Musculoskeletal-tumors for students adapted - 10 February 2023 318 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteochondroma Morphology Osteochondromas are mushroom shaped and range in size from 1 to 20 cm. The outer layer of the head of the osteochondroma is composed of benign hyaline cartilage varying in thickness Newly formed bone forms the inner portion of the head and stalk, with the stalk cortex merging with the cortex of the host bone. 319 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteochondroma (exostosis) Gross 320 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Osteochondroma (exostosis) Microscopic The cap is benign hyaline cartilage, resembling disorganized growth plate undergoing endochondral ossification. Newly formed bone forms the inner portion of the head and stalk 321 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Patients are generally in the 2ed decade ○Seek medical advice because of a bony mass. ○Activity-related pain occurs because the mass irritates surrounding muscles. ○Compression of an adjacent nerve causes radicular pain or paresthesia. 322 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Histologic examination demonstrates a bony stalk covered by a cartilaginous cap 323 lll Musculoskeletal-tumors for students adapted - 10 February 2023 324 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○May undergo malignant transformation, usually to a chondrosarcoma. (1% to 2% ) ○Occurs primarily in patients with hereditary multiple exostosis during the adult years. ○Signs suggestive of malignant transformation include pain and continued growth of the osteochondroma after skeletal maturity 325 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Treatment for a symptomatic osteochondroma is marginal excision that includes the cartilaginous cap and the overlying perichondrium. ○Recurrence is uncommon. 326 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ENCHONDROMA ○ Relatively common benign tumor that may occur at any age ○ More than half of cases involve the small bones of the hands and feet. ○ Other common sites are the metaphysis of the distal femur and the proximal humerus. ○ Many enchondromas are asymptomatic and are discovered by chance on radiographs taken for other reasons 327 lll Musculoskeletal-tumors for students adapted - 10 February 2023 328 lll Musculoskeletal-tumors for students adapted - 10 February 2023 MAFFUCCI’S SYNDROME ○Multiple enchondromatosis with soft tissue hemangiomas 329 lll Musculoskeletal-tumors for students adapted - 10 February 2023 OLLIER’S DISEASE ○Multiple enchondromatosis, especially involving the hands and feet. ○One extremity is affected more than the other 330 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Asymptomatic solitary enchondroma may be treated with observation. ○Large lesions in the hand that are expanding the cortex or that have caused a pathologic fracture can be treated by curettage with or without bone grafting 331 lll Musculoskeletal-tumors for students adapted - 10 February 2023 NONOSSIFYING FIBROMA ○very common ○causes no symptoms and rarely requires treatment ○discovered incidentally during radiography for an unrelated injury ○typically occur in the metaphysis of the femur or tibia. 332 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Radiographs show a radiolucent lesion that is eccentric (abutting one cortex) and surrounded by a rim of sclerotic, reactive bone 333 lll Musculoskeletal-tumors for students adapted - 10 February 2023 GIANT CELL TUMOR OF BONE ○A distinct, benign, but locally aggressive lesion of unknown origin ○Occurs in young adults after closure of the growth plate. ○A slight female predominance ○Common locations include the distal femur, proximal tibia, and distal radius. 334 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Giant Cell Tumor This is a neoplasm that contains large numbers of osteoclast like giant cells admixed with mononuclear cells. These tumors are slightly more common in females. 335 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Radiographic features include a lytic, eccentric lesion that involves the epiphysis and metaphyseal region of bone. ○The cortex is frequently thin and often expanded. ○The subchondral bone may be eroded. 336 lll Musculoskeletal-tumors for students adapted - 10 February 2023 337 lll Musculoskeletal-tumors for students adapted - 10 February 2023 338 lll Musculoskeletal-tumors for students adapted - 10 February 2023 339 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Typical presenting symptoms include localized pain Swelling reactive joint effusion. ○Giant cell tumors are unpredictable ○Occasionally, malignant transformation occurs. 340 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Treatment options include curettage bone grafting filling of the defect with cement. ○Recurrent lesions or lesions that have extended into the joint require widemargin excision and reconstruction 341 lll Musculoskeletal-tumors for students adapted - 10 February 2023 SOLITARY BONE CYST ○A relatively common pediatric bony lesion ○ M:F = 2:1 ○Common locations include proximal humerus proximal femur. ○Patients typically experience pain after a pathologic fracture occurs. 342 lll Musculoskeletal-tumors for students adapted - 10 February 2023 343 lll Musculoskeletal-tumors for students adapted - 10 February 2023 344 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Active cysts abut the growth plate occur more often in patients younger than 10 years associated with a higher recurrence rate. ○Latent cysts, seen in older children separated from the physis by a margin of normal bone. Thicker bony cortex indicates progressive ossification and healing. ○The “falling-leaf” sign a fragment of the eggshell-thin cortex that was displaced into the cavity after a pathologic fracture. 345 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Treatment of active lesions or lesions at risk of fracture includes injection therapy with Steroids ○autologous bone marrow ○ another substance with the goal of promoting bone formation and healing. ○ ○Lesions of the proximal femur are at greater risk for a disabling fracture. Flexible intramedullary nails or other fixation devices may be used as internal struts. ○The perforation of a cyst by these devices stimulates the healing process. 346 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ANEURYSMAL BONE CYST (ABC) ○ Is a reactive process ○ Rapidly expansile lesion with multiple blood filled cystic cavities. ○ Age 5-20 ○ Rapid onset of pain 347 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Before effective chemotherapy was developed, approximately 80% of patients died of metastases, even after prompt amputation ○Standard treatment now includes Biopsy confirmation of diagnosis staging studies preoperative chemotherapy for 11 weeks surgical resection postoperative chemotherapy for several more weeks. 348 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Improved reconstructive techniques have increased the number of limb-sparing operations to approximately 80%. ○With current treatment, the 5-year disease-free survival rate for persons with stage II osteosarcoma is approximately 70%. 349 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Chondrosarcoma Chondrosarcomas comprise a variety of tumors sharing the ability to produce neoplastic cartilage 350 lll Musculoskeletal-tumors for students adapted - 10 February 2023 351 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Chondrosarcoma Gross features SITE; pelvis, shoulder, ribs. rarely involve the distal extremities. 352 lll Musculoskeletal-tumors for students adapted - 10 February 2023 CHONDROSARCOMA ○ less common and grows more slowly than osteosarcoma ○ Primary chondrosarcomas located centrally within the medullary canal more common among males a peak incidence at between 30 and 60 years of age. Frequent sites include the proximal femur, pelvis, proximal humerus, and scapula. ○ Secondary chondrosarcomas typically associated with a previous osteochondroma located on the periphery of bone, but they may occur in an extraosseous soft tissue location. 353 lll Musculoskeletal-tumors for students adapted - 10 February 2023 354 lll Musculoskeletal-tumors for students adapted - 10 February 2023 355 lll Musculoskeletal-tumors for students adapted - 10 February 2023 356 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Low-grade chondrosarcomas may be difficult to differentiate from benign osteochondromas or enchondromas. ○ Radiographs show a permeative radiolucent lesion with areas of calcification that may be diffuse (“salt and pepper” pattern) or more discrete (“popcorn” pattern). ○ The incidence of distant metastases is related to the degree of malignancy. 357 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Chondrosarcoma is treated by surgical resection. ○Radiation therapy is not helpful ○Chemotherapy is reserved for patients with metastases 358 lll Musculoskeletal-tumors for students adapted - 10 February 2023 EWING SARCOMA ○The second most common malignant bone tumor, after osteosarcoma ○The age range is 5 to 25 years, with peak incidence at between 10 and 20 years ○more common among males. ○The most common site is the femur, followed by the tibia, humerus, pelvis, and fibula 359 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○Pain is the most common presenting symptom. ○In advanced cases, systemic symptoms such as fever and malaise may be noted the condition may mimic osteomyelitis 360 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Radiographs show a permeative pattern of destruction in the diaphysis or the metaphyseal portion of bone. ○ Thinning and erosion of the cortex is common and a Codman triangle, or “onion skin” periosteal reaction, may be seen 361 lll Musculoskeletal-tumors for students adapted - 10 February 2023 362 lll Musculoskeletal-tumors for students adapted - 10 February 2023 363 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○After appropriate staging and biopsy have been performed the patient is treated with inductive chemotherapy. The tumor then is further evaluated for treatment with wide-margin surgical resection or irradiation. The survival rate is approximately 70% for patients without metastases 364 lll Musculoskeletal-tumors for students adapted - 10 February 2023 365 lll Musculoskeletal-tumors for students adapted - 10 February 2023 366 lll Musculoskeletal-tumors for students adapted - 10 February 2023 367 lll Musculoskeletal-tumors for students adapted - 10 February 2023 368 lll Musculoskeletal-tumors for students adapted - 10 February 2023 369 lll Musculoskeletal-tumors for students adapted - 10 February 2023 370 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Lipoma Very common benign tumor Subcutaneous tissue of the trunk and limbs in the middle-aged and elderly Soft, slowly growing mass Lipoma variants: Angiolipoma: thin-walled small blood vessels occupy significant portion of the lesion Spindle-cell lipoma: mixture of mature adipocytes, short bundles of collagen and small uniform spindle cells 371 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Liposarcoma The most common malignant soft tissue tumor Adults (peak incidence 40-60 years) Site: lower limb and retroperitoneal space Subtypes: Well-differentiated lipoma-like liposarcoma (atypical lipomatous tumor): closely resemble lipoma, but a few spindle or stellate cells with hyperchromatic atypical nuclei, high reccurence rate, no meastases Myxoid liposarcoma: small undifferentiated mesenchymal cells ad lipoblast set in a myxoid stroma, plexiform „chickenwire“ network of capillaries, good prognosis, rare metastases Pleomorphic liposarcoma: mixed cell population (spindle cells, tumor giant cells and small number of lipoblasts), poor prognosis, frequent metastases 372 lll Musculoskeletal-tumors for students adapted - 10 February 2023 Leiomyoma Skin, subcutaneous tissue, uterus, gastrointestinal tract Leiomyosarcoma Mesentery, retroperitoneal space, wall of large veins, skin, subcutaneous tissue, deep soft tissues of limbs Signs of malignancy: large size, high mitotic rate, areas of necrosis, marked cellular pleomorphism 373 lll Musculoskeletal-tumors for students adapted - 10 February 2023 374 lll Musculoskeletal-tumors for students adapted - 10 February 2023 RECENT 375 lll Musculoskeletal-tumors for students adapted - 10 February 2023 376 lll Musculoskeletal-tumors for students adapted - 10 February 2023 377 lll Musculoskeletal-tumors for students adapted - 10 February 2023 378 lll Musculoskeletal-tumors for students adapted - 10 February 2023 379 lll Musculoskeletal-tumors for students adapted - 10 February 2023 380 lll Musculoskeletal-tumors for students adapted - 10 February 2023 381 lll Musculoskeletal-tumors for students adapted - 10 February 2023 382 lll Musculoskeletal-tumors for students adapted - 10 February 2023 383 lll Musculoskeletal-tumors for students adapted - 10 February 2023 384 lll Musculoskeletal-tumors for students adapted - 10 February 2023 385 lll Musculoskeletal-tumors for students adapted - 10 February 2023 386 lll Musculoskeletal-tumors for students adapted - 10 February 2023 ○ Early detection, proper techniques of diagnosis and treatment can dramatically improve the chances of survival & achieving functional limb salvage. 387 lll Musculoskeletal-tumors for students adapted - 10 February 2023