Bone tumors
• Rare tumors (< 2%)
• More in young ages
Outline
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Introduction (signs, symptoms, investigation)
Benign tumor
Malignant tumor
Metastatic bone tumor
Classification
• Origin
– Primary
– Secondary (95%): breast, lung, prostate, kidney and
thyroid
• cell type:
– Bone Osteoma, osteosarcoma
– Cartilage Chondroma, Chondrosarcoma
– Marrow Hemangioma, angiosarcoma
– Fibrous tissueFibroma, fibrosarcoma
• Tumor type:
– Benign: Osteoma, osteochondroma
– Malignant:: Osteosarcoma, chondrosarcoma
Symptoms and Signs
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Asymptomatic and discovered accidentally.
General: fatigue, fever, wt. loss
Mass can be felt at the tumor site.
Pain:
– May worsen at night and awakes patient, caused by
– Tumor compression on surrounding tissue
– Hemorrhage in the tumor
– Pathological fractures
Swelling
Local tenderness
Warmth
Pathological fracture: may be the first sign.
Malignant vs. Benign Tumors
• Rapid growth
• Warmth
• Tenderness
• Ill defined edges
All are suggestive of malignancy.
Investigations
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History and examination
Imaging (x-ray, CT, MRI & radionuclide scanning)
Biopsy
Labs
• Ca & P: Greater than normal levels may indicate bone
metastasis.
• PTH: Lower than normal levels may indicate bone metastasis.
• ALP isoenzyme: Higher than normal ALP levels may indicate
Paget's disease, osteoblastic bone cancers, osteomalacia and
rickets.
• LDH: High values indicate poor prognosis
Plain x-ray
• Most useful
• Could see:
• Lump
• Cysts
• Bone destruction
• Cortical thickening & periosteal reaction
• Important to notice:
• Where
• How many
• Cystic or not
• Margins
• Destruction
Periosteal reaction
• Periosteal hypertrophy which develops in response to
periosteal irritation. They are a non-specific sign.
• They have many causes:
- Infections
- Tumors (both benign & malignant)
- Benign tumors are thick & smooth or completely absent
- Malignant tumors are thinner & irregular (wavy).
- Healing fractures
- Chronic stress
Periosteal reactions seen
in the distal tibia and
fibula.
Periosteal reaction at the
distal radius with
irregular edges:
malignant.
Osteosarcoma of the
distal femur:
Codman’s triangle
can be seen:
periosteum is being
“lifted off”.
Midshaft periosteal
reaction with smooth +
thick edges: this is a
benign osteoma.
• Periosteal reaction of tibia healing from a
fracture showing a smooth and thick.
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CT and MRI
• Asses the extent of the tumor
• Relation to surrounding structures
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Radionuclide scanning:
• Helpful in revealing site of a small tumor
• Skip lesions
• Silent secondary deposits
Multiple hot spots seen:
lung cancer which has
metastasized to vertebrae.
Biopsy
• Allows us to reach a diagnosis.
• Allows us to plan for treatment.
Methods:
• Open biopsy: surgical procedure done under GA.
• Zonal biopsy: open biopsy from transition zone.
• Excisional biopsy: excision of the entire tumor.
• Large–bore needle biopsy: aspirating cells.
Complications:
1. Hemorrhage
2. Wound break down
3. Infection
4. Pathological fractures
Benign tumors
Benign bone tumors
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Non ossifying fibroma
Osteochondroma (the Commonest)
Osteoid osteoma
Enchondroma
Giant cell tumor of bone
Osteoblastoma
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Most bone tumors are benign
Most often are asymptomatic
Unlikely to spread
Usually found in the biggest bones (femur, tibia &
humerus)
• Some types are more common in specific places
(near the growth plates)
• Appearance and location of mass on radiographs
are keys to diagnosis.
Osteochondroma (exostosis)
• Commonest benign tumor of bone
• More in male <25y.
• Solitary
• Mature bone with cartilaginous cap.
• Common sites are the fast growing sites of long bones (lower
end of femur and upper end of tibia), crest of ileum &
shoulder.
• Flattened (sessile) or stalk-like (exostosis)
• Most likely caused by Congenital defect or trauma of the
perichondrium, which results in the herniation of a fragment of the
epiphyseal growth plate through the periosteal bone cuff.
• Osteochondromas Small risk of malignant
transformation(<1%)
Symptoms:
• A hard, immobile, detectable mass that is painless
• Lower-than-normal-height for age
• Muscle soreness
• One leg or arm may be longer than other
• Pressure or irritation with exercise
• X-Ray:
• Exostosis: well defined bony projection
• Calcified cartilage in large lesions
Treatment: excision if becoming bigger and more painful.
Well defined bony projection
• Solitary osteochondroma.
• Lateral radiograph of a
sessile osteochondroma of
the distal femur
Non-ossifying fibroma
• Fibrous tissue within bone ossiffy in time
• Asymptomatic, incidental findings
• Metaphysis of long bones
• Occasionally multiple lesion
• Developmental defect, seen in children
• As bone grows, defect becomes less obvious
• May enlarge and cause pathological fracture
• No treatment, unless there is pathological fracture
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Well marginated radiolucent lesion
Distinct multilocular appearance
Osteoid osteoma
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Neoplastic proliferation of osteoid and fibrous tissue
More in male < 30 year
more in vertebra or long bones
Less in mandible or other craniofacial bones.
Small in size (<1.5 cm)
Oval or rounded shape
Pain (severe) worse at night ,not relieved by rest but relieved
by aspirin.
• Types: Cortical, cancellous, subperiosteal.
• Treatment: Complete removal after careful localization by
CT.
X-Ray
• Nidus: tiny radiolucent area
• Diaphysis  surrounded by dense bone and
thickend cortex
• Metaphysis  less cortical thickening
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Male 23 years old
History of increasing pain in the knee
& relieved by aspirin.
• Plain radiograph in a
25-year-old male with
cortical osteoid
osteoma. shows a
radiolucent nidus
surrounded by fusiform
cortical thickening
a 25-year-old male with cortical osteoid osteoma.
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Radionuclide bone scan shows focal intense activity at tumor site.
• 6y old child who presented with left hip pain.
• Well-defined area of sclerosis surrounded by a ring of
radiolucency in the left femoral neck.
• Note the absence of periosteal reaction that suggests
intramedullary or cancellous osteoid osteoma.
• Transaxial CT scan through the proximal shaft of the right
femur in a 17-year-old boy.
• Osteoid osteoma adjacent to the endosteal margin of the cortex.
• Central sclerotic focus in the radiolucent nidus
Osteoid osteoma of transverse process of vertebra
Malignant tumors
• Primary
• Secondary (metastasis)
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Uncommon cancer
Most commonly affects the long bones
20 % of pediatric bone tumors are malignant.
66% of adult bone tumors are malignant, most
commonly mets.
• The most common type of bone cancer in adults is
metastatic cancer from other organs
Primary bone cancer
Risk factors:
1. Radiotherapy & chemotherapy
2. Paget's disease
3. Family Hx (hereditary retinoblastoma)
Signs & symptoms
• Fever, Night sweats, Fatigue & Unintended weight loss
• Bone pain that often is nocturnal
• Swelling & tenderness near the affected area
• Pathological fractures
Osteosarcoma
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Most common primary bone malignancy
Incidence: 2.8 per million
M >F
Age 10-25 years (the 8th most common childhood cancer)
Prognosis
• Aggressive tumor
• Metastasis to the lung
• 5-year survival
– Without mets is 70%
– With mets is 25%
Where
Mainly affects metaphysis
of long bones
More in:
• Knee
– Distal femur
– Upper tibia
• Humerus (prox.end)
• Maxilla
Clinical features
• Pain:
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Dull aching
Progressive
Constant
Worse at night
Swelling
Redness
Hotness
Tenderness
Pathological fracture
DDX
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Stress fracture
Ewing's sarcoma
Osteomyelitis
Osteochondroma
Osteoblastoma
Bone cysts
Chondroblastoma
Chondrosarcoma
Giant cell tumor
Diagnosis:
• Radiological studies:
1. X-Ray
2. CT-scan
3. Bone scan & MRI
• Bone biopsy, the only definitive method to
determine whether a tumor is malignant or
benign.
Treatment:
• Surgical resection
• Preoperative & postoperative chemotherapy
X-ray findings
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Lesion
Cortical destruction
Extension to the marrow or soft tissue
Codman’s triangle a term used to describe the triangular area
of new subperiosteal bone that is created when a lesion, often
a tumour, raises the periosteum away from the bone.
5. Sunburst Effect
Osteosarcomas can be
• Predominantly osteolytic
• Predominantly osteoblastic
• Mixture
Sunburst Appearance
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Clinical appearance of a teenager who presented with
osteosarcoma of the proximal humerus
Swelling throughout the deltoid region
Disuse atrophy of the pectoral muscule
• White arrow:
codman triangle
• Black arrow:
soft tissue mass
Patholigical
fracture
Ewing sarcoma
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A malignant round-cell tumor.
Rare disease (incidence 0.6 per million
2nd most common bone malignancy in pediatrics.
M>F
Age 10-20 years
Usually the lesions are diaphyseal
Mets (30%), most commonly in the lungs & other
bones & less commonly in the bone marrow.
Most common
areas:
• Pelvis
• Femur
• Humerus
• Ribs
• Clavicle
Clinical feature:
• Pyrexia
• Pain:
– Constant
– Increase with movement
• Limping
• Swelling, warm, tender & red
Radiological studies:
1. X-Ray
1. Lytic medullary lesion
2. Onion skin appearance
2. CT-scan
3. Bone scan & MRI
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White arrow: onion skin apperance
Red circle: sunburst periosteal reaction
Blue circle: osteolytic lesion
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Periosteal
reaction
Osteolytic
lesion
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Periosteal
reaction
Osteolytic
lesion
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Periosteal
reaction
Osteolytic
lesion
Treatment:
1. Local radiotherapy combined with systemic
chemotherapy
2. In young children amputation may be necessary
due to severe compromise of bone growth.
Prognosis, 5-year survival
• 50% with the 1st approach
• 75% with the 2nd approach
Metastatic bone tumor
• Most common malignant lesion of the bone.
• The most common sites of spread of cancers are lung, liver &
skeleton.
• Carcinomas are much more likely to metastasize to bone than
sarcomas
• Typically multifocal BUT renal and thyroid carcinomas produce
only a solitary lesion.
• Common sites for metastasis:
– Vertebrae, pelvis, proximal parts of the femur, ribs, proximal
part of the humerus, and the skull.
– Batson venous plexus >> more mets to the axial skeleton
– Hands & feet are rare
– 50% of them originate from lung neoplasms.
• Mets:
1. Direct extension
2. Retrograde venous flow
3. Seeding with tumor emboli via the blood circulation
Destructive expanded
osteolytic lesion in the
metacarpal of the thumb
in a 55-year-old man with
lung carcinoma.
Mets (adults)
• Osteoblastic behaviour
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Prostate
Stomach
Bladder
Breast
 Osteolytic behaviour
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Lung
Kidney
Colon
Thyroid
Breast
Typical x-ray appearance of osteolytic bone metastases. This plain pelvic xray film of a 75-year-old patient with breast carcinoma shows multiple
osteolytic bone lesions. =>decrease in bone density.
Typical x-ray appearance of osteoblastic bone metastases. This plain
pelvic x-ray film of a patient with prostate cancer shows multiple
osteoblastic metastases to the pelvis and lumbar (L4) and sacral (S1)
vertebral bodies.=>increase in bone density
Mets (kids)
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Neuroblastoma
Wilm’s tumor
Osteosarcoma
Ewing’s sarcoma
Rhabdomyosarcoma
Presentation
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Pain which results in reduced mobility.
Bone weakness which predispose to pathologic fractures.
Palpable masses (large bony lesions).
Neurologic impairment due to spinal epidural compression.
Anemia (decreased red blood cell production) is a common
blood abnormality in these patients.
• Past history of primary malignant tumor symptoms, BUT
others did not complain of anything before.
• A radiograph of a
destructive pathological
fracture on the left hip, in a
man with metastatic renal
cell cancer.
• The patient underwent
replacement of the upper
femur due to extensive
destruction of the bone
around the hip.
Approach
• History & physical examination
• Radiological studies
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Plain X-ray
MRI
CT scan
Bone scan (Technetium-99m)
• Laboratory studies
• Biopsy
Radiological studies
• X-ray: destruction of bone and/or lucent Lesions of Bone
• Bone scan: most cost-effective and available whole-body screening
test for the assessment of bone metastases.
• CT
– Useful in evaluating suspicious bone scintiscan findings
– Useful in guiding needle biopsy, particularly in vertebral lesions.
• MRI
– Useful in evaluating suspicious bone scintiscan findings
– Help in detecting metastatic lesions before changes in bone
metabolism
– Helpful in determining the extent of local disease in planning
surgery or radiation therapy.
Hot spots: Increased
osteoclastic activity
X-ray
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RadioIsotope
Pt. presented with pain in the right upper thigh
X-ray showing METS in upper 1/3 of the femur
Radioisotope scan revealed many deposits in other parts of the skeleton.
Treatment
Divided into:
1. Systemic therapy
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Chemotherapy
Hormone therapy
Immunotherapy
2. Local therapy
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Radiation therapy
Surgery
Treatment
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Radiation therapy combined with chemotherapeutic or
hormonal agents, is the most common treatment modality.
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Early use of radiation and bisphosphonates (zoledronic acid,
pamidronate) slows bone destruction.
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Some tumors are more likely to heal after radiation therapy:
– Blastic lesions of prostate and breast
– Lytic destructive lesions of lung and renal cell
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Surgery is indicated in fractures or large metastatic mass.
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A woman with advanced metastatic breast cancer to bone
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Pain in both her right and left hips
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A special partial hip replacement was necessary on the right because
the hip joint was involved.
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On the left, a special nail could be used to strengthen the femur bone
below the hip.
Thank You
Good Luck