BONE TUMORS Assoc. Prof. Melih Güven Yeditepe University Hospital Department of Orthopaedics and Traumatology

Learning Objectives Classification of benign bone tumors Charasteristic clinical and radiological features of most common benign bone tumors Definition of tumor like lesions Classification of malign bone tumors Charasteristic clinical and radiological features of most common malign bone tumors Charasteristic features of metastatic bone tumors Surgical applications in benign and malign bone tumors

Bone tumors General knowledge Benign tumors Tumor like lesions Malign tumors Metastatic bone tumors

General approaches Initial referral Pain Deeply, sharp and increased over time Localized sensitivity and rush Pathologic fracture Deformity Incidental finding

General approaches First stage evaluation Anamnesis Duration and level of pain, number and duration of the lesions, age, loss in weight, fever, weakness Physical examination Site and size of the lesion, mobility, sensitivity,LAP Radiological evaluation Codman triangle, onion skin view, sunrise view Laboratory findings ALP, serum Ca level, ESR, LDH, protein electrophoresis

General approaches Second stage evaluation CT Bone scintigraphy – Tc 99m Anjiography MRI PET – CT

General approaches Radiological evaluation Definition of the radiographs Where is the tumor? Name of the bone, proximal-distal, metaphysis-diaphysis What is the localisation of the tumor? Central, medullary, cortical How does the tumor effect the bone? Lysis, sclerosis, destruction, deformity Any surrounding abnormalities?

General approaches Second stage evaluation Biopsy Closed Fine needle aspiration biopsy Trochar biopsy Needle biopsy under CT control Open Incisional biopsy Excisional biopsy Frozen section biopsy (intraoperative)

Staging Staging of benign bone tumors (Enneking) Stage I: Latent thick capsule, no reactive zone can grow up in children and adolescents, no growing in adults, spontaneous healing can occur Stage II: Active thick capsule, adhesions between capsule and surrounding soft tissue, thick reactive zone no spontaneous healing, rarely metastasis

Grading Staging of benign bone tumors (Enneking) Stage III: Agressive irregular border of the lesion, very thin capsule thick and edematous reactive zone Tumor grows up rapidly into the surrounding tissues, no restrictive tissues around the tumor

Staging Staging of malignant bone tumors (Enneking) G (Grade) : G1 %10 > metastasis potency , G2 %20 < metastasis potency T (Compartment) : intracompartmental (T1) or extracompartmental (T2) M (Metastasis): Lymph nodule or far metastasis IA G1 T1 M0 IB G1 T2 M0 IIA G2 T1 M0 IIB G2 T2 M0 IIIA G1-G2 T1 M1 IIIB G1-G2 T2 M1

General classification Tumors with osseous origin     a-Benign:  Osteoma, Osteoid osteoma, Osteoblastoma b-Malignant:   Osteosarcoma Tumors with cartilaginous origins     a- Benign : Chondroma, Osteochondroma, Chondroblastoma, Chondromixoid fibroma     b- Malignant :  Chondrosarcoma                                   

General classification Tumors with bone marrow origins Ewing sarcoma Reticulum cell carcinoma of the bone Lymphosarcoma of the bone Multiple or solitary myeloma Gaint cell tumors Gaint cell bone tumors (osteoclastoma)                           

General classification   Tumor like lesions (Fibrous, cystic) Solitary bone cyst (unicameral bone cyst) Aneurysmal bone cyst Non-ossifying fibroma (fibrous cortical defect) Eosinophilic granuloma Fibrous dysplasia Myositis ossificans Brown tumor (hyperparathyreoidismus)

Treatment First of all, LIFE !! Extremity preserving surgery Usable extremity Physical appearance of the body Psychological compliance Sociocultural compliance

Surgical treatment 1.Intracapsular: 2.Marginal excision: - Benign, latent lesions 2.Marginal excision: - Excision of the lesion with reactive zone - Benign, active lesions

Surgical treatment 3.Wide resection: - Resection of the tumor with surrounding healthy- normal tissues - Benign, aggressive lesions; malignant low grade lesions (with adjuvant therapies) 4.Radical resection: - Resection of the whole, entire compartment - Malignant high grade lesions 5. Amputation

Adjuvant therapies Chemotherapy Radiotherapy Local adjuvants: Neoadjuvant (8-12 weeks) Adjuvant (6-12 months) Drugs: metotrexate, cyclophosphamid, ifosfamide, doxorubicin, vincristine ve cis-platine Radiotherapy Local adjuvants: Phenol, hydrogene peroxide, liquid nitrogen, bone cement, alcohol, coterisation, hot water (80°C)

BENIGN BONE TUMORS

Osteochondroma (Exostosis)

Enchondroma

Enchondroma Ollier disease Maffuci synd.

Osteoid osteoma

Osteoblastoma

Gaint cell bone tumor (Osteoclastoma)

Chondroblastoma

Benign bone tumors Osteochondroma Enchondroma Osteoid osteoma Multiple familial osteochondromatosis Enchondroma Osteoid osteoma Osteoblastoma Gaint cell bone tumor Chondroblastoma

TUMOR LIKE LESIONS

Simple (solitary) bone cyst

Aneurysmal bone cyst

Eosinophilic granuloma

Non-ossifying fibroma (Fibrous cortical defect)

Fibrous dysplasia mlgn 5 years later

Tumor like lesions Simple (solitary) bone cyst Aneurysmal bone cyst Eosinophillic granuloma Fibrous cortical defect Fibrous dysplasia

MALIGNANT BONE TUMORS

Osteosarcoma Birkaç ay sonra

Osteosarcoma Classification: Parosteal osteosarcoma Clasic osteosarcoma Parosteal osteosarcoma Periosteal osteosarcoma Endosteal osteosarcoma Telengiectatic osteosarcoma Small cell osteosarcoma Intracortical osteosarcoma Secondary osteosarcoma Paget, Rt, low grade Chondrosarcoma, fibrous dysplasia,bone infarct

Chondrosarcoma

Chondrosarcoma Classification: Low grade, borderline, high grade Primary Low grade, borderline, high grade Secondary Multiple familial osteochondromatosis, Ollier disease, Mafucci syndrom

Ewing’s sarcoma

Multiple myeloma

Chordoma

Malignant bone tumors Osteosarcoma Chondrosarcoma Ewing’s sarcoma Multiple myeloma Chordoma

METASTATIC BONE TUMORS

Metastatic bone tumors Pain (most common), ROM limitation, pathologic fracture, cord compression, hypercalcemia Most common; breast in females, prostate and lung in males Breast cancer %73 Ductal carcinoma Prostate cancer %68 Adeno ca Thyroid cancer %42 Papiller ca Lung cancer %36 Renal carcinoma %35 Clear cell ca Rectum carcinoma %11

Metastatic bone tumors Metastasis; Direct Indirect Lymphogenic Hematogenic Localisation of metastasis; - vertebra % 69 - pelvis % 41 - femur % 25 - cranium % 14 Osteoblastic or osteolytic Batson vertebral venous plexus

Breast metas. Renal met. Prostat met. Prostate met. ob ol Lung met.

Metastatic bone tumors Diagnosis; Bone scintigraphy – Tc 99m Radiography CT MRI PET-CT Biopsy Standard

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