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

2. 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

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

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

5. 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

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

7. 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?

8. 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)

9. 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

10. 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

11. 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-G T1 M1
IIIB G1-G T2 M1

12. 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
                                  

13. 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)
                          

14. 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)

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

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

17. 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

18. 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)

19. BENIGN BONE TUMORS

20. Osteochondroma (Exostosis)

21. Enchondroma

22. Enchondroma
Ollier disease
Maffuci synd.

23. Osteoid osteoma

24. Osteoblastoma

25. Gaint cell bone tumor (Osteoclastoma)

26. Chondroblastoma

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

28. TUMOR LIKE LESIONS

29. Simple (solitary) bone cyst

30. Aneurysmal bone cyst

31. Eosinophilic granuloma

32. Non-ossifying fibroma (Fibrous cortical defect)

33. Fibrous dysplasia
mlgn
5 years later

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

35. MALIGNANT BONE TUMORS

36. Osteosarcoma
Birkaç ay sonra

37. 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

38. Chondrosarcoma

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

40. Ewing’s sarcoma

41. Multiple myeloma

42. Chordoma

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

44. METASTATIC BONE TUMORS

45. 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

46. 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

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

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

49. THANKS