1. BONE TUMOURS
Day : Tuesday
Date :
Time :

2. Bone Tumours Understand the clinical algorithm
WHAT SHOULD YOU KNOW
Understand the clinical algorithm
Correlate clinical presentation with radiological features
Understand the classification and types of bone tumours
Comprehend the management of bone tumours
Understand the necessity for a team-approach
Correlate Pathological findings with clinical presentation (Clinico-pathological correlation)

3. BONE TUMOURS may result in amputation
rare but
may result in amputation
disfigurement and great physical challenge

4. Classification of bone tumours
Simple classification
A i. Primary
ii Secondary- more common
B i. Benign oma
ii. Malignant sarcoma

5. Primary Bone tumors are classified
according to the cell of origin

6. Histologic Type
Benign
Malignant
Hematopoietic (40%)
Myeloma
Malignant lymphoma
Chondrogenic (22%)
Osteochondroma
Chondrosarcoma
Chondroma
Dedifferentiated chondrosarcoma
Chondroblastoma
Mesenchymal chondrosarcoma
Chondromyxoid fibroma
Osteogenic (19%)
Osteoid osteoma
Osteosarcoma
Osteoblastoma
Unknown origin (10%)
Giant cell tumor
Ewing tumor
Adamantinoma
Histiocytic origin
Fibrous histiocytoma
Malignant fibrous histiocytoma
Fibrogenic
Metaphyseal fibrous defect (fibroma)
Desmoplastic fibroma
Fibrosarcoma
Notochordal
Chordoma
Vascular
Hemangioma
Hemangioendothelioma
Hemangiopericytoma
Lipogenic
Lipoma
Liposarcoma
Neurogenic
Neurilemmoma

7. Diagnosis of Bone Tumours
1. Age of patient
2. Location of tumour
3. Radiological appearance
4. Histological features

8. AGE(probably the most important clinical clue).
Age group
Most common benign lesions
Most common malignant tumors
0-20
non-ossifying fibroma fibrous dysplasia simple bone cyst aneurysmal bone cyst osteochondroma (exostosis) osteoid osteoma osteoblastoma chondroblastoma chondromyxoid fibroma
eosinophilic granuloma
Ewing's sarcoma leukemic involvement metastatic neuroblastoma
osteosarcoma, Ewing's sarcoma,
enchondroma giant cell tumor
chondrosarcoma
40 & above
osteoma
metastatic tumors myeloma leukemic involvement chondrosarcoma osteosarcoma (Paget's associated) MFH chordoma

9. SITE OF LONG BONE INVOLVEMENT (most primary bone tumors have favored sites within long bones; this may provide a clue to diagnosis).
Diaphyseal lesions centered in the cortex: Osteoid osteoma
Diaphyseal intramedullary lesions: Ewing's sarcoma, lymphoma, myeloma. Common for fibrous dysplasia and enchondroma
Metaphyseal intramedullary lesions: Osteosarcoma is usually centered in the metaphysis. Chondrosarcoma and fibrosarcoma often present as metaphyseal lesions. Osteoblastoma, enchondroma, fibrous dysplasia, simple bone cyst, and aneurysmal bone cyst are common in this location.
Metaphyseal lesions centered in the cortex: Classic location for a non-ossifying fibroma (NOF). Also, a common site for osteoid osteoma.
Epiphyseal lesions: Chondroblastoma (Ch) and Giant Cell Tumor (GCT) are almost invariably centered in the epiphysis. Chondroblastoma is a rare tumor seen in children and adolescents with open growth plates. GCT is the most common tumor of epiphyses in skeletally mature individuals with closed growth plates. GCT often shows metaphyseal extension.
Metaphyseal exostosis: Osteochondroma

10. Radiological Features

11. Benign Tumours Osteochondroma
Also known as an exostosis, is a cartilage –capped
out growth.
Men are affected three times more often
than women
Develop in bones of endochondral origin and arise from the metaphysis near the growth plate of long bones especially about the knee

12. Development over time of an osteochondroma
beginning with an outgrowth from the epiphyseal cartilage

13. Osteochondroma Clinically present as slow growing masses
Can be painful if they impinge on a nerve
or if stalk is fractured.
In many cases, they are detected as an
incidental finding.
Rarely they give rise to chondrosarcoma

14. Osteochondroma of femur
The white arrows point to a mushroom-shaped, peduculated bony excresence arising from the anteromedial aspect of the distal femoral metaphysis, attached to the parent bone and pointing away from the metaphyisis
Osteochondroma
of femur

15. Osteochondroma

16. Chondroma Benign tumours of hyaline cartilage
May arise within the medullary cavity-enchondroma
May arise on the surface of bone – subperiosteal chondroma
Enchondromas are the most common
Located in the metaphyseal region of tubular bones
Most enchondromas are asymptomatic and detected
as incidental finding

17. Enchondroma of the phalanx with a
pathological fracture

18. Enchondroma with a nodule of hyaline cartilage encased by a thin layer of reactive bone.

19. Osteoid osteoma and Osteoblastoma
Have identical histology
Osteoblastoma larger than osteoid osteoma

20. Osteoid osteoma < 2 cm in greatest dimension
Affects teenagers and adolescents
75 % of patients < 25 years
Affects cortex of femur or tibia
Painful lesion
Relieved by salicylate

21. Osteoid osteoma of
Femoral neck

22. Osteoid osteoma

23. 1. Compare and contrast : with respect to: Chondrosarcoma
Osteosarcoma
Chondrosarcoma
Giant cell tumor
Ewing's tumor
with respect to:
Histogenesis
age of group affected
location in the skeleton
histologic hallmarks
clinical behaviour
prognosis

24. Osteosarcoma (OS) Most common primary malignant tumor of the bone
Mesenchymal tumor
Cancerous cells produce bone matrix
75 % occur in patients younger than 20 years of age

25. Osteosarcoma (OS)
Primary osteosarcoma arise in the
metaphysis of long bones of the extremities
Secondary osteosarcomas occur in older patients with Paget’s disease
More common in men than women
Common sites are distal end of femur
or proximal tibia

26. Osteosarcoma (OS)
Patients with Mutation of Rb gene are predisposed to osteosarcoma
Concurrent trauma to bones and joints
In the elderly OS often arises from pre existing bone diseases eg: Paget’s disease of bone

27. Osteosarcoma (OS)
Clinical Presentation
Painful and progressively enlarging
masses
Spread through blood stream
The tumour breaks through the cortex
and lifts the periosteum
Often metastasizes to the lungs

29. Osteosarcoma on distal end of femur
Cortex is
destroyed

30. Neoplastic osteoblasts forming osteoid

31. Chondrosarcoma Frequency is about half of osteosarcoma
Second most common malignant matrix producing tumor
Mean age for chondrosarcoma is 43 years
Men are affected more than women

32. Chondrosarcomas Commonly arise in the central portions of the skeleton
including Pelvis, proximal femur, ribs, sternum and shoulder girdle

33. Chondrosarcoma Present as painful progressively enlarging masses
Prognosis depends on size of tumor
Spreads to lungs and skeleton

35. Chondrosarcoma

36. Chondrosarcoma Tumor has developed in the proximal femur
Not destroyed the cortex
Has a bluish, glassy appearance , reminiscent of cartilage

37. Malignant neoplastic cells produce a chondroid matrix

39. The aggressiveness of chondrosarcomas can be predicted by their histologic grade. Grading system is based on three parameters: cellularity, degree of nuclear atypia and mitotic activity.
Grade 1 (low-grade) Very similar to enchondroma. However, the cellularity is higher, and there is mild cellular pleomorphism. The nuclei are small but often show open chromatin pattern and small nucleoli. Binucleated cells are frequent. Mitoses are very rare. Grade 1 chondrosarcomas are locally aggressive and prone to recurrences, but usually do not metastasize.
Grade 2 (low-grade) The cellularity is higher than in Grade 1 tumors. Characteristic findings are moderate cellular pleomorphism, plump nuclei, frequent bi-nucleated cells, and occasional bizarre cells. Mitoses are rare. Foci of myxoid change may be seen. Unlike Grade 1 tumors, about 10% to 15% of Grade 2 chondrosarcomas produce metastases.
Grade 3 (high-grade) Characteristic findings are high cellularity, marked cellular pleomorphism, high N/C ratio, many bizarre cells and frequent mitoses (more than 1 per hpf). These are high grade tumors with significant metastatic potential.

40. Giant cell tumour of bone (GCT)
Contains a profusion of multinucleated
osteoclast type giant cells
Relatively uncommon benign
But locally aggressive
Usually arises during 5th decade
Slight female predominance

41. Involve both epiphysis and metaphysis
Giant cell tumour of bone (GCT)
Involve both epiphysis and metaphysis
In adolescents limited to metaphysis
Common sites are distal femur and proximal tibia

46. Ewing sarcoma(ES) Primary malignant small round cell tumour
Ewing sarcoma has the youngest
average age at presentations (10-15 years)
Boys slightly more often affected than girls

47. Ewing sarcoma(ES)
Pelvis is the most common site
usually arises in the diaphysis of
long bones especially femur
followed by tibia and humerus

48. Ewing sarcoma of tibia from a child

50. The following studies are required to support the diagnosis of ES and PNET:
Demonstration of t(11;22) or EWS-FLI-1 fusion transcript (present in both ES and PNET) Immunostains(both ES and PNET are positive for CD99/O13. In addition, PNET shows positive staining with neural markers) EM (ES cells are undifferentiated and show prominent glycogen deposits; PNET shows neural differentiation)

51. The pathways of spread include
Ewing sarcoma(ES)
The pathways of spread include
Direct extension
Lymphatic or vascular dissemination
Intraspinal seeding

52. Secondary tumours of bone
Metastatic cancer to bone is
more common than primary
cancer of bone

53. 75% of bone metastasis originate from
Cancers of prostate
breast
kidney
lung
thyroid
Metastatic lesions are multifocal
Produce a lytic and or blastic reaction

54. Bone metastasis

55. Bone metastasis

56. Prostatic carcinoma metastatic to bone