TUMORS OF BONE

PRIMARY TUMORS.
Both benign and malignant are uncommon comparing with malignancies arising from other tissues.
Also uncommon compared to secondary tumors arising from metastases to the skeleton from primary
carcinoma of,breast,prostate ,lung or kidney.
Primary tumors present difficulties in diagnosis and treatment.and need to be differentiated from
other tumor like lesions that affect the bone.
• Tumours arising from bone arise from mesenchymal tissue and if
malignant are called sarcomas.
• They are normally classified by the predominant tissues,I,e
bone,cartilage or fibrous tissue.
• CLINICAL FEATURES
• Local pain unrelated to activity.
• Local limb swelling.
• Pathological fractures.
• Or compination of the above symptoms.
• Many benign tumors are asymptomatic and may be diagnosed by
chance during radiology.
• IMAGING
• Bone tumors are well evaluated using plain radiography.
• MRI scanning is required to evaluate extend of tumor and its relation
to key anatomical structures.
• in evaluation the following are key to correct diagnosis.
• AGE.
• Most tumors are found in certain age groups.ewing sarcoma and bone
cysts occur in children and young adults.
• Chondrosarcoma affects pts over 40 years.
• SINGLE OR MULTIPLE LESIONS.
• Most true primary bone tumors are solitary in nature
• Multiple bone lesions suggest bone metastasis.
• TUMOR SITE.
• Bone involved and site.
• Giant cell tumors are usually found in sub articular surfaces.
[epiphyseal areas].
• MARGIN OF LESION.
• Slow growing lesions have well defined and sometimes scelorotic
margins and are mostly benign.
• Rapidly growing tumors are ill defined and appear to permeate
diffusely into the surrounding bone.
• While this may indicate a malignant process ;other progressive
conditions like osteomyelitis may give similar appearance.
• Appearance of matrix
• Lesions of cartilage tissue will tend to show areas of calcification.
• A lesion from bone forming cells may contain areas of ossification.
• These findings narrow down the ddx.
• PERIOSTEAL REACTION.
• The appearance of periosteal reaction gives clues to the nature of
underlying lesion.
• A thick well organized periosteal reactions implies a slow growing
tumor e.g. osteoid osteoma.
• Layers of thin periosteum indicate a fast growing malignant lesion.
• BREACH OF CORTEX.
• Indicates an aggressive invasive lesion.
• SOFT TISSUE MASS;
• Extension into the soft tissue is also evidence of a rapidly growing
mass.
• NB;Age of patient and site of tumor is very helpful in making a correct
differential diagnosis.
• Investigations.
• BLOOD;esr,c reactive protein =bone infxn.
• Hyper calcaemia =excessive bone resorption from hyperthyroidism or
the presence of bone metastases or myeloma deposits.
• Plasma protein with high globulin levels show presence of multiple
myeloma.
• Increased serum acid phosphatase shows presence of prostatic
carcinoma.
• BIOPSY;
• From the lesion for histological and bacteriological purposes.
• Treament,
• Depends on whether benign or malignant, individual types of tumor.
Classification of primary bone tumors
BENIGN POINT OF ORIGIN MALIGNANT
Osteoma bone Osteo sarcoma

Osetoid osteoma
Osteo blastoma
Giant cell tumor
Enchondroma Cartilage. Chondrosarcoma.
Osteo
chondroma[cartilag
ecapped exostosis]
Chondromyxoid
fibroma.
chondroblastoma
Fibrous Fibrous tissue Malignant fibrous
corticaldefectnon histiocytoma.
ossifying fibroma
begnin origin malignant
Simple bone cyst Uncertain origin Ewings sarcoma
Aneurysmal bone cyst Adamantinoma.
OSTEO CHONDROMA
• Commonest benign tumor of bone.
• Presents at age 10 to 20 yrs.
• PATHOLOGY.
• Tumor originates from childhood, from epiphysesial cartilage plate.
• As bone grows outgrowth is left behind and points away from adjacent joint.
• Grows outward from the bone like a mushroom with a bony stalk in
continuity with cortex of underlying bone.
• The bony stalk has a larger cap of cartilage which continues to grow until
cessation of skeletal growth.
• Ordinary osteochondroma is single but in multiple exoxtoses it affects
several bones.
• Risk of malignancy is more inexostoses than in solitary
osteochondroma.
• CLINICAL FEATURES.
• Circumscribed painless hardening near the joint.
• May become painfull due to pressure effect from adjacent nerve or
vascular structures.or from underlying pseudo bursa.
• Increases in pain and size should be regarded with suspicion.
IMAGING
• PLAIN XRAY;=mushroom like stalk of the bony tumor.
• The larger cartilaginous cap only seen after calcification after skeletal
maturity is achieved.
• Patients with skeletal lessions must be adviced to seek imaging
services if swelling becomes if swelling enlarges or becomes painfull.
• TREATMENT
• Excise tumor if it enlarges and take it for histological examination.
Giant cell tumor.[osteo clastoma.]
• Though this tumor is reffered to as benign ,it tends to recur after
local removal.
• Occurs in the age of 20-40yrs.
• 10% behaves as malignant tumor, metastasizing through the blood to
the lungs.
• PATHOLOGY.
• Common sites are lower end of femur,upper end of tibia,lower end of
radius and upper end of humerus.[ossification center of long bones.]
• May also occur in spine and sacrum .
• Mostly occurs in the epiphyseal region and almost extends to the
joint surface.
• New bone forms beneath the raised periostiun so bone end is
expanded and pathological fracture is common.
• Histologically.the tumor has abundant mononuclear cells oval or
spindle shaped stromal cells profusely interspersed with giant cells
that contain several nuclei[upto 50.,]hence the name giant cell tumor.
• The giant cells represent fused conglomeration of oval or spindle
shaped stromal cells which show mitotic figures.
• CLINICAL FEATURES.
• Pain at site of tumor.
• Gradually increasing local swelling.
• Pathological fractures.
• Bony swelling which may be tender on firm palpation.
• IMAGING.
• XRAYS=shows lytic destruction of bone substance.
• Expansion of cortex,with no sclerotic ream or priosteal reaction.
• Tumor tends to grow accentrically and involve articular surfsaces of the
bone.
• MRI helps to determine extend of soft tissue involvement.
• TREATMENT
• Depends on site of tumor.
• Curettage of content with high speed burr.
• Recurrence occurs in 20-25%.this is reduced by us of chemotherapy,
• Tumor excision in cases of multiple recurrence.
• Radiotherapy.
• Radiotheraphy can bring permanent cure.
• Radiotheraphy is fearead to induce malignant change later in life.so
raditheraphy is recommended in sites inaccessible to radiotheraphy
esp spine and sacrum.
MALIGNANT TUMORS OF BONE.
• There are five commonest malignant primary tumors of bone.
• Osteogenic sarcoma
• Chondrsarcoma
• Malignant fibrosarcoma
• Ewings tumor
• Myeloma[plasmocytoma.
• Secondary metastatic tumors.
Osteogenic sarcoma.
• It’s a tumor of childhood and adolescent occurring most coomnly btn
10-25yrs.
• In latter life it occurs as acomplication of pagets dx.
• PATHOLOGY
• Arises from primitive bone forming cells.
• Commonest sites are lower end of femur,upper of tibia,and upper
end of humerus.
• These are areas which had most active growth before bone fusion.
• Tumor begins in the metaphysis .destroys bone structure then burdt
to the surrounding soft tissues.
• Seldom crosses epiphyseal cartilage into the epiphyses itself.
• Histological appearance is wide and any connective tissue may be
represented.e.g fibrous,cartilage tissues but with some neoplastic
new bone or osteoid tissue that indicate the real nature of the lesion.
• Tumors metastases early through blood stream to lungs and other
bones.
Clinical features
• Pain associated with gradual swelling.
• o/e.diffuse bone thickening near the end of bone close to the joint.
• Warmer than normal skin.
• Stretched and shinny skin.
• IMAGING.
• PLAIN XRAYS.Irregular medullary and cortical destruction of the
metaphysis.
• Later cortex appears to have burst open at one or more places of
tissue extension.
MRI
.accurate tumor delianation and extend of invassin of tissues.
There is usually evidence of bone formation under the corners of aggressive
periosteal reaction.[codman’s triangle].
Sunray appearance.i.e well marked radiating spicules of new bone are seen
within the tumor.
Radio isotope scanning .
CXR shows.pulmonary metastases.
Ct scan.of the lung field is now mandatory for pre treatment staging.it can
detect metastases to the lungs before they appear in xrays.
D/D

• sub acute osteomyelitis.

• chondrosarcoma.
• giant cell tumor.
• malignant fibrous histiocytoma
• Ewings tumor;
• biopsy is important for d/d.[fna or open biopsy.]
Prognosis
Good prognosis due to chemotherapy.
High survival rate and sometimes lasting cure.
Treatment
• Chemotheraphy.eg methotrexate,doxorubicin amonest others.
• Chemotheraphy is started before surgical rx.continued to 6/12 to a
year after ablation of tumor.
• Surgery.limb salvage surgery.as opposed to amputation.
MYELOMA[MYELOMATOSIS,PLASMAC
YTOMA.]
• Tumor of bone marrow,occurs in older adults,50-70yrs.
• Initially presents as single lesion but later spread to involve bone
marrow at other sites.
• Its ultimately fatal,though modern treatment produces long term
remission of upto 10 years.
• PATHOLOGY;
• Arises from the plasma cells of bone marrow and disseminates to many
parts of the skeleton through the blood.by the time pts seek treatment
the tumor foci are multiple.affectiving majorly the bones containing red
bone marrow.
• Less commonly the tumor may present as a solitary plasmacytoma
spreading to other skeletal sites after several years .
• The lesions are often small and circumscribed but occasionally large.
• The bone is replaced by tumor tissue and there is no reaction in the
surrounding bone.
• Pathological fracture is common especially in the spine.
• Histologically the tumor consists of a mass of small round cells of
plasma cell type which are larger than normal but not uniform.
 Clinical features
• Adult past middle age.
• There is general ill health with pain at one or more tumor sites or
sometype pathological fractures.
• O/E.patient is pale from associated anaemia due to suppression of red
bone marrow function.
• There is local tenderness over the affected bone ,but there may be no
obvious swelling or deformity unless there is pathological fracture.
• Patient is likely to develop infxn due to reduced body immunity.
imaging
• Xray shows multiple punched out lytic lesions in bones containing red
blood cells.eg ribs, vertebral bodies, pelvic bones, skull and proximal
ends of femur.
• MRI. Useful for multiple skeletal lessions esp in suspected spinal
involvement due to its superior soft tissue resolution.
• INVESTIGATIONS.
• microcytic anaemia,
• ESR increased.
• Bence jones protein is present in urine in more then half the cases.
• SERUM GLOBULIN ,increased ,so much that the albumin globulin ratio
is reversed[normal is 2-1]
• Bone marrow biopsy .
• DIAGNOSIS.
• confirmed by bone marrow biopsy when radiological features are
equivocal
• PROGNOSIS
• Fatal,though prognosis can improve due to therapy..
treatment
• Radiotherapy
• Chemotherapy‘.
• Bone marrow transplant.
• Biphosphates in increased hypercalceamia to inhibit excessive bone
resorption.