BEST CERVICAL SPINE TREATMENT IN INDIA | SHISHIR SPINE CENTER

Diagnosis of Malignant Bone Tumours

Dr Shishir Kumar PG Ortho

• • • • •

X Ray Evaluation Other Imaging Techniques Biopsy Classification Brief overview of important tumours

Algorithm of Evaluation Benign or Malignant

Age

Location

Special features

Lodwig’s Classification 1.

2.

3.

4.

Patterns of Osteolysis Matrix Periosteal Reaction Soft tissue extension

Geographic destruction o IA: geographic sclerotic margin o IB: geographic unsharp margin o IC: geographic no margin

II. Moth eaten like destruction • Moth eaten • Permeative

Patterns of bone destruction

Matrix • Osteoid • Chondroid

Periosteal reaction • Solid • Lamellated • Hair on end Sunburst

Periosteal reaction • Solid

Osteoid osteoma

Periosteal Reaction • Lamellated

Infection

• Multilayered

Ewing

Periosteal Reaction • Codman’s triangle

Osteosarcoma

Soft tissue Involvement

Age Malignant tumours more common after 30 years Benign tumours more common before 30 years and most often before physis closure

Location

Special Investigations • • • •

Bone Scan CT Scan MRI PET Scan

Biopsy • Single most important procedure • Should not be taken lightly • An inadequately performed biopsy -does not allow proper diagnosis -May end up in amputation/limb salvage - have a negative impact on survival

• Clinically and radiologically benign-appearing lesions—no biopsy • Indicated in - benign aggressive tumours -malignant tumours -questionable lesions to confirm the clinical diagnosis -accurately classify

Timing of Biopsy • • • •

After all imaging studies have been completed After Full staging completed Can interfere with imaging if done earlier Biopsy of all • Local • Skip • Metastatic lesion

Biopsy technique • • • •

Sarcomas grow heterogenously Single biopsy not enough Multiple representative biopsies Thorough evaluation of radiology

Main concern about biopsy---infiltration of biopsy tract with tumour----convert a limb salvage to amputation

Principles of Biopsy • Part of the lesion is most representative of the underlying disease • Extraosseous component is as representative as bony component • First biopsy the soft tissue component • Avoid violating the cortex as predisposes to pathological fractures • Done only if no extraosseous element present • Biopsy point along planned incision • Shortest way to lesion • must not violate more than one compartment • Must be remote from neurovascular bundles

Types of Biopsy • • • •

FNAC Tru-cut Incisional Excision

Biopsy tibia

Biopsy shoulder

Sighting of incision

Sighting incision

Bone window

Insertion of drain

Ennekin staging Stage 1a

Grade Low (G1)

Site Intracompartment (T1)

Metastasis No Metastasis (M0)

1b

Low (G1)

Extracompartment (T2)

No Metastasis (M0)

2a

High (G2)

Intracompartment (T1)

No Metastasis (M0)

2b

High (G2)

Extracompartment (T2)

No Metastasis (M0)

3

Any Grade

Any T

Regional or distant mets

Excision • • • •

Intracapsular excision Marginal excision Wide excisions Radical excision and amputation

WHO CLASSIFICATION • • • •

BONE FORMING – osteosarcoma; CARTILAGE FORMING - chondrosarcomas GIANT CELL TUMORS MARROW TUMORS – Ewing’s ; lymphomas; multiple myeloma • VASCULAR & other connective tissue TUMORS – Angiosarcoma, ; Fibro sarcoma, Malignant Fibrous Histio cytoma • MISCELLANEOUS – Chordoma ; adamantinoma; neurosarcoma Radiation induced sarcoma

Osteosarcoma (Osteogenic sarcoma) • Mesenchymal tumor in which cancellous cell produce bone matrix.

• Most common primary malignant tumor of bone • All age group but has bimodal age distribution • 75% in person younger than 20 years of age • Second peak occur in elderly who have predisposing condition – Paget disease, bone infarct, prior irradiation – Males> females

• Usually arise from metaphysis of long bones of extremities, and almost 50% occur about the knee. • Beyond the age of 25 years incidence in flat bones and long bones is almost equal.

Osteosarcoma

Osteosarcoma

Classical

Codman’s triangle

Sunrays appearance

Osteosarcoma

Codman's triangle

Osteosarcoma

Osteosarcoma

Imperceptable

Sclerosis

Telengectiatic

Chondrosarcoma • Definition: – Malignant tumor of chondroblasts cells Second most common malignant matrix producing tumor

• Etiology: – The tumor may arise de novo (primary) or secondary to preexisting enchondroma, exostosis (osteochondromas) or Paget’s disease – Primary chondrosarcoma is very uncommon, arises centrally in the bone and found in children

• Chondrosarcoma sub classified according to – • Site – Central (intramedullary) Peripheral (juxtacortical and surface) • Histologically - Conventional (hyaline/myxoid) Clear cell Dedifferentiated Mesenchymal Conventional central tumors constitute about 90% of chondrosarcoma

• Commonly after 40 years of age • Clear cell and especially mesenchymal variant occur in younger patients in their 20s.

• Male > female • It is most common in the femur, humerus, ribs and on the surface of the pelvis • Patients with Ollier's disease (multiple enchondromatosis) or Maffucci's syndrome (multiple enchondromas and hemangiomas) are at much higher risk of chondrosarcoma than the normal population.

• Biopsy - Incisional biopsy done • Gross examination – Chondrosarcoma is a grayish-white, lobulated mass. It may have focal calcification, mucoid degeneration, or necrosis

Investigations • X – ray – Chondrosarcoma is a fusiform, lucent defect with scalloping of the inner cortex and periosteal reaction. Extension into the soft tissue may be present as well as punctate or stippled calcification of the cartilage matrix.

Chondrosarcoma

• C.T. scan – Helpful in defining the integrity of the cortex and distribution of calcification.

• MRI – Surgical planning as it demonstrates the intraosseus and soft tissue involvement of the tumor.

MRI is also helpful in evaluating possible malignant degeneration of osteochondromas by allowing accurate measurements of the cartilage cap

Chondrosarcoma

Ewing’s Sarcoma • Ewing sarcoma, a highly malignant neoplasm • predominantly affecting children and adolescents • Approximately 90% of Ewing sarcomas occur before age 25 • Histogenesis: neurally derived small round cell malignancy very similar to the so-called primitive neuroectodermal tumor (PNET) • disease is extremely rare in black persons

Areas of involvement

Ewing sarcoma has a predilection for the diaphysis of the long bones ribs flat bones such as the scapula and pelvis

Clinical presentation • present as a localized painful mass • with systemic symptoms such as fever, malaise, weight loss, and • an increased erythrocyte sedimentation rate.

• These systemic symptoms may lead to an erroneous diagnosis of osteomyelitis.

Radiological features • poorly defined, • permeative or moth-eaten type of bone destruction, • Associated with an aggressive periosteal response that has an onionskin (or “onion peel”) • less commonly, a “sunburst” appearance, • and a large soft-tissue mass .

• Occasionally, bone lesion itself imperceptible • Often confused with osteomyelitis

• Other, less common, manifestations Thickened cortex or Saucerication Expansion of bone Pathologic fractures

permeative bone destruction associated with an aggressive periosteal reaction

CT section through the lesion demonstrates a large soft-tissue mass, which is not clear on the conventional study. obliteration of the marrow cavity by tumor.

saucerisation

Bone destruction is almost imperceptible shows a large soft-tissue mass

Onion skin appearance

Moth eaten appearance

Conclusion • Malignant bone tumours are rare • X Ray screening may at times have subtle abnormalities that can be missed • CT Scan and MRI remain the main imaging modalities as compared to benign lesions • Biopsy is of utmost important as it determines the further management

Thank You