common malignant bone tumors

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COMMON MALIGNANT BONE TUMORS1.METASTASES 2.OSTEOID ORIGIN:OSTEOSARCOMA 3.CHONDROID ORIGIN:CHONDROSARCOMA 4.FIBROUS ORIGIN:.MALIGANT FIBROUS HISTIOCYTOMA 5.MARROW TUMORS:1.EWINGS SARCOMA 2.PRIMARY BONE LYMPHOMA 6.NOTOCHORD ORIGIN:CHORDOMA

METASTASESMOST COMMON SECONDARIES BONE TUMORS SOLITARY BONE METASTASES MOST COMMON WITH BREAST , BRONCHUS , PROSTATE , KIDNEY AND THYROID INCIDENCE VERY HIGH BREAST CANCER 73% - 80% MOST COMMON SITES : VERTEBRAE , PELVIS , PROXIMAL FEMORA , HUMERI , SKULL AND RIBS RADIOLOGICAL FEATURES : XRAYS LYTIC AND MULTIPLE , OCCURS IN THE MEDULLARY CAVITY OF THE BONE POORLY DEFINES MEDULLARY DESTRUCTION ONLY LESION OF APPROXIMATELY 20 MM CAN BE VISUALIZED IN OSTEOPOROSIS EVEN LARGER LESIONS CANNOT BE VISUALIZED. HYPERNEPHROMA ALWAYS CAUSES LYTIC METASTASES

PELVIC XRAY SHOWING EXPANSILE LYTIC METASTASIS

XRAY SPINE SHOWING OSTEOBLASTIC METASTASIS

BREAST CARCINOMA MIXED APPEARANCE OSTEOBLASTIC CHANGE SEEN IN OSTEOSARCOMA METS

PROSTATE ALWAYS OSTEOBLASTICMETASTASES

CAUSES

IDENTIFICATION OF MULTIPLE METASTASES 1.TC MDP BONE SCINTIGRAPHY MOST COST EFFECTIVE METHOD THOUGH WHOLE BODY MRI IS SENSITIVE BUT NOT COST EFECTIVE. SCINTIGRAPHY FINDINGS:

HOT SPOT- MULTIPLE SITES OF INCREASED SKELETAL ACTIVITY -IF BLOOD SUPPLY IS INTACT / OSTEOBLASTIC COLD SPOT - WHICH INFARCTS OR SHOWS NO OSTEOBLASTIC RESPONSE - MOST COMMONLY SEEN WITH RENAL METASTASES OCCASIONALLY A COMBINATION OF BOTH HOT AND COLD LESIONS OCCUR SUPER SCAN - DIFFUSE OSTEOBLASTIC METASTATIC DISEASE GENERALIZED INCREASE IN SKELETAL ACTIVITY WITH REDUCED OR ABSENT RENAL ACTIVITY MRI :

ANY AREA OF UNEXPLAINED NCREASED UPTAKE SHOULD BE EXAMINED WITH MRI. T1W REDUCED SIGNAL INTENSITY T2W /FSFSE INCREASED SIGNAL INTENSITY APPEARS AS A HYPERINTENSE 'HALO' AROUND A LESION HIGHLY SPECIFIC FEATURE OF METASTASES. SOURCE OF PRIMARY TUMOR CAN BE DETECTED BY NON INVASIVE AND COST EFFECTIVE TECHNIQUES LIKE USG AND X-RAY EXAMINATION. FEATURES FOR DIFFERENTIATING BETWEEN METASTASES AND NON-METASTATIC LESION: POSITIVE FEATURE FOR IDENTIFYING METASTASES: 1.DIAPHYSEAL INVOLVEMENT 2.VERTEBRAL BODY INVOLVEMENT 3.PEDICLES INVOLVEMENT FEATURES SUGGESTIVE OF NON METASTATIC LESION 1.ABSENCE OF BONE EXPANSION 2.ABSENCE OF FLORID PERIOSTEAL REACTION 3.ABSENCE OF TUMOR BONE FORMATION 4.ABSENCE OF LARGE SOFT TISSUE MASS

PRIMARY MALIGNANT TUMOR OF OSTEOID ORIGINOSTEOSARCOMAMOST COMMON PRIMARY MALIGNANT BONE TUMOR

CLASSIFICATION : PRIMARY AND SECONDARY PRIMARY OSTEOSARCOMA: 1.CENTRAL CONVENTIONAL HIGH GRADE AND LOW GRADE 2.INTRACORTICAL OR SURFACE PAROSTEAL , PERIOSTEAL OR HIGH GRADE 3.MULTICENTRIC OSTEOSARCOMATOSIS 4.EXTRA SKELETAL OR SOFT TISSUE SECONDARY OSTEOSARCOMA :

CAUSES 1.PAGETS DISEASE 2.RADIOTHERAPY 3.DEDIFFERENTIATED CHONDROSARCOMA

PART

OF

ALSO ASSOCIATED WITH 1.LIFRAUMENI SYNDROME 2.FAMILIAL RETINOBLASTOMA 3.ROTHMUND -THOMPSON SYNDROME RADIOLOGICAL FEATURES:

SURFACE

OSTEOSARCOMA

SHOWING COTICAL DESTRUCTION AND EXTRAOSSEUS MASS LOCATED IN METAPHYSEAL REGION CORTICAL DESTRUCTION IS COMMON RESULTS IN EXTRA OSSEUS MASS WHICH COMMONLY SHOWS TYPICAL OSSEUS CLOUD LIKE MATRIX MINERALIZATION METAPHYSEAL LESION WITH MOTH EATEN OR

PERMEATIVE PATTERN OF BONE DESTRUCTION

INTENSELY SCLEROTIC INTRAMEDULLARY OSTEOSARCOMA ALSO SHOWS CODMAN'S TRIANGLE AND EXTRAOSSEUS MASS IN THE DISTAL FEMUR MEDULLARY LESION IS PREDOMINANTLY LYTIC MEDULLARY SCLEROSIS OCCURS DUE MINERALIZATION OF TUMOR OSTEOID INTRAMEDULLARY SCLEROSIS LESION SHOWS TO

DENSE

SUN-BURST APPEARANCE PERIOSTEAL REACTION USUALLY DISORGANIZED OR PERPENDICULAR TO THE CORTEX

CODMAN'S TRIANGLE PERIOSTEAL REACTION LEADING TO SEPARATION AND LIFTING UP OF PERIOSTIUM . VARIATIONS: ENTIRELY LYTIC PSEUDO CYSTIC FORM

MRI STAGING , SHOWS EXTENT OF TUMOR CLEARLY METASTASIS : HEMATOGENOUS METASTASIS : LUNG , SUBPLEURAL , RARELY CAUSE PNEUMOTHORAX. SCINTIGRAPHY: INCREASED UPTAKE PLAIN FILM AND CT : CALCIFIED MASS SKIP METASTASIS :RARE BUT ESSENTIAL TO IMAGE ENTIRE BONE IF DETECTION IS TO BE MADE.

CHONDROID MALIGNANT TUMOR CHONDROSARCOMACLASSIFICATION: PRIMARY OR SECONDARY CENTRAL OR PERIPHERAL HISTOLOGICAL GRADING HIGH , MYXOID , LOW ,DEDIFFERENTIATEDDEVELOPMENT OF HIGH GRADE NON CHONDROID NEOPLASM AGE : 50 YRS C/F : PAIN ,PALPABLE MASS , PATHOLOGICAL FRACTURE COMMON SITES: PELVIS , PROXIMAL FEMUR AND PROXIMAL HUMERUS

RADIOLOGICAL FEATURES: PLAIN RADIOGRAPH:

RADIOLOGICALLY OCCULT LARGE PELVIC MASS LOW GRADE TUMORS MATRIX MINERALIZATION AND ENDOSTEAL SCALLOPING .PERIOSTEAL REACTION IS PRESENT

CALCIFIED MASS CHONDROSARCOMA ARISING FROM THE ILIUM

CALCIFIC CHONDROSARCOMA ARISING FROM THE LOWER FEMUR METAPHYSES SHOWING CORTICAL DESTRUCTION , NO PERIOSTEAL REACTION AND CALCIFIED TUMOUR MATRIX

MYXOID GRADE : BONE EXPANSION ALSO

JUXTACORTICAL MASS WITH 1.CALCIFICATION (ARROWS) 2.ENDOSTEAL SCALLOPING 3.PERIOSTEAL REACTION 4.MOTHEATEN APPEARANCE ALSO SEEN

HIGH GRADE : CORTICAL DESTRUCTION , PERIOSTEAL REACTION , BONE EXPANSION DEDIFFERENTIATED UNUSUALLY AGGRESSIVE RADIOLOGICAL FEATURES INSPITE OF CORTICAL SCALLOPING THE PERIOSTEAL REACTION RESULTS IN INCREASED CORTICAL THICKNESS. MRI: DEFINES THE EXTENT OF SOFT TISSUE EXTENSION WITH GREAT ACCURACY

T2W- INCREASED SIGNAL MASS INTERMEDIATE SI ADJACENT TO HYPERINTENSE TUMOR MASS INDICATES DEDIFFERENTIATED TUMOR

T2W IMAGE SHOWING INCRESED SIGNAL INTENSITY WITH THE TUMOUR SURROUNDING THE BONE IN THIS CASE OF PERIOSTEAL OSTEOSARCOMA

T1W SLIGHTLY HYPOINTENSE TO MUSCLES AND HYPERINTENSE SIGNAL FOCALLY FOR MARROW

MATRIX MINERALIZATION FOCAL AREAS OF SIGNAL VOID POST CONTRAST ENHANCEMENT IS MINIMAL AND SHOWS PERIPHERL OR SEPTAL PATTERN DUE TO DECREASED VASCULARIZATION IDENTIFICATION OF MALIG CHANGE IN OSTEOCHONDROMA DESTRUCTION OF PART OF CARTILAGE CAP USG MEAUREMENT OF CARTILAGE CAP SIZE OF > 20 MM INDICATES MALIGNANT CHANGE IN OSTEOCHONDROMA

MALIGANANT FIBROUS TUMORSMALIGNANT FIBROUS HISTIOCYTOMAMOST COMMON PRIMARY MALIGANANT FIBROUS TUMOR 25 30% ARISE FROM PAGET'S DISEASE , POST RADIOTHERAPY, BONE INFARCTION LOCATION:METAPHYSES OF LONG BONES ARE PREDOMINANTLY INVOLVED AROUND KNEE , HUMERUS and PELVIS AGE : 4TH DECADE , 6 80 YEARS RADIOLOGICAL FEATURES: PRIMARY LYTIC AND DESTRUCTIVE ,

METAPHYSEAL PERIOSTEAL REACTION UNCOMMON SOFT TISSUE MASS MAY BE SEEN MIMICS GCT BY EXTENDING TO SUBARTICULAR SURFACE NO SPECIFIC DIAGNOSTIC FEATURES FOUND ON MRI

MARROW TUMORSEWINGS TUMOR PRIMARY LYMPHOMA OF BONE EWING'S SARCOMA AGE GROUP -< 20 YRS 75% < 30 YRS 95% SYSTEMIC SYMPTOMS PYREXIA , ELEVATED ESR , SIMULATES INFECTION AND SIGNIFIES DISEMINATED DISEASE WITH POOR PROGNOSIS SITE OF OCCURANCE:DIAPHYSEAL TUMOR OCCURING IN FEMUR, HUMERUS ,PELVIC BONES AND RIBS. LESIONS MOSTLY SINGLE , BUT MULTIPLE

LESIONS ALSO SEEN READILY METASTASIZES TO BONE RADIOGRAPHIC APPEARANCE: PERMEATIVE PATTERN OF LYTIC BONE DESTRUCTION WITH A WIDE ZONE OF TRANSITION. CORTICAL DESTRUCTION PRESENT EXTRAOSSEUS SOFT TISSUE/ SUBPERIOSTEAL MASS PRESENTSUBPERIOSTEAL LESION CAN ERODE OUTER CORTEX AND CAUSE SAUCERIZATION CODMAN TRIANGLE AND HAIR ON END APPEARANCE DUE TO PERIOSTEAL REACTION PRESENT .CORTICAL THICKENING , BONE EXPANSION and PATHOLOGICAL FRACTURES RARE

EWING'S SARCOMA ARISING FROM PROXIMAL HUMERAL METAPHYSES AND DIAPHYSES SHOWING LYTIC MOTH-EATEN BONE DESTRUCTION , CODMAN'S TRIANGLE AND CORTICAL DESTRUCTION .BONE EXPANSION SEEN .NO SCLEROSIS AS SEEN WITH OSTEOSARCOMA ,NO CALCIFICATION AS SEEN WITH CHONDROSARCOMA

XRAY SHOWS LAMELLAR ONION SKIN PERIOSTEAL REACTION SEEN IN EWING'S

SARCOMA.PERMEATIVE BONE DESTRUCTION SEEN. OCCASIONALLY SPINAL AND FLAT BONE LESIONS CAN CAUSE SCLEROTIC APPEARNCE RESEMBLING OSTEOSARCOMA CT/MRI SHOWS LARGE EXTRA OSSEUS COMPONENT . INTRAOSSEUS COMPONENT IS ACCURATELY DEMOSTRATED DIFFERENTIAL DIAGNOSIS: OSTEOMYELITIS TRAUMA LYTIC OSTEOSARCOMA PRIMARY BONE LYMPHOMA IN PATIENTS MORE THAN 30 YRS OF AGE

PRIMARY BONE LYMPHOMAAKA 1. RETICULUM CELL SARCOMA 2.LYMPHSARCOMA OF BONE INVOLVEMENT OF SINGLE SITE IN BONE WITH NO OTHER SITE INVOLVED FOR SIX MONTHS AFTER DIAGNOSIS USUALLY A LYMPHOMA NON HODGKIN'S B-CELL

RADIOLOGICAL FEATURES : SIMILAIR TO EWING'S SARCOMA

PERMEATIVE LYTIC DESTRUCTIVE LESION REPORTED IN 74% RELATIVE ABSENCE OF CORTICAL DESTRUCTION IS A CHARACTERISTIC FEATURE SEQUESTRA AS SEEN IN OSTEOMYELITIS ARE ALSO CHARACTERISTICALLY SEEN MRI : EXTENSIVE INVOLVEMENT OF MEDUALLY CANAL WITH LARGE EXTRAOSSEUS MASS AND LITTLE CORTICAL BONE DESTRUCTION

NOTOCHORD ORIGIN TUMORCHORDOMAMIDLINE TUMOR , AXIAL LOCATION AGE : 50 - 70YRS SITE : SACROCOCCYGEAL (50%) , CLIVAL TUMOR (40%) SYMPTOMS : CONSTIPATION , BLADDER DYSFUNCTION ,CRANIAL NERVE PALSIES AND PELVIC MASS . RADIOLOGICAL FEATURES: SACRAL MASS , DESTRUCTIVE , SOMETIMES OCCULT FEW CASES EXTRAOSSEOUS MASS CALCIFICATION IN CLIVUS LESION SELLA AND CLIVUS MAY

BE DESTROYED MRI : T1W LOW SI MASS WITH EXTRAOSSEUS EXTENSION , HIGH SI occur BECAUSE OF HEMORRHAGE AND HIGH PROTEIN CONTENT T2W HIGH SI LESION MASS WITH LOW SI INTERNAL SEPTATIONS AND WELL DEFINED MARGINS

MRI T1W IMAGE SHOWING THUMB SIGN(ARROWS) OF PONS DUE TO IMPINGEMENT OF THE TUMOUR WHICH APPEARS ANTERIOR AND HYPODENSE TO PONS