workshop bone tumor

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BONE TUMORBONE TUMOR

Rahadyan Magetsari MD.

Dept Of Orthopedics SurgeryMedicine Faculty Gadjah Mada University

Sardjito Hospital Yogyakarta.

CPC Case from 2008 – 2013 (July)CPC Case from 2008 – 2013 (July)

Year

Clinical FeaturesClinical Features Non Spec. long time may-elapse until tumor is diagnosed

Cardinal symptoms : - Pain, swelling and general discomfort - Limited mobility, pathologic Fx.

INTRODUCTION TO BONE NEOPLASMAINTRODUCTION TO BONE NEOPLASMA

PainPainFirst and most common symptom in malignant B.T

Initially as “rheumatic pain” intermittent, at rest more intense – disturb sleep – spread into adjacent joint arthritis – post traumatic phenomenon • Later persistent and piercing pain intolerable need opiate tx


SwellingSwellingBenign – develop slowly

Malignant – develop rapidly


Mass conditionMass condition

Border – size – tenderness – consistency – temperature – skin mobility – mobility of tumor

Advanced: skin changes: tense – shiny – prominent veins, temperature - eventually ulceration


Limitation of Movement Limitation of Movement Lesion close to the joint Reactive sinovitis

PaPaththologic Fx.ologic Fx. May as the first symptom for the patient to seek medical treatment occur with no prior symptoms – such in bone cyst

Malignant: occur in advanced stage of osteolytic process


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Benign: Stage 1

Stage2

Stage3

Malignant Stage 1a

stage 1b

Stage 2a

Stage 2b

Stage 3

ImagingImaging

First step in work up/determining aggressiveness plain x-ray1. Location, 2.Periosteal Rx, 3.Margin/Zone of transition, 4.Pattern of destruction, 5.Soft tissue invol.


Permeative Moth-eaten Geographic

MORE AGRESSIVE/ “Malignant”

Work UpWork Up History: - Duration, progression, pain - Trauma ? Family history of neoplasma - Previous tx: radiotherapy ?

P.E. : Mass location etc.

Lab: - Blood routine

ESR: - infection & neoplasm CRP: indicates systemic inflammation/process

Serum alkaline phosphatase (SAP) bone turn over

Serum Latic Dehydrogenase (LDH) necrotic condition

INTROINTRODDUCTION TO BONE NEOPLASMAUCTION TO BONE NEOPLASMA

Work UpWork Up

MRI skip lesion, soft tissue conditionBone surveyBone scans Tc 99 Screening in negative plain x-ray but with consistent complain Detect: - Activity of a lesion - Solitary or multiple - Metastatic lesion - Early phase: evaluation of blood flow Gallium 67: - Longer than Tc 99 (2 hours) 24-72 hours - Differentiate infection from neoplasm


Work UpWork Up

Final Step:

- Biopsy: FNAB, core biopsy & open biopsy


Work UpWork Up

Biopsy should NOT considered as a minor surgery Open biopsy should be performed by the same surgeon, who do definitive surgery!! RSCM: first procedure: closed biopsy FNAB in RSCM: - accuracy in bone lesion: 79,7% literature: 70 – 95% - accuracy in OsteoSa : 93% literature: 80 – 95%

If FNAB inconclusive open biopsy


• TEAM APPROACH” :Orthopaedic Surgeon, Pathologist and Radiologist.

•“THREE PILLARS” of the team in our setting it is called the “CPC” (Clinico Pathological Conference) of BT

•CPC plus: include Medical & Rö-Oncologist, Rehabilitation


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BENIGN BENIGN BONE TUMORBONE TUMOR

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•Most often•Fibrous tissue•Asymptomatic, (found in x-rays)•Metaphyisis of the long bone >>>

Non Ossifying FibromaNon Ossifying Fibroma(fibrous cortical defect)(fibrous cortical defect)

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X-ray finding

Radiolucent area with border around dense

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• Growing bone with small defect cured.

• Defect >>> Pathologic fracture.

• Not lead to become malignant.

Treatment • No therapy• Pathologic fracture : curretage

bone graft.

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FIBROUS DYSPLASIA

Trabecular bone replaced with fibrous tissue

Sign and Symptoms :

-Pain-Limping-Bone enlargement-Deformity-Pathologic fx 5 - 10% -- malignant -- FIBROSARCOMA

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Radiologic findings

Cystic Area in the metaphysis / diaphisis of the bone

“ground glass”

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Treatment

• Small lesion -- no treatment• Big lesion -- curettage - bone graft• >> big -- graft - bone cement• Deformity -- osteotomy.

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OSTEOID OSTEOMA

• Complain >>> size of the tumor• Female, << 30 y.o.• Femur and tibia. • Complaining: persistent pain ( localized / spreading ).• Typically : pain will be relief <<< with Salicylat.• Late to diagnosed : fx. Muscle atrophy, weakness -- limping.

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Radiologic Findings

Small radiolucent area “ NIDUS “

Therapy: remove the nidus.

DD/ brodies abses

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ENCHONDROMA

• Asymptomatic.

• It happened to find the pathologic fractures.

• Long bone at the hand and foot.

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Radiologic Findings

Radiolucent area with calcifications at the center

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Therapy

• Not necessary.

• Pathologic Fx -- curettage + bone graft.

• Recurrent >> -- end block .

• To become malignant < 2%.

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Male, 27 yoEnchondroma

Day post operation 4 week post operation

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OSTEOCHONDROMA

• Very often.• Tumor at the distal of the physeal plate .• >> Metaphysis area.• Young people.• Pain: nerve compression.

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Radiologic findings

Tumor at the metaphysis area

Therapy: Excision.

Male 24 yo. Male 24 yo. Pedenculeted OsteochondromaPedenculeted Osteochondroma

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Male 14 yo. Sessile Osteochondroma

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Become malignant

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SYMPLE BONE CYST

In children.Long bone -- ( prox femur and humerus).

Radiologic findings

• Strict border.• Lucent area at meta and physeal pl.• Thinning of the cortex.

D/ : cyst (+).

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Therapy:

• Conservative -- !!! Pathologic fx.• Cyst is big -- aspiration -- methyl prednisolon.• Pathologic fx -- curettage -- bone chips. ( !!! Epiphyseal plate destroyed)

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ANEURYSMAL BONE CYST

Often found : young people metaphysis

Radiologic findings

Lucent area with strict border.

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Therapy:

Low risk for the pathologic fx.

Curettage -- bone graft.

Bone graft was absorbed ---- bone cement.

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GIANT CELL TUMOR.

• Origin ?• Young people. • Pathologic fx 10 - 15%.• Most often found in : distal femur - prox tibia. Prox humerus. Distal radius.

• Pain and swelling

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Radiologic findings

• “ soap buble appearence”.• “ ballooned “ -- thinning of the cortex .• Pushing the surrounding of soft tissue.

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Therapy:

• histology finding: low grade - benign : curettage + bone graft/bone cement.

•Aggressive & recurrent : excision ----- bone block. Prosthese.

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Juni 2010

Juli 2010Oktober 2010

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Malignant Malignant Bone tumorBone tumor

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CHONDROSARCOMA

• 40 – 50 y.o. • Male > Female.• Growing slowly.

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Primer chondrosac : All of the bone (metaphysis).

Radiologic finding :

Lucent area with central calcification.

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Secondary Chondrosac :

• From osteochondroma• scapula and pelvis.

Radiologic findings

Exostosis bone surrounding withcalcification

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Sign & Symptom:PainEnlargement of the tumorPathologic fx

CT & MRI : to find the sign of metastatic

Therapy: Wide excision + prosthetic replacement

( radio and chemo resistant )

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OSTEOSARCOMA

• The most malignant.• Young adult.• Very easily spread out: localized and long distance. • Most often at the metaphysis of the long bone

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Sign and Symptoms :

Pain : the main complain . Persistant. More in the night.Mass (+).Pathologic - rare.

Lab/:

Alk posphatase >>>.Led >>>>>>.

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Radiologic findings :

Wide Lucent area Some with dense areaElevation of periosteal --- “Codmans triangle”.Multiple layers of the cortex -- “ sunburst “

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Radioisotop --- skip lesion.CT & MRI.Biopsy !!!

Therapy:

Mortality rate >>>

radical surgery adjuvant chemotherapy

EWING”S SARCOMA

• From bone marrow endothelial cell.• 10 - 20 y.o. • Long bone : tibia, fibula, clavicle.

Sign and Symptoms :

• Pain and swelling.• Pyrexia• LED >>.


• Diaphysis.• “ONION PEEL EFFECT”.• Destruction - (osteosac).• Periosteal reaction.• Ossification.

Diagnosis : problems !!! Infektion ? Osteosarcoma ? ( meta ).

Therapy:Contraversion • Prognosis always worst

• Not only surgery needed.

Chemo pre op -- wide excisi / amputation.Radio th/ - -- excision. be followed by chemo th/ 1 year.

MYELOMA

From bone marrow plasma cell.at : femur, humerus, skull bone.45 - 65 y.o.

Sign and Symptoms:

• Persistent pain at the spine.• Weakness of the extremities muscle.• Anemia, cahexia• LED >>.

The most frequent cause of the secondary osteoporosisand compression fracture on the 45 y.o.

Laboratory : “ BENCE - JONES PROTEIN “ ( protein value at urine )

Sternal Punction : typical “MYELOMA CELLS”

Radiologic findings:

“ PUNCHED - OUT “

Therapy :

Less pain : radio th/ chemo th/.

Pathologic fx --- I.F. + bone cement.

Spinal fx.

METASTATIS BONE DISEASE.

More often than primary bone tumorThe most frequent cause for the secondary bone tumor

Spread out from : Ca. Mamae Prostate Kidney Lung Thyroid.

Metastatic Osteoblastic Ca Metastatic Osteoblastic Ca ProstateProstate


7474

Metastatic Osteolytic Metastatic Osteolytic CarcinomaCarcinoma

Metastatic Osteolytic Metastatic Osteolytic CarcinomaCarcinoma

From breast

From thyroid

From kidney

From lung

From prostate gland

Mostly occurred at : spine pelvic femur - humerus.

Sign and Symptoms :>> 50 - 70 y.o.Painfull.

Laboratory :

LED>>Hb <<alk pos >> acid pos >> ( Ca prostate )


Osteolitic : “ Mouth eaten “bone destruction -- pathologic fx

Radioscintigraphy :

Therapy:

• Radical treatment ( surgery + radio th/.)• Pain : narcotic. Radio th/.• Fractures : intra medullary nailing . Plate and screw.• Prophylactic fixation.• Spinal stabilization : stable type -- brace. Unstable -- I.F. & radio th/.

Limb salvage

Lung MetastasesLung Metastases

SummarySummary

1.1. Usia anak dan usia pertumbuhan, nyeri di Usia anak dan usia pertumbuhan, nyeri di daerah sendi.daerah sendi.

2.2. Benjolan di saerah sendi.Benjolan di saerah sendi.

3.3. Fraktur ‘patologis’.Fraktur ‘patologis’.

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Anamnesa: ganas vs jinakAnamnesa: ganas vs jinak

Pemeriksaan fisik: ganas vs jinakPemeriksaan fisik: ganas vs jinak

Radiologis: 5 langkah membacaRadiologis: 5 langkah membaca

Diagnosis: team approach (CPC)Diagnosis: team approach (CPC)

Terapi: ablasi vs salvageTerapi: ablasi vs salvage

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