This document discusses bone tumors. It covers the initial evaluation, presenting symptoms, history taking, physical examination, laboratory tests, investigations such as x-rays and scans, biopsy procedures and principles, classification, staging, principles of surgery including amputation vs limb salvage and achieving appropriate surgical margins, and treatment techniques such as curettage.

1. BONE TUMORS
Dr Barun Kumar Patel
APOLLO HOSPITALS
BHUBANESWAR

2. Qns
 1. discuss the principles of limb
salvage surgery in malignant bone
tumor. List the indications and
contraindications?
 2.describe clinical feature , radiology
,and treatment of non ossifying
fibroma ?
 3.discuss the anatomy of parathyroid
gland, describe the clinical feature ,
radiological presentation of adenoma
of parathyroid gland. What is hungry
bone syndroma.

3.  4. briefly describe methods to cover
defects after excision of primary
malignant tumors of bone .what is
extracorporeal irradiated tumor bone ?
 5.discuss the pathology ,clinical
features and management of synovial
chondromatosis ?
 6. write shortnotes on giant cell
varients , fibrous dysplacia ?

4.  7. define giant cell tumor of bone ,
describe in brief clinical features
,diagnosis and management principles
of GCT of upper end of tibia.
 8. Indication of limb salvage surgery in
malignant bone tumors , describe the
techniques of limb salvage in
osteosarcoma ?

5.  9.briefly describe the clinical features
and pathology of ewing’s sarcoma .
Outline the principles of treatment in a
case of ewing sarcoma of upper end
of humerus ?
 10.discuss the various methods
available for treatment of giant cell
tumor of proximal tibia in a 30 yr old
man ?

6. INITIAL EVALUATION
 Carried out in 4 phases
1 st phase – involves
High index of suspicion for tumors
Routine X-rays
Routine lab facilities
Meticulous history
Thorough physical examination
2 nd phase -is prebiopsy regional evaluation, to determine
size,location and type of tissue involved
3 rd phase – is the actual biopsy.
4 th phase – is undertaken if presumptive clinical & path
evidence sugestive of malignancy,
search for mets is done, using CT scan of lung & Tc-99 bone
scan

7. PRESENTING SYMPTOMS
 Pain
 Mass
 An abnormal radiographic finding detected during evaluation
of unrelated problem
 PAIN:- is most frequent symptom
-deep constant pain,poorly localised,worse at night
-initially controlled by analgesics,later requires
narcotics
 MASS:- rate of enlargement is important
-Fluctuating mass can be cyst,ganglion or
hemangioma
-Family H/O masses near the joint may be indicator of
Ollier’s disease or Maffucci Syndrome

8. Cont…
 NEUROLOGICAL SYMPTOM:- found in
few patients such as sacral tumors & with
tumors located near the nerve causing
compression of nerve,especially common in
sciatic notch ,inguinal canal & popliteal
fossa
 UNEXPLAINED SWELLING OF THE
LOWER EXTREMITY :- found in pelvic
tumors which are painless & without a
palpable mass & cause swelling due to
compression of iliac vein

9. HISTORY OF THE PATIENT
 AGE:- most imp information, bcoz of their
presentaion in specific age group.
 1 st decade- usually ABC ,SBC
 2 nd decade-
Chondroblastoma,osteosarcoma,Ewings
 3 rd decade- GCT
 4 th decade- chondrosarcoma
 5 th decade- Multiple myeloma
 SEX:- less imp than age
Some tumors like GCT are more in
females

10. Cont…
 RACE:- little imp, Ewings rare in african descent
 H/O any exposure to radiation Tt or Carcinogens-
bone seeking radionucleotide can cause sarcoma.
 Various chemlcal carcinogens-
methylcholanthrene,zinc beryllium silicate, beryllium
oxide.
 Currently the most worrisome & controversial is Nickel
which is used in many orthopedic device

11. PHYSICAL EXAMINATION
 Evaluation of patient’s general health
 TUMOR MASS should be measured & its location, shape,
consistency, mobility, tenderness, local temp & change with
position should be noted.
 SKIN & SUBCUTANEOUS TISSUE :
 Small dilated superficial veins overlying the mass are produced by
large tumors
 REGIONAL LYMPH NODES: sign of metastatic disease
 Atrophy of surrounding musculature should be recorded,also
neurological deficits & adequacy of circulation

12. LABORATORY TEST
 Alkaline phosphatase test: Normally, this enzyme is
present in high levels when bone-forming cells are very
active . High levels of alkaline phosphatase can also be an
indicator of bone tumors (when the tumor creates abnormal
bone tissues).
 PTH test: Lower-than-normal level of parathormone can be
an indicator of bone cancer.
 Serum phosphorus: Higher than normal levels of
phosphorus can be an indicator of bone cancer.
 Ionized calcium and serum calcium: Higher than normal
levels of calcium can be an indicator of bone cancer.

13. Cont…
 OTHER TESTS
Hemoglobin
CBC
ESR
CRP
Glucose tolerance test
PSA,PAP
Electrophoresis & urinary Bence Jones
protein

14. INVESTIGATIONS
 X-RAY
 CT SCAN
 MRI
 TECHNETIUM BONE SCAN-This type of scan uses a very low
radioactive material (diphosphonate) to see whether or not the
cancer has spread to other bones and the damage suffered by
the bone.
 PET- Positron Emission Tomography uses radioactive glucose to
locate cancer. This glucose contains a radioactive atom that is
absorbed by the cancerous cells and then detected by a special
camera

21. BIOPSY
 The biopsy is the most conclusive as it confirms if the
tumor is malignant or benign, the type (primary or
secondary ), and stage
 According to the tumor size and type and purpose (to
remove entire tumor or only a small tissue sample),
biopsies can be
: needle biopsy , incisional biopsy , excisional
biopsy
 1. Needle biopsy: a small hole is made in the affected
bone and a tissue sample from the tumor is removed.
There are two types of needle biopsies:
Fine needle aspiration : During this procedure, the tissue
sample is removed with a thin needle attached to a syringe
Core needle aspiration : a small cylinder of tissue
sample is removed from the tumor with a rotating knife like
device.
 2. Incisional biopsy : During this procedure, the surgeon
cuts into the tumor and removes a tissue sample.

22. Principles of biopsy
 Biopsy should be done after clinical,
laboratory, and radiographic
examinations are complete
 biopsy track should be considered
contaminated with tumor cells , biopsy
track needs to be excised en bloc with
the tumor
 Transverse incisions avoided because
they are difficult to excise with the
specimen

23.  deep incision through a single muscle
compartment not to contaminating an
intermuscular plane
 Major neurovascular structures be avoided
 Soft tissue extension of bone lesion should be
sampled because leading edge contains most
viable tumor for making diagnosis
 If tourniquet used,limb elevated before inflation
but not to be exsanguinated by compression to
prevent “squeezing” the tumors cells into the
systemic circulation

24. Cont…
 If a hole is made in bone, should be round or
oval to minimize stress concentration and
prevent a subsequent fracture, which could
preclude limb salvage surgery
 The hole be plugged with methacrylate to
limit hematoma formation
 sample more than just the pseudocapsule
surrounding the lesion

25. Cont…
 frozen section should be sent
intraoperatively to ensure that diagnostic
tissue has been obtained
 If drain used, it should exit in line with
incision so that the drain track can be
easily excised en bloc with tumor
 wound should be closed tightly in layers

26. Cont…

27. classification
Revised WHO Classification –
Schajowicz(1994)

28. STAGING
 Staging of benign bone tumours as described by
Enneking
 stages of benign tumors designated by Arabic
numbers, and malignant tumors by Roman
numerals
 stage 1, latent; stage 2, active; and stage 3,
aggressive

29.  Stage 1 -lesions are
intracapsular,
usually asymptomatic,
and
frequently incidental
findings
 Radiographic features –
well-defined margin
with thick rim of reactive
bone.
no cortical destruction
or expansion.
 not require treatment –
not compromise the
strength of the bone
resolve spontaneously

30.  Stage 2-
intracapsular
actively growing
cause symptoms or
pathological fracture
 Radiographs-well-
defined margins
expand and thin
cortex.
thin rim of reactive
bone
 Treatment -
extended curettage

31.  Stage 3 –
extracapsular
broken through
reactive bone and
cortex
 MRI shows soft tissue
mass, and
metastases may
present in 5% of
patients
 Treatment -extended
curettage
marginal or wide
resection,
 local recurrences are
common.

32.  The staging system for malignant tumors adopted
by the Musculoskeletal Tumor Society, and
originally developed by Enneking is based on the
histological grade, the local extent, and the
presence or absence of metastasis
 Bone sarcomas are broadly divided as follows:
 • Stage I All low-grade sarcomas.
 • Stage II Histologically high-grade lesions.
 • Stage III Sarcomas which have metastasized

33.  stage I-lesions are well-differentiated,
have few mitoses, and
exhibit moderate cytological atypia
 risk for metastases is low (<25%)
 stage II-poorly differentiated
high mitotic rate and
high cell-to-matrix ratio
 Stage III-lesion that metastasized
regardless of size or grade of primary
tumor
Anatomical compartments are the
natural anatomical barriers to tumor
growth, such as cortical bone, articular
cartilage, fascial septa, or joint capsules

34. Surgical stages as described by
Enneking

36.  The AJCC staging soft tissue sarcomas
based on
tumor grade (low or high),
size (≤5 cm or >5 cm in greatest
dimension),
depth (superficial or deep to the fascia),
and
presence of metastases

38. PRINCIPLES OF SURGERY
AMPUTATION VERSUS LIMB SALVAGE
 issues to be considered whenever
contemplating limb salvage instead of an
amputation
1. Would survival be affected by the
treatment choice?
2. How do the short-term and long-term
morbidity compare?
3. How would the function of a salvaged
limb compare with that of a prosthesis?
4. Are there any psychosocial
consequences?

39.  involvement of neurovascular structures,
displaced pathological fracture, complications
secondary poorly performed biopsy preclude
limb salvage procedures
 choice between limb salvage and amputation
made on basis of expectations and desires of
patient and family
 multimodal treatment including surgery and
chemotherapy, improved long-term survival
for patients.

40.  patients with a local recurrence despite
wide margins represent aggressive or
chemotherapy-resistant disease , has
poor outcomes regardless of surgical
procedure
 most important aspect of surgical
procedure is attainment of a wide margin
regardless of achieved by amputation or
local resection

41.  Amputation often requires
nonstandard flaps for closure or
bone graft augmentation for a more
functional residual limb
 Complications - infection, wound
dehiscence, chronically painful limb,
phantom limb pain, and bone
overgrowth requiring revision
surgery
 Limb salvage is associated with
greater perioperative and long-
term morbidity
 Complications- greater risks of
infection, wound dehiscence, flap
necrosis, blood loss, and dvt
 long term complications like
periprosthetic fractures, prosthetic
loosening or dislocation, nonunion
of the graft-host junction, allograft
fracture, leg-length discrepancy,
and late infection
 more likely to need multiple future
operations for treatment of
complications including

42.  regard to function, location of tumor is most
important issue
 Resection of upper extremity lesion with limb
salvage, even sacrificing one or two major
nerves, provides better function than
amputation and prosthetic fitting
 resection of a proximal femoral or pelvic
lesion with local reconstruction provides
better function than after hip disarticulation or
hemipelvectomy

43.  Around ankle and foot, large sarcomas
treated with amputation and prosthetic fitting
 osteosarcoma around the knee treated with
wide resection with prosthetic knee
replacement or transfemoral amputation
 osteoarticular allograft reconstruction, allograft
arthrodesis, and rotationplasty are less
prefered

44.  patients with amputations had difficulty walking on
steep, rough, or slippery surfaces but active and least
worried about damaging limb
 Patients with arthrodesis performed most of physical
work but had difficulty with sitting, especially in back
seats of cars, theaters
 Patients with arthroplasty led more sedentary lives ,
protective of limb but had less difficulty with activities of
daily living

45.  probability of limb survival after resection
depends on type of reconstruction and
location of tumor(most imp issue).
 proximal reconstructions outlasting
distal reconstructions. ( inverse of the
prognosis for patient survival, with distal
sarcomas better prognosis than proximal
ones.)

46.  No study has shown significant
difference between amputation and limb
salvage with regard to psychological
outcome or quality of life in long-term
survivors of sarcoma.
 patient ultimately make the final decision
in light of long-term goals and lifestyle
decisions.

47. MARGINS
 In oncological surgical procedure, the
surgical margin must be appropriately
defined
 orthopaedic oncology, surgical margin
described by one of four :
intralesional, marginal, wide, or radical

48.  intralesional margin-
plane of surgical
dissection is within the
tumor
 appropriate for
symptomatic benign
lesions when the
surgical alternative
would be to sacrifice
important anatomical
structures ,
or
as a palliative
procedure in case of
metastatic disease

49.  marginal margin -plane
of dissection passes
through
pseudocapsule(surroundi
ng reactive tissue referred
as pseudocapsule)
 treat most benign lesions
and some low-grade
malignancies.
 marginal resection leaves
microscopic disease
leading to local
recurrence in high grade
malignancies
 marginal resection
preferable if alternative is
more mutilating procedure

50. Cont..
 Wide margins -plane of dissection is
in normal tissue
 no specific distance , entire tumor
remains completely surrounded by rim
of normal tissue
 quality of margin is more important
than the quantity (thickness) of the
margin
 wide margins are goal of most
procedures for high-grade

51.  Radical margins -all
compartments
containing tumor
removed en bloc
 previously the
procedures of choice
for most high-grade
neoplasms
 amputations defined
further by any of the
four margins

52. CURETTAGE
 Many benign bone
tumors treated by
curettage
 curettage is
associated with
higher rate of local
recurrence than
resection, but allows
a better functional
result
PRINCIPLES OF
CURETTAGE
 done by first making
large cortical window

53.  Next, cavity is enlarged to
normal host bone in each
direction with a power burr
 Finally, cavity and wound
TO be copiously irrigated
to remove any debris and
tumor cells
 Extended” curettage - use
of adjuvants, such as liquid
nitrogen, phenol,
polymethyl methacrylate,
or thermal cautery to
extend destruction of tumor
cells

54. filling the cavity
 -through autogenous
bone graft, allograft,
demineralized bone
matrix, artificial bone
graft substitutes, or
bone cement
 Autogenous bone
graft must be
harvested using
different set of
instruments to prevent
contamination of the
donor site

55.  Autogenous bone graft provides most
rapid and most reliable healing rate as it
is osteogenic, osteoinductive, and
osteoconductive
 But is associated with morbidity harvest
site, may not available in sufficient
quantity to fill a large cavity
 cancellous allograft (only
osteoinductive)incorporated easily,
available in large quantities and not
involve further operative morbidity

56.  demineralized bone matrix used as
filling agent after curettage of benign
bone tumors
 is osteoconductive and osteoinductive
 Artificial bone graft substitutes (
calcium sulfate, calcium phosphate) are
osteoconductive, easy to use, and
readily available
 used alone or in combination with
autogenous bone graft, bone marrow
aspirates, or demineralized bone matrix

57.  bone cement is also used as a filling
agent
 has the advantage of providing
immediate stability, makes
rehabilitation easier and lessens risk
of pathological fracture
 another advantage of bone cement is
detection of local recurrence
 recurrent tumor recognized as an
expanding lucency adjacent to bone