1. MANAGEMENT OF
PRIMARY BONE
TUMOURS
DR TELLA A.O.
23/01/13

2. OUTLINE
• OVERVIEW
• CLINICAL EVALUATION
- History of the patient
- Physical Examination
- Investigations
- Treatment
• FOLLOW-UP
• PROGNOSIS
• CONCLUSION

3. OVERVIEW
• Bone tumours can be very diverse in
morphology and biologic potential
• Most bone tumours are benign (˃95% of
cases)
• Malignant tumours may be primary or
secondary
- Primary malignant bone tumours are very
rare (˂0.2% of all cancers-NCCN)

4. OVERVIEW
• Most primaries occur in long bones
• May be quite difficult to diagnose
specifically
• Morbidity and mortality worse in
developing countries
• Multimodal approach to management has
improved survival

5. CLINICAL EVALUATION
• High index of suspicion is the first step in
management
• Requires a multidisplinary team
• Core Group:
- Orthopaedic oncologist
- Bone pathologist
- Medical/paediatric oncologist
- Radiation oncologist
- Musculoskeletal radiologist

6. CLINICAL EVALUATION
• Management involves:
○ Meticulous history
○ Thorough physical examination
○ Prebiopsy radiological evaluation
○ Biopsy
○ Other relevant investigations
○ Staging of the tumour
○ Treatment plan

7. HISTORY OF THE PATIENT
● PRESENTING SYMPTOMS:
Pain
Mass
An abnormal radiographic finding detected
during evaluation for other conditions
Neurological symptoms
Previous radiation exposure
Constitutional symptoms
History of trauma
● AGE OF THE PATIENT – a very important clue

9. PHYSICAL EXAMINATION
● Evaluation of patient’s general health
● TUMOR MASS should be measured & its
location, shape, consistency, mobility,
tenderness noted
● SKIN & SUBCUTANEOUS TISSUE :
Small dilated superficial veins overlying the
mass are produced by large tumors
Café-au-lait spots & subcutaneous
neurofibromas indicate Von
Recklinghausen’s disease

10. PHYSICAL EXAMINATION
● REGIONAL LYMPH NODES: sign of
metastatic disease
● Atrophy of surrounding musculature
● Neurological deficits
● Peripheral pulses → Adequacy of
circulation.
● Other systems e.g chest

12. RADIOGRAPHIC EVALUATION
• Plain X-rays
• Bone Scans
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Angiography
• PET Scans

13. PLAIN X-RAYS
• Provides most useful diagnostic information
in evaluation of bone tumours
• Guides the selection of other imaging
techniques
• Radiographic parameters are different for
both benign and malignant bone tumours:
- Location and nature of the lesion
- Periosteal reaction
- Soft tissue changes
- Matrix of the tumour
- pathological fracture

15.  Geographic pattern
 Ex: Most benign tumours
Non-ossifying
fibroma
Unicameral Bone
Cyst

16.  MOTH-EATEN PATTERN
 Ex: Multiple myeloma, Osteosarcoma

17.  PERMEATIVE PATTERN
 Ex: Ewing’s sarcoma

18. PERIOSTEAL REACTIONS
• Benign tumours:
- None
- Solid
• Malignant tumours
- Codman’s triangle
- Sunburst
- Onion skinning or Lamellated

19.  Codman’s triangle

20.  Sunburst

21.  Onion skinning

22. CartilaginousOsteoblasticNo matrix

23. EXPANSILE LESIONS OF BONE
Enchondroma
Fibrous
Dysplasia

24. BONE SCANS
• Uses very low radioactive
material like technetium
to assess spread to other
bones
- Polyostotic involvement
- Skeletal metastases
• Isotope Thallium-201
used to assess tumour
response to
chemotherapy

25. CT SCANS
• CT depicts transverse
anatomic relationship
of the tumour to
surrounding structures
• 3-D reconstruction
useful in pre-op
planning e.g pelvis
• Helps in evaluation of
pulmonary metastases

26. MRI
• Has better contrast
discrimination
• Images can be
performed in any
plane
• Useful in detecting
neurovascular
bundles and skip
metastases

27. ANGIOGRAPHY
• Useful in
determining
relationship of major
vessels to the
tumour
• Pre-op embolization
of a highly vascular
tumour can be done
prior to surgical
resection

28. ADDITIONAL INVESTIGATIONS
►LABORATORY INVESTIGATIONS:
• FBC, ESR, E/U/Cr
• Serum Cacium & Phosphate
• Serum electrophoresis
• Urinary Bence Jonce Protein estimation

29. DIFFERENTIAL DIAGNOSES

30. DIFFERENTIALS

31. BIOPSY
• Tissue sampling for pathological evaluation
• The planning and technique is important
- Error may have negative impact on survival
• Biopsy of bone tumours can be done open or
closed
- Needle biopsy to be done with image
guidance
• Patient should be well prepared

32. BIOPSY
• The smallest longitudinal incision compatible with
obtaining adequate sample should be employed
• Knife and bone curette should be used to avoid
crushing the specimen
• Small circular holes minimise stress risers on the bone
• Meticulous haemostasis must be maintained
- Careful use of tourniquet
• Exposure should violate one compartment
• Drain to pass through incision wound
• All biopsies must be cultured and vice versa

33. BIOPSY

34.  Enneking surgical staging system

35. TREATMENT
• INITIAL RESUSCITATION
- Anaemia to be corrected
- Pain control
- Antibiotics
• Palliative treatment for metastatic
disease

37. CURETTAGE OF BONE TUMOURS
• Used for benign active tumours e.g unicameral
bone cyst, aneurysmal bone cyst, giant cell
tumour
• The technique involves creating a window and
‟scooping” out the tumour
• The bony defect created can then be
reconstructed using bone graft, PMMA or
biologic fillers
• Cryosurgery (use of liquid Nitrogen) is often
used to kill remaining tumour cells

39. AMPUTATION
• Involves the removal of the entire bone and soft
tissues at a safe proximal level to the tumour
• Often indicated in complex tumours with
neurovascular compromise and tumours
complicated with infection and severe soft
tissue compromise
• Requires careful planning :
- patient’s goal and expectations
- Oncologic and functional outcome
• May entail intralesional, marginal , wide or
radical excision

41. LIMB-SPARING PROCEDURE
• Currently being employed due to advances in
imaging modalities and availability of tumour
prosthesis
• Requires patient preparation, staging studies,
adequate biopsy, pre-op and post-op
chemotherapy
• Phases of operation:
○ Tumour resection
○ Skeletal reconstruction
○ Soft tissue reconstruction

42. REQUIREMENTS
• No major neurovascular
involvement
• Wide resection of
affected bone and cuff of
normal tissues
• Resection of bone 3-4cm
beyond abnormal uptake
on bone scan
• Complete soft tissue
coverage
• Contraindications:
1. Major neurovascular
involvement
2. Pathologic fractures
3. Inadequate biopsy
4. Tumour complications
e.g infection, muscle
necrosis
5. Skeletal immaturity

43. METHODS OF SKELETAL
RECONSTRUCTION
• Autograft (vascularised)
• Allograft (Osteoarticular)
• Modular endoprosthesis
• Allograft-prosthetic composites
• Expandable prosthesis
• Rotationplasty
• Arthrodesis
• Limb lenghtening

47. LIMB-SPARING VS AMPUTATION
• Survival of the patient
• Functional outcome
• Complications
• Psychological factors
• Cost

48. CHEMOTHERAPY
• Effective multiagent chemotherapy has improved
overall survival of patients
• Could be given as Noeadjuvant or Adjuvant therapy
• Neoadjuvant chemotherapy avoids tumour
progression and decreases tumour spread at time of
surgery
• Not very useful in cartilaginous and low-grade
tumours
• Patient must be well prepared
• Response to chemotherapy needs to be measured

49. RADIOTHERAPY
• Most primary malignant bone tumours are
relatively radioresistant
• Useful in multiple myeloma, Ewing’s
sarcoma, spinal tumour
• Brachytherapy or EBRT employed

50. FOLLOW-UP CARE
• Aim is to detect local recurrence or metastatic
disease
• Patients are seen at regular intervals after
completion of initial treatment
• Entails adequate assessment of the patients
- Physical examination
- Lab investigations
- Imaging studies
• Long term complications of treatment also
evaluated

51. CONCLUSION
• Treatment of MSS tumours still expanding
• Results better with dedicated centres
- Multidisplinary team
- Research oriented
- Tumour registry
• Early detection and appropriate treatment
remains the key in reducing morbidity and
mortality