bone tumor staging systems
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Bone tumor staging systems
Prepared by:Dr. Abdullah K. Ghafour2nd year IBFMS trainee
Supervised by: Dr. Ali Abdulnabi Alwan
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• Bone tumors are classified into: Primary bone tumors Secondary bone tumors ( Metastasis)
• Primary bone tumors are much less than secondary tumors
• All age groups affected, but some tumors occur in certain age
• Almost every bone can be affected, but some tumors prefer certain location
General considerations
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Bone tumor
frequency
according to age
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Classification of primary bone tumors ; according to the normal cell of origin and apparent pattern of differentiation
Histologic type Benign MalignantHematopoietic (40%) Myeloma, lymphoma
Chondrogenic (22%)
Osteochondroma, chondroma, chondroblastoma, chondromyxoid fibroma
Chondroscarcoma, dedifferentiated and mesenchymal chondrosarcoma
Osteogenic (19%) Osteoid osteoma, osteoblastoma Osteosarcoma
Unknown (10%) Giant cell tumor Ewing sarcoma, giant cell tumor, adamantinoma
Histiocytic Fibrous histiocytoma Malignant fibrous histiocytoma
Fibrogenic Fibroma Desomplastic fibroma, fibrosarcoma
Notochordal Chordoma
Vascular HemangiomaHemangioendothelioma, hemangiopericytoma, angiosarcoma
General considerations
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Table 1: frequency of malignant tumors:
Metastatic tumor 28.4%Osteogenic sarcoma 27.2%Ewing’s sarcoma 12.4%NHL 10.6%Chondrosarcoma 8.3%Plasma cell myeloma 8.3%Miscellaneous 4.8%
General considerations
Table 4: incidence of bone metastasis:
Cancer type incidence
Median survival
(mo.)Myeloma 70 –
95%6
Prostate 65 - 75 %
36
Breast cancer
65 – 75 %
24
Thyroid cancer
60 % 48
Lung cancer 30 – 40 %
7
Bladder cancer
40 % 6-9
Renal cancer 20 – 25 %
12
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location of Tumors:General considerations
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Bone tumor management principles:
• In treating tumors we strive to reconcile two conflicting principles: the lesion must be removed widely enough to ensure that it does not recur, but damage must be kept to a minimum.
• The balance between these objectives depends on knowing (a) how the tumor usually behaves (i.e. how aggressive it is), and (b) how far it has spread. The answers to these two questions are embodied in the staging system
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Bone tumor staging:•In bone tumors, staging incorporates the
degree of differentiation as well as local and distant spread, in order to estimate the prognosis of the patient.
•The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is a critical element in determining appropriate treatment
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Purposes of staging:
•Determine tumor type•Determine prognosis•planning treatment•Compare results between study groups•Delineate extent of local and distant
disease
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Staging Studies:Conventional radiographyMRICT scan
o Tumor siteo Chest CT
Nuclear imagingAngiographyBone Tumor Specimens:
o Fine-needle Aspiration Biopsyo Biopsyo Curettageo Resections and Amputations
Adjunctive Diagnostic Techniqueso Histochemistry, Immunohistochemistry, and Electron
Microscopyo Cytogenetic/Molecular Genetic Techniques
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Conventional radiography
•Cortical destruction?•Periosteal reaction? •Involvement of joint space?•Tumor multifocal?•Internal composition of tumor•Is involved bone normal?•What part of the bone?•Tumor interaction with surrounding non-
neoplastic tissue
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MRI•Evaluates entire bone and adjacent joint•Best test for intraosseous extent and soft•tissue extent•Skip metastatic lesions•Proximity to vascular structures•Occasionally helpful in diagnosis of bone
or soft tissue tumors (experienced radiologist)
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CT scan▫Good for evaluating cortical details and destruction▫Subtle cortical erosions (endosteal ; periosteal)▫Calcifications / ossification▫Chest CT: Presence of metastatic disease
Bone Scintigraphy▫Whole body bone scan▫Sites of bony metastasis▫Active lesion??
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Prognosis of bone cancer depends on:1. overall stage of disease2. presence of metastasis3. skip lesions within the same bone4. histologic grade5. tumor size
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Bone tumor staging systems:•The are two staging systems that are
commonly used:
▫Musculoskeletal Tumor Society MSTS or Enneking System
▫American Joint Committee on Cancer AJCC Staging System
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MSTS (Enneking) Staging System: most popular and useful for orthopaedic
surgeons
two systems: malignant lesions: are defined using Roman
numerals (e.g. I, II, III) benign lesions: are defined using Arabic
numbers (1,2,3)1= latent lesion 2=active lesion3=aggressive lesion
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• Stage 1; Latent ▫ Well defined margin▫ Grows slowly and then stops▫ Heals spontaneously e.g. osteoid osteoma▫ Negligible recurrence after intracapsular resection
• Stage 2; Active▫ Progressive growth limited by natural barriers▫ Well defined margin but may expand thinning cortex e.g.
ABC▫ Negligible recurrence after marginal excision▫ Rx. marginal resection
• Stage 3; aggressive▫ Growth not limited by natural barriers e.g. GCT▫ Metastasis present in 5% of these ptatients▫ Have high recurrence after intracapsular or marginal
resection▫ Extended resection preferred
Enneking staging of benign tumors
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Enneking staging of benign tumors
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Incorporates :
• Tumor Grade ▫ histologically, tumors are graded based on the percentage of cellular atypia;
low grade tumors (I) low metastatic potential e.g. paraosteal osteosarcoma
high grade tumors (II) greater metastatic potential e.g. intramedullary osteosarcoma, Ewing's sarcoma, dedifferentiated
chondrosarcoma
• Tumor Compartments (Site)▫ Intracompartmental (A)
bone tumors are confined within the cortex of the bone▫ Extracompartmental (B)
bone tumors extend beyond the bone cortex
• distant spread▫ metastasis
Enneking staging of malignant tumors
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Enneking staging of malignant tumors
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AJCC staging for bone sarcomasit has been used a new, more complex classification of the primary malignant osseous tumors
Tumor grade Low grade tumor (I) High grade tumor (II)
Tumor size <8cm -A >8cm –B
Lymph node metastasis• N0 - no regional lymph node metastases• N1 - regional lymph node metastases
Presence and location of metastasis Skip metastasis -III Pulmonary metastasis -IVA Non-pulmonary metastasis -IVB
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AJCC staging for bone sarcomas
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Bone tumor staging systems:
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References:• Solomon L., Warwick D. , Nayagam S.,[2010] Apley’s System of
Orthopaedics and Fractures, 9th ed. Hodderarnold comp.,London, UK.• Miller M. , Thompson S. , Hart J. ,[2012] REVIEW OF ORTHOPAEDICS
[PDF], 6th ed. by Saunders, an imprint of Elsevier Inc. , Philadelphia, USA.• Canale S. , Beaty J. , [2007] Campbell’s Operative Orthopaedics [PDF], 11th
ed. By Mosby, An Imprint of Elsevier , Tennessee, USA.• Richard J. O’Donnell, MD, Annual Meeting of the Musculoskeletal Tumor
Society [2013] San Francisco, California• American Joint Committee on Cancer • [PDF] Purposes and Principles of
Cancer Staging , published in this manual is effective for cancer cases diagnosed on or after January 1, 2010.
• Alina Maria Sisu, Loredana Gabriela Stana[2012] On the Bone Tumours, incidence classification and staging [PDF] , New York, USA.
• L.-G. Kindblom, MD, PhD, [2008] Bone Tumors: Epidemiology,Classification, Pathology, [PDF] Birmingham B15 , 2TT, UK
• Martin M. Malawer, Paul Sugarbaker, [2012] Musculoskeletal Cancer Surgery , Washington Cancer Institue , Washington , USA.
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