bone tumours overview

8/9/2019 Bone Tumours Overview

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Bone Tumors OverviewFor Medical Students

Abdelfattah Fawzi Khdeir M.D.

Ortho & Trauma esident!ebron " #$%


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A classification of bone tumors. Modified after evised '!O (lassification ) Scha*owicz +%,,-


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!STO/

As0m1tomatic until the abnormalit0 is discovered on 2"ra0.

Must be ca1able of s1ontaneous resolution

Situated where there is room for incons1icuous e21ansion

Age :

Durin3 childhood """ +fourth or si2th decades-

M0eloma is seldom seen before the si2th decade

In patients > 70 years of age, metastatic bone lesions are more

common than all primary tumors together.


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!STO/

4ain 5

a1id e21ansion with stretchin3 of surroundin3

tissues

(entral haemorrha3e

De3eneration in the tumour

4atholo3ical fracture

6er0 1ainful if it is enca1sulated in dense bone

+e.3. an osteoid osteoma-.


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!STO/

• Neurological symptoms (paraesthesiae or

numbness)

• Pathological fracture may be the first (an only)

clinical si3nal.

n elderl0 1eo1le an0 brea7 in the mid"shaftshould be re3arded as 1atholo3ical until 1roved

otherwise.


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89AM:ATO:

• A lump , !here oes it arise" Is it iscrete or ill"defined; s it soft or

hard< or 1ulsatile; And is it tender;

• #!elling is sometimes iffuse, an the o$erlying s7in warm and

inflamed= it can be difficult to distin3uish a tumor from infection or ahaematoma.

• f the tumor is near a *oint there ma0 be an effusion and>or limitation of

mo$ement.

• #pinal lesions , whether beni3n or mali3nant< often cause muscle

spasm an bac% stiffness, or a painful scoliosis


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9"A/S


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9"A/S

• (ortical thic7enin3< a discrete lum1< a ?c0st@ or ill"defined destruction.

• 'here is the lesion5 in the meta1h0sis or the dia1h0sis;

• s it solitar0 or are there multi1le lesions;

• Are the mar3ins well"defined or ill"defined;

• emember that ?c0stic@ lesions are not necessaril0 hollow cavities5 an0

radiolucent material +e.3. a fibroma or a chondroma- ma0 loo7 li7e a

c0st.


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9"A/S

• f the boundar0 of the ?c0st@ is shar1l0 defined it is 1robabl0 beni3n= if

it is haz0 and diffuse it su33ests an invasive tumour.

• Sti11led calcification inside a c0stic area is characteristic of cartila3e

tumors.

• oo7 carefull0 at the bone surfaces5 1eriosteal newbone formation and

e2tension of the tumour into the soft tissues are su33estive of

mali3nant chan3e.

• oo7 also at the soft tissues5 Are the muscle 1lanes distorted b0

swellin3; s there calcification;


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ADO:(D8 S(A:::C

• Scannin3 with ,,mTc"meth0l di1hos1honate +,,mTc"

MD4- shows non"s1ecific reactive chan3es in bone

• This can be hel1ful in revealin3 the site of a small

tumour +e.3. an osteoid osteoma- that does not show

u1 clearl0 on 2"ra0.

• s also useful for detectin3 s7i1 lesions or ?silent@

secondar0 de1osits.


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(OM4T8D TOMOCA4!/

• t shows more accuratel0 both intraosseous and

e2traosseous e2tension

• eveal sus1ected lesions in inaccessible sites<

li7e the s1ine or 1elvis


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M

• ts 3reatest value is in the assessment of tumor

s1read5 +a- within the bone< +b- into a nearb0 *oint

and +c- into the soft tissues.

• Blood vessels and the relationshi1 of the tumor to

the 1erivascular s1ace are well defined.

• M is also useful in assessin3 soft"tissue tumours

and cartila3inous lesions.


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• Tumors ) differential dia3nosis

+a- This hu3e swellin3 was sim1l0 a clotted haematoma.

+b- Bone infection with 1atholo3ical fracture.

+c- Florid callus in an un"united fracture.

+d- ar3e erosion in the calcaneum b0 a 3out0 to1hus.

+e- Bone infarcts


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STAC:C OF BO:8 TMOS

• # s0stems " one for mali3nant lesions and one for beni3n lesions

– Mali3nant lesions are defined usin3 oman numerals +e.3. < < -

• e.3. osteosarcoma most commonl0 1resents as sta3e B

– Beni3n lesions are defined usin3 Arabic numbers +%


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STAC:C OF BO:8 TMOS


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STAC:C OF BO:8 TMOS

• Tumor (om1artments

– ntracom1artmental• bone tumors are confined within the corte2 of the bone

–

82tracom1artmental• bone tumors e2tend be0ond the bone corte2

• Tumor Crade

– !istolo3icall0< tumors are 3raded based on the 1ercenta3e of cellular at01ia • ow 3rade tumors

– low metastatic 1otential

– e.3. 1arosteal osteosarcoma

• !i3h 3rade tumors – 3reater metastastatic 1otential

– e.3. intramedullar0 osteosarcoma< 8win3s sarcoma< dedifferentiated chondrosarcoma


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MSTS +8nne7in3- Sta3in3 S0stem

• Musculoskeletal Tumor Society system


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• A 13-year-old girl presents with an isolated distal femur

osteosarcoma that extends into the soft tissue. Work-up is negatie

for metastasis! "ut "iopsy reeals a high grade lesion. What is the

stage of this tumor "y the Musculoskeletal Tumor Society system#

•

1. $ A

• %. $$ A

•

3. $ &• '. $$ &

• (. $$$


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• +a- 4lain 2"ra0 shows a destructive lesion of the 1ro2imal tibia< almost certainl0 an osteosarcoma

• +b


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B8:C: BO:8 8SO:S


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:O:"OSSF/:C FBOMA +FBOS

(OT(A D8F8(T-

• The commonest beni3n lesion of bone.

• A develo1mental defect in which a nest of fibrous tissue

a11ears within the bone and 1ersists for some 0earsbefore ossif0in3.

• t is as0m1tomatic and is almost alwa0s encountered in

children as an incidental findin3 on 2"ra0.

• The commonest sites are the meta1h0ses of lon3 bones


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(OT(A D8F8(T-

• (ommon in children G"%G 0ears old

+8stimated that $H of children with o1en 1h0sis

have a nonossif0in3 fibroma-

• I$H in lower e2tremit0

• (ommon locations include the 7nee +distal femur and

1ro2imal tibia- and distal tibia


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(OT(A D8F8(T-

• The &'ray appearance is meta1h0seal eccentric Jbubbl0J

l0tic lesion surrounded b0 sclerotic rim

• views in different 1lanes ma0 show that a lesion thata11ears to be ?central@ is actuall0 ad*acent to or within the

corte2< hence the alternative name ?fibrous cortical defect@.

• Although it loo%s cystic on &'ray, it is a solid lesionconsistin3 of unremar7able fibrous tissue with a few

scattered 3iant cells.


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(OT(A D8F8(T-


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(OT(A D8F8(T-

• As the bone 3rows the defect becomes less obvious and it

eventuall0 heals s1ontaneousl0.

• There is no ris7 of mali3nant chan3e.

• reatment is usually unnecessary.

• If thedefect is ver0 lar3e or has led to re1eated fractures< it can betreated b0 curetta3e and bone 3raftin3.

• ecurrence is rare.


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FBOS D/S4ASA

• Areas of trabecular bone are re1laced b0

cellular fibrous tissue containin3 flec7s of

osteoid and woven bone.

• t ma0 affect 5

One bone +monostotic-

One limb+monomelic-

Man0 bones +1ol0ostotic-.


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FBOS D/S4ASA

Females males

Found in an0 and all a3es

Onset for LGH of 1atients at $ 0ears of a3e

An0 bone can be involved

The 1ro2imal femur is most common site


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Mc(une Albri3ht s0ndrome

(ondition defined b0 5

The 1resence of s7in abnormalities +cafe au lait s1ots-

8ndocrine abnormalities 5

+4recocious 1ubert0-

enal 1hos1hate wasin3 due to FCF"# +onco3enic

osteomalacia-

4ol0ostotic fibrous d0s1lasia


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+(afe au lait s1ots-

ar3er and more irre3ular borders than neurofibromatosis


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4ol0ostotic Fibrous D0s1lasia


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N4unched"outJ lesion with well defined mar3in of sclerotic bone

!i3hl0 l0tic lesions or a 3round 3lass a11earance


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?She1herd@s (roo7@ Deformit0


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Treatment

• :ono1erative

– observation

• indications

– as0m1tomatic 1atients

– Di1hos1honate thera10

• indications – s0m1tomatic 1ol0ostotic fibrous d0s1lasia

• effective in decreasein3 1ain and reducin3 bone turnover


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Treatment

• O1erative

– internal fi2ation and bone 3raftin3

• indications – s0m1tomatic lesions

–

im1endin3>actual fractures throu3h lesions in areas of hi3h stress +femoral nec7- – severe deformit0

– neurolo3ic com1romise in the s1ine

• techniue – never use auto3enous cancellous bone< as the trans1lanted bone will uic7l0 turn into

fibrous d0s1lastic woven bone

– use cortical or cancellous allo3rafts – intramedullar0 device more effective than a 1late in the lower e2tremit0

– Osteotomies for deformities


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• Mali3nant transformation to fibrosarcoma

occurs in $.G 1er cent of 1atients with

monostotic lesions and u1 to G 1er cent of

1atients with Albri3ht@s s0ndrome.


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OST8OD OST8OMA

• This tin0 bone tumour + %.G cm in diameter- causes

s0m1toms out of all 1ro1ortion to its size.

• 4atients are usuall0 under $ 0ears of a3e and males1redominate.

• An0 bone e2ce1t the s7ull ma0 be affected< but over half

the cases occur in the femur or tibia.

• T01icall0 the 1ain is relieved b0 salic0lates.


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OST8OD OST8OMA

• G$H in dia1h0sis or meta1h0sis of lon3 bones of lower

e2tremit0 +tibia< femur-

– 1ro2imal femur tibia dia1h0sis 1osterior elements of the s1ine

fin3ers and car1us feet

• The most common location is the 1ro2imal femur

• The most common intra"articular location is the hi1 *oint

• The most common locations in the hand are the sca1hoid and

1ro2imal 1halan2


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OST8OD OST8OMA

• 4atho1h0siolo30

– thou3ht to be from nerve fibers associated with blood vessels within the nidus

– 1ain is secondar0 to 1rosta3landin secretion and (O9%># e21ression

• (O9%># e21ression in tumor ma7es it sensitive to :SAD thera10

• Associated conditions

– ortho1aedic manifestations

• 1ainful scoliosis

• 3rowth disturbance

• fle2ion contractures

• 4ro3nosis

– 1ain from lesions usuall0 resolves after an avera3e of 0ears

– the lesion s1ontaneousl0 resolves in G"L 0ears

– in the s1ine< earl0 resection +within %I months- leads to resolution of scoliosis in

0oun3 children +%%0ears-


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OST8OD OST8OMA


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OST8OD OST8OMA

• S0m1toms

– 1ain that

• increases with time

• worse at ni3ht and with drin7in3 8TO!• relieved b0 :SADS

• ma0 be ad*acent to *oint and mimic arthritis

– hand lesions ma0 1resent with 1ainless swellin3


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OST8OD OST8OMA

• 4h0sical e2am

– Point effusions

– (ontractures

– im1

– Muscle atro1h0

– Ma0 1resent as 1ainful nonstructural scoliosis

• As a result of 1aravertebral s1asm• The osteoid osteoma is located on the concave side at

the a1e2 of the curve


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OST8OD OST8OMA

• adio3ra1hs

– ntensl0 reactive bone around radiolucent nidus

• :idus is %.G cm +otherwise osteoblastoma-

• :idus ma0 be difficult to see on 1lain 2ra0 – Because intense 1eriosteal reaction ma0 obscure the nidus


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OST8OD OST8OMA

• The im1ortant &'ray feature is a small raiolucent area< the so"called ?nidus@.

• esions in the dia1h0sis are surrounded b0 dense sclerosis and cortical

thic7enin3= this ma0 be so mar7ed that the nidus can be seen onl0 in fine

cut (T scans.

• esions in the meta1h0sis show less cortical thic7enin3.

• ,,mTc"MD4 scinti3ra1h0 reveals intense< localized activit0.

• t is sometimes difficult to distin3uish from a small Brodie@s abscess without

bio1s0.


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Osteoid osteoma The 2"ra0 a11earance de1ends on the site of the lesion.

+a- 'ith cortical tumours there is mar7ed reactive bone thic7enin3 leavin3 a small lucent nidus


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OST8OD OST8OMA

• (T 5

• Stud0 of choice

• To identif0 nidus surrounded b0 a sclerotic rim


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OST8OD OST8OMA

• Bone scan 5

• alwa0s hot with intense focal u1ta7e


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Treatment

• :ono1erative

– clinical observation and :SAD administration

• indications

– :SADS are %st line and will lead to a dramatic decrease ins0m1toms

» QG$H can be treated with :SADS alone

– Also indicated for 1ainful s1ine lesions without scoliosis

– Fin3erti1 lesions +distal 1halan2- ma0 not res1ond to :SADS


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OST8OD OST8OMA

• 4ercutaneous radiofreuenc0 ablation

– elative indications

• Failure of medical mana3ement

• 4eriarticular lesions< which increase the ris7 of cartila3e in*ur0 and 1remature de3enerative disease.

• S1inal lesions +controversial- " de1ends on the location of the lesion and 1ro2imit0 to neural elements

– (ontraindications

• lesions close to s1inal cord or nerve roots

– Techniue

• done under (T 3uidance

• 1robe at I$",$ de3 ( for R minutes to 1roduce a %cm zone of necrosis

– Outcomes

• ,$H of 1atients are successfull0 treated with %"# sessions of FA

• %$"%GH recurrence rate


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OST8OD OST8OMA

• Sur3ical resection indications

– ocation of lesion is not amenable to (T 3uided

1ercutaneous radiofreuenc0 ablation

– S1ine lesion associated with 1ainful scoliosis

– f the e2cision is li7el0 to wea7en the host bone +es1eciall0

in the vulnerable medial corte2 of the femoral nec7-<

1ro1h0lactic internal fi2ation ma0 be needed.

http://upload.orthobullets.com/topic/8012/images/osteoid%20osteoma%202.jpghttp://upload.orthobullets.com/topic/8012/images/osteoid%20osteoma%201.jpg


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Osteoblastoma

+CA:T OST8OD OST8OMA-

• A33ressive beni3n osteoblastic tumor of bone

– Jbi3 brotherJ of osteoid osteoma +nidus #cm-

• elativel0 rare

• less common than osteoid osteoma

• males females +#5%-

• ma*orit0 of 1atients %$"$ 0ears of a3e

– location• most common in 1osterior elements of s1ine

• Associated conditions

– onco3enic osteomalacia

– secondar0 AB(

• %$H"$H associated with secondar0 AB(


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Osteoblastoma

• S0m1toms

– 4ain

• slowl0 1ro3ressive dull achin3 1ain

• not relieved b0 :SADS – Ma0 see neurolo3ic s0m1toms with s1ine involvement

• 4h0sical e2am

– Swellin3

– Muscle atro1h0

– im1


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Osteoblastoma

• adio3ra1hs

– findin3s

• l0tic or mi2ed l0tic"blastic lesion with radiolucent nidus #cm

• reactive sclerotic bone

• RRH corticall0 based< H medullar0 based• often e21ansile with e2tension into soft tissues with rim of reactive bone

– #GH a11ear ver0 a33ressive and often mista7en for mali3nant lesion

• (T

– indications

• necessar0 to full0 evaluate lesion

• Bone scan

– hot with intense focal u1ta7e

http://upload.orthobullets.com/topic/8013/images/osteoblastoma%20ct.jpg


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Osteoblastoma


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Osteoblastoma


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Osteoblastoma

• :ono1erative

– observation

• indications

– rarel0< if ever< indicated as the lesion will continue to 3row

• O1erative

– curetta3e or mar3inal e2cision with bone 3raftin3

• indications – standard of care

• recurrence %$"#$H

(hondroma +a- The hand is a common site


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(hondroma +a- The hand is a common site.

+b- Another chondroma before and after curetta3e and

bone 3raftin3.


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8nchondromas

• location – usuall0 found in the medullar0 cavit0 of

the dia1h0sis or meta1h0sis

– the most common location is the hand +R$H-

»

the most common bone tumor in the hand is theenchondroma

– other locations include the distal femur +#$H-< 1ro2imal

humerus +%$H- and tibia

– rare in the s1ine and 1elvis


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8nchondromas

• 4atho1h0siolo30 5

• enchondromas re1resent incom1lete

endochondral ossification

– chondroblasts and fra3ments of e1i1h0seal

cartila3e esca1e from the 1h0sis< dis1lace into the

meta1h0sis and 1roliferate there


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Olliers disease +Multi1e 8nchondromatosis-


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8nchondromas

– Maffuccis s0ndrome

• S1oradic inheritance with no 3enetic 1redis1osition

• Multi1le enchondromas and soft"tissue an3iomas

• adio3ra1hicall0< enchondromas in Maffuccis s0ndrome mar7edl0e21and the bone and an3iomas are seen as small< round calcified

1hleboliths

•

is7 of mali3nant transformation u1 to %$$H

• Also has increased ris7 of visceral mali3nancies +astroc0toma< C

mali3nanc0-

http://upload.orthobullets.com/topic/8018/images/maffucci%20foot.jpg


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Maffuccis s0ndrome


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Maffuccis s0ndrome


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8nchondromas

• S0m1toms

– As0m1tomatic< discovered incidentall0 on

radio3ra1hs

• usuall0 true for enchondromas in lon3 bones and foot – 4atholo3ic fracture

• often seen with enchondromas in the hand

http://upload.orthobullets.com/topic/8018/images/patho%20fracture%202.jpg


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8nchondromas


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8nchondromas

– 4ain• 4ain is uncommon

•

'hen a 1atient 1resents with an enchondroma and 1ainin the ad*acent *oint< the cause of 1ain is often unrelated

to the tumor

• nli7e enchondroma< most chondrosarcomas have non"mechanical 1ain +rest 1ain and nocturnal 1ain-


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8nchondromas

• 4h0sical e2am

– Shortenin3 and an3ular deformities• enchondromas ma0 disru1t the 3rowth 1late

– Multi1le bluish an3iomas in Maffuccis s0ndrome

http://upload.orthobullets.com/topic/8018/images/maffucci%20hand2.jpg


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8nchondromas

• adio3ra1hs• s7eletal surve0 if 1ol0ostotic disease is sus1ected

– Findin3s

• 'ell defined< lucent< central medullar0 lesions that calcif0over time

• % to %$cm in size – meta1h0seal location when the0 first a11ear

–

a11ear more dia1h0seal as the lon3 bone 3rows• N4o1"cornJ sti11led calcification and rin3s

• Minimal endosteal erosion +G$H width of corte2-


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N4o1"cornJ sti11led calcification and rin3s

" (ortical e21ansion and thinnin3 ma0 be 1resent +8s1eciall0 in the hand-

http://upload.orthobullets.com/topic/8018/images/maffucci%20hand%20xr2.jpg


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" Ma0 have 1urel0 l0tic a11earance +8s1eciall0 in hand-

Olliers disease


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Ollier s disease

enchondromas mar7edl0 e21and the bone

bones are d0s1lastic< with shortenin3 and bowin3

Maffuccis s0ndrome


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Maffucci s s0ndrome

8nchondromas mar7edl0 e21and the bone

An3iomas are visible as calcified 1hleboliths

http://upload.orthobullets.com/topic/8018/images/maffucci%20hand%20xr1.jpghttp://upload.orthobullets.com/topic/8018/images/maffucci%20xr.jpg


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8nchondromas

• nli7e enchondromas< chondrosarcomas dis1la0 – (ortical thic7enin3 and destruction

– 8ndosteal erosions and scallo1in3 G$H of the width of the

corte2

–

Are lar3er +Gcm-


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8nchondromas

• :ono1erative

– Observation

• indications –

Treatment for vast ma*orit0 of as0m1tomatic enchondromas• Follow u1

– Serial radio3ra1hs for interval 3rowth +ever0 "R months for %"#

0ears< then annuall0-

– on3 term follow"u1 for 1atients with multi1le enchondroma

s0ndromes

h d


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8nchondromas

• O1erative – intralesional curetta3e and bone 3raftin3

• indications – lesion that shows an0 chan3e on serial 2ra0s

–

radio3ra1hs sus1icious for low"3rade chondrosarcoma – lar3e lesions at ris7 for recurrent fracture

• outcomes – local recurrence is unusual

– immobilization< followed b0 curretta3e and bone 3raftin3

• indications – 1atholo3ic fracture in small tubular bones +hand lesions-

• techniue – immobilize until fracture union< followed b0 curretta3e and 3raftin3

h d


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8nchondromas

• Mali3nant transformation

– is7 of transformation of enchondroma to low"3rade

chondrosarcoma

• Solitar0 enchondroma – ris7 of transformation is %H

• Olliers disease +multi1le enchondromatosis- – ris7 of transformation is #G"$H

•

Maffuccis s0ndrome – ris7 of transformation is #"%$$H

– also has hi3h ris7 of fatal visceral mali3nanc0

(h d bl


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(hondroblastoma

• A beni3n chondro3enic lesion +differs from 3iantcell tumor b0 its chondroid matri2-

• #5% male5female

• most 1atients under #G 0ears of a3e

– ocation

• 81i1h0seal lesion in 0oun3 1atients +usuall0 around %# 0ears

of a3e-

• (ommon locations include distal femur< 1ro2imal tibia<

1ro2imal humerus< 1ro2imal femur< and a1o1h0sis or triradiate

cartila3e of the 1elvis

• T01icall0 e1i1h0seal but ma0 occasionall0 cross the 1h0sis

(h d bl


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(hondroblastoma

• 4atho1h0siolo30

– Thou3ht to arise from cartila3inous e1i1h0seal 1late

• 4ro3nosis

– %"#H of beni3n chondroblasts metastasize to the

lun3s +similar to 3iant cell tumor in this res1ect-

– ecurrence is %$H"%GH after sur3ical resection

(h d bl t


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(hondroblastoma

• 'ell"circumscribed e1i1h0seal l0tic lesion with thin rim ofsclerotic bone that is shar1l0 demarcated from normal

medullar0 cavit0

• esions often cross 1h0sis into meta1h0sis

• Sti11led calcifications within the lesion ma0 or ma0 not be

1resent +#GH"GH-

• (ortical e21ansion ma0 be 1resent


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(h d bl t


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(hondroblastoma

• O1erative – e2tended intralesional curetta3e and bone 3raftin3

• indications –

standard of treatment in s0m1tomatic individuals• techniue

– ma0 do local ad*uvant treatment with 1henol or cr0othera10

– esection of rare beni3n 1ulmonar0 metastasis

• indications – if 1ulmonar0 metastasis

+ -


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OST8O(!O:DOMA +(ATAC8"(A448D 89OSTOSS-

• A beni3n chondro3enic lesion derived from aberrant cartila3e fromthe 1erichondral rin3 that ma0 ta7e the form of

– Solitar0 ostoechondroma

– Multi1le !ereditar0 82ostosis +M!8-

The most common beni3n bone tumor

(ommon in adolescents and 0oun3 adults +teste ages: , *0, *+, +0, +-

ocation

• Occur on the surface of the bone and often at sites of tendon insertion

•

(ommon locations include – 7nee +1ro2imal tibia< distal femur-

– 1ro2imal femur

– 1ro2imal humerus

– subun3al e2ostosis +occurs most often at hallu2-


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OST8O(!O:DOMA


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OST8O(!O:DOMA

• 4atho1h0siolo30 – Solitar0 osteochondromas can arise because of

• Salter"!arris fracture

• Sur3er0

• adiation thera10 +commonest beni3n radiation"induced bonetumor-

– 4athoanatom0

• !amartomatous 1roliferation of bone and cartila3e

• 4ossibl0 arise from 3rowth 1late cartila3e that 3rows throu3h thecorte2 b0 endochondral ossification under the 1eriosteum

• Stal7 of the lesion is cortical and cancellous bone formed from

ossified cartila3e

OST8O(!O:DOMA


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OST8O(!O:DOMA

• Associated conditions – secondar0 chondrosarcoma

• A mali3nant condition that results from mali3nant transformation of a

solitar0 osteochondroma or M!8 " Occurs in older 1atients +tested a3es5 G$- – Most common location of secondar0 chondrosarcoma is the 1elvis +usuall0 occur as

low"3rade chondrosarcomas-

• 4ro3nosis

–

is7 of mali3nant transformation is

• %H with solitar0 osteochondroma

• QG"%$H with M!8 develo1 secondar0 chondrosarcoma

M lti1le !ereditar 8 ostosis +M!8-


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Multi1le !ereditar0 82ostosis +M!8-

• Disorder characterized b0 multi1le osteochondromas

• Other name Multi1le Dia1h0sial Aclasis

• 4atho1h0siolo30

–

Mutations affect the 1reh01ertro1hic chondroc0tes of the 1h0sis• Autosomal dominant

• 4ro3nosis

– GH"%$H mali3nant transformation to chondrosarcoma in

1atients with M!8

– 4ro2imal lesions more li7el0 to under3o mali3nant

transformation than distal lesions

Osteochondroma


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Osteochondroma

– S0m1toms

• Most lesions are as0m1tomatic

• suall0 1resent with 1ainless mass• Ma0 have mechanical s0m1toms or s0m1toms of

neurovascular com1ression

• The0 continue to 3row until s7eletal maturit0

– 4h0sical e2am• 4al1able mass

• ma0 have mechanical s0m1toms secondar0 to mass

Multi1le hereditar0 e2ostosis +M!8-


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1 0 + -

– S0m1toms• imb deformities

– Most common sites of deformit0 include the 7nee< forearm< and an7le

» Femoral shortenin3 and limb"len3th discre1anc0

» (o2a val3a

» Knee val3us +because of shortened fibula- and 1atellar dislocation

» An7le val3us +because of shortened fibula-

– 11er e2tremit0 deformities are well tolerated and lead to little loss of function

» lnar shortenin3

» adial bowin3 and radial head dislocation

» Ma0 be treated with e2ostosis e2cision< ulnar len3thenin3 and radial closin3 wed3e

osteotom0

• Point 1ain – ma0 have s0m1toms of 1remature OA



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1 0 + -

– 4h0sical e2am• Most common deformities include

– lnar shortenin3 and radial bowin3

– adial head dislocation

– lnar deviation of the hand

• Secondar0 chondrosarcoma

– acute onset of 1ain in adults with M!8 should raise

sus1icion for mali3nanc0

Osteochondroma


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Osteochondroma

• adio3ra1h – Sessile +broad base- or 1edunculated +narrow stal7- lesions found on

the surface of bones

• hi3her ris7 of mali3nant de3eneration in sessile lesions

• 1edunculated lesions 1oint awa0 from the *oint

– (ontinuit0 with native tissue• corte2 of the lesion continuous with corte2 of the native bone

• medullar0 cavit0 of lesion continuous with medullar0 cavit0 of native bone

– (artila3e ca1 is usuall0 radiolucent and involutes at s7eletal maturit0

– :odules of meta1lastic cartila3e can occur within the bursa over cartila3e ca1s

• (T or M

– used to better characterize lesions

Osteochondroma


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Osteochondroma

– :ono1erative

• Observation alone – indications

» as0m1tomatic or minimall0 s0m1tomatic cases

– O1erative

• Mar3inal resection at base of stal7< includin3 cartila3e ca1 – indications

» s0m1tomatic lesions• lesion ma0 cause inflammation to surroundin3 tissue

• lesion ma0 be cosmeticall0 dis1leasin3

– tr0 to dela0 sur3er0 until s7eletal maturit0



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– :ono1erative

• observation – indications

» most 1atients do not reuire intervention 1rior to reachin3 s7eletal maturit0

– O1erative

• sur3ical e2cision of the osteochondroma – indications

» dislocated radial heads

» loss of forearm rotation

– outcomes

» sim1le e2cision of the osteochondroma o1timizes chance of im1roved motion

• Secondar0 chondrosarcoma – o1erative

• wide sur3ical resection – treat same as t01ical chondrosarcoma


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(om1lications


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(om1lications

• Tendon com1ression – lesions around the shoulder can 3ive rise to

• rotator cuff im1in3ement

• subsca1ularis tear

• bici1ital tendinitis

• (hondrosarcoma – in adults< cartila3e ca1 #cm is associated with increased chance of

mali3nanc0

– mean a3e of dia3nosis< %0rs

• seldom in %st decade or after Gth decade of life

• Bursa formation

• ecurrence

– #"GH of cases after resection

Osteochondroma +a- A 0oun3 3irl 1resented with this lum1 on her le3. t felt bon0 hard. +b- 9"ra0 e2amination

showed the t01ical features of a lar3e cartila3e ca11ed e2ostosis= of course the cartila3e ca1 does not show on 2 ra0 unless


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showed the t01ical features of a lar3e cartila3e"ca11ed e2ostosis= of course the cartila3e ca1 does not show on 2"ra0 unless

it is calcified. The bon0 1art ma0 be sessile< 1edunculated or cauliflower"li7e.

Osteochondroma ) treatment +a- This #$"0ear"old man had 7nown about the lum1 on his left sca1ula for man0

0ears. !e sto11ed 3rowin3 at the a3e of %I but the tumour continued to enlar3e. +b- Des1ite the beni3n histolo30 in the


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bio1s0< the tumour to3ether with most of the sca1ula was removed= sections ta7en from the de1ths of the lesion showed

at01ical cells su33estive of mali3nant chan3e.

nicameral Bone (0st


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nicameral Bone (0st

• Also referred to as a sim1le bone c0st

• A non"neo1lastic< serous fluid"filled bone lesion thou3ht to result

from tem1orar0 failure of medullar0 bone formation near the 1h0sis

• usuall0 found in 1atients #$ 0ears of a3e

– location

• usuall0 found in the 1ro2imal humerus of 0oun3 1atients

• can be found in other locations includin3 1ro2imal femur< distal tibia< ilium<

calcaneus< and occasionall0 metacar1als< 1halan3es< or distal radius• arises in the meta1h0sis ad*acent to 1h0sis and 1ro3resses toward the dia1h0sis

with bone 3rowth

nicameral Bone (0st


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nicameral Bone (0st

• 4ro3nosis – As a 1atient a11roaches s7eletal maturit0< a B( will

often decrease in size and ma0 heal after 3rowth is

com1lete

– Fracture healin3 usuall0 does not lead to c0st resolution

– euires close follow u1 while in active 1hase due torecurrence and ris7 of fracture or 3rowth arrest

nicameral Bone (0st


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nicameral Bone (0st

• (lassification is im1ortant as it im1actstreatment

• Active – if c0st is ad*acent to the 1h0sis

• atent

– if normal bone se1arates c0st from 1h0sis

atent B(


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atent B(


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NFallen leafJ si3n +1atholo3ic fracture with fallen cortical fra3ment in base of em1t0 c0st is

1atho3nomonic -


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1atho3nomonic -

nicameral Bone (0st


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nicameral Bone (0st

• :ono1erative

– mmobilization alone

• indications – 1ro2imal humerus lesions with 1atholo3ic fracture +%GH of lesions fill in with native bone

after acute fracture-

– As1iration>meth0l1rednisolone acetate in*ection

• indications – active c0sts +communicates with 1h0sis- in the 1ro2imal humerus

• techniue – usuall0 reuires several in*ections< es1eciall0 in ver0 0oun3 children

– bone marrow in*ections have recentl0 been re1orted to be effective

Sim1le bone c0sts

+a- A t01ical solitar0 +or unicameral- c0st ) on the shaft side of the 1h0sis and e21andin3

th t


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the corte2

+b- n*ection with meth0l1rednisolone< and +c- healin3. +d- Fracture throu3h a c0st.

nicameral Bone (0st


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nicameral Bone (0st

• O1erative – (uretta3e and bone 3raftin3 >" internal fi2ation based on tumor

location

•

ndications – s0m1tomatic latent c0sts that have not res1onded to steroid in*ections

– latent c0sts in the 1ro2imal femur that are a structural concern and at ris7 for fracture

and osteonecrosis

– 1ro2imal femoral lesions with a 1atholo3ic fracture have a hi3h rate of refracture and

malunion when treated nono1erativel0 therefore< internal fi2ation is recommended

• (ontraindications – avoid in active lesions as communication with 1h0sis ma0 lead to 3rowth arrest

Aneur0smal Bone (0st


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• A beni3n and non"neo1lastic reactive bone lesion filled withmulti1le blood"filled cavities

– (an be locall0 destructive to normal bone and ma0 e2tend to soft

tissue

• LGH of 1atients are #$ 0rs.

– ocation

• #GH in s1ine

• #$H in lon3 bones +distal femur< 1ro2imal tibia-

• suall0 in meta1h0sis

• 4osterior elements of 1elvis

• Ma0 be found in similar location as telan3iectatic osteosarcomas



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• adio3ra1hs – e21ansile< eccentric and l0tic lesion with bon0

se1tae +Jbubbl0 a11earanceJ-

– usuall0 in meta1h0seal

• M or (T scan

– will show multi1le fluid lines



114/182




115/182


• :ono1erative – :ono1erative fracture mana3ement

• ndications – AB( with acute fracture

» indicated until fracture has healed. Once healed< treat as an AB( without fracture unless the fracture has

led to s1ontaneous healin3 of the AB(

• O1erative

– A33ressive curetta3e and bone 3raftin3• ndications

– s0m1tomatic AB( without acute fracture

• Techniue – some use ad*uvant treatment +1henol-

• Outcomes – local recurrence in u1 to #GH and more common in children with o1en 1h0ses

Ciant (ell Tumor


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Ciant (ell Tumor

• A beni3n a33ressive tumor t01icall0 found in the e1i1h0sis of lon3bones

– more common in females +unli7e most bone tumors which show male

1redominance-

– a3es $"G$ 0ears

• ocation

– G$H occur around 7nee +distal femur or 1ro2imal tibia-

– %$H in sacrum and vertebrae +sacrum is most common site in a2ial s7eleton-

• while C(T can rarel0 occur in the s1ine< it usuall0 occurs in the vertebral bod0

– Distal radius is third most common location

– 4halan3es of the hand is also a ver0 common location

– Ma0 arise in the a1o1h0sis +li7e chondroblastoma-

Ciant"cell tumours The tumour alwa0s abuts

i h * i i


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a3ainst the *oint mar3in

Ciant (ell Tumor


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Ciant (ell Tumor

• Mali3nanc0 – 4rimar0 mali3nant 3iant cell tumor

• metastatic to lun3 in #"GH

•

hand lesions have 3reater chance of metastasis

– Secondar0 mali3nant 3iant cell tumor

• occurs followin3 radiation or multi1le resections of 3iant

cell tumor

8ccentric l0tic e1i1h0seal>meta1h0seal lesion that often e2tends

into the distal e1i1h0sis and borders subchondral bone


119/182

into the distal e1i1h0sis and borders subchondral bone

Ciant (ell Tumor


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Ciant (ell Tumor

• :ono1erative – radiation alone

• indications – onl0 indicated for ino1erable or multi1l0 recurrent lesions

• outcomes –

leads to %GH mali3nant transformation – Medical mana3ement

• indications – medical thera10 can be used to au3ment or re1lace sur3ical mana3ement de1endin3 on the

s1ecific clinical scenario

– Bis1hos1honates

»

osteclast inhibitors which ma0 decrease the size of the defect in 3iant cell tumors – Denosumab

» monoclonal antibod0 a3ainst A:K"li3and

» recent clinical trials su33est denosumab can decrease the size of the bone defect in 3iant

cell tumor

Ciant (ell Tumor


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Ciant (ell Tumor

• O1erative – 82tensive curetta3e and reconstruction +with ad*uvant

treatment-

• ndications – lesions amenable to curretta3e

– hand lesion treatment is controversial

» if no cortical brea7throu3h treat with curetta3e and cementin3

» if si3nificant cortical brea7throu3h consider intercalar0

resection +with free fibular 3raft- vs. am1utation


122/182


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4MA/ MAC:A:T BO:8

TMOS

(hondrosarcoma


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(hondrosarcoma

• Mali3nant chondro3enic lesions can occur in two forms

– 4rimar0 chondrosarcoma

• which includes – ow"3rade< hi3h"3rade< de"differenitated chondrosarcoma

– (lear cell chondrosarcoma – Mesench0mal chondrosarcoma

– Secondar0 chondrosarcoma

• arises from beni3n cartila3e lesions includin3 – Osteochondroma +%H ris7 of mali3nant transfomation-

– Multi1le hereditar0 e2ostosis +%"%$H ris7 of mali3nant transformation-

– 8nchondromas +%H ris7 of mali3nant transformation-

– Olliers disease +#G"$H ris7 of mali3nant transformation-

– Maffuccis +%$$H ris7 of mali3nant transformation-

(hondrosarcoma At the a3e of #$ 0ears< this 0oun3 man com1lained of 1ain in the ri3ht

3roin= 2"ra0 showed an osteochondroma of the ri3ht inferior 1ubic ramus.

+a- A bio1s0 showed ?beni3n@ cartila3e but a 0ear later the tumour had


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+a- A bio1s0 showed beni3n cartila3e but a 0ear later the tumour had

doubled its size +b-< a clear si3n that it was mali3nant

(hondrosarcoma


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( o d osa co a

• A3e & location – Found in older 1atients +$"LG 0rs-

– There is a sli3ht male 1redominance

– Most common locations include the 1elvis< 1ro2imalfemur< sca1ula

–

Tumor location is im1ortant for dia3nosis as thesame histolo30 ma0 be dia3nosed as beni3n in the

hand but mali3nant if located in the lon3 bones

(hondrosarcoma


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• Crade – IGH of chondrosarcomas are 3rade % or #

– %GH of chondrosarcomas are 3rade or dedifferentiated chondrosarcoma

• de"differentiated chondrosarcomas are hi3h 3rade lesions which develo1 from low

3rade chondroid lesions

• 4ro3nosis

– a2ial and 1ro2imal e2tremit0 lesions have a more a33ressive course

– histolo3ic 3rade correlates with survival

•

Crade 5 ,$H survival• Crade 5 R$"L$H survival

• Crade 5 $"G$H survival

• De"differentiated chondrosarcoma5 %$H survival

(hondrosarcoma


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• (hondrosarcoma sub"t01es

• (lear cell chondrosarcoma

– mali3nant immature cartila3inous tumor accountin3for #H of all chondrosarcomas

– most common in rd and th decades of life

–

1resents as an e1i1h0seal lesion and can bemista7en for low"3rade chondroblastoma

– locall0 destructive with 1otential to metastasize

(hondrosarcoma

http://upload.orthobullets.com/topic/8023/images/clear%20cell%202.jpg


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• Mesench0mal chondrosarcoma

– Ma0 occur at several discontinuous sites at

1resentation and can occur in the soft tissues

– Treatment includes neo"ad*uvant chemothera10

followed b0 wide sur3ical resection

(hondrosarcoma


130/182

• adio3ra1hs• 0tic or blastic lesion with reactive thic7enin3 of

the corte2

– ow"3rade chondrosarcomas show• Similar a11earance to enchondromas with additional

cortical thic7enin3>e21ansion and endosteal erosion

– !i3h"3rade chondrosarcomas show• cortical destruction and a soft tissue mass

ow"3rade chondrosarcomas


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3

(hondrosarcoma


132/182

ntra"lesional J1o1cornN mineralization ma0

be seen


133/182

be seen

de"differentiated chondrosarcomas radio3ra1hicall0 show a lower3rade chondroid lesion with su1erim1osed hi3hl0 destructive

area consistent with the hi3h 3rade transformed dedifferentiated


134/182

area consistent with the hi3h 3rade transformed dedifferentiated

chondrosarcoma

(hondrosarcoma


135/182

• O1erative – intra"lesional curetta3e

• indications – Crade % lesions

– treatment of 3rade % lesions located in the 1elvis or a2ial

s7eleton is controversial

» man0 authors recommend wide e2cision of all

chondrosarcomas +even 3rade %- if located in the 1elvis

(hondrosarcoma


136/182

– 'ide sur3ical e2cision• indications

– 3rade # or lesions

– some sa0 3rade % lesions in 1elvis

• historicall0< there is no si3nificant role for radiation or chemothera10

in t01ical intramedullar0 chondrosarcoma

– 'ide sur3ical e2cision combined with multi"a3ent

chemothera10

• indications – mesench0mal chondrosarcoma

– the role of chemothera10 in de"differentiated chondrosarcoma is ver0

controversial

ntramedullar0 Osteosarcoma


137/182

0

• ntramedullar0 osteosarcoma is the most common 1rimar0 sarcomaof bone

– The most common mali3nanc0 of bone is metastatic disease

– The most common 1rimar0 mali3nanc0 of bone is m0eloma

– suall0 occurs in children and 0oun3 adults

• bimodal distribution of occurrence – ma*orit0 occur in the second decade of life

– second 1ea7 in occurrence is in elderl0 1atients with 4a3ets disease

– Most common site is the distal femur and 1ro2imal tibia

– Other common sites include 1ro2imal humerus< 1ro2imal femur< and 1elvis



138/182

0

• Mali3nanc0 – Most commonl0 dia3nosed as Sta3e B +hi3h 3rade< e2tra"

com1artmental< no metastases-

–

%$"#$H of 1atients 1resent with 1ulmonar0 metastases +obtain (T ofchest-

• un3 is most common site of metastasis

• Bone is second most common site

• Cenetics – 4atients who carr0 the etinoblastoma tumor su11ressor 3ene +b-

are 1redis1osed to osteosarcoma



139/182

0

• 4ro3nosis – LRH lon3"term survival with modern treatment

– 4oor 1ro3nostic factors include

• Advanced sta3e of disease +most 1redictive of survival-

• es1onse to chemothera10 +as *ud3ed b0 1ercent tumor necrosis of resected

s1ecimen-

• Tumor site and size

• 821ression of 4"3l0co1rotein

• !i3h serum al7aline 1hos1hatase

• !i3h lactic deh0dro3enase• 6ascular involvement

• Sur3ical mar3ins

• T01e of chemothera10 re3imen

)haracteristic "lastic and destructie lesion


140/182

Sun"burst or hair on end 1attern of matri2 mineralization


141/182

+(odmans Trian3le-


142/182


143/182

Osteosarcoma )1atholo30 +a- After resection this lesion was cut in half= 1ale tumour

tissue is seen occu10in3 the distal third of the femur and e2tendin3 throu3h the corte2.


144/182



145/182

• A %"0ear"old 3irl 1resents with 7nee 1ain for # months es1eciall0at ni3ht. She denies fevers and wei3ht loss. !er 1h0sical e2am

reveals a 1ainful thi3h mass. A radio3ra1h is shown in Fi3ure A.

'hat is the ne2t most a11ro1riate ste1 in mana3ment;

%. e1eat radio3ra1hs in months with observation

#. 82ternal beam radiation and chemothera10

. Sur3ical bio1s0 and culture directed intravenous antibiotics

. :eoad*uvant chemothera10 followed b0 wide e2cision andad*uvant chemothera10

G. M of the entire bone< whole bod0 bone scan and (T chest



146/182



147/182

•

O1erative• Multi"a3ent chemothera10 and limb salva3e resection

– ndications• hi3h 3rade osteosarcoma

– (hemothera10• 1reo1erative chemothera10 3iven for I"%# wee7s followed b0 maintenance chemothera10 for R"

%# months after sur3ical resection

• ,IH necrosis after neo"ad*uvant chemothera10 is 3ood 1ro3nostic si3n

• e21ression of multi"dru3 resistance +MD- 3ene 1ortends 1oor 1ro3nosis – tumor cells can 1um1 chemothera10 out of cell with MD e21ression

– 1resent in #GH of 1rimar0 lesions and G$H of metastatic lesions



148/182

– Sur3ical techniue• Trend towards limb salva3e whenever 1ossible

• Overall survival in osteosarcoma is eual after limb

salva3e vs. am1utation to deal with local e2tent of

disease

• 'ide sur3ical resection

–

indications• indicated in low 3rade osteosarcoma such as 1arosteal

osteosarcoma


149/182

Osteosarcoma ) o1erative treatment 4osto1erative 2"ra0s showin3 an

endo1rosthetic re1lacement followin3 wide resection of the lesion +Stanmore

m1lants 'orldwide-.


150/182

1 -

4arosteal Osteosarcoma


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•

A low 3rade osteosarcoma • More common in females< a3e $"$

– ocation

• occurs on surface of meta1h0sis of lon3 bones

• most common sites include 1osterior distal femur< 1ro2imal tibia< and 1ro2imal humerus – I$H cases occur in the femur

• marrow invasion occurs in #GH of cases

• 4ro3nosis

– ,GH lon3 term survival when local control has been achieved

• dedifferentiation of 1arosteal osteosarcoma is a 1oor 1ro3nostic factor

• invasion into the medullar0 cavit0 does not affect lon3"term survival

!eavil0 ossified< lobulated mass arisin3 from corte2

a11ears stuc7 onto corte2


152/182

4arosteal osteosarcoma +a


153/182

4arosteal Osteosarcoma


154/182

• O1erative – 'ide local sur3ical e2cision

• ndications – standard of care in most 1atients

• Techniue – man0 consider 3eometric osteotom0 of involved bone to decrease

lon3 term morbidit0 and retain native *oint

• (hemothera10 – chemothera10 not indicated unless there is a hi3h 3rade com1onent

• Outcomes – often curative

8win3s Sarcoma


155/182

• A distinctive small round cell sarcoma • t01icall0 found in 1atients from G"#G 0ears of a3e

• second most common bone tumor in children

• uncommon in African Americans and (hinese

– locations

• QG$H are found in the dia1h0sis of lon3 bones – the most common locations include 1elvis< distal femur< 1ro2imal

tibia< femoral dia1h0sis< and 1ro2imal humerus

• Cenetics

– t+%%5##- translocation found in all cases

8win3s Sarcoma


156/182

• 4ro3nosis – Survival

• R$"L$H lon3 term survival with isolated e2tremit0 disease at 1resentation and

a11ro1riate treatment>tumor res1onse to chemothera10

• $H lon3 term survival with 1elvis lesions

• %GH lon3 term survival if 1atient 1resents with metastatic disease

– 4oor 1ro3nostic factors

• s1ine and 1elvic tumors

• tumors 3reater than %$$cm

• ,$H necrosis with chemothera10

• elevated lactic deh0dro3enase levels

• 1G mutation in addition to t+%%5##- translocation

8win3s Sarcoma


157/182

• 4resentation – 1ain often accom1anied b0 fever

– often mimics an infection

• 4h0sical e2am

– swellin3 and local tenderness

ar3e destructive lesion in the dia1h0sis or

meta1h0sis with a moth"eaten a11earance


158/182

1 0 11

4eriosteal reaction ma0 3ive Jonion

s7inJ or JsunburstJ a11earance


159/182

11

8win3@s tumour 82am1les of 8win3@s tumour in

+a- the humerus< +b- the mid"shaft of the fibula and +c- the lower end of the fibula.


160/182

8win3s Sarcoma


161/182

• abs – 8S is elevated

– 'B( is elevated

–

anemia is common – lactic deh0dro3enase

•

Bone marrow bio1s0 – reuired as 1art of wor7u1 for 8win3s to rule out

metastasis to the marrow

8win3s Sarcoma


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• O1erative

– chemothera10 and limb salva3e resection

• indications – standard of care in most 1atients

• chemothera10 – 1reo1erative chemothera10 3iven for I"%# wee7s followed b0 sur3ical resection and

maintenance chemothera10 for R"%# months

• irradiation – current trend is towards sur3ical resection and awa0 from irradiation due to lon3

term morbidit0 associated with radiation – situations where radiation ma0 be used

» non"resectable tumors +e3. lar3e s1inal tumors-

» 1atients who 1resent with widel0 metastatic disease

8win3s Sarcoma


163/182

• Small"round"cell tumor differential +b0 a3e- – G 0rs5 neuroblastoma or leu7emia

– G"%$ 0rs5 eosino1hilic 3ranuloma

–

G"$ 0rs5 8win3s sarcoma – $ 0rs5 l0m1homa

– G$ 0rs5 m0eloma

Multi1le M0eloma


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•

A neo1lastic 1roliferation of 1lasma cells that 1resents withs7eletal lesions

– neo1lastic 1lasma cells 1roduces immuno3lobulins

• heav0 chains5 3C +G#H-< 3A +#%H-< 3M +%#H-

• li3ht chains5 7a11a or lambda

– a7a Bence Pones 1roteins

• Disease forms

– disease ta7es multi1le forms that var0 in treatment and 1ro3nosis and

includes

• multi1le m0eloma

• solitar0 1lasmac0toma

• osteosclerotic m0eloma

Multi1le M0eloma


165/182

• Bone scans are cold in $H so obtain a s7eletal

surve0

M0eloma The characteristic 2"ra0 features are bone rarefaction< vertebral

com1ression fractures< e21andin3 lesions +t01icall0 in the ribs and 1elvis- and

1unched"out areas in the s7ull and the lon3 bones.


166/182

Multi1le M0eloma


167/182

•

Serum labs – anemia

– elevated creatinine

– h01ercalcemia

• 1resent in $H of 1atients due to e2cessive resor1tion of bone

– 8S often elevated – S484 +serum 1rotein electro1horesis-

• M s1i7e 1resent +G$H 3C< #GH 3A-

• rine

– 1roteinuria

– 484 +urine 1rotein electro1horesis-

• ma0 show Bence Pones 1roteins +secreted immuno3lobulin 7a11a and lambda li3ht

chains-


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M8TASTAT( BO:8 DS8AS8

Metastatic (ancer of Bone


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• Metastatic cancer is the most common reasonfor a destructive bone lesion in adults

– carcinomas that commonl0 s1read to bone include

•

breast• lun3

• th0roid

• enal

• Adrenal• 4rostate



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•

Bone is the third most common site for metastaticdisease +behind lun3 and liver-

• (ommon sites of metastatic lesions include

– A2ial s7eleton +vertebral bodies< 1elvis< ribs-» thoracic s1ine is most common site of bon0 metastasis

– 4ro2imal limb 3irdle

» 1ro2imal femur is most common site of fracture secondar0

to metastatic bone lesions



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• 4ro3nosis• Median survival in 1atients with metastatic bone

disease

– Th0roid5 I months

– 4rostate5 $ months

– Breast5 # months

–

Kidne05 variable de1endin3 on medical condition but ma0 beas short as R months

– un35 R months



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• 6ascular s1read 5• Batsons vertebral 1le2us

– valveless venous 1le2us of the s1ine that 1rovides a route

of metastasis from or3ans to a2ial structure

includin3 vertebral bodies< 1elvis< s7ull< and 1ro2imal limb3irdles

•

Arterial tree metastasis – mechanism b0 which lun3 and renal cancer s1read to the

distal e2tremities



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• 4url0 l0tic or mi2ed l0tic>blastic lesions

– lun3< th0roid< and renal are 1rimaril0 l0tic

– R$H of breast (A is blastic – ,$H of 1rostate (A is blastic

(ortical metastasis are common in lun3

cancer


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esions distal to elbow and 7nee are usuall0

from lun3 or renal 1rimar0


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•

Coal of treatment in metastatic disease is 1ain control andmaintainence of 1atient inde1endence

• Bis1hos1honate thera10

• Stabilization of com1lete fracture< 1osto1erative radiation

• 4ro1h0lactic stabilization of im1endin3 fracture< 1osto1erative

radiation

• 4reo1erative embolization ) enal > Th0roid


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S0novial (hondromatosis

A11le (ore A11earance


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4i3mented 6illonodular S0novitis


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• 46:S is an idio1athic monoarticular reactive s0novial disease

– characterized b0 e2uberant 1roliferation of s0novial villi and nodules

• most commonl0 in adults a3e $"G$ but can occur at an0 a3e

– location• ma0 be localized +intra"articular or classic form-

• 7nee is the most common site of involvement +I$H- – other involved sites include hi1< shoulder< and an7le

• can be diffuse +e2tra"articular e2tension- – when e2tra"articular 7nown as 3iant cell tumor of tendon sheath

» occurrin3 alon3 tendon sheaths of hands and feet

• 4athoanatom0 and etiolo30

– half of 1atients re1ort 1rior histor0 of trauma to afflicted re3ion• thou3ht to be a reactive 1rocess


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•

Arthrocentesis – 3rossl0 blood0 effusion

• Arthrosco10 +3ross a11earance-

– brownish or reddish inflamed s0novium is t01ical of 46:S



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•

O1erative – total s0novectom0

– intra"articular disease

» techniues ran3e from arthrosco1ic 1artial s0novectom0 to full0 o1en

total s0novectom0

» de1endent on e2tent and location of disease» freuent recurrence is common

» mostl0 due to incom1lete s0novectom0

– e2tra"articular

» mar3inal e2cision is adeuate for 3iant cell tumor of tendon sheath

»

recurrence +which is common- is treated with re1eat e2cision

bone tumours overview

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