CASE REPORTCASE REPORT

Primary Bone Tumor at the Primary Bone Tumor at the LeftLeft distal distal Radius Radius SSuspuspectect Benign Benign

BY:BY:Riswan Idris Riswan Idris C111 06 097C111 06 097SUPERVISORSUPERVISOR

Dr. M.Ruksal Saleh Sp.OTDr. M.Ruksal Saleh Sp.OT

PATIENT IDENTITYPATIENT IDENTITYName Name : : Mrs.KMrs.KAgeAge : : 4444 years old years old SexSex : Female: FemaleMRMR : 48 04 03: 48 04 03AdmittedAdmitted : 29-09-2011: 29-09-2011

Chief complainChief complain : : Lump in the left wrist joint Lump in the left wrist joint

AnamnesisAnamnesis : : Suffered since 5 months ago Suffered since 5 months ago before admitted to the hospital. Initially the before admitted to the hospital. Initially the patient realized there is a lump 5 months ago patient realized there is a lump 5 months ago at her left wrist due to pain which gradually at her left wrist due to pain which gradually got bigger until now as big as tennis ball.She got bigger until now as big as tennis ball.She felt pain (mild pain) every day not depend on felt pain (mild pain) every day not depend on the time. The pain got worse especially in the time. The pain got worse especially in activity.activity.

Cont..Cont.. History of bone setter (+)History of bone setter (+) History of Night pain (-)History of Night pain (-) History of similar disease on Family (-)History of similar disease on Family (-) History of Trauma (-)History of Trauma (-) History of Fever (-)History of Fever (-) History of weigh loss (-)History of weigh loss (-) history of lose of appetite (-).history of lose of appetite (-). Defecation & urinate normalDefecation & urinate normal Patient left handedPatient left handed

GENERAL STATUSGENERAL STATUSModerate illness / Moderate illness / wellwell nourish / con nourish / conciciousous

Vital signVital signBP = 1BP = 1330/0/880 mmHg 0 mmHg PR = PR = 8686 x/min x/min RR = 20 x/minRR = 20 x/minT = 36.7T = 36.7o o C (axillar)C (axillar)

LOCAL STATUSLOCAL STATUSLeft Wrist RegionLeft Wrist RegionI I : : Lump at distal radius as big as size of Lump at distal radius as big as size of

tennis ball, venectation (-), skin colour same as tennis ball, venectation (-), skin colour same as vicinity vicinity

P : P : tenderness (+), temperature same as tenderness (+), temperature same as vicinity, well defined border, immobile, vicinity, well defined border, immobile, smooth surface, consistency is firm.smooth surface, consistency is firm.Size of the lump 7 cm x 4 cm x 3 cmSize of the lump 7 cm x 4 cm x 3 cm

A : Bruit (-)A : Bruit (-)

Cont..Cont..ROM: ROM: active and passive mov active and passive movement is difficult ement is difficult

to evaluate due to pain to evaluate due to pain

NVDNVD : Sensibility is good, : Sensibility is good, CRT < 2 second, CRT < 2 second, ulnaris and radialis artery were ulnaris and radialis artery were

palpablepalpable

Clinical PictureClinical Picture

LABORATORY FINDINGSLABORATORY FINDINGS WBCWBC 55,,55 x 10 x 1033 /uL /uL RBCRBC 4,4,1313 x 10 x 106 6 /uL/uL HGBHGB 12,12,44 g/ dL g/ dL HCTHCT 3366,,11 % % PLTPLT 189 189 x 10x 1033 /uL /uL BSBS 106 mg/dl106 mg/dl UreumUreum 1144 g/dl g/dl Creatinin 0,Creatinin 0,66 g/dl g/dl SGOTSGOT 4747 g/dl g/dl SGPTSGPT 1919 g/dl g/dl ALPALP 124124 HbSAgHbSAgNegativNegativ Ca125Ca125 9.769.76

RADIOLOGICAL FINDINGSRADIOLOGICAL FINDINGSThorax X-rayThorax X-ray

AP VIEWAP VIEW

DIAGNOSISDIAGNOSIS

Primary Bone Tumor at the Primary Bone Tumor at the LeftLeft distal distal Radius Radius SSuspuspectect Benign Benign

MANAGEMENTMANAGEMENT Analgetik Analgetik Planning :Planning : - Biopsy (FNA)- Biopsy (FNA)

DISCUSSIONDISCUSSION

Neoplasia is a development of Neoplasia is a development of new cells, abnormal and new cells, abnormal and progressive, when the cells never progressive, when the cells never reach a mature stage.reach a mature stage.

The Bone tumor is classified into :The Bone tumor is classified into : Primary Bone TumorPrimary Bone Tumor Secondary Bone TumorSecondary Bone Tumor

DIAGNOSIS OF DIAGNOSIS OF TUMOURSTUMOURS

Clinical EvaluationClinical Evaluation AnamnesisAnamnesis Physical ExaminationPhysical Examination

Laboratory FindingsLaboratory Findings Enzim Serum Alakali Phospatase (SAP)Enzim Serum Alakali Phospatase (SAP) Latic Dehydrogenase (LDH)Latic Dehydrogenase (LDH)

Radiology FindingsRadiology Findings Plain X-RayPlain X-Ray CT-ScanCT-Scan MRIMRI Bone ScanBone Scan

BiopsyBiopsy Needle BiopsyNeedle Biopsy Open BiopsyOpen Biopsy

Staging of TumorStaging of Tumorby ennekingby enneking

BenignBenign Stage 1 Stage 1 Stage 2Stage 2 Stage 3Stage 3

MalignantMalignant Stage I Stage I : I.a, I.b: I.a, I.b Stage IIStage II : II.A, IIb: II.A, IIb Stage IIIStage III

Cont..Cont..

Principles Of Principles Of ManagementManagement

Once Clinical and radiological Once Clinical and radiological examination have suggested the examination have suggested the most likely diagnosis, further most likely diagnosis, further management proceeds as follows :management proceeds as follows : Benign, asymptomatic lesionsBenign, asymptomatic lesions Benign, symptomatic or enlarging Benign, symptomatic or enlarging

tumourstumours Suspected malignant tumoursSuspected malignant tumours

Methods of TreatmentMethods of Treatment

Tumour ExcisionTumour Excision Intracapsular Intracapsular

(intralesional)(intralesional) Marginal Marginal

ExcisionExcision Wide ExcisionWide Excision Radical Radical

ResectionResection

AmputationAmputation Considering the difficulties of limb –sparing Considering the difficulties of limb –sparing

surgery particulary for high-grade tumours surgery particulary for high-grade tumours or if there is doubt about whether the or if there is doubt about whether the lession is intracompartmentallession is intracompartmental

Amputation may be curative but it is Amputation may be curative but it is sometimes performed essentially to achieve sometimes performed essentially to achieve local control of a tumour which is resistant local control of a tumour which is resistant to chemotherapy and radiation therapy. to chemotherapy and radiation therapy.

RadiotherapyRadiotherapy Radiotherapy may also be employed postoperatively Radiotherapy may also be employed postoperatively

when a marginal or intralesional excision has when a marginal or intralesional excision has occurred, so as to “sterilize”the tumour bed. occurred, so as to “sterilize”the tumour bed.

Multi –agent chemotherapy Multi –agent chemotherapy Multy agent chemotherapy is now the preferred Multy agent chemotherapy is now the preferred

neoadjuvant and adjuvant treatment for malignant neoadjuvant and adjuvant treatment for malignant bone and soft tissue tumoursbone and soft tissue tumours

For sensitive tumours, modern chemotherapy For sensitive tumours, modern chemotherapy regimens effectively reduce the size of the primary regimens effectively reduce the size of the primary lesions, prevent metastatic seeding and improve the lesions, prevent metastatic seeding and improve the chance of survival.chance of survival.

Benign Bone TumoursBenign Bone TumoursPredominant

TissueBenign Bone

tumoursDecade Localized of

Bone

Bone Forming Osteoma 2-3 At the Sinus paranasalis bone ,Skull

Osteoid Osteoma

1-2 Diafisis,Efipisis, metafisis

Osteoblastoma 2-3 At tthe spine,Flat bone

Cartilage Forming

Enchondroma 2 Diafisis

Osteochondroma

1 Diafisis

Chondroblastoma

1 Efipisis

Chonromyxoid fibroma

2-3 Metafisis

Giant Cell Tumour

Benign Osteoclastoma

3-4 Epifisis

FIBROUS DYSPLASIAFIBROUS DYSPLASIA Fibrous dysplasia is a developmental Fibrous dysplasia is a developmental

disorder in trabecular bone are replaced disorder in trabecular bone are replaced by cellular fibrous tissue containing fleck by cellular fibrous tissue containing fleck of osteoid and woven boneof osteoid and woven bone

If the lesion are large bone weakened If the lesion are large bone weakened and pathological fracturesand pathological fractures

Common site proximal Common site proximal femur ,tibia,humerus,ribs and cranio femur ,tibia,humerus,ribs and cranio facial bones.facial bones.

Aneurysma Bone CystAneurysma Bone Cyst Encountered at any age and in Encountered at any age and in

almost any bonealmost any bone Thougt more often in young adults Thougt more often in young adults

and in the long bone metaphysesand in the long bone metaphyses Patients may complain of pain Patients may complain of pain

Osteoid OsteomaOsteoid Osteoma Benign lession are osteoblasticBenign lession are osteoblastic More dominant in male aged 20 – 25 More dominant in male aged 20 – 25

yearsyears Pain can be relieved by aspirin Pain can be relieved by aspirin

treatmenttreatment Attack the long bone like femur & Attack the long bone like femur &

TibiaTibia

OsteoblastomaOsteoblastoma The tumor similiar to osteoid The tumor similiar to osteoid

osteoma but has a larger sizeosteoma but has a larger size Found in young adulthood, pain in Found in young adulthood, pain in

the lesion areathe lesion area It tends to occur in the spine ,flat It tends to occur in the spine ,flat

bonesbones

EncondromaEncondroma Benign neoplasma of the bone cavity Benign neoplasma of the bone cavity

barsalbarsal Obtained in young adulthood and no Obtained in young adulthood and no

complaints of paincomplaints of pain

OsteochondromaOsteochondroma Benign bone tumours are the most Benign bone tumours are the most

widelywidely Acquiandred in adolescence and a Acquiandred in adolescence and a

lump that does not painlump that does not pain Found in the long bone metafisis and Found in the long bone metafisis and

especially in the distal femur, tibia especially in the distal femur, tibia proksimal and humerus proksimal proksimal and humerus proksimal

ChondroblastomaChondroblastoma Tumours are rarely foundTumours are rarely found Obtained at the age under 20 yearsObtained at the age under 20 years Most commonly affects the bones of Most commonly affects the bones of

the humerus,femur and tibiathe humerus,femur and tibia

Giant Cell Tumour Giant Cell Tumour Giant Cell Tumour,Which Represent 5 Giant Cell Tumour,Which Represent 5

% of all prymary bone tumours% of all prymary bone tumours Most commonly in the distal Most commonly in the distal

femur,proximal tibia,proximal femur,proximal tibia,proximal humerus,distal radiushumerus,distal radius

The patien is usually a young adult The patien is usually a young adult who complains of pain at the end of a who complains of pain at the end of a long bone ; sometimes there is slight long bone ; sometimes there is slight swelling.swelling.

X- rays show of along radiolucent X- rays show of along radiolucent area situated accentrically at the area situated accentrically at the end of a long bone and bounded by end of a long bone and bounded by the subchondral bone plate.the subchondral bone plate.

The centre sometimes has a soap –The centre sometimes has a soap –bubble appearance due to ridging of bubble appearance due to ridging of the surrounding bone.the surrounding bone.

Biopsy is essentialBiopsy is essential

Cont..Cont.. Phatology the tumour has a Phatology the tumour has a

reddish,fleshy appearancereddish,fleshy appearance Aggressive lesions have a poorly Aggressive lesions have a poorly

defined edge and extend well into defined edge and extend well into the surrounding bonethe surrounding bone

The tumour has the potential to The tumour has the potential to transform into malignancytransform into malignancy

TreatmentTreatment Well confined, slow growing lesions with Well confined, slow growing lesions with

benign histology can safely be treated by benign histology can safely be treated by thorough curettage & stripping of the thorough curettage & stripping of the cavity with burrs and gouges,followed by cavity with burrs and gouges,followed by swabbing with hydrogen peroxide or by swabbing with hydrogen peroxide or by the application of liquid nitrogen.the application of liquid nitrogen.

More aggressive tumours ,and reccurent More aggressive tumours ,and reccurent lesions, should be treated by excision lesions, should be treated by excision followed,if necessary, by bone grafting or followed,if necessary, by bone grafting or prosthetic replacementprosthetic replacement

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