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Bone Tumors

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Title: Bone Tumors


1
Bone Tumors
  • ?.??.??? ?????????

2
????????????????????
  • 1. ??????????????????????????????????????
    (General consideration of bone tumors)
  • 2. ??????????????????????????????????????
    (Approach to diagnosis of bone tumors)
  • 2.1 ?????????????????????????????? (Clinical
    diagnosis)
  • 2.2 ???????????????????????????? (Radiographic
    diagnosis)
  • 2.3 ???????????????????????? (Pathological
    diagnosis)
  • 3. ????????????????????????????????????????????
  • 4. ???????????????????????
  • 4.1 ????????????????????? (Primary bone
    tumors)
  • 4.2 ??????????????????????? (Secondary bone
    tumors)
  • 6. ????????????????????????? (Differential
    diagnosis)
  • 5. ?????????????????????????????? (Prognosis of
    bone tumors)

3
???????????????????
  • ???????? 1 ???/??????????/???????????????????????
    ???????????? ?????????????????????????????????????
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  • ???????? 2 ???/??????????/???????????????????????
    ????? ???????????????????? ???????????????????????
    ???????? ???????????????????? ?????????????????
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  • ???????? 3 ???/??????????/???????????????????????
    ????? ??????????????????????????
    ???????????????????????? ???????????????????
    ??????????????????????????????????????
    ???????????????????? ?????????????????
    ????????????????

4
2.3 ??????????
  • II NEOPLASM ( ICD10, C00-D48) 
  • ???????? 2 ???/??????????/????????????????????????
    ???? ???????????????????? ????????????????????????
    ??????? ???????????????????? ?????????????????
    ???????????????? ??????????????????
    ????????????????????????? ????????????????????????
    ?????????????????????????????????????? benign
    neoplasm of skin and subcutaneous tissue
  • ???????? 3 ???/??????????/????????????????????????
    ???? ??????????????????????????
    ???????????????????????? ???????????????????
    ??????????????????????????????????????
    ???????????????????? ?????????????????
    ???????????????? benign and malignant neoplasm
    of oral cavity, larynx, nasopharynx, eyes,
    esophagus, stomach, colon, liver and biliary
    tract, pancreas, lungs, bone, breast, vulva,
    uterus, cervix, ovary, placenta, prostate gland,
    testes, kidney, urinary bladder, brain, thyroid
    gland, lymph node, hemopoietic system ( leukemia,
    multiple myeloma) malignant neoplasm of skin
    and subcutaneous tissue

5
????????????
  • 1. ???????????????????????????????????????????????
    ?????????????????
  • 2. ???????????????????? ?????????? ???????????
    ?????????????????????????????? ????????????????
    ????????????????????
  • 3. ?????????????????????????????????????????????
    ???????????????????????????????????????????????
  • 4. ???????????????????????????????????????????????
    ???????????????
  • 5. ??????????????????????????????????
    ??????????????????????
  • 6. ???????????????????????????????????????????????
    ????????????????????????????????

6
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7
History
  • Age location
  • Circumstances of presentation
  • Symptoms (constitutional)
  • Associated Conditions
  • Review of system
  • Natural History/ prior investigations

8
Questions to be asked
  • 1.  The patients age Certain tumors are
    relatively specific to particular age groups.
  • 2.  Duration of complaint Benign lesions
    generally have been present for an extended
    period (years). Malignant tumors usually have
    been noticed for only weeks to months.
  • 3.  Rate of growth A rapidly growing mass, as in
    weeks to months, is more likely to be malignant.
    Growth may be difficult to assess by the patient
    if it is deep seated, as can be the case with
    bone. Deep lesions may be much larger than the
    patient thought (tip-of-the-iceberg
    phenomenon).
  • 4.  Pain associated with the mass Benign
    processes are usually asymptomatic.
    Osteochondromas may cause secondary symptoms
    because of encroachment on surrounding
    structures. Malignant lesions may cause pain.
  • 5.   History of trauma With a history of
    penetrating trauma, one must rule out
    osteomyelitis. With a history of blunt trauma,
    healing fracture must be entertained.

9
Questions to be asked
  • 6.   Personal or family history of cancer
  • Adults with a history of prostate, renal, lung,
    breast, or thyroid tumors are at risk for
    development of metastatic bone disease.
  • Children with neuroblastoma are prone to bony
    metastases.
  • Patients with retinoblastoma are at an increased
    risk for osteosarcoma. Secondary osteosarcomas
    and other malignancies can result from treatment
    of other childhood cancers.
  • Family history of conditions such as LiFraumeni
    syndrome must raise suspicion of any bone lesion.
  • Furthermore, certain benign bone tumors can run
    in families (e.g., multiple hereditary
    exostoses).
  • 7.   Systemic signs or symptoms Generally, no
    significant findings should exist on the review
    of systems with benign tumors. Fevers, chills,
    night sweats, malaise, change in appetite, weight
    loss, and so forth should alert the physician
    that an infectious or neoplastic process may be
    involved.

10
Physical Examination
  • General Exam
  • Gait, inspection, body proportion symmetry
  • Medical
  • Organs Lungs, Breast, Thyroid, Prostate, Kidneys
  • Lymphatic
  • Other masses
  • Skin

11
Physical Examination
  • Sites of Interest
  • Physical Interest
  • Size
  • Site/Location
  • Superficial/Deep
  • Tenderness
  • Consistency (soft/firm)
  • Mobile/fixed
  • Vascular
  • Neural (Tinel)

12
Physical examination should be documented
  • 1.   Skin color
  • 2.   Warmth
  • 3.   Location
  • 4.   Swelling swelling, in addition to the
    primary mass effect, may reflect a more
    aggressive process
  • 5.   Neurovascular examination changes may
    reflect a more aggressive process
  • 6.   Joint range of motion of all joints in
    proximity to the region in question, above and
    below
  • 7.   Size a mass greater than 5 cm should raise
    the suspicion of malignancy
  • 8.   Tenderness tenderness may reflect a more
    rapidly growing process
  • 9.   Firmness malignant tumors tend to be more
    firm on examination than benign processes this
    applies more to soft tissue tumors than to
    osseous ones
  • 10. Lymph nodes certain sarcomas (e.g.,
    rhabdomyosarcoma, synovial sarcoma, epithelioid,
    and clear cell sarcomas all have increased rates
    of lymph node involvement)

13
Plain X-ray
  • Size
  • Site/Location
  • Whats it doing to bone?
  • Host bone response
  • What type of matrix is being made?
  • Cortical changes
  • Soft tissue mass

14
Site/Location
  • Types of bone
  • Long bone / Flat bone
  • Intramedullary / Eccentric / Cortical lesion
  • Epiphysis / Metaphysis / Diaphysis

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Size
  • The larger the lesion the more
  • likely to be
  • aggressive or malignant

17
What is the tumor doing to bone?
  • Geographic / Moth-eaten / Permeative lesions
  • Define the margin or interface between the host
    bone and the lesion
  • Narrow zone of transition
  • clear / well-defined border
  • Wide zone of transition
  • difficult to be certain where
  • the lesion starts and stops

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What is the host bone response?
  • Bone often responds to lesions by making new bone
  • Marginal sclerosis
  • Periosteal new bone formation
  • Interrupted
  • Continuous

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What type of matrix being made?
  • Cartilage matrix
  • Calcified rings, arcs, dots, pop corn-like
  • Ossified matrix
  • Bone forming, osteoblastic

24
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Is the cortex eroded?
  • Cortical erosion by the tumor and remodeling
    process of the host bone is the hallmark of
  • Active
  • Aggressive
  • Malignant

27
Soft tissue mass?
  • Some bone tumor present with a large soft tissue
    component
  • Osteosarcoma
  • Lymphoma
  • Infection

28
Radiographic example
29
Radiographic example
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32
Bone Tumors
  • Bone-forming tumors (Osteogenic tumors)
  • Cartilage tumors
  • Fibrogenic tumors / fibrohistiocytic tumors
  • Ewing sarcoma / PNET
  • Haematopoietic tumors
  • Giant cell tumors
  • Notochordal tumors
  • Vascular tumors
  • Myogenic / lipogenic / neural and epithelial
    tumors
  • Tumors of undefined neoplastic nature

33
Bone Tumors
  • Bone forming tumors
  • Benign
  • Osteoma
  • Osteoid osteoma
  • Osteoblastoma

34
Bone Tumors
  • Bone forming tumors
  • Malignant
  • Primary osteosarcoma
  • Conventional
  • Non-conventional
  • Secondary osteosarcoma

35
Osteoid Osteoma
  • A benign osteoblastic tumor
  • Usually cortical lesion in long bones
  • Present with unrelenting pain, worse at night,
    relieved by NSAIDS
  • May produce deformities of bone and soft tissue

36
Osteoid Osteoma
  • Radiographic appearance the nidus
  • central lucent area
  • peripheral sclerotic area
  • Less than 1 cm

37
Osteoid Osteoma
38
Osteoid Osteoma
  • Microscopic
  • sharply demarcated from surrounding bone
  • (no permeation)
  • thin, anastomosing strands of osteoid and/or
    woven bone (no cartilage)
  • thicker, more compact bone in older lesions
  • osteoblastic rimming
  • loose intervening fibrovascular tissue (not
    marrow)

39
Osteoblastoma
  • Larger than 1 cm
  • much more destructive, progressive
  • more prone to recurrence
  • 1/5th as common as osteoid osteoma
  • Sites
  • predilection for axial skeleton (70)
  • may be cortical or intramedullary

40
Osteoblastoma
  • Microscopic

41
Osteoblastoma
  • Aggressive Osteoblastoma
  • same general architecture as osteoblastoma
  • older age group (gt30)
  • larger, round to
  • epithelioid osteoblasts
  • variable mitotic rate (may be high)
  • locally destructive

42
Osteosarcoma
  • A malignant neoplasm of bone that produces
    osteoid
  • Most common 1º malignant bone tumor
  • 2nd decade (60 under 25)
  • Malesgtfemales
  • Long bones, especially distal femur

43
OsteosarcomaConventional, intramedullary
  • 90 of all osteosarcomas
  • 90 are under age 30
  • present with pain of 1 to 8 months duration
  • usually serum alkaline phosphatase elevated
  • not specific (OM, Obl, callus, children)
  • rise with recurrence or metastasis

44
OsteosarcomaConventional, intramedullary
  • Sites
  • metaphysis of long bones (the longer the bone,
    the greater the chance)
  • distal femur (1/3)
  • proximal tibia and radius
  • rare in hands and feet

45
OsteosarcomaConventional, intramedullary
  • Radiographic appearance
  • mixed lytic and sclerotic
  • large, infiltrating metaphyseal lesion
  • Codmans triangle
  • erodes cortex and extends into soft tissue
  • fluffy or cumulus cloud densities

46
OsteosarcomaConventional, intramedullary
47
OsteosarcomaConventional, intramedullary
48
OsteosarcomaSkip Lesion
49
Osteosarcoma
  • Although usually in the long bones, may occur in
    other places
  • Craniofacial
  • Small bones
  • Extraskeletal
  • (soft tissue)

50
OsteosarcomaHistology
  • Infiltration and destruction of normal bone
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