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BONE TUMORS
By Dr Utsav Agrawal
-Account for only about 02 of all tumors-Commonest bone tumour is secondaries from other sites-Commonest primary bone tumour multiple myeloma second- osteosarcoma- A high index of suspicion and thorough history and physical examination is required
PRESENTING SYMPTOMS PAIN - is most frequent symptom -deep constant painpoorly localisedworse at night -initially controlled by analgesicslater requires narcotics
MASS- may be painfulpainless - rate of enlargement is important -Fluctuating mass can be cystganglion or hemangioma -Family HO masses near the joint may be indicator of Ollierrsquos disease or Maffucci Syndrome
NEUROLOGICAL SYMPTOM- found in few patients such as sacral tumors amp with tumors located near the nerve causing compression of nerveespecially common in sciatic notch inguinal canal amp popliteal fossaUNEXPLAINED SWELLING OF THE LOWER EXTREMITY- found in pelvic tumors which are painless amp without a palpable mass amp cause swelling due to compression of iliac vein
Patient may present with an abnormal radiographic finding detected during evaluation of unrelated problem
Patient may also come with complaint of weight loss respiratory gastro or genito-urinary disturbances
Approach to bone tumorsCarried out in 4 phases ndash1st phase ndash involves
High index of suspicion for tumorsMeticulous historyThorough physical examinationRoutine X-raysRoutine lab facilities
2nd phase ndash is prebiopsy regional evaluation to determine size location and type of tissue in involved in the tumor This includes CT and MRI3rd phase ndash is the actual biopsy4th phase ndash is undertaken if presumptive clinical amp path evidence is suggestive of malignancy Here search for metastasis is done using CTHRCT of lung amp Tc-99 bone scan
HISTORYAGE- most important as most tumors present in specific age group
1st decade- usually ABC SBC2nd decade-ChondroblastomaosteosarcomaEwings3rd decade- GCT4th decade- chondrosarcoma5th decade- Multiple myeloma
SEX- less imp than ageSome tumors like GCT are more in females
FAMILY HISTORYRACE- little imp Ewings rare in african descentHO any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcomaVarious chemlcal carcinogens- methylcholanthrenezinc beryllium silicate beryllium oxideCurrently the most worrisome amp controversial is Nickel which is used in many orthopedic devices
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
-Account for only about 02 of all tumors-Commonest bone tumour is secondaries from other sites-Commonest primary bone tumour multiple myeloma second- osteosarcoma- A high index of suspicion and thorough history and physical examination is required
PRESENTING SYMPTOMS PAIN - is most frequent symptom -deep constant painpoorly localisedworse at night -initially controlled by analgesicslater requires narcotics
MASS- may be painfulpainless - rate of enlargement is important -Fluctuating mass can be cystganglion or hemangioma -Family HO masses near the joint may be indicator of Ollierrsquos disease or Maffucci Syndrome
NEUROLOGICAL SYMPTOM- found in few patients such as sacral tumors amp with tumors located near the nerve causing compression of nerveespecially common in sciatic notch inguinal canal amp popliteal fossaUNEXPLAINED SWELLING OF THE LOWER EXTREMITY- found in pelvic tumors which are painless amp without a palpable mass amp cause swelling due to compression of iliac vein
Patient may present with an abnormal radiographic finding detected during evaluation of unrelated problem
Patient may also come with complaint of weight loss respiratory gastro or genito-urinary disturbances
Approach to bone tumorsCarried out in 4 phases ndash1st phase ndash involves
High index of suspicion for tumorsMeticulous historyThorough physical examinationRoutine X-raysRoutine lab facilities
2nd phase ndash is prebiopsy regional evaluation to determine size location and type of tissue in involved in the tumor This includes CT and MRI3rd phase ndash is the actual biopsy4th phase ndash is undertaken if presumptive clinical amp path evidence is suggestive of malignancy Here search for metastasis is done using CTHRCT of lung amp Tc-99 bone scan
HISTORYAGE- most important as most tumors present in specific age group
1st decade- usually ABC SBC2nd decade-ChondroblastomaosteosarcomaEwings3rd decade- GCT4th decade- chondrosarcoma5th decade- Multiple myeloma
SEX- less imp than ageSome tumors like GCT are more in females
FAMILY HISTORYRACE- little imp Ewings rare in african descentHO any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcomaVarious chemlcal carcinogens- methylcholanthrenezinc beryllium silicate beryllium oxideCurrently the most worrisome amp controversial is Nickel which is used in many orthopedic devices
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
PRESENTING SYMPTOMS PAIN - is most frequent symptom -deep constant painpoorly localisedworse at night -initially controlled by analgesicslater requires narcotics
MASS- may be painfulpainless - rate of enlargement is important -Fluctuating mass can be cystganglion or hemangioma -Family HO masses near the joint may be indicator of Ollierrsquos disease or Maffucci Syndrome
NEUROLOGICAL SYMPTOM- found in few patients such as sacral tumors amp with tumors located near the nerve causing compression of nerveespecially common in sciatic notch inguinal canal amp popliteal fossaUNEXPLAINED SWELLING OF THE LOWER EXTREMITY- found in pelvic tumors which are painless amp without a palpable mass amp cause swelling due to compression of iliac vein
Patient may present with an abnormal radiographic finding detected during evaluation of unrelated problem
Patient may also come with complaint of weight loss respiratory gastro or genito-urinary disturbances
Approach to bone tumorsCarried out in 4 phases ndash1st phase ndash involves
High index of suspicion for tumorsMeticulous historyThorough physical examinationRoutine X-raysRoutine lab facilities
2nd phase ndash is prebiopsy regional evaluation to determine size location and type of tissue in involved in the tumor This includes CT and MRI3rd phase ndash is the actual biopsy4th phase ndash is undertaken if presumptive clinical amp path evidence is suggestive of malignancy Here search for metastasis is done using CTHRCT of lung amp Tc-99 bone scan
HISTORYAGE- most important as most tumors present in specific age group
1st decade- usually ABC SBC2nd decade-ChondroblastomaosteosarcomaEwings3rd decade- GCT4th decade- chondrosarcoma5th decade- Multiple myeloma
SEX- less imp than ageSome tumors like GCT are more in females
FAMILY HISTORYRACE- little imp Ewings rare in african descentHO any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcomaVarious chemlcal carcinogens- methylcholanthrenezinc beryllium silicate beryllium oxideCurrently the most worrisome amp controversial is Nickel which is used in many orthopedic devices
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Approach to bone tumorsCarried out in 4 phases ndash1st phase ndash involves
High index of suspicion for tumorsMeticulous historyThorough physical examinationRoutine X-raysRoutine lab facilities
2nd phase ndash is prebiopsy regional evaluation to determine size location and type of tissue in involved in the tumor This includes CT and MRI3rd phase ndash is the actual biopsy4th phase ndash is undertaken if presumptive clinical amp path evidence is suggestive of malignancy Here search for metastasis is done using CTHRCT of lung amp Tc-99 bone scan
HISTORYAGE- most important as most tumors present in specific age group
1st decade- usually ABC SBC2nd decade-ChondroblastomaosteosarcomaEwings3rd decade- GCT4th decade- chondrosarcoma5th decade- Multiple myeloma
SEX- less imp than ageSome tumors like GCT are more in females
FAMILY HISTORYRACE- little imp Ewings rare in african descentHO any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcomaVarious chemlcal carcinogens- methylcholanthrenezinc beryllium silicate beryllium oxideCurrently the most worrisome amp controversial is Nickel which is used in many orthopedic devices
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
HISTORYAGE- most important as most tumors present in specific age group
1st decade- usually ABC SBC2nd decade-ChondroblastomaosteosarcomaEwings3rd decade- GCT4th decade- chondrosarcoma5th decade- Multiple myeloma
SEX- less imp than ageSome tumors like GCT are more in females
FAMILY HISTORYRACE- little imp Ewings rare in african descentHO any exposure to radiation Tt or Carcinogens- bone seeking radionucleotide can cause sarcomaVarious chemlcal carcinogens- methylcholanthrenezinc beryllium silicate beryllium oxideCurrently the most worrisome amp controversial is Nickel which is used in many orthopedic devices
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Precursor lesionsHigh Risk Ollier disease (Enchondromatosis) Maffucci syndrome Familial retinoblastoma syndrome Rothmund-Thomson syndrome (RTS)Moderate Risk Multiple osteochondromas Polyostotic Paget disease Radiation osteitisLow Risk Fibrous dysplasia Bone infarct Chronic osteomyelitis Metallic and polyethylene implants Osteogenesis imperfecta Giant cell tumour Osteoblastoma and chondroblastoma
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
PHYSICAL EXAMINATIONEvaluation of patientrsquos general healthTUMOR MASS should be measured amp its location shape consistency mobility tenderness local temp amp change with position should be notedSKIN amp SUBCUTANEOUS TISSUE Small dilated superficial veins overlying the mass are produced by large tumorsCafeacute-au-lait spots amp subcutaneous neurofibromas indicate Von Recklinghausenrsquos diseaseA venous malformation on the same of body as the cartilagenous tumor is an indicator of Maffucci SyndromeREGIONAL LYMPH NODESshould be carefully palpated for signs of metastatic diseaseAtrophy of surrounding musculature fasciculations should be recordedNeurological deficitsCirculation should be assessed and compared with opposite siteJoints specially proximal and distal to the mass should be carefully examined for range of motion discontinuity or intra-articular masses
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Location of tumors
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Laboratory InvestigationsHemoglobinCBCESRCRPPrastrate specific antigen PAPElectrophoresis amp urinary Bence Jones proteinAlkaline phosphatase test Normally this enzyme is
present in high levels when bone-forming cells are very activeHigh levels of alkaline phosphatase can also be an indicator of bone tumors
PTH test
Serum phosphorus
Ionized calcium and serum calcium
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
BiopsyIt is the most conclusive test
Types Open Incisional Biopsy 1Incisional
2 Excisional
Closed percutaneous core Biopsy
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Surgical Staging - EnnekingThe Enneking system for the surgical staging of bone and soft-tissue tumors is based on grade (G) site (T) and metastasis (M) and uses histologic radiologic and clinical criteria
GradeG0 - Benign lesion
G1 - Low-grade malignant lesion
G2 - High-grade malignant lesion
SiteT0 - A benign tumor that is confined within a true capsule and the lesions anatomic compartment of origin (ie a benign intracapsular intracompartmental lesion)
T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (ie an intracompartmental lesion)
T2 - A lesion that has spread beyond its anatomic compartment of origin (ie an extracompartmental lesion)
MetastasisM0 - No regional or distant metastasis
M1 - Regional or distant metastasis
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Enneking system for malignant tumors
Stage Grade Site Metastasis
IA Low G-1 Intracompartmental T1
-
IB Low G-1 Extracompartmental T2
-
IIA High G-2 Intracompartmental T1
-
IIB High G-2 Extracompartmental T2
-
III Any G Any T Regional distant metastasis
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Enneking System for Benign Tumors
Stage Definition Behaviour Example
1 Latent Remains static or heals spontaneously
Non-ossifying fibroma
2 Active Progressive but limited by natural barriers
Aneurysmal bone bone cyst
3 Locally Aggressive
Progressive growth not limited by natural barriers
GCT
Barriers- Cortical bone articular caritlage joint capsule fascia tendinous origin and inertion sites of muscles
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
TNM StagingPrimary tumour (T) TX primary tumour cannot be assessed
T0 no evidence of primary tumourT1 tumour 1048617 8 cm in greatest dimensionT2 tumour gt 8 cm in greatest dimensionT3 discontinuous tumours in the primary bone site
Regional lymph nodes (N) NX regional lymph nodes cannot be assessed
N0 no regional lymph node metastasisN1 regional lymph node metastasis
Distant metastasis (M) MX distant metastasis cannot be assessedM0 no distant metastasisM1 distant metastasisM1a lungM1b other distant sites
G Histopathological GradingLow GradeHigh Grade
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
TNM Staging
Stage T N M G
IA T1 NoNx Mo G12 Low Grade
IB T2 NoNx Mo G12 Low Grade
IIA T1 NoNx Mo G34 High
IIB T2 NoNx Mo G34 High
III T3 NoNx Mo Any G
IVA Any T NoNx Any M Any G
IVB Any T N1 Any M Any GAny T Any N M1b Any G
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Classification (WHO)Bone-forming tumoursCartilage forming tumoursGiant-cell tumourMarrow tumoursVascular tumoursOther connective tissue tumoursOther tumoursSecondary malignant tumours of bone
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Bone forming tumours
BenignOsteomaOsteoid osteoma or
osteoblastomaIntermediateAggressive
osteoblastoma
MalignantOsteosarcoma Central (Medullary) Peripheral (Surface)ParostealPeriostealHigh grade surface
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Cartilage forming tumours
Benign Chondroma Enchondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma
Malignant Chondrosarcoma Differentiated
chondrosarcoma Juxtacortical
chondrosarcoma Mesenchymal
chondrosarcoma Clear cell
chondrosarcoma
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Giant cell tumourOsteoclastoma
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Marrow tumoursEwingrsquos sarcomaNeuroectodermal tumourMalignant lymphoma of bone
(Primarysecondary)Myeloma
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Vascular tumoursBenignHaemangiomaLymphangiomaGlomus tumourIntermediateHaemangio endotheliomaHaemangio pericytomaMalignantAngiosarcomaMalignant haemangio pericytoma
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Other connective tissue tumoursBenignBenign fibrous
histiocytomaLipomaIntermediateDesmoplastic
fibroma
MalignantFibrosarcomaMalignant fibrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Other tumoursBenignNeurilemmomaNeurofibroma
MalignantChordomaAdamantinoma
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
Secondary malignant tumours of boneFrom primary inThyroidBreastBronchusKidneyProstate
