APPROACH TO BONE TUMOURSDr Nikrish S Hegde

• TUMOUR = MASS = NEOPLASM

• MALIGNANT TUMOUR / MALIGNANT NEOPLASM

• BENIGN TUMOURS MAY SHOW MALIGNANT PROPERTIES

CLASSIFACATION OF BONE TUMOURS

PARTS OF A GROWING BONE

WHAT HAPPEN WITH TIME?

IMAGING MODALITIES FOR BONE LESIONSThe radiologic modalities most often used in analyzing tumors and tumor-like lesions include:• conventional radiography • angiography (usually arteriography)• computed tomography (CT)• magnetic resonance imaging (MRI)• scintigraphy (radionuclide bone scan) and • fluoroscopy- or CT-guided percutaneous soft tissue

and bone biopsy.

CONVENTIONAL RADIOGRAPHY• suffice to make a correct diagnosis .• confirmed by biopsy and histopathologic

examination.

Conventional radiography yields the most useful information about the location and morphology of a lesion,• Location• Calcification• Ossification• Periosteal Reaction

COMPUTED TOMOGRAPHY• Provide a precise evaluation of the extent of a

bone lesion .• CT is moreover very helpful in delineating a bone

tumor having a complex anatomic structure.• CT examination is crucial in determining the

extent and spread of a tumor in the bone if limb salvage is contemplated, so that a safe margin of resection can be planned .

• CT is also useful for monitoring the results of treatment.

• Evaluating the relationship between the tumor and the surrounding soft tissues and neurovascular structures is particularly important for planning limb-salvage surgery.

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ARTERIOGRAPHY• Arteriography is used mainly to map out bone

lesions and to assess the extent of disease.• Demonstrate the vascular supply of a tumor 1) Preop intra-arterial chemo 2) Biopsy• Arteriography is often useful in planning for limb-

salvage procedures because it demonstrates the regional vascular anatomy.

• Interventional procedures

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MRI• MRI offers distinct advantages over CT.• It has a few disadvantages as well.• In the evaluation of intraosseous and

extraosseous extensions of a tumor, MRI is crucial because it can determine with high accuracy the presence or absence of soft-tissue invasion by a tumor .

• Assist in differentiation of intraarticular tumor extension from joint effusion.

• Cant assess ossification and calcification.

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SCINTIGRAPHY• Indicator of mineral turnover.• A bone scan is useful in localizing tumors and

tumor-like lesions in the skeleton.• In most instances a radionuclide bone scan cannot

distinguish benign lesions from malignant tumors.

APPROACH - CLINICALLY• AGE

• DURATION

• RACE

RADIOLOGICAL APPROACH• With so many imaging techniques available to

diagnose and characterize the bone tumor further, radiologists and clinicians are frequently at a loss as to how to proceed in a given case.

• Clinical presentation• Effectiveness• Benefits• Cost• Restrictions

• In the evaluation of bone tumors, conventional radiography are still the standard diagnostic procedures.

• It should always be done.• Most of the time, the choice of further imaging

technique is dictated findings on radiograph.• If osteoid osteoma is suspected based on the

clinical history conventional radiography followed by scintigraphy and then it should be followed by CT.

CT vs MRI• If radiographs are suggestive of a malignant bone

tumor, MRI or CT should be used next to evaluate both the intraosseous extent of the tumor and the extraosseous involvement of the soft tissues.

• If there is no definite evidence of soft-tissue extension, then CT is superior to MRI.

• If the radiographs suggest cortical destruction and soft-tissue mass, then MRI would be the preferred modality .

Radiographic Features of Bone Lesions

SITE• The site of a bone lesion is an important feature,

because some tumors have a predilection for specific bones or specific sites in the bone .The sites of some lesions are so characteristic that a diagnosis can be suggested on this basis alone, as in the case of parosteal osteosarcoma or chondroblastoma . Moreover, certain entities can be readily excluded from the differential diagnosis on the basis of the lesion's location

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BORDERS(ZONE OF TRANSITION)• IA – WELL DEFINED WITH SCLEROSIS

• IB- WELL DEFINED BUT NO SCLEROSIS

• IC- POORLY DEFINED

MATRIX• Only two of these—osteoblastic and cartilaginous

tissue—can usually be clearly demonstrated radiographically.

• Identification of tumor bone within or adjacent to the area of destruction should alert the radiologist to the possibility of osteosarcoma/reactive sclerosis.

• Osteosarcoma-cloudy - cotton like fluffy deposits.• Cartilage is identified by the presence of typically

popcorn-like, punctate, annular, or comma-shaped calcifications in lobules.

• A completely radiolucent lesion may be either fibrous or cartilaginous .

BONE DESTRUCTION• The type of bone destruction caused by a tumor is

primarily related to the tumor growth rate.• Not pathognomonic for any specific neoplasm.

• Geographic.

• Moth Eaten.

• Permeative.

PERIOSTEAL REACTION• Categorized as uninterrupted or interrupted .• The first type of reaction is marked by solid layers

of periosteal density, indicating a long-standing benign process.

• Also seen in nonneoplastic processes such as Langerhans cell histiocytosis, osteomyelitis, bone abscess or in fractures in the healing stage.

• The interrupted type of periosteal reaction suggests malignancy or a highly aggressive nonmalignant process and may present as a sunburst pattern, a lamellated (onion-skin) pattern, a velvet pattern, or a Codman triangle.

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SOFT TISSUE EXTENSION• Benign tumors and tumor-like bone lesions usually

do not exhibit soft-tissue extension; thus, almost invariably, a soft-tissue mass indicates an aggressive lesion and one that is in many instances malignant .

• With few exceptions—such as giant cell tumors, aneurysmal bone cysts, osteoblastomas, or desmoplastic fibromas.

• In the case of a bone lesion associated with a soft-tissue mass, it is always helpful to determine which condition arose first.

MULTIPLICITY OF LESIONS• A multiplicity of malignant lesions usually

indicates metastatic disease, multiple myeloma, or lymphoma. Very rarely do primary malignant lesions, such as an osteosarcoma or Ewing sarcoma, present as multifocal disease. Benign lesions, however, tend to involve multiple sites, as in polyostotic fibrous dysplasia multiple osteochondromas, enchondromatosis, Langerhans cell histiocytosis.

BENIGN vs MALIGNANT

• Although it is sometimes very difficult to distinguish benign from malignant bone lesions on the basis of radiography alone, certain characteristic features favour one designation over the other.

MONITORING RESULTS• Radiography is used mainly to document the results of

surgical resection of benign lesions such as osteoid osteoma or to follow-up after curettage of benign tumors or tumor-like lesions and application of bone gratfs. In the case of malignant tumors, radiographic films permit one to demonstrate the position of endoprostheses or bone grafts in limb-salvage procedures.

• The effectiveness of chemotherapy is best CT and MRI.

• Recurrence or metastatic spread of a tumor can be effectively shown at an early stage on scintigraphy, CT, or MRI.

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COMPLICATIONS.

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Malignant transformation

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Growth disturbance

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Pathological fracture

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Erosion of adjacent bone.

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