Management of

Bone Tumors
Saurabh Agrawal
Multidisciplinary team approach…
Factors to consider
Type
Size
Stage
Age
BENIGN INTERMEDIATE MALIGNANT

Latent – no treatment Grading & staging

unless symptomatic  Locally aggressive
– frequent Surgical resection
Active – biopsy & recurrence; may with other modalities
curettage as required
en bloc
require
Limited capacity for resection
recurrence but if  Close follow-up
occurs it is non-
destructive
Surgery
For primary operable tumours, the options are tumor excision withlimb
salvage , oramputations .
For locally advanced lesions amputation may be considered
Resection with clean margins (pseudocapsule and cuff of normal tissue)
Margin of resection – as per local staging imaging, closest critical structure
(e.g., neurovascular bundle)
Limb salvage can be challenging in the skeletally immature because
resection requires excision of the physes, particularly those around the knee,
with subsequent implications for limb length discrepancy
(Benign & intermediate)
Reconstruct…
endoprosthetic replacement
allograft-prosthetic composite
allograft using donated bone extracorporeal sterilization and reimplantation
of the patient’s own bone
vascularized and non-vascularized autograft
arthrodesis
Neoadjuvant and Adjuvant
therapies
To reduce the size of large tumors prior to surgery
To treat micrometastases by systemic chemotherapy
Local control using radiation therapy
Benign lesions
Osteochondroma Enchondroma Osteoid Giant cell tumor
osteoma (osteoclastoma)
Treatmen Benign – excision Usually no treatment CT-guided  extended intralesional
t Malignant – wide required but radiofrequency curettage with a detailed
excision or curettage can be ablation debridement of the lesion
amputation done if it is painful or wall + use of adjuvants like
causes pathological phenol, bone cement, liquid
# nitrogen
 Excision with reconstruction
 Amputation
 Radiotherapy - spine
Osteosarcoma
Chemotherapy
Multiagent chemotherapy with doxorubicin, cisplatin, high dose methotrexate,
isofosfamide and etoposide for minimum 3 cycles prior to local control by
surgery.
Supportive care to manage the s/e of the drugs

*Since OS is radioresistant so radiotherapy is not used commonly in

management
Ewing’s sarcoma
Radiation sensitive tumour
Radiotherapy, in combination with chemotherapy can achieve local control but
definitive surgery when feasible has to be regarded as the first choice of local
therapy
 Definitive RT - if complete surgery is not feasible e.g., spine, skull, pelvis, head and
neck, thorax; 55-60 Gy in 28-30 fractions over 5-7 weeks
 Postop RT - gross residual disease or positive surgical margins or poor histological
response in the surgical specimen (i.e.>10% viable tumour cells); 45-50.4 Gy in 25-28
fractions over 5-6 weeks
 Palliative RT - incurable or metastatic disease for alleviation of local symptoms like
pain, bleeding, fungation or metastatic symptoms like dyspnoea, spinal cord
compression, brain metastases etc.
Chemotherapy
Multiagent therapy preferred with doxorubicin, cyclophosphamide, ifosfamide,
vincristine, dactinomycin, and etoposide
Total duration is 48 weeks
Supportive care to manage the s/e of the drugs
Metastatic bone disease
Most common malignancy of bone
Most common primary tumours to metastasize to bone
Males – prostate carcinoma
Females – breast carcinoma
Children – adrenal neuroblastoma
Other – lungs, renal and thyroid carcinomas
Common sites (in order of frequency) – thoracic spine, proximal femur, pelvis,
proximal humerus, scapula, distal femur and ribs
C/F - pain, swelling, abdominal mass, pathological fracture, spinal cord
compression and hypercalcaemia
X-ray appearance –
blastic/sclerotic – prostate
lytic – kidney, thyroid, lung
mixed – breast
Biopsy –
solitary bone lesion,
no known primary cancer,
a long disease-free interval following a previous malignancy, or
history of more than one previous invasive cancer
Management
Analgesia
Hormonal therapy, bisphosphonates, chemotherapy, radiotherapy
Bisphosphonates are useful in metastatic breast and prostate carcinoma and
multiple myeloma
Surgery for intractable pain, or impending or pathological fractures
THANK YOU
References
Apley and Solomon’s System of Orthopaedics and Trauma, 10e (2018)
ICMR. Consensus Document for Management of Soft Tissue Sarcoma and
Osteosarcoma (2016)
Essential Orthopaedics, 5e (2015)