Neoplastic conditions of the Bone

Definition of Neoplasia, Neoplasm

The word Neoplasia directly means new growth, and

the resulting mass of growth is known as neoplasm

Definition by British Oncologist Willis was the most acceptable, which

states that:

A neoplasm is an abnormal mass of tissue, the growth of which

exceeds and is uncoordinated with that of the normal tissue and
persists in the same excessive manner even after cessation of the
stimuli which evoked the change.
 Some facts

Most bone neoplasms develop during the first several decades of life and
have a propensity for the long bones of the extremities

Benign tumors greatly outnumber their malignant counterparts, and

occur with greatest frequency within the first 3 decades of life (<30
years).

Whereas in older adults, the bone tumor is likely to be malignant.

Excluding neoplasms originating from hemato- poietic cells (myeloma, lymphoma, and leukemia),

osteo- sarcoma is the most common primary cancer of bone,

followed by chondrosarcoma and Ewing sarcoma.
Classification of Bone tumors

(Table in next slide)

 History
1. prolonged Hx (chronic case)
2. Usually asymptomatic until discovered incidentally on X-ray.
3. Age
- Children and adolescents:
Benign lesions
TRO Ewings tumour (malignant)
TRO Osteosarcoma (malignant)
- 40<age<70
Chondrosarcoma (malignant)
Fibrosarcoma (malignant)
Myeloma (malignant)
- age above 70 years old.
Metastatic tumours more common than primary bone tumours.
4. Pain (presentation depends on the type of lesion)
- Persistent and progressive pain
5. Swelling - Usually presents as a painful lump.
6. History of trauma
7. Neurological deficits: Numbness or paraesthesiae or numbness due to
compression of peripheral nerve.
8. Pathological fractures
 Physical Examination
Examination of a lump
+ Site
+ Tenderness
+ Borders (discrete or ill defined)
+ Consistency (hard or soft)
+ Pulsatile?
+ associated with swelling and rise in temperature?
TRO infection and haematoma.

Examination of a joint (If tumour near a joint),

+ effusion of joint
+ limitation of movement
Examination of the spine (if tumour at spine)
+ Muscle spasm
+ Back stiffness
+ Painful scoliosis

Examination of the draining lymphnodes

 Imaging
* All planned imaging should be done before proceeding to biopsy

1. X rays
- most useful of all imaging.
2. Radionuclide scanning (Skeletal scintigraphy)
- 99mTc-methyl diphosphonate (99mTc- MDP)
- shows non-specific reaction in bones.
- effective for detecting skipped / silent lesions.
3. Computed tomography
- shows extension of tumour relative to the
surrounding structures.
- Also able to show metastasis
4. Magnetic resonance imaging
- Greatest value in assessment of tumor spread
- Also effective in assessing soft tissue tumours and
Cartilaginous lesions.
 Laboratory Investigations
1. Full blood count (suspect Anaemia - non specific)
- RBC (x10^6/uL) male 4.5 - 6.5, female 3.8 - 4.8
- Hb (g/dl) male 13.0 - 17.0, female 12.0 - 15.0
- WBC (x10^9/L) male and female 4.0-10.0
2. Erythrocyte sedimentation rate (increased - non specific)
3. Serum alkaline phosphatase (20 - 70 U/L) (elevated - non specific)
4. Serum protein electrophoresis (abnormal globulin fraction - Myeloma)
5. Urine analysis - Bence Jones proteins (Myeloma cast)
6. Serum acid phosphatase (increased) (suggests prostate carcinoma)(0-
0.8U/L)
 biopsy
Biopsy should never be regarded as a minor operation.

1. Needle Biopsy
- Jamshidi or a Trucut needle
- with Ultrasound or CT guidance.
- Send to microbiology lab (TRO infection)
2. Open Biopsy
- More reliable, but with significant morbidity.
- Done only if 1. No diagnosis from needle biopsy, 2. needle
biopsy place neurovascular structures at risk.
- Excision biopsy (whole lesion removed) for benign lesions
- Curettage for cysts
 Differential Diagnosis
* because some conditions may mimic a tumour.
1. Soft Tissue Haematoma
- Acute onset
- points from history
2. Myositis ossificans
- Occurs shortly after injury.
- Becomes less painful soon.
3. Stress fracture
- Healing callus looks like osteosarcoma histopathologically.
- Adequate history and consultation to prevent error in diagnosing.
4. Tendon avulsion injuries
- Osgood-schlatter disease best know.
- some less familiar sites.iliac crest, the ischial tuberosity, the
lesser trochanter of the femur
5. Bone infection
- Osteomyelitis.
6. Gout
- X ray shows large poorly defined excavation.
7. Other bone lesions
- Non neoplastic lesions like fibrous cortical defects, medullary infarcts
and bone islands commonly mistaken for tumours
 Staging of tumour

* In treatment of neoplastic bone lesions,

Minimal damage vs Area of excision
 Aggressiveness

Benign
* Subdivided into Latent, Active and Aggressive

Malignant
* Subdivided into Low-grade and High-grade

* Low grade - moderately aggressive, late metastasis

* High grade - Very aggressive, early metastasis
Behaviour
 Spread

Intracompartmental
Lesions that are confined to an enclosed tissue space

Extracompartmental
extend into interfascial or extrafascial planes with no natural barrier to proximal or distal spread
 Surgical Staging
For bone sarcomas

1. Stage 1 - All low grade sarcomas

2. Stage 2 - Histologically high grade lesions
3. Stage 3 - Sarcomas which have metastasized
 Surgical Staging
For soft tissue tumours

American Joint Committee for Cancer Staging System

based on:
+ Grade (G)
+ Size (T)
+ Lymphnode involvement (N)
+ Metastasis (M)

Extra note:
* different from Enneking system because
- Increased number of histological grades. (from low, high to 1,2,3)
- Use of size of tumour (less than or greater than 5cm) rather than
whether it is intra or extracompartmental.
 Principles of Management

* Multidisciplinary
* Best conducted at tertiary centres
* Cooperation of doctors of multiple specialities
1. Benign, asymptomatic lesions:
+ No doubt in diagnosis, discharge patient.
+ If appearance not pathognomic, acquire biopsy to confirm

2. Benign, symptomatic or enlarging tumours

+ Biopsy to confirm diagnosis
+ if aggressive, remove via marginal excision.
+ If aggressive, curettage for benign cysts.

3. Suspected malignant tumours

+ Admit patient for more detailed examination, investigations.
+ Imaging (x ray, CT).
+ Plan mode of treatment
 Methods of treatment

1. Tumour excision

2. Limb Salvage

3. Amputation

4. Multi-agent Chemotherapy

5. Radiotherapy
 1. Tumour excision

+ Intracapsular (intralesional) excision and curettage

- applicable to benign lesions
- low risk of recurrence.
- Acrylic cement after curettage decreases risk of local recurrence
+ Marginal excision (goes beyond the tumour, but only just)
- Also suitable for benign lesions. Resulting cavity filled with graft bone.
- use for malignant tumours.
+ Wide excision
- appropriate for intracompartmental lesions (grade IA)
- Use in conjunction with chemotherapy for grade IIA lesions.
+ Radical excision
- required for grae tumours (IIA or IIB)
- Entire compartment (including tumours location) is removed en bloc without
 2. Limb Salvage

Considered before amputation,

when functional limb can be preserved,
and no skipped lesions
the local control of tumour as good as that obtained by amputation

Steps
1. Wide excision with preservation of neurovascular structures.
2. Resulting defects replaced by bone grafts ( for short diaphyseal
segments) and Custom-made implants (for longer gaps)
3. Osteo articular segments replaced by large allografts, endoprostheses,
or allograft-prosthetic composites.
4. Extendible implants used in growing children
 3. Amputation

limb-sparing surgery difficult, and consisting of high grade tumour, or

unsure if lesion is intracompartmental.

AMPUTATION and early rehabilitation may be the wisest option.

Sometimes performed when chemotherapy and radiotherapy fails.

 4. Multiagent Chemotherapy

Now preferred neoadjuvant and adjuvant treatment for malignant bone and soft
tissue tumours.

Drugs currently in use are Methotrexate, Adriamycin, Cyclophosphamide,

vincristine, cis-platinum.

Treatment: 8 - 12 weeks preoperatively.

Patient assessed by examining the resected tissue for tumour necrosis. (>90%
necrosis means good response)

Then, maintenance chemotherapy for subsequent 6 - 12 months.

 5. Radiotherapy

High energy radiation used to destroy radiosensitive tumours.

eg: Ewings sarcoma - radiosensitive.

Sometimes combined with Chemotherapy.

Usually the combination is used for high grade tumours, tumours in
inaccessible sites, lesions that are inoperable because of their size, proximity
to major vessels, or advanced local spread, marrow-cell tumours, metastatic
deposits and for palliative local tumour control where no surgery is planned.

Radiotherapy can be used post-operatively to sterilize tumour bed.

complications: post-irradiation spindle cell sarcoma, pathological facture in

weightbearing bones.