CLASSIFICATION

• Primary

Secondary (metastases)

• Primary tumors: Benign Malignant

Benign tumours

• Osteoma

• Osteoid ostioma

• Osteoblastoma

Malignent tumours

1. Osteosarcoma (Osteogenic sarcoma)

2. Chondrosarcoma

3. Osteoclastoma (Giant cell tumor )

4. Ewing sarcoma

Osteosarcoma(Osteogenic sarcoma)

• Most common primary malignant tumor of bone

• Clinically:– Males> females– Most occur in teenagers (age 10-25 years)– Localized pain and swelling

• Classic X-ray findings:1. Codman's triangle (periosteal elevation)

2. Sunburst pattern

3. Bone destruction

• Pathology:– Often involves the metaphysic of long bones– Usually around the knee (distal femur and

proximal tibia)– Large firm white tan mass with necrosis and

hemorrhage

• Secondary osteosarcoma:– Occurs in old people– Associated with paget disease or chronic

osteomyelitis– Highly aggressive

Chondrosarcoma

• Definition:– Malignant tumor of chondroblasts

• Etiology:– The tumor may arise as primary or secondary to

preexisting enchondroma, exostosis or Paget disease

• Clinically:– Male> females– Age: 30-60 years– Enlarged mass with pain and swelling– Typically involves the pelvic bones, spine and

shoulder girdle

ChondrosarcomaChondrosarcoma

Giant cell tumor (Osteoclastoma

• Uncommon malignant neoplasm containing mult-inucleated giant cells admixed with stromal cells

• It is a locally malignant bone tumor with a high rate of recurrence

• Clinically:– Females>males– Age: 20-50 years– Bulky mass with pain and fractures

• X-ray:– Expanding lytic lesion surrounded by a thin rim

of bone– It may have a soap bubble appearance

Soap bubble appearanceSoap bubble appearance

• Pathology:– Often involves the epiphysis of long bones– Usually around the knee– Red or brown mass with cystic degeneration

Ewing sarcoma

• Malignant neoplasm of undifferentiated cells arising within the marrow cavity

• Clinical features:– Males>females– Most occur in teenagers (5-20)– Presented with pain, swelling and tenderness

• X-ray:– Concentric, onion skin layering of new periosteal bone

• Pathology:– Often affects the diaphysis of long bones– Most common sites are the femur, pelvis and

tibia– White tan mass with necrosis and hemorrhage

Clinical Presentation

• PAIN The pain may be progressive for many months, and

initially be confused with more common sources such as muscle soreness, overuse injury or "growing pains."

Night pain is an important clue to the true diagnosis (25%)

The primary reasons for delay in the diagnosis is failure to obtain radiographs at the initial visit.

Pain that fails to resolve or is present at rest or wakes the patient from sleep should alert the clinician that further evaluation is needed.

• Swelling Palpable mass is noted in up to 1/3 of patients at the first visit.

• Limp In smaller children, a limp may be the only

symptom

• Restriction of movement of the adjacent joint

• Pathological FractureThis can increase the rate of local recurrence of the tumor after surgery and decrease the patient’s overall survival

• Fever, malaise or other constitutional symptoms

diagnosis

Lab tests-Full blood count, ESR, CRP.

LDH (elevated level is associated with poor prognosis)

ALP (elevated levels at diagnosis signify increased risk of pulmonary metastasis) .

Platelet count Electrolyte levelsLiver function testsRenal function testsUrinalysis

Imagining studies

Plain x-raysObtain plain films of the suspected lesions in 2 views. With joint above and joint below

• CT scanning CT scanning of the chest is more sensitive than is

plain film radiography for assessing pulmonary metastases. MRI

MRI of the primary lesion is the best method to assess the extent of intramedullary disease as

well as associated soft-tissue masses .Bone Scan

A bone scan should be obtained to look for skeletal metastases or multi focal disease.

• Thallium scanMonitor effects of chemotherapyDetect local recurrence of tumor

• Angiography Determine vascularity of the tumorDetect vascular displacement and

determine relationship of vessels to the tumor Identify vascular anomaliesEstimate effects of chemotherapy.

• Once all the initial imaging & lab exam has been done biopsy is performed to conform the diagnosis.

Radiology

• Site

• Size

• Effect on bone

• Response of Bone

• Matrix

• Cortex

• Soft tissue

• Types of biopsy

Fine needle aspiration

Core needle biopsy

Open incisional biopsy

staging

The staging system is typically depicted as follows• Stage I: Low grade tumors

I-A intra compartmentalI-B extra compartmental

• Stage II: High grade tumorsII-A intra compartmentalII-B extra compartmental

• Stage III: Any tumors with evidence of metastasis

Treatment

1. Radiological staging 2. Biopsy to confirm diagnosis

3. Preoperative chemotherapy,Radiotherapy4. Repeat radiological staging

(access chemo response, finalize surgical tx plan)

5. Surgical resection with wide margin6. Reconstruction using one of many techniques7. Post op chemo based on preop response

•

PHYSIOTHERAPY MANAGEMENT

Pain managemet

General Conditioning

Stump Management

Palliative care

Adaptive device management

Prognostic Factors • Extant of the disease

– Pts with pulmonary, non pulmonry (bone) or skip metastasis have poor prognosis

• Grade of the tumor– High grade tumor have poor prognosis

• Size of the primary lesion– Large size tumors have worse prognosis then small size tumors

• Skeletal location– proximal tumors do worse than distal tumors.

• Secondary osteosarcoma: Poor prognosis

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