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Diagnosis of Malignant Bone Tumours:

Diagnosis of Malignant Bone Tumours Dr Shishir Kumar PG Ortho

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X Ray Evaluation Other Imaging Techniques Biopsy Classification Brief overview of important tumours

Algorithm of Evaluation :

Algorithm of Evaluation Benign or Malignant Age Location Special features

Lodwig’s Classification:

Lodwig’s Classification Patterns of Osteolysis Matrix Periosteal Reaction Soft tissue extension

Geographic destruction :

Geographic destruction IA : geographic sclerotic margin IB: geographic unsharp margin IC: geographic no margin

II. Moth eaten like destruction:

II. Moth eaten like destruction Moth eaten Permeative

Patterns of bone destruction:

Patterns of bone destruction


Matrix Osteoid Chondroid

Periosteal reaction:

Periosteal reaction Solid Lamellated Hair on end Sunburst

Periosteal reaction:

Periosteal reaction Solid Osteoid osteoma

Periosteal Reaction:

Periosteal Reaction Lamellated Infection

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Multilayered Ewing

Periosteal Reaction:

Periosteal Reaction Codman’s triangle Osteosarcoma

Soft tissue Involvement:

Soft tissue Involvement


Age Malignant tumours more common after 30 years Benign tumours more common before 30 years and most often before physis closure



Special Investigations:

Special Investigations Bone Scan CT Scan MRI PET Scan


Biopsy Single most important procedure Should not be taken lightly An inadequately performed biopsy -does not allow proper diagnosis -May end up in amputation/limb salvage - have a negative impact on survival

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Clinically and radiologically benign- appearing lesions—no biopsy Indicated in - benign aggressive tumours -malignant tumours -questionable lesions to confirm the clinical diagnosis -accurately classify

Timing of Biopsy:

Timing of Biopsy After all imaging studies have been completed After Full staging completed Can interfere with imaging if done earlier Biopsy of all Local Skip Metastatic lesion

Biopsy technique:

Biopsy technique Sarcomas grow heterogenously Single biopsy not enough Multiple representative biopsies Thorough evaluation of radiology Main concern about biopsy---infiltration of biopsy tract with tumour ----convert a limb salvage to amputation

Principles of Biopsy:

Principles of Biopsy Part of the lesion is most representative of the underlying disease Extraosseous component is as representative as bony component First biopsy the soft tissue component Avoid violating the cortex as predisposes to pathological fractures Done only if no extraosseous element present Biopsy point along planned incision Shortest way to lesion must not violate more than one compartment Must be remote from neurovascular bundles

Types of Biopsy:

Types of Biopsy FNAC Tru -cut Incisional Excision

Biopsy tibia:

Biopsy tibia

Biopsy shoulder:

Biopsy shoulder

Sighting of incision:

Sighting of incision

Sighting incision:

Sighting incision

Bone window:

Bone window

Insertion of drain:

Insertion of drain

Ennekin staging:

Ennekin staging Stage Grade Site Metastasis 1a Low (G1) Intracompartment (T1) No Metastasis (M0) 1b Low (G1) Extracompartment (T2) No Metastasis (M0) 2a High (G2) Intracompartment (T1) No Metastasis (M0) 2b High (G2) Extracompartment (T2) No Metastasis (M0) 3 Any Grade Any T Regional or distant mets


Excision Intracapsular excision Marginal excision Wide excisions Radical excision and amputation


WHO CLASSIFICATION BONE FORMING – osteosarcoma; CARTILAGE FORMING - chondrosarcomas GIANT CELL TUMORS MARROW TUMORS – Ewing’s ; lymphomas; multiple myeloma VASCULAR & other connective tissue TUMORS – Angiosarcoma , ; Fibro sarcoma, Malignant Fibrous Histio cytoma MISCELLANEOUS – Chordoma ; adamantinoma; neurosarcoma Radiation induced sarcoma

Osteosarcoma (Osteogenic sarcoma):

Osteosarcoma (Osteogenic sarcoma) Mesenchymal tumor in which cancellous cell produce bone matrix. Most common primary malignant tumor of bone All age group but has bimodal age distribution 75% in person younger than 20 years of age Second peak occur in elderly who have predisposing condition – Paget disease, bone infarct, prior irradiation Males> females

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Usually arise from metaphysis of long bones of extremities, and almost 50% occur about the knee. Beyond the age of 25 years incidence in flat bones and long bones is almost equal.

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Codman’s triangle Sunrays appearance Osteosarcoma

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Codman's triangle Osteosarcoma

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Chondrosarcoma Definition: Malignant tumor of chondroblasts cells Second most common malignant matrix producing tumor Etiology: The tumor may arise de novo (primary) or secondary to preexisting enchondroma , exostosis ( osteochondromas ) or Paget’s disease Primary chondrosarcoma is very uncommon, arises centrally in the bone and found in children

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Chondrosarcoma sub classified according to – Site – Central (intramedullary) Peripheral ( juxtacortical and surface) Histologically - Conventional (hyaline/ myxoid ) Clear cell Dedifferentiated Mesenchymal Conventional central tumors constitute about 90% of chondrosarcoma

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Commonly after 40 years of age Clear cell and especially mesenchymal variant occur in younger patients in their 20s. Male > female It is most common in the femur, humerus , ribs and on the surface of the pelvis Patients with Ollier's disease (multiple enchondromatosis ) or Maffucci's syndrome (multiple enchondromas and hemangiomas ) are at much higher risk of chondrosarcoma than the normal population.

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Biopsy - Incisional biopsy done Gross examination – Chondrosarcoma is a grayish-white, lobulated mass. It may have focal calcification, mucoid degeneration , or necrosis


Investigations X – ray – C hondrosarcoma is a fusiform, lucent defect with scalloping of the inner cortex and periosteal reaction. Extension into the soft tissue may be present as well as punctate or stippled calcification of the cartilage matrix .

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C.T. scan – H elpful in defining the integrity of the cortex and distribution of calcification . MRI – S urgical planning as it demonstrates the intraosseus and soft tissue involvement of the tumor. MRI is also helpful in evaluating possible malignant degeneration of osteochondromas by allowing accurate measurements of the cartilage cap

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Ewing’s Sarcoma:

Ewing’s Sarcoma Ewing sarcoma, a highly malignant neoplasm predominantly affecting children and adolescents Approximately 90% of Ewing sarcomas occur before age 25 Histogenesis : neurally derived small round cell malignancy very similar to the so-called primitive neuroectodermal tumor ( PNET) disease is extremely rare in black persons

Areas of involvement:

Areas of involvement Ewing sarcoma has a predilection for the diaphysis of the long bones ribs flat bones such as the scapula and pelvis

Clinical presentation:

Clinical presentation present as a localized painful mass with systemic symptoms such as fever, malaise, weight loss, and an increased erythrocyte sedimentation rate. These systemic symptoms may lead to an erroneous diagnosis of osteomyelitis.

Radiological features:

Radiological features poorly defined, permeative or moth-eaten type of bone destruction, Associated with an aggressive periosteal response that has an onionskin (or “onion peel”) less commonly, a “sunburst” appearance, and a large soft-tissue mass . Occasionally , bone lesion itself imperceptible Often confused with osteomyelitis

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Other, less common, manifestations Thickened cortex or Saucerication Expansion of bone Pathologic fractures

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permeative bone destruction associated with an aggressive periosteal reaction CT section through the lesion demonstrates a large soft-tissue mass, which is not clear on the conventional study. obliteration of the marrow cavity by tumor .



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Bone destruction is almost imperceptible shows a large soft-tissue mass

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Onion skin appearance

Moth eaten appearance:

Moth eaten appearance


Conclusion Malignant bone tumours are rare X Ray screening may at times have subtle abnormalities that can be missed CT Scan and MRI remain the main imaging modalities as compared to benign lesions Biopsy is of utmost important as it determines the further management

Thank You:

Thank You