neoplasia

2. Introduction :
• Neoplasia : It is defined as a mass of tissue
formed as result of abnormal, excessive,
uncoordinated, autonomous and purposeless
proliferation of cells.
• Term Neoplasia includes both Benign and
Malignant.

3. FEATURES BENIGN (DIFFERENTIATED) MALIGNANT (UNDIFFERENTIATED)
MACROSCOPIC FEATURES
Boundaries Encapsulated or well
circumscribed
Poorly circumscribed and irregular
Surrounding tissue Often compressed Usually invaded
Secondary Changes Occur less often Occur more often
MICROSCOPIC FEATURES
Pattern Usually resemble tissue of origin No resemblance
Nucleo – Cytoplasmic
Ratio
Normal Increased
Pleomorphism Absent usually Often present
Anisonucleosis Absent Generally present
Hyperchromatism Absent Often present
Growth Rate
Usually Slow Rapid
Metastasis Absent Frequently Present
Contrasting Differences between Benign and Malignant Tumours

4. Routes of Metastasis :
• Haematogenous Spread : Most common spread in
musculoskeletal tumours
• Lymphatic Spread : rare in musculoskeletal tumours.
• Seen in Rhabdomyosarcoma, Synovial sarcoma,
Malignant fibrous histiocytoma .
• Direct Implantation :
– Through surgeons scalpel, needles, sutures, FNAC,
diagnostic or excision biopsy
• Spread through CSF :
– malignant tumours of ependyma and leptomeninges
rarely spread through CSF to vertebrae.

5. Classification of Tumours
1. WHO Classification :
widely accepted and is based on histogenesis
and histological criteria.
2. Classification based on origin of tumours
3. Classification based on site of lesions.

6. Modified WHO Classification of BONE TUMOURS
• 1. Bone forming tumours :
Benign :
Osteoma
Osteoid Osteoma
Osteoblastoma
Intermediate
Aggressive
Osteoblastoma
Malignant
Osteosarcoma
Conventional osteosarcoma
Telangiectatic osteosarcoma
Juxta cortical or Parosteal
Osteosarcoma
Periosteal Osteosarcoma

7. 2. Cartilage forming Tumours
• BENIGN :
• Chondroma
• Enchondroma
• Osteochondroma
• Chondroblastoma
• Chondromyxoid fibroma
• MALIGNANT :
• Chondrosarcoma
• Juxtacortical
chondrosarcoma
• Mesenchymal
chondrosarcoma
• Clear cell
chondrosarcoma
• De differentiated
chondrosarcoma
• Malignant
chondroblastoma

8. 3. Giant Cell Tumours :
– Osteoclastoma
– Malignant giant cell tumour
– Giant cell tumour in Pagets disease
– GCT occurring in non epithelial region
– Giant cell variants : tumors which histologically show the osteoclastic
giant cells
1 - aneurysmal bone cyst
2- osteoclastoma
3- chondroblastoma
4- unicameral bone cyst
5- chondromyxoid fibroma
6- non osteogenic fibroma
7- fibrous dysplasia
8- brown tumor of hyperparathyroidism .

9. 4. Marrow tumours
•Ewing sarcoma
•Reticulosarcoma
•Lymphosarcoma
•Myeloma

10. 5. Vascular Tumours
–Benign :
» Haemangioma
» Lymphangioma
» Glomus Tumour
–Intermediate or inderminate variant :
» Haemangio endothelioma
» Hemangio pericytoma
–Malignant :
» Angiosarcoma
» Malignant haemangio pericytoma

11. 6. Other Connective tissue tumours
• Benign :
» Benign fibrous histiocytoma
» Lipoma
• Intermediate :
» Desmoplastic fibroma
• Malignant :
» Fibrosarcoma
» Liposarcoma
» Malignant mesenchymoma
» Malignant fibrous histiocytoma
» Leiomyosarcoma
» Undifferentiated sarcoma

12. 7. Other Tumours
• Chordoma
• Adamantinoma
• Neurilemmoma
• Neurofibroma
8. Unclassified Tumours

13. 9. Tumour Like Lesions
• Solitary Bone cysts
• Aneurysmal bone cyst
• Juxta articular bone cyst (Intra osseous ganglion)
• Metaphilic fibrous defect ( non ossifying fibroma)
• Eosinophilic granuloma
• Fibrous dysplasia
• Myositis ossificans
• Brown Tumour or hyperparathyroidism
• Intraosseous epidermoid cyst
• Giant cell granuloma

14. Classification based on origin of tumours
1. Primary Bone tumours : Derived from bone
2. Metastatic bone Tumours : Due to Mets from :
–Breast Lytic + Blastic lesions
-Kidney Lytic
–Prostate Blastic
- Adrenal Lytic
–Thyroid Lytic
- Intenstine Lytic
- Lung, Liver Lytic
- Urinary Bladder, Uterine Cervix Lytic lesions
3. Tumour Like Lesions : Non neoplastic Conditions that resemble
tumours.
Eg : Solitary Bone cyst, Aneurysmal Bone cyst, Fibrous Dysplasia, Brown`s
tumour.

15. Classification based on site of Origin
1. Epiphyseal
Osteoclastoma, Chondroblastoma
2. Metaphyseal
Osteioid osteoma, Osteochondroma,
Osteoblastoma, Bone cysts, Osteogenic Sarcoma
3. Diaphyseal
Ewing`s sarcoma, Multiple myeloma

16. General Concepts in Tumour Terminology
• True Capsule :
• Surrounds a benign lesion and is composed of
compressed normal cells and mature fibrous tissue.
• Pseudocapsule :
• Compressed tumour cells.
• Fibrovascular zone of reactive tissue with an
inflamamtory component that interdigitates with normal
tissue and contains satellite lesions.

17. • Compartment :
It refers to bone or muscle of origin;
– For Muscle, compartment is that within its Fascia.
– For Bone :
• Intracompartmental implies Bone tumour within the
cortex
• Extracompartmental implies a bone tumour that
destroys the cortex and spreads in to the surrouding
tissue.

18. • Skip Metastasis :
• A skip metastasis, is defined as a tumor nodule that is
located within the same bone as the main tumor or on
the opposing side of joint but not in continuity with it.
• High grade sarcomas have the ability to break through
the pseudo capsule and metastasize within the same
compartment.
– MRI Scan better identifies them.

19. Satellite lesion
Tumour nodule
within reactive zone.
Intra Osseous Skip Mets :
Embolization of tumour
cells within the marrow
sinusoids.
Transarticular Skip Mets :
Occur via periarticular
venous anastamosis – Very
poor prognosis

20. GRADING and STAGING of TUMOURS
• To determine prognosis and choice of treatment.
GRADING :
• It is defined as macroscopic and microscopic degree of
differentiation of tumour
• BORDER`s GRADING :
– GRADE I : Well differentiated; <25% Anaplastic cells
– GRADE II : Moderately Differentiated; 25-50% Anaplastic cells
– GRADE III : Moderately differentiated; 50-75% Anaplastic cells
– GRADE IV: Poorly differentiated; >75% Anaplastic cells

21. Enneking`s Grading of Tumours
• G0 Histologically benign
(well differentiated and low cell to matrix ratio)
• G1 Low grade malignant
– (few mitoses, moderate differentiation and local spread
only); Have low risk of metastases
• G2 High grade malignancy
– (frequent mitoses, poorly differentiated); High risk of
metastases

22. STAGING OF TUMOURS
• STAGING is defined as extent of spread of tumour.
– It is determined by clinical examination, Investigations and
pathological studies.
– Common staging systems are
1. ENNEKING `S STAGING SYSTEM
2. AJCC SYSTEM
3. TNM STAGING ( Union International Cancer centre
Geneva Staging System )

23. ENNEKING`s STAGING OF BENIGN
TUMOURS
1. Latent—low biological activity; well marginated;
remains static or heals spontaneously;
often incidental findings (i.e., nonossifying
fibroma)
2. Active—symptomatic; limited bone destruction;
progressive growth but limited by natural barriers;
may present with pathological fracture (i.e., aneurysmal
bone cyst)
3. Aggressive—aggressive; bone destruction/soft tissue
extension; do not respect natural barriers (i.e., giant
cell tumor)

24. • GTM classification described by Enneking is adopted
by Musculoskeletal Tumour society and is based on
surgical grading (G), location (T), lymphnode
involvement & metastasis (M)
Enneking`s staging of malignant tumours
STAGE GRADE SITE
I A Low – G1 Intracompartmental T1
I B Low – G1 Extracompartmental T2
II A High G2 Intracompartmental T1
II B High G2 Extracompartmental T2
III A Any grade with regional or distal
Metastases
Intracompartmental T1
III B Any grade with regional or distal
Metastases
Extracompartmental T2

25. American joint committee on cancer system bone
sarcoma classification (AJCC Classification)
The AJCC system for bone sarcomas is based on tumor grade, size, and presence and
location of metastases.

27. TNM STAGING (Union International Cancer
centre Geneva Staging System)
• T – Primary Tumour – T0 to T4
– In Situ lesion T0 to largest and most extensive T4 primary
tumour
• N – Nodal involvement – N0 to N3
– No lymph nodes involvement N0 to wide spread nodal
involvement N3
• M – Metastasis – M0 to M2
– No Metastasis M0 to distant metastasis M2

28. CLINICAL PRESENTATION
• Pain :
– Initially may be activity related, but in case of malignancy
there could be progressive pain at rest and at night.
– In benign tumours, pain may be activity related when it is
large enough to compress surrounding soft tissue or when
it weakens bone.
– A benign Osteioid osteoma may cause night pain initially
that classically gets relieved with Aspirin.

29. • In case of soft tissue sarcomas patients may come with
mass rather than pain but in some exceptions like nerve
sheath tumours, they have pain and neurological
conditions.
• Age : It is the most important denominator because
most musculoskeletal tumours occur within specific age
ranges.
• Sex : Very few tumours show sex prediliction.
• Eg GCT is commoner in females.
• Family History : may be present in tumours like
exostosis/ von recklenghausen`s disease.

30. INVESTIGATIONS
Serological investigations :
• 1. Complete Blood Picture :
– Haemoglobin : to rule out anaemia that may be due
to replacement of bone marrow by neoplastic
process.
– ESR : raised in mets, Ewing`s sarcoma, lymphoma,
leukemias
• 2. Increased Prostate Specific Antigens (PSA)
with Prostatic Acid Phosphatase levels in a case
of blastic lesions of x ray is the diganostic of Mets
secondary to Prostate Carcinoma .

31.  3. Serum alkaline phosphatase (ALP)
 Biological marker of tumour activity.
 Increases significantly when tumour and metastasis are
highly osteogenic.
 ALP levels decline after Surgical removal of primary
tumour and elevates if metastasis aggravates.
 Good prognostic tool.
• Increased in following conditions: -
– Osteoblastic bone tumors (metastatic or osteogenic
sarcoma)
– 5-Nucleotidase and GGT ( Gamma glutamyl Trasferase ) are
elevated in liver pathology along with Alkaline
phosphatase, where as in bone pathologies only ALP is
increased.

32.  4. Antisarcoma Antibodies :
 Monoclonal antibodies can be detected by
immunohistochemical assays.
 Antibodies binding to sarcoma cell surface antigens
have specificity.
 5. Osteocalcin – A : Helpful in diagnosing heavily bone
producing types of tumours.
 6. Serum Calcium : Hypercalcemia is often due to Mets,
Myeloma, Hyperparathyroidism.
 7. Abnormal Serum protein electrophoresis along with
bence jones proteins in urine is classical of Multiple
myeloma

33. Flow Cytometry
• A sample of cells are treated with special antibodies that stick
to the cells only if certain substances are present on their
surfaces.
• The cells are then passed in front of a laser beam. If the cells
now have antibodies attached to them, the laser will cause
them to give off light, which can be measured and analyzed by
a computer.
• Flow cytometry can help determine type of those abnormal
cells and help in diagnosing a tumour early.

34. INVESTIGATIONS: RADIOGRAPHS
• Phemister's Law = the most common site of
infection & tumours is the fastest growing site
of the long bone
• To see a lucent lesion in bone, an estimated 30
to 50 % of the bone must first be lost
[Harris & Heaney, N Engl J Med 1969]

35. Radiographic Evaluation
• Five important parameters in evaluating a
tumour on a X RAY are
1. Anatomic site
2. Borders
3. Bone destruction
4. New Matrix ( Bone) formation
5. Periosteal reaction

36. A. Anatomic Sites – X ray
• Anatomic site Specific anatomic sites of the
bone give rise to specific groups of lesions.

38. Characteristic Locations
• Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior

39. Characteristic Locations
• Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior

40. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior
Characteristic Locations

41. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior
Characteristic Locations

42. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, Pelvis
• Osteoblastoma
Spine, posterior
Characteristic Locations

43. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine - posterior
elements
Characteristic Locations

45. B. Borders
• The border reflects the growth rate and the response of the
adjacent normal bone to the tumor.
• Most tumors have a characteristic border
• Benign lesions (e.g., nonossifying fibromas and unicameral
bone cysts) have well-defined borders and a narrow
transition area that is often associated with a reactive
sclerosis.
• Aggressive or benign tumors (e.g., chondroblastoma and
GCTs) tend to have faint borders and wide zones of transition
with very little sclerosis, reflecting a faster-growing lesion.
• Poorly delineated or absent margins indicate an aggressive or
malignant lesion

46. C. Bone destruction
• Bone destruction is the hallmark of a bone
tumor.
• Three patterns of bone destruction are
described
1. Geographic,
2. Moth-eaten,
3. Permeative.

47. Geographic Bone Destruction
Complete destruction of
bone from boundary to
normal bone
• Non-ossifying fibroma
• Chondromyxoid fibroma
• Eosinophilic granuloma
Non-ossifying fibroma

48. Moth-eaten Bone Destruction
• Areas of destruction with
ragged borders
• Implies more rapid growth
• Probably a malignancy
Examples:
• Myeloma
• Metastases
• Lymphoma
• Ewing’s sarcoma
Multiple Myeloma

49. Permeative Bone Destruction
• Ill-defined lesion with multiple
“worm-holes”
• Spreads through marrow space
• Wide transition zone
• Implies an aggressive
malignancy
• Round-cell lesions
Examples:
• Lymphoma, leukemia
• Ewing’s Sarcoma
• Myeloma
• Osteomyelitis
• Neuroblastoma Leukemia

50. Patterns of Bone Destruction
Geographic Moth-eaten Permeative
Less malignant More malignant

51. D. Matrix formation
• Calcification of the matrix, or new bone formation,
may produce an area of increased density within the
lesion.
• Calcification typically appears as flocculent or
stippled rings or clusters.
• The appearance of the new bone varies from dense
sclerosis that obliterates all evidence of normal
trabeculae to small, irregular, circumscribed masses
described as "wool" or "clouds."
• Calcification and ossification may appear in the same
lesion.
• Neither type of matrix formation is diagnostic of
malignancy.

52. Tumor Matrix
• Osteoblastic
– Fluffy, cotton-
like or cloud-
like densities
– Osteosarcoma

53. Cartilaginous :
– Comma-shaped,
punctate, annular,
popcorn-like
as Enchondroma,
chondrosarcoma,
chondromyxoid
fibroma
Tumor Matrix
Chondrosarcoma

54. Expansile Lesions of Bone
Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia

55. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone
Renal cell carcinoma

56. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone

57. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone

58. E. Periosteal reaction
• Periosteal reaction is indicative of malignancy
but not pathognomonic of a particular tumor.
• Any widening or irregularity of bone contour
may be regarded as periosteal activity.

59. Solid Periosteal Reactions
Chronic osteomyelitis
• Single solid layer or multiple
closely apposed and fused
layers of new bone attached
to the outer surface of
cortex resulting in cortical
thickening.
• It is uniterrupted or
continous.

60. Types of Solid Periosteal Reaction
• 1. SOLID BUTTRESS
• Seen in Aneurysmal bone cyst, chondromyxoid fibroma
• 2. Solid Smooth or Elleptical layer
• Seen in Osteoid osteoma and osteoblastoma
• 3. Undulating type :
• Seen in long standing varicosities, periosteitis, chronic
lymphaoedema.
• 4. Single Lamellar reaction :
• Seen in Osteomyelitis, Stress Fractures, Langerhans cell
histiocytosis.

61. Interupted Periosteal Reactions
• Commonly seen in
Aggressive/malignant
tumours.
– Onion-Peel ( lamellated)
– Ewings sarcoma
– Gouchers disease
– Sunburst
– Codman’s triangle
Ewing sarcoma

62. Sunburst type of periosteal reaction
Fine lines of increased
density representing newly
formed specules of bone
radiate laterally from and at
right angles to the surface of
the shaft giving a typical
sun ray appearance.
Osteo-sarcoma

63. Codman’s triangle
– When the tumour breaks
through the cortex and
destroys the newly formed
lamellated bone, the remnants
of the latter on both ends of
the break through area may
remain as a triangular structure
known as codman triangle.
Also seen in Osteosarcoma,
Ewings sarcoma,
Chronic Osteomyelitis
Osteo-sarcoma

64. Periosteal Reactions
Solid onion-peelSunburst Codman’s
triangle
Less malignant More malignant

65. Radiographic Features in a Benign vs.
Malignant

66. Mnemonic for Luscent bone lesions =
FOGMACHINES
Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumour
Metastasis/ Myeloma
Aneurysmal Bone Cyst
Chondroblastoma/ Chondromyxoid Fibroma
Hyperparathyroidism (brown tumour)/
Haemangioma
Infection
Non-ossifying Fibroma
Eosinophilic Granuloma/ Enchondroma
Simple Bone Cyst

67. • It delineates intra and extra
osseous extent of tumour.
• It can reliably distinguish
between infection and tumor.
• CT scan identifies accurately area of cortical break through, soft
tissue extension, medullary spread and proximity of the tumour
to neurovascular bundle and evaluating integrity of cortex
• To differentiate solid and cystic lesions.
• Most sensitive investigation to detect Pulmonary mets.
CT scan:-

68. • Best imaging
– to localise the nidus of an osteiod osteoma,
– to detect a thin rim of reactive bone around an aneurysmal bone cyst,
– to evluate calcification in a suspected cartilagenous lesion and
– to evaluate endosteal cortical erosion in a suspected chodrosarcoma.
• To differentiate between the neoplastic mass and
inflammatory condition : Neoplastic masses displace soft tissue
fat planes where as they are obliterated in inflammatory
conditions.
• It cannot differentiate benign from malignant tumours
accurately.
• Except in detecting pulmonary mets, Contrast CT is better than
plain CT.

69. • It has better contrast
discrimination than any other
modality.
• Helps in detecting skip lesions
• Assesses the tumor relationship
with adjacent soft tissue, joints
and blood vessels.
• It can visualize bone marrow
content and demonstrate
intramedullary extension of
neoplasm.
MRI:-

70. • It is the investigation of choice in local staging of
musculoskeletal tumours.
• On MRI, it is not possible to accurately
differentiate benign from malignant tumours. But
if the following criteria are present, lesion can be
considered as a malignant one :
– 1. Mass with irregular Border
– 2. Non homogenous signal intensity with extra
compartmental extension
– 3. Peri tumoral edematous reaction.
– 4. Soft tissue mass situated deep to fascia and
measuring more than 5 cm in greatest diameter is likely
to be a sarcoma.

71. • It uses radioactive glucose to locate cancer by observing
high glycolysis rates in a malignant tissue metabolism.
• It has low specificity as the FDG ( Fluoro labelled deoxy
glucose) can also accumulate in benign aggressive and
inflammatory lesions.
• Also helpful in evaluating the tumour after chemotherapy.
• Micromets are better visulaised.
PET- Positron Emission
Tomography

72. Most reliable means of determining vascular anatomy.
• Reactive zone is best seen on early arterial phase,
while the intrinsic vascularity is best seen on late
venous phase as a tumour blush.
• Transcatheter embolisation is done as a definitive
treatment in some benign vascular tumours.
Angiography

73. Angiography demonstrating
vascularity of a tumour
Embolization of a vascular
lesion, performed at least 6
hours prior to surgery, is
expected to significantly
reduce intraoperative blood
loss.

74. • Technetium (99mTC) bone scans are used.
• It is an indicator for mineral turnover.
• Whenever there is altered local metabolism in remodeling
bone, increased vascularity or mineralization , the isotope
uptake is enhanced mainly in reactive zone surrounding the
lesions.
• Confirms epiphyseal spread of tumour.
• Helps in detecting multiple lesions like multiple
osteochondroma, enchondroma.
• Where as a MRI helps in detecting skip lesions
Nuclear Imaging -Bone scan Scinitigraphy

75. Bone scan showing HOT
SPOTS over proximal
humerus and ribs
It detects the presence
of skeletal metastasis
and delineates it from
primary else where in
the body.

76. • Bone scinitigraphy tends to show larger area of
extension of medullary involvement of tumour
as the radio active agent also localises the area
of hyperemia and edema adjacent to tumour.
• Nuclear imaging is advantageous only to
identifying whether skeletal involvement is
solitary or multiple.

77. • Not routinely used in diagnosis of sarcoma; as it
better differentiates only bony cystic lesions.
• However Ultrasound is used in guided
percutaneous biopsy.
• In patients treated with prosthetic implants, USG
is the modality that depicts early recurrence as
MRI produces blurred and artifact images due to
metallic implants.
Ultrasound

78.  Used for definitive diagnosis.
• Principles of biopsy:
 Opted only after all other investigations are performed.
 A biopsy can be done by FNAC, core needle biopsy, or an
open incisional procedure.
 FNAC may be 90% accurate at determining malignancy;
however, its accuracy at determining specific tumor type is
much lower.
– Trephine or core biopsy is recommended and often yields
an adequate sample for diagnosis.
– Complications are greater with incisional biopsy; but least
likely to be associated with a sampling error, and provides
the sample for additional diagnostic studies, such as
cytogenetics and flow cytometry.
Biopsy

79. – Core biopsy is preferred if limb spraying is an option as it entails
less contamination than open biopsy.
– A small incisional biopsy can be performed if core biopsy
specimen is inadequate.
– Performed under torniquet (possibly) - the limb may be elevated
before inflation but should not be exsanguinated by
compression bandage.
 Longitudinal incisions preferred as transverse excision are
extremely difficult or impossible to excise with the specimen.
 NV bundle not exposed. Dissection through muscle (not
between) to prevent contamination of tumour.

80.  Approach for open biopsy is made through region of definitive
surgical excision. If a drain is used, it should exit in line with the
incision so that the drain track also can be easily excised en
bloc with the tumor. Wound is closed tightly in layers.
 Meticulous haemostasis is arrested by use of bone wax/ Poly
Methyl Metha Acrylate(PMMA) to plug the cortical window.
 Always sample the tissues from periphery of lesion which
contains most viable tissue.
 Never biopsy a periosteal reaction / codmans traingle as it
contains a new reactive bone and could be false negative.

81. • If hole must be made in bone during biopsy, defect should be
round or oval to minimize stress concentration, which otherwise
could lead to pathological fracture.
•Torsional strength is not affected by length of defect. Always
attempt to keep defects less than 10% of bone diameter.
•When biopsy size is greater than 20% of bone diameter, torsional
strength decreases to 50%.

82. Examples of poorly performed biopsies
Biopsy resulted in irregular defect in bone, which led to pathological
fracture

83. Examples of poorly performed
biopsies
Transverse incisions
should not be used
Needle biopsy track
contaminated patellar
tendon
Multiple needle
tracks contaminate
quadriceps tendon

84. Drain site was not placed in line with
incision
Needle track placed posteriorly,
location that would be extremely
difficult to resect en bloc with
tumor if it had proved to be
sarcoma

85. • Biopsy should be done only after clinical, laboratory,
and radiographic examinations are complete.
• Completion of the evaluation before biopsy aids in
planning the placement of the biopsy incision, helps
provide more information leading to a more accurate
pathological diagnosis, and avoids artifacts on
imaging studies.
• If the results of the evaluation suggest that a primary
malignancy is in the differential diagnosis, Biopsy is
not done unless it is possible to operate the case in
the centre.

86. • Curettage resection and restoration of function by
limb salvage procedures or amputation is primary
form of surgical correction.
• Based on surgical plane of dissection in relation to
tumour, Enneking formulated following types of
resection.
1) Intralesional Resection
2) Marginal resection
3) Wide (Intracompartmental) resection
4) Radical (Extracompartmental) resection
SURGICAL OPTIONS

87. • An intralesional margin is one in which the plane of surgical
dissection is within the tumor.
• This type of procedure is often described as “debulking”
because it leaves behind gross residual tumor.
• This procedure may be appropriate for symptomatic benign
lesions when the only surgical alternative would be to
sacrifice important anatomical structures.
• This also may be appropriate as a palliative procedure in the
setting of metastatic disease.
• Intralesional resection is through the psuedocapsule of the
tumor directly in to the lesion. Macroscopic tumour is left
behind. Curettage is intralesional proceedure.
1) Intralesional Resection :

88. CURETTAGE
• Cortical window with rounded margins is made
• When possible, the window is sized larger than the tumour
so that the entire tumour is readily seen.
• The rounded margins reduce the risk of subsequent
fracture.
• Large curetts should be used to remove the lesional tissue.
• Tumour margin should be treated with cryotherapy, PMMA
cementage or phenol – alcohol cauterisation, argon beam
coagulation in case of aggressive tumours.
• If curettage weakens the bone, graft using allograft or
autograft with or with out internal fixation is indicated.

89. • A marginal margin is achieved when the closest plane of
dissection passes through the pseudocapsule.
• This type of margin usually is adequate to treat most benign
lesions and some low-grade malignancies.
• In high-grade malignancy, however, the pseudocapsule often
contains microscopic foci of disease, or “satellite” lesions.
• A marginal resection often leaves behind microscopic disease
that may lead to local recurrence if the remaining tumor cells
do not respond to adjuvant chemotherapy or radiation
therapy.
2) Marginal Resection

90. • Intracompartmental
• Wide margins are achieved when the plane of dissection is in
normal tissue.
• Although no specific distance is defined, the Resection
includes removal of entire tumour, + Reactive zone & cuff of
normal tissue.
• If the plane of dissection touches the pseudocapsule at any
point, the margin should be defined as being marginal and not
wide.
• Although sometimes impossible to achieve, wide margins are
the goal of most procedures for high-grade malignancies.
3) Wide Resection

91. 4] Radical
Radical margins are achieved when all the compartments that
contain entire tumor and structure or origin of lesion are
removed en bloc.
The plane of dissection is beyond the limiting fascial & bone
borders.
For deep soft-tissue tumors, this involves removing the entire
compartment (or multiple compartments) of any involved
muscles.
However, with improvements in imaging studies, radical
procedures now are rarely performed because equivalent
oncological results usually can be obtained with wide margins
.

92. ENNEKING`s Classification of Surgical Procedures for Bone
Tumors
Margin Local (Mode of resection)
LIMB SALVAGE OPTIONS
Amputation(Mode of amputation)
Intralesional Curettage or debulking Debulking amputation
Marginal Marginal excision Marginal amputation
Wide Wide local excision Wide through bone, amputation
Radical Radical local resection Radical disarticulation

93. Enneking`s
Classification of
Resection of
tumours.

94. 1] Limb Salvage Proceedures
2] Amputations
SURGICAL OPTIONS

95. • It is designed to accomplish removal of a malignant tumour &
reconstruction of the limb with an acceptable oncologic,
functional & cosmetic result.
• It is sub amputative wide resection with preservation of the
limb & its function.
• Indications :
• Stage IA Stage IIA & Stage IIIA (All intracompartmental
tumours)with good response to pre-operative chemotherapy
• Skin should be uninvolved and free
• There should be feasibility of keeping a cuff of normal tissue
surrounding the tumour
• Upper extremity lesions are more suitable for limb sparing
surgery
 Tumours with good pre-operative chemotherapy response
LIMB SALVAGE PROCEDURES

96. • Reconstruction of bone defect may be done by
1] Osteoarticular allograft reconstruction
2] Allograft-prosthesis composite reconstruction
3] Endoprosthetic reconstruction.
4] Allograft arthrodesis
5} Rotationplasty
6} Turnoplasty
Surgical reconstructive options :

97. • Amputation provides definitive surgical treatment when limb sparing
is not a prudent one.
• Common amputations in malignant tumours:
– Proximal humerus : fore quarter amputation
– Distal femur : hip disarticulation
– Proximal tibia : mid thigh amputation
AMPUTATIONS

98. Ennekings Classification of
Amputations

99. • Adjuvant chemotherapy:
– To treat presumed micrometastasis
• Neo adjuvant[induction]
– Before surgical resection of the primary tumour
Advantages:
– It controls micro metastasis and improves survival rate.
– Chemotherapy makes limb salvage surgery easier.
– Decreases tumor size and vascularity.
– The response to Chemotherapy can be evaluated after
surgery.
Chemotherapy

100. • With Megavoltage radiotherapy tumor cell can be destroyed.
• High voltages are administered in short sessions.
• Radiation therapy should be started immediately after
diagnosis before surgery to prevent metastasis .
• Chemotherapy increases the susceptibility of tissues to
irradaition.
• Protect all normal tissue biopsy scars to prevent radiation
necrosis.
• Distribute the dose in accordance with distribution of tumor.
RADIOTHERAPY

101. Diagnosis
Neoadjuvant chemotherapy + Radiation
Resection/ surgery Repeat Chemo + Radiation
Adjuvant + irradiation +chemo Histological Grading
SEQUENCE OF TREATMENT

102. • Gene therapy in sarcomas :
• Targeting Osteocalcin promoter.
• Osteocalcin is produced both in Osteoblastic[100%]and fibroblastic[70%]
Osteosarcoma.
• LIQUID BRACHYTHERAPY :
– Injecting Intra arterial infusion of chemotherapeutic drugs with
brachytherapy
– It is in Phase 2 trials currently.
• Cryotherapy is used in curettage after resection of primary
tumour to prevent chances of recurrence.
• PMMA, Phenol, liquid nitorgen commonly used
cryoprecipitates.
RECENT ADVANCES

103. Oncologist BoneTumours
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
Histopathologist
Molecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit
MUSCULOSKELETAL
TUMOURS are Evolving in to
a multi disciplinary
approach

104. OSTEOCHONDROMA
• Osteochondroma is a bony exostosis projecting from the
external surface of a bone.
• It is usually has a hyaline lined cartilaginous cap
• The cortex and spongiosa of the lesion merge with that of the
host bone

105. • When the lesion is seen in a single bone , it is called
solitary osteochondroma
• If two or three bones are involved , with no familial
history , the condition is known as multiple
ostechondromas
• Widespread ostechondromas are associated with a
positive familial history, and the condition is known
as Heriditary Multiple Exostosis

106. INCIDENCE
• Most common skeletal growth/tumor
• Approximate incidence is 50% of all benign bone
tumors
• Male : Female ratio 2:1
• Most are encountered in childhood and
adolescence
• 75% occur before the age of 20
• Many cases may not be diagnosed due to the
silent nature of the disease

107. PATHOPHYSIOLOGY
• Developmental lesions rather than true neoplasms.
• These lesions result from the separation of a fragment of
epiphyseal growth plate cartilage, which subsequently
herniates through the periosteal bone cuff .
• The mechanism likely results from the remodeling during
growth of the long bone.
• Persistent growth of this cartilaginous fragment and its
subsequent enchondral ossification (maturation) result in a
subperiosteal osseous excrescence with a cartilage cap that
projects from the bone surface.
• After adolescence and skeletal maturity, osteochondromas
usually exhibit no further growth.

108. The development of an osteochondroma, beginning with an
outgrowth from the epiphyseal cartilage
 Histology:
•Covered by thin layer of periosteum.
•Binucleate chondrocytes in lacunae.
•Contains hyaline cartilage, bony tissue
and normal bone marrow particle.

109. LOCATION

110. UNCOMMON SITES
• Metacarpals
• Condylar process of the mandible
• Base of the skull
• Talus
• Calcaneus
• Spine
• Distal end of the clavicle( can cause rotator cuff
syndrome)

111. TYPES

112. Sessile Variant
• Creates a broad based exostosis
lacking an elongated projection
• Causes a long asymmetric elongation
of the bone
• Amorphous , spotty calcification is
absent
• Occur at the metaphyseal – diaphyseal
region

113. Pedunculated Variant
• Knee is the most common location (tibia and fibula)
• Metaphysis is the common site of involvement
• Lesion has a slender stalk with a cartilaginous dome
• The cartilage may show dense amorphous / spotty
calcification

114. CLINICAL FEATURES
• Most are asymptomatic
• Symptoms arise as a result of their
1. Location
2. Size
3. Pressure effects on adjacent structures
• Tendon or nerve irritation
• Usual complaint is hard palpable mass

115. COMPLICATIONS

116. MALIGNANT TRANSFORMATION
• Presents with
1. Growth of lesion after skeletal maturity
2. Pelvis / shoulder (mostly sessile variety)
3. < 1 % in solitary , > 10% in HME
4. Increasing mass and pain at the site of lesion in absence
of fracture, bursitis or nerve compression
• Radiologically
– Bone destruction
– Dispersed calcification in cartilaginous cap
– Soft tissue mass

117. X RAY - Pedunculated
• Lateral radiograph of a
pedunculated osteochondroma of
the distal femur.
• COAT HANGER EXOSTOSIS : The
lesion invariably point away from
the joint due to muscle pull

118. X RAY Sessile
• Lateral radiograph of
a sessile
osteochondroma of
the distal femur.

119. USG
• Ultrasonography can be applied to analyze the
cartilaginous cap of an osteochondroma.
• Ultrasonography is also valuable in the diagnosis of
bursitis and other complications associated with
osteochondromas, such as arterial or venous
thrombosis, as well as aneurysm and
pseudoaneurysm formation.

120. CT SCAN
• Allows optimal demonstration of the pathognomonic
cortical and medullary continuity of the lesion and
parent bone .
• Mineralization in the cartilage cap allows a correct CT
measurement .
• Cartilage cap thickness greater than 2 cm in adults
and 3 cm in growing children suggests malignant
transformation .

121. MRI
• MRI is useful for assessing the continuity of the
parent bone with the cortical and medullary bone in
an osteochondroma.
• MRI also provides information about inflammation in
reactive bursa formation, impingement syndromes,
and arterial and venous compromise. This study is
the method of choice for evaluating compression of
the spinal cord, nerve roots, and peripheral nerves.

122. TREATMENT
• No treatment necessary for asymptomatic
osteochondromas (Observation) .
• If the lesion is causing pain or neurologic symptoms due
to compression, it should be Excised
– None of the cartilage cap or perichondrium should be
left in the resection bed or recurrence can occur.
• Patients with many large osteochondromas should have
regular radiographic screening exams for the early
detection of malignant transformation
• In adults if the osteochondroma has recently become
bigger, then urgent surgery is done due to fear of
malignancy

123. HEREDITARY MULTIPLE EXOSTOSES
• Autosomal dominant condition
• Mutations in the EXT1 and EXT2 genes cause
hereditary multiple exostoses
• Multiple osteochondromas
• Asymmetric growth at the knees and ankles and
Short stature
• Malignant transformation rates as high as 25%

124. ENCHONDROMA
• Enchondromas (or chondromas) are a
relatively common benign medullary
cartilaginous neoplasm with benign imaging
features.

125. EPIDEMIOLOGY
• Enchondromas are most frequently diagnosed
in childhood to early adulthood with a peak
incidence of 10-30 years.
• They account for ~5% (range 3-10%) of
all bone tumours and ~17.5% (range 12-24%)
of benign bone tumours .

126. CLINICAL FEATURES
• Mostly, they are an incidental finding.
• They are usually asymptomatic, but may be
complicated by a pathological fracture or
malignant transformation into a low-
grade chondrosarcoma. The latter is rare.
• It is important to note that if an enchondroma
is painful in the absence of a fracture, it
should be considered malignant.

127. PATHOLOGY
• Enchondromas arise from rests of growth plate
cartilage/chondrocytes that subsequently proliferate
and slowly enlarge and are composed of mature
hyaline cartilage.
• Hence, they are seen in any bone formed from
cartilage.
• Lesions are usually <3 cm, translucent, nodular, and
are grossly grey-blue.

128. ASSOCIATIONS
• Two syndromes are associated with multiple
enchondromas:
• Ollier disease
• Maffucci syndrome

129. LOCATION
• Almost all enchondromas are
located centrally within the
medullary cavity of tubular bones.
• The typical distribution is:
Small tubular bones of the hands
and feet: 50%
Large tubular bones, e.g. femur,
tibia, humerus
• Rarely an enchondroma may
extend through the cortex and
demonstrate an exophytic growth
pattern.
• This is known as an Enchondroma
Protuberans, and may either be
seen sporadically or as part
of Ollier disease.

130. RADIOGRAPHIC FEATURES
• When located in the phalanges, enchondromas are expansile and
are usually purely lytic. In other locations, enchondromas are
expansile, with characteristic “rings and arcs” calcifications.
• Typically, enchondromas are small 1-2 cm lytic lesions with non-
aggressive features:
• narrow zone of transition
• sharply defined scalloped margins: may have mild endosteal
scalloping
• expansion of the overlying cortex may be present, but there should
not be cortical breakthrough unless fractured
• chondroid calcifications may be present: rings and arcs calcification
• no periosteal reaction
• no soft tissue mass

131. • The majority of enchondromas more frequently arise
in the metaphyseal region, owing presumably to
their origin from the growth plate , although they are
frequently seen in the diaphysis.
• They only rarely are seen in the epiphysis, and a
cartilaginous lesion in an epiphysis is more likely to
be a chondrosarcoma .

132. • MRI is useful in evaluating for soft tissue extension
and for confirming the diagnosis. Enchondromas
appear as well circumscribed somewhat lobulated
masses replacing marrow.
• Nuclear medicine - Increased uptake on the bone
scan can be seen with enchondromas. Intense
uptake occurs with underlying pathological
fracture or cortical expansion in small bones .

133. COMPLICATIONS
• Pathological fractures
• Malignant transformation into chondrosarcomas

134. TREATMENT
• The majority of enchondromas remain asymptomatic
and require no treatment.
• In the setting of a fracture, the bone may be allowed
to heal.
• If necessary, a curettage and bone grafting can be
performed at a later time.
• If malignant transformation is suspected, which
occurs in less than 5% of cases, then treatment is
more aggressive .