Tumours

Will Aston, Timothy Briggs, Louis

Solomon
 Tumours, tumour-like lesions & cysts
similar clinical presentation & management
evolving definitive classification of bone tumours &
some disorders move from one category to another
mimic each other

Incidence
Benign lesions: quite common
Primary malignant: rare

critical decisions on T/t: a working knowledge of all

the important conditions is necessary (i.e. its
essential to differentiate 3 conditions)
 Classification of bone tumours
Based on recognition of dominant tissue in
lesions
Advantage: Knowing cell line from which
tumour has sprung may help with both
diagnosis & planning of treatment
Pitfalls in the approach of bone tumour classification:
most pervasive tissue is not necessarily the tissue
of origin
there is not necessarily any connection between
conditions in one category
there is often no relationship between benign &
malignant lesions with similar tissue elements
(e.g. osteoma and osteosarcoma)
the commonest malignant lesions in bone
metastatic tumours are not, strictly speaking,
bone tumours, i.e. not of mesenchymal origin.
Revised WHO Classification of bone tumours
Schajowicz (1994)
Predominant tissue Benign Malignant
Bone forming Osteoma, Osteoid Osteosarcoma: central,
osteoma, Osteoblastoma peripheral, parosteal
Cartilage forming Chondroma, Chondrosarcoma:
Osteochondroma, central
Chondroblastoma, peripheral
?Chondromyxoid fibroma juxtacortical
clear-cell
mesenchymal
Fibrous tissue Fibroma, Fibrosarcoma
Fibromatosis
Mixed ?Chondromyxoid fibroma
Giant-cell tumours Benign osteoclastoma Malignant osteoclastoma
Marrow tumours Ewings tumour
Myeloma
Vascular tissue Haemangioma Angiosarcoma
Haemangiopericytoma Malignant
Haemangioendothelioma haemangiopericytoma
Predominant tissue Benign Malignant
Other connective tissue Fibroma Fibrosarcoma
Fibrous histiocytoma Malignant fibrous
Lipoma histiocytoma
Liposarcoma

Other tumours Neurofibroma Adamantinoma

Neurilemmoma Chordoma
 Clinical presentation of bone tumours
History
History: prolonged; delay in obtaining T/t
Asymptomatic; abnormality discovered on x-ray
i.e. incidental finding on x-ray (more likely with
benign lesions)
non-ossifying fibroma (benign): common in
children but rare > 30yrs; capable of spontaneous
resolution
Malignant tumours: silent if slow-growing &
situated in a room for inconspicuous expansion
(pelvis cavity)
 History
Age
During childhood & adolescence: many benign
lesions; primary malignant tumours (Ewings
tumour & osteosarcoma)
In older people (fourth or sixth decades) :
Chondrosarcoma & fibrosarcoma
seldom seen before the sixth decade (>60yrs) :
myeloma (commonest of all primary malignant
bone tumours)
over 70 years: metastatic bone lesions are more
common than primary tumours
 History
Pain
common complaint
gives little indication of nature of lesion
Progressive & unremitting pain is a sinister symptom
even a tiny lesion may be very painful if it is
encapsulated in dense bone (e.g. an osteoid osteoma)
caused by
a) rapid expansion with stretching of surrounding
tissues
b) central haemorrhage or degeneration in tumour or
c) an incipient pathological fracture
History
Swelling or appearance of a lump: alarming
patients seek advice only when a mass
becomes painful or continues to grow
(medical adviced seeked on growing or painful
mass)
History
of trauma: offered frequently;significant
whether injury initiates a pathological change
or merely draws attention to what is already
there remains unanswered
 History
Neurological symptoms (paraesthesiae or
numbness)
caused by pressure upon or stretching of a
peripheral nerve
Progressive dysfunction is more ominous &
suggests invasion by an aggressive tumour
History
Pathological fracture
may be the first (and only) clinical signal
Suspicion is aroused if the injury was slight; in
elderly people, whose bones usually fracture
at the cortico-cancellous junctions, any break
in the mid-shaft should be regarded as
pathological until proved otherwise
 c/fs of bone tumours
Prolonged; silent; asymptomatic & incidental finding on x-ray
Pain: pressure symptom (osteoid osteoma); central hhg /degn;
pathological #
Swelling:painful growing mass
Pathological #: with slight trauma; in elderly (at mid-shaft)
Trauma: initiate pathology or draw attention
Paresthesia & numbness: pressure symptom; progressive
dysfunction: aggressive tumour
Age: child & adolescence (bening; primary tumour like Ewing &
osteosarcome); old (40/60yr): chondrosarcoma, fibrosarcoma; (>60
yrs: myeloma); > 70 yrs: mets
4P + AST
 Examination will focus on the symptomatic part
Lump:
Site (where does it arise? ): Spinal lesions (benign or
malignant) cause muscle spasm & back stiffness, or
a painful scoliosis
discrete or ill-defined (diffuse swelling with warm &
inflamed overlying skin: DD difficult to diff. tumour,
hematoma, infection)
soft or hard
pulsatile
Tender
Tumour near a jt: an effusion and/or limitation of
movement
Examination in asymptomatic part
area of lymphatic drainage (pelvis, abdomen,
chest & spine)
 IMAGING
Plain x-rays
most useful of all imaging techniques
Provides informative detail can seldom be relied on
for a definitive diagnosis in which the appearances
are pathognomonic (osteochondroma, non-ossifying
fibroma, osteoid osteoma) except in some where
further investigations will be needed
Do all forms of imaging (bone scans, CT or MRI)
before undertaking a biopsy as biopsy may distort the
appearances
Location of lesion: in metaphysis or the diaphysis
solitary or multiple lesions
margins well-defined or ill-defined
Plain x-rays
Bony abnormality seen
cortical thickening
a discrete lump
ill-defined destruction
hollow cavities or radiolucent area (DD: cyst,
fibroma or chondroma)
a cyst (sharply defined boundary: benign; hazy &
diffuse boundary: invasive tumour)
Stippled calcification inside a cystic area is
characteristic of cartilage tumours
Plain x-rays
Bone surfaces suggestive of malignant change:
periosteal newbone formation &
extension of the tumour into soft tissues
Plain x-rays
soft tissues
Distorted muscle planes by swelling
Any calcification
 Plain x-ray summary
Most useful in pathognomic lesions like osteochondroma,
non-ossifying fibroma, osteoid osteoma
Do all imaging before biopsy as biopsy distorts appearance
Site (D,E, M), number & border of lesion
Bony abnormality: thickened cortex, lump, hollow
radiolucent cavity (cyst, fibroma, chondroma), stippled
calcification inside cyst (cartilage tumour), cyst (sharp
border: benign; hazy border: invasive); ill-defined
destruction
Bony surface: periosteal new bone formation & extension
into soft t/s (malignancy)
Soft-tissue abnormality: distorted muscle plane,
calcification
RADIONUCLIDE SCANNING
Scanning with 99mTc-methyl diphosphonate
(99mTc-
MDP) shows non-specific reactive changes in
bone; this
can be helpful in revealing the site of a small
tumour
(e.g. an osteoid osteoma) that does not show
up clearly
on x-ray. Skeletal scintigraphy is also useful for
detecting
skip lesions or silent secondary deposits.
 \
COMPUTED TOMOGRAPHY
CT extends the range of x-ray diagnosis; it shows
more accurately both intraosseous and extraosseous
extension of the tumour and the relationship to surrounding
structures. It may also reveal suspected
lesions in inaccessible sites, like the spine or pelvis; and
it is a reliable method of detecting pulmonary metastases.
MAGNETIC RESONANCE IMAGING
MRI provides further information. Its greatest value is
in the assessment of tumour spread: (a) within the
bone, (b) into a nearby joint and (c) into the soft tissues.
Blood vessels and the relationship of the tumour
to the perivascular space are well defined. MRI is also
useful in assessing soft-tissue tumours and cartilaginous
lesions.