Orthopaedic & Traumatology Department

Soetomo General Hospital

Surabaya
2015

1
Introduction
Orthopaedic: the art and science of prevention,
investigation, diagnosis and treatment of disorders and
injuries of the musculoskeletal system by medical,
surgical and physical means (Rabert B. Salter 1970)

System musculoskeletal
1. Bone
2. Joint
3. Muscle, tendon and ligament
4. Nerve
5. Vascular
Musculoskeletal System

1. Bone
2. Joint
3. Muscle, tendon
4. Ligament
5. Nerve
6. Vessel

Region
1. Upper
extremity
2. Lower
extremity
3. Spine
4. Shoulder girdle
5. Pelvic girdle
Classification Of
Musculoskeletal Tumor

BENIGN MALIGNANT

PRIMARY

SECONDARY

METASTASIS
Classification Of
Musculoskeletal Tumor
Malignant
1. Primary; malignant musculoskeletal tumor that origin
from musculoskeletal tissue
2. Secondary; malignant musculoskeletal tumor that
transformation from benign lesion of musculoskeletal
tissue
3. Metastasis; malignant musculoskeletal tumor that origin
from outside musculoskeletal tissue (breast, thyroid,
lung, etc.)
 WHO Classification Of Bone Tumours
Tissue of origins Benign Malignant
Cartilage Tumours Osteochondroma Chondrosarcoma
Chondroma
Chondroblastoma
Chondromyxoid fibroma
Osteogenic Tumours Osteoid osteoma Osteosarcoma
Osteoblastoma
Fibrogenic Tumours Desmoplastic fibroma Fibrosarcoma
Fibrohistiocytic Tumours Benign fibrous histiocytoma Malignant fibrous
histiocytoma
Primitive Ewing sarcoma
Neuroectodermal Tumour
Haematopoietic Tumours Plasma cell myeloma
Malignant lymphoma, NOS
Giant Cell Tumour Giant cell tumour Malignancy in giant cell
tumour
Notochordal Tumours Chordoma
Vascular Tumours Haemangioma Angiosarcoma
 WHO Classification Of Bone Tumors

Tissue of origins Benign Malignant

Smooth Muscle Tumours Leiomyoma Leiomyosarcoma

Lipogenic Tumours Lipoma Liposarcoma

Neural Tumours Neurilemmoma
Miscellaneous Tumours Adamantinoma
Metastatic malignancy
Miscellaneous Lesions Aneurysmal bone cyst
Simple cyst
Fibrous dysplasia
Osteofibrous dysplasia
Langerhans cell histiocytosis
Erdheim-Chester disease
Chest wall hamartoma
Joint Lesions Synovial chondromatosis
Precursors Of Malignancy In Bone
Bone Tumors
Epidemiology
 Primary tumors of bone are relatively uncommon
 Bone sarcomas
 0.2% of all neoplasms
 One tenth that of their soft tissue sarcoma
 The most common primary malignant tumor of
bone
 Osteosarcoma 35 %
 Chondrosarcoma 25%
 Ewing sarcoma 16%
 The age-specific frequencies and incidence rates of
bone sarcomas as a group are clearly bimodal
 The first peak occurs during the second decade of life
 The second peak occurs in patients older than sixty.
Bone Tumors
Epidemiology
 Osteosarcoma occurs predominantly in patients younger
than age twenty, and in this group 80% occur in long bones
of the extremities
 Chondrosarcomas have age-specific incidence rates
showing a gradual increase up to age 75, >50 % of
chondrosarcomas occur in the long bones of the
extremities
 Ewing sarcoma tends to arise in the diaphysis, the major
peak occurring during the first and second decade of life
Approach for Diagnosis

Steps for diagnosis

1. History taking (anamnesis)
2. Physical diagnostic
3. Investigations
a. Laboratory
b. Imaging (radiology)
c. Pathology
4. Clinicopathology
Confrence (CPC)
a. Diagnostic
b. Treatment
History Taking (Anamnesis)

1. Asymptomatic
2. Pain
3. Lump
4. Pathologic fracture
Physical Diagnosis
Inspection
1. Color
2. Venaectasi
3. Shine
4. Ulceration

Palpation
1. Temperature
2. Tenderness
3. Surface
4. Margin
5. Consistency
6. Mobile/fixed
Investigations
Investigations
1. Laboratory
2. Imaging (radiology)
a. Plain photo
b. CT Scan
c. MRI
d. Bone Scintigraphy
3. Pathology
a. Cytology
b. Histopatology
 Investigations (Imaging)
Plain Photo
1. Site
2. Type of destructions
3. Periosteal reactions
4. Border of tumor
5. Matrix
6. Bony and soft tissue
expansion
7. Multiplicity

+
Age
Diagnos
Plain Photo - Location
Plain Photo - Location

Parosteal Sarcoma
Plain Photo
Type of Destruction
Plain Photo
Periosteal Reaction
Plain Photo Type
of Matrix
Plain Photo - Border
Plain Photo - Multiplicity

Multiple Myeloma Eosinophilic Granuloma

Plain Photo - Extention
Plain Photo – Tumor Origin
 Investigations (Imaging)

CT Scan
 Show of detail of bone destruction.
 Sagital and coronal view
CT Scan
CT Scan (3 Dimension)
Investigations (Imaging)

MRI
• Anatomical mapping
of the tumor
a. Soft tissue
extension
b. Neurovascular
involvement
c. Intramedullary
extension
d. Detect skip lesion

10th Grand Round Solo 17 Des 2011

 Investigations (Imaging)

Bone Scintigraphy
 Investigations

Pathology
Biopsy
1. Fine needle aspiration biopsy
a. Minimal invasive
b. Cytology
2. Open biopsy Cytology
a. Invasive (surgery)
b. Histopathology

Histopathology
History Taking

Clinico-Pathology
Physical Conference (CPC)
(Multidisciplinary Diagnosis
Examination
Approach)

Treatment
Investigation
1. Laboratory
2. Imaging
3. Pathology
Result
Clinico-Pathology Conference (CPC)
(Multidisciplinary Approach)

10th Grand Round Solo 17 Des 2011

Surgical Staging System (Enneking)
Benign tumor

Stage Description Grade Site Metastasis

1 Latent G0 T0 M0

2 Active G0 T0 M0

3 Aggressive G0/G1 T1/T2 M0/M1

Surgical staging of bone sarcoma
Pre-operative
• Neoadjuvant chemoterapy
• Radiotherapy

Operative

Post-operative
• Huvos grading system ;
adjuvant chemoterapy
• Radiotherapy
10th Grand Round Solo 17 Des 2011
7/7/2019 NEOPLASMA JARINGAN TULANG 37
 TUMOR JINAK
 Osteoid osteoma
 Osteoma
 Osteoblastoma
 Enchondroma
 Multiple exostosis (osteochondroma)
 Eosynophilic granula
 Aneurysimal bone cysts
 Giant cell tumor

7/7/2019 NEOPLASMA JARINGAN TULANG 38

Osteoid osteoma
 Dewasa muda jarang
anak-anak
 Femur proximal, tulang
tibia, spine (posterior)
 Gejala
 Nyeri, terutama malam
hari
 X-ray ada nidus (sangat
sukar ditemukan)
 Treatment
 Sembuh spontan
 Daerah stress = curet

7/7/2019 NEOPLASMA JARINGAN TULANG 39

 Osteoma
 Dewasa muda, jarang
pada anak-anak
 Skull, mandibula ,1/3
tengah tibia
 Tumbuh sangat lambat,
jarang mengeluh
 X-ray : masa tulang
padat pada permukaan
cortex
 Treatment : eksisi bila
sangat mengganggu

7/7/2019 NEOPLASMA JARINGAN TULANG 40

Osteblastoma
 Ukuran besar > 2 cm mirip
osteoid osteoma
 Pada dewasa
 Tanpa “night pain”
 Lokasi : posterior aspect of
spine
 X-ray : gambar osteolytic
dikelilingi reactive zone tipis
 DD :
 osteoid osteoma
 Aneurysimal bone cyst
 Eosynophillic granuloma
 Terapi :
 Eksisi enblock

7/7/2019 NEOPLASMA JARINGAN TULANG 41

 Osteochondro
ma
Sering pada anak sedang
tumbuh
 Ada benjolan-benjolan
dekat sendi
 Biasanya pada tulang
panjang :
 Proximal tibia, humerus,
distal femur, pelvis dan
scapula
 Keluhan : benjolan,
kadang ada bursitis,
kadang ada gangguan
pertumbuhan

7/7/2019 NEOPLASMA JARINGAN TULANG 42

 Osteochondroma
 X-ray : benjolan
tulang, bisa panjang,
datar atau
bertangkai, sungkup
cartilage kadang-
kadang ada
kalsifikasi
 Treatment : Bila
mengganggu =
marginal excision

7/7/2019 NEOPLASMA JARINGAN TULANG 43

 Giant Cell tumor = osteoclastoma
 Usia 20-40 tahun
 Laki > perempuan
 Epifisis pada femur
distal dan tibia proximal,
radius distal
 Sering datang dengan
fraktur patologis
 X-ray : lesi radilusen
dikelilingi daerah
reaktif, penipisan cortex

7/7/2019 NEOPLASMA JARINGAN TULANG 44

 Giant Cell tumor =
osteoclastoma
 Treatment
 Bila kecil: kuret + bone
graft (bone cement)
 Besar : salvage
procedure

7/7/2019 NEOPLASMA JARINGAN TULANG 45

 Surgery of Musculoskeletal
Tumor

Types of excision Plane of Dissection Result

Intralesional Curretage or debulking Leaves macroscopic
tumor
Marginal Pericapsular reactive zone Likely to leave
microscopic tumor
Wide Normal cuff of tissue May leave skip lesion
(intracompartment)
Radical Whole bone or whole No residual
compartment of muscle
Surgery for Benign Bone Tumors
Stage Treatment Reconstruction

1 Observation None
Intralesional excision Local grafting
2 Intralesional excision Local grafting
Cementation
3 Marginal or en bloc Structural grafting
excision Endoprosthesis
Allograft
Composite
MARGINAL EXCISION (OSTEOCHONDROMA)
INTRALESIONAL EXCISION – CEMENTATION
( GIANT CELL TUMOR)
 TUMOR GANAS

7/7/2019 NEOPLASMA JARINGAN TULANG 50

 TUMOR GANAS
 Osteosarcoma
 Chondrosarcoma
 Fibrous histiocytoma
 Fibrosarcoma
 Ewing sarcoma
 Myeloma

7/7/2019 NEOPLASMA JARINGAN TULANG 51


OSTEOSARCOMA
= Osteogenic sarcoma
 Paling sering dari semua
tumor ganas tulang
 Type :
 Classic osteosarcoma
 Parosteal osteosarcoma
 Periosteal osteosarcoma
 Umur : dekade 2
 Laki > perempuan
 Lokasi metafisis dari :
 femur distal,
 tibia proximal (50%)

7/7/2019 NEOPLASMA JARINGAN TULANG 52

 OSTEOSARCOMA
 Lokasi lain :
 Humerus proximal
 Femur proximal
 pelvis
 Gejala
 Benjolan yang nyeri (night pain)
 Biasanya datang sudah infiltrasi ke soft
tissue & epifisis

7/7/2019 NEOPLASMA JARINGAN TULANG 53

 OSTEOSARCOMA
 Diagnostic :
 X-ray :
 Gambaran blastic, kadang-
kadang disertai lystic permeatif
kerusakan cortex disertai usaha
new bone formation (sun ray
appeareance) sehingga
menimbulkan elevasai
periosteum
( segi tiga Codman)
 DD :
 Ewing Sarcoma
 osteomyelitis

7/7/2019 NEOPLASMA JARINGAN TULANG 54

 OSTEOSARCOMA
 DD :
 Ewing Sarcoma
 Osteomyelitis
 Prognosis dan Terapi
 Chemoterapi preop.
 Reseksi + Limb salvage
procedure
 Chemoterapi postop.
 Prognosis jelek

7/7/2019 NEOPLASMA JARINGAN TULANG 55

CHONDROSARCOMA
 Tumor ganas tulang
rawan
 Laki-laki usia 30-50
tahun
 Lokasi : pelvis, femur
proximal bahu
 Keluhan : rasa nyeri
yang sangat hebat

7/7/2019 NEOPLASMA JARINGAN TULANG 56

CHONDROSARCOMA
 25% kasus berasal dari
enchondroma atau bone exostosis
yang transformasi ganas
 Gambaran x-ray : radiolusen,
permeative dengan kalsifikasi
seperti “salt and pepper” atau
popcorn” patern

7/7/2019 NEOPLASMA JARINGAN TULANG 57

CHONDROSARCOMA

Terapi dan prognosis

 Radioterapi dan chemoterapi
tidak efektif
 Dilakukan wide (Salvage)
excision
 Prognosis jelek

7/7/2019 NEOPLASMA JARINGAN TULANG 58

EWING SARCOMA
 Sangat ganas
 Berasal dari sel
reticuloendothelial cell
(bone marrow)
 Keganasan tulang
tersering ke 4
 Usia : 10-15 tahun
 Laki > perempuan
 Sering datang sudah
infiltratif

7/7/2019 NEOPLASMA JARINGAN TULANG 59

EWING SARCOMA
 Keluhan : benjolan yang sangat
nyeri, berasal dari tulang disertai
pembesaran soft tissue disertai
gejala : demam, lemah, BB  ,
sering disertai anemia
 Lokasi : daerah diaphysis
 Femur -> ilium -> tibia -> humerus ->
fibula -> costa

7/7/2019 NEOPLASMA JARINGAN TULANG 60

EWING SARCOMA
Diagnosis
 Gambaran permeatif pada daerah diaphysis
disertai bercak-bercak osteolytic
 Cortex : onion skin appearance
 bone scan : high uptake
 DD :
 osteomyelitis
 osteosarcoma
 eosynophillic granuloma

7/7/2019 NEOPLASMA JARINGAN TULANG 61

EWING SARCOMA

Prognosis & Terapi

 Kombinasi chemoterapi
 radiasi – reseksi
 akan memperbaiki prognosis

7/7/2019 NEOPLASMA JARINGAN TULANG 62

 Surgery for Malignant Bone
Tumors

Stage TREATMENT
IA  Marginal/Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
IB  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 ANV incorporation : Amputation/Disarticulation
IIA  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 Chemotherapy / radiation
IIB  Wide Excision
 Reconstruction : Autograf, Allograf, Prosthesis
 Chemotherapy / radiation
 ANV incorporation: Amputation/Disarticulation/
Exarticulation
III A/B  Palliative & Pain controle
10th Grand Round Solo 17 Des 2011
 OSTEOSARCOMA
Chemotherapy – wide excision + intercalary allograft -
chemotherapy

10th Grand Round Solo 17 Des 2011

Chondrosarcoma

10th Grand Round Solo 17 Des 2011

 Chondrosarcoma
Wide exicision + hemiarthroplasty

10th Grand Round Solo 17 Des 2011

7/7/2019 NEOPLASMA JARINGAN TULANG 67
Metastase
 Introduction

Primary site Procentage

 The most Breast 47 - 85 %
common cause Prostate 54 - 85 %
of a destructive Thyroid 28 - 60 %
lession of the
Lung 32 - 50 %
skeleton in adult
Kidney 33 - 40 %
 More than
Bladder 42 %
primary sarcoma
Liver 16 %
of the bone
Rectum 8 - 13 %
Gastro -.Intestinal 3 - 11 %
Ovarium 9%
Oesophagus 5- 7%
Metastatic pathway through through The most common site of MBD
Batson’s vertebral vein plexus
General mechanism of tumor cell metastasis to the bone ( Guise TA,
Mundy GR, Endocrine Review 19(1):18-54. 1998 )
MOST COMMON PROBLEMS IN
OSTEOLYTIC METASTASIS

1. Pain
2. Hypercalcemia
3. Pathologic Fracture
4. Nerve compression
5. Impair Mobility & Function
 Principal Of Treatment MBD

1. PAIN CONTROL
2. INHIBITION OF OSTEOLYSIS
3. HANDLING COMPLICATION
Treatment Modalities

NON SURGERY
and
SURGERY
Treatment Of Bone Metastasis

1. PAIN CONTROLE
* Analgesic
* Radiation
* Chemotherapi
2. INHIBITION OF OSTEOLYSIS
3. HANDLING COMPLICATION
Who 3 – Step Pain Management ‘Ladder’
Treatment Of Bone Metastasis

1. PAIN CONTROLE
2. INHIBITION OF OSTEOLYSIS
* BISPHOSPHONATES
* CALCITONIN
* MITHRAMYCIN
3. HANDLING COMPLICATION

FER/AOA-IOA/06
 TUMOR METASTASE
Metastase Paru
Metastase payudara
Metastase ginjal
Metastase prostat
Metastase thyroid

7/7/2019 NEOPLASMA JARINGAN TULANG 78

TUMOR METASTASE
 Metastasis lesion dibandingkan primary lesion 25 :1
 Meta dari
 Prostate
 Payudara
 Thyroid
 Paru
 ginjal

7/7/2019 NEOPLASMA JARINGAN TULANG 79

 TUMOR METASTASE

 Sering meta ke
 Vertebra
 Costa
 Batok kepala

7/7/2019 NEOPLASMA JARINGAN TULANG 80

TUMOR METASTASE

 Pada anak-anak biasanya dari :

 Neuroblastoma
 Leukemia
 Ewing Sarcoma

7/7/2019 NEOPLASMA JARINGAN TULANG 81

TUMOR METASTASIS
 Meta dari ginjal, prostat &
thyroid biasanya
hypervasculer
 Gambaran x-ray
 Blastic : prostate
 Lytic : paru, mama, GIT,
thyroid, myeloma dan
lymphoma.

7/7/2019 NEOPLASMA JARINGAN TULANG 82

TUMOR METASTASIS
 Bila ke tangan atau kaki biasanya dari paru
 Prognosis : jelek

7/7/2019 NEOPLASMA JARINGAN TULANG 83

Treatment Of Osteolitic
Metastasis
SURGICAL
MANAGEMENT

IT HAS TO BENEFIT
IMPROVING LIFE QUALITY
Surgical Treatment
GENERAL CONSIDERATION

 Palliative surgery
 Improved 5-year survival rate :
 Breast cancer 75 - 85%
 Prostate cancer 73 - 92%
 Mean survival rate after pathologic fracture
(Harrington 1982) :
 Breast cancer, 22.6 months
 Prostate cancer, 29.3 months
 Kidney, 11,8 months
 Lung, 3.6 months
 The incidence unknown origin metastatic to the bone
15%
Surgical Treatment
GENERAL CONSIDERATION

 Life expectancy at least 6 to 12 week consider for

surgical candidate
 Patient recovery time from surgery should not outlast
estimated time survival
 Provide immediately stable reconstruction
 Scoring assessment to predict the surgical candidate

FER/AOA-IOA/06
 Scoring
Assessement

FER/AOA-IOA/06
 Scoring Assessement
(Abdurrahman,1998 )

• Subjective Assessement:
A. Degree of Pain ( 1-2-3 )
B. Pain Related movement ( 0-5 )
• Objective Assesement:
C. Number of local extension (3-2-1-0)
D. Ulceration ( 0-5 )
E. Pathologic fracture situation ( 0-5-10 )
F. Physical Status ( 10-0 )
G. Operability of the tumor ( 1-0 )

Total Sore: ( A+B+C+D+E+F) x G

Score < 25 = Not Recommended for Surgery

FER/AOA-IOA/06
Metastasis breast cancer
Metastasis breast cancer
Metastasis lung cancer

FER/AOA-IOA/06
FER/AOA-IOA/06
Thank You

93