1. NTRU PG CME- Gandhi Med.Col.Secunderabad 27-5- 2012Aggressive & Malignant Bone Tumours An Overview Prof. A. Srinivasa Rao M.S.(Ortho); Fellow Ortho. Path.(USA)EMERITUS PROFESSORGandhi Medical College, SecunderabadConsultant, KIMS, SecunderabadHonorary Fellow, IOA

2. Bone TumoursAggressiveMalignant Giant Cell Tumour Osteosarcoma Aggressive ChondrosarcomaChondromyxoid Ewings sarcomaFibroma Multiple Myeloma AggressiveOsteoblastoma 3. ClinicalAge 4. AgeOsteosarcoma Immature SkeletonEwings sarcomaChondromyxoidOsteosarcoma fibroma Bimodal IncidenceOsteoblastoma Adolescents & > 65 yrs Mature SkeletonGiant cell tumourChondrosarcomaMultiple Myeloma 5. AgeEwingsSarcomaNEUROBLASTOLYMPHOMAMA 6. AgeGiant CellTumour If a diagnosis of GCT is to be madein an immature skeleton thinkseveral times Lichtenstein 7. ClinicalSymptoms & Signs 8. SymptomsLocalised Swelling Generalised body aches GCT Multiple Myeloma Osteosarcoma- Symtoms ignored forquitesometime Chondrosarcoma- Can be mistaken for Ewings sarcoma many otherconditions with generalised bodyachesOsteoporosis/Osteomalacia, FMS etc. 9. Swelling May not be obvious Especially if the tumour is deepREST PAIN 10. Wasting of Muscles Disproportionate toDuration of diseaseTuberculosis MalignancyRheumatoidDisease 11. RadiologyUtility ofPlain Radiograph Dimension View inThird of CTMRI ExtentIn DiagnosisLesion Intra/Extra CompartmentalSTAGINGIsotope Scan Lesionselewhere 12. IMAGINGPLAIN Enneking`s four questionsRADIOGRAPHY 1. Where is the lesion? 2. What is the lesion doing to bone?Transition zone 3. How is the tissue responding to lesion? Reactive zone 4. Does anything suggest histology? Calcification, Ossification, Ground glass appearance Etc. 13. ALTRMCPS Age of Skeleton - Mature or Immature Location Transitional zone Reactive zone Matrix Cortex Periosteal reaction Soft tissue swelling 14. Location ALTRMCPS Which Bone? Which Part of the Bone? - Epiphysis - Metaphysis - Diaphysis Eccentric or Concentric? 15. Zones of TransitionA LT R M C P S Narrow - Sharp Sclerotic BENIGN - Sharp Lytic Wide - Ill-defined or hazy AGGRESSIVE / - Moth eatenMALIGNANT - permeative 16. Zone of Transition ALTRMCPSNarrow Non-ossifying Fibroma Sharp Sclerotic 17. Zone of TransitionNarrow Giant Cell TumourSharp Lytic 18. Zone of TransitionWideAggressive GCTIll-defined or hazy 19. Zone of Transition WideNH L Met Ca. Breast Moth eaten 20. Zone of Transition Wide PermeativeMalignant Tumour 21. ALTR MCZone of Reaction PSLocalised Sclerotic Wide ScleroticBrodies AbscessOst.Osteoma 22. MatrixALTRMCPSCalcification -Ground Glass Fib.Dys. Chondrosarc 23. MatrixCloud like Ossific densities inBone =Osteosarcoma 24. CortexALTRMCPSIntact orBroken Wide Zone of Transition and Broken Cortexcould be signs of Aggressiveness /Malignancy 25. Periosteal Reaction ALTR MC P S 26. Periosteal ReactionSun BurstappearanceCodmans Triangle 27. ALTR MC PSSoft Tissue Enormous soft tissueseenin Ewings Sarcoma 28. Radiographic differences betweenBenign& Malignant TumoursIGNANTR BENIGNMALIGNANT 29. Early DiagnosisMANDATORYTO INCREASE SURVIVAL RATE 30. OS Early diagnosis Suspect OS : * Minor injury disproportionate duration of pain or increasing pain * Pain associated with sclerosis or erosions in the metaphysis without fever 31. AYESHA 14 yrsPain without injury 2 weeks3 wks Later 2 mths Later 32. Mankin Biological behaviorCriteriaScore____________________0_________1____ SizeSmallBig MarginationPresentAbsent Cortex Intact Destroyed Soft tissue mass Absent Present_________________________________Score0-1 Benign 2 Aggressive 3-4 Malignant 33. Diagnosis of Bone Tumours IMAGINGProblem- Not seen on plain Radiographss- Mistaken Diagnosis - MRI - Edema mistaken for tumour 34. Problem Imaging 1Not seenon plainRadiograph 35. Problem Imaging 2MistakenDiagnosisStress fracture Osteoid OsteomaABCTel. OS 36. Problem Imaging 3MRIEdemamistakenFor TumourHistologyNO TumourIn this area 37. Histopathology 38. Diagnosis of Bone Tumours BIOPSYProblem- FNAC vs WBNABs- Sampling Error 39. Problem Biopsy 1FNAC vs Cytology cellsWBNAB Biopsy Tissue Group of cells identified by matrixproduced by cells 40. Problem Biopsy 2SamplingErrorA A B B 41. Diagnosis of Bone Tumours HISTOLOGYProblem - Heterogenous nature ofsOsteosarcoma- Round cell Tumours- Giant cell variants - Reactive conditions mistaken fortumours - Benign vs Malignant - Path. Fr. Mistaken for Tumour - Primary or Mets - Tumour vs Infection 42. ProblemsHistology - 1OsteosarcomaHeterogeneityOsteoblasticChondroblasticFibroblasticGC richTelangiectaticSmall cell OSFibrousHistiocytoma-like 43. Problem Histology 2Ewings sarcoma Round Cell Tumours of Bone Ewings sarcoma Primary Lymphoma ofbone MetastaticNeuroblastoma EmbryonalRhabdomyosarcoma Small cellOsteosarcoma Mesenchymal cellChondrosarcoma Metastatic small cell 44. Problems Histology 3GCT Giant Cell Variants Chondroblastoma ChondromyxoidFibroma Simple Bone Cyst ABC Brown Tumour ofHyperparathyroid Nonossifying Fibroma Ossifying Fibroma 45. Problem Histology 4ReactiveConditionsmistakenfor Tumour- Exuberantcallus-Organisinghematoma- Myositisossificans 46. Problem Histology 4ReactiveCALLUSConditionsmistakenfor Tumour-Exuberant callus-Organisinghematoma OS- Myositis 47. Problem Histology 4ReactiveConditionsmistakenforTumours- Exuberantcallus- Organisinghematoma- Myositisossificans 48. Problem Histology 5Benign vsMalignant Secondary Chondrosarcoma arisingfrom osteochondromatosis -Histology may be misleading appears benign Aggressive Chondromyxoid Fibromacan be mistaken for low gradeChondrosarcoma Aggressive Osteoblastomaborderlines on Osteosarcoma Clinical picture & Radiology help to a great extent to differentiate 49. Problem Histology 6Pathologicalfr. MistakenforTumourNeedleBiopsy -Chondrosarco -Open BiopsymaTuberculosis 50. Problem Histology 7Primary vs Met. Neuroblastoma orMetastasescarcinoma vs Ewings immunohistochemistry 51. Problem Histology 8Tumour vsInfectionRadiology Ewings SarcomaHistology Plasmacytes -Plasmacytomawith path #Clinical OsteomyelitisPlasmacytic Osteomyelitis 52. Problem Histology 8Tumour vsInfectionOSTEOMYELITISLow GradeINTRAMEDULLARYOSTEOSARCOMA 53. Problem Histology 8Tumour vsInfection* Ewings Sarcoma &Osteomyelitis are confused with each otherClinically, Radiologically and evenHistologically* Culture a tumour &Biopsy anInfection 54. The gross anatomy asrevealed in radiographs isoften a safer guide to correctclinical conception thanvariable and uncertainnature of a small piece of 1922 EWINGtissue Importance of Correlation ofHistology & Radiology 55. Diagnosis of Bone Tumours Final Diagnosis CLINICAL IMAGEOLOGYPATHOLOGY (Radiology) 56. Prof. Dr. Walter PutscherOrthopedic Pathologist, Boston, USANo Pathologist shall ever sign out a report without seeing the Radiograph 57. Prof. Peter G BulloughProfessor of Orthopedic PathologyHospital for Special Surgery,Cornell University,NEW YORK If I were you, I will run to the Radiology department and get the x-ray films and make them available before the Histology slides are studied 58. DICTUMThe Pathologist should receive the Clinical &Radiological findings while dealing with thediagnosis of Bone Tumours 59. Thank YouThank YouThank YouThank You For YourThank YouThank You Patient HearingThank YouThank YouThank YouThank YouThank YouThank YouThank YouThank You