History Age & location Circumstances of presentation Symptoms (constitutional) Associated Conditions Review of system Natural History/ prior investigations
Questions to be asked 1. The patient’s age: Certain tumors are relatively specific to particular age groups. 2. Duration of complaint: Benign lesions generally have been present for an extended period (years). Malignant tumors usually have been noticed for only weeks to months. 3. Rate of growth: A rapidly growing mass, as in weeks to months, is more likely to be malignant. Growth may be difficult to assess by the patient if it is deep seated, as can be the case with bone. Deep lesions may be much larger than the patient thought (“tip-of-the-iceberg” phenomenon). 4. Pain associated with the mass: Benign processes are usually asymptomatic. Osteochondromas may cause secondary symptoms because of encroachment on surrounding structures. Malignant lesions may cause pain. 5. History of trauma: With a history of penetrating trauma, one must rule out osteomyelitis. With a history of blunt trauma, healing fracture must be entertained.
6. Personal or family history of cancer: Adults with a history of prostate, renal, lung, breast, or thyroid tumors are at risk for development of metastatic bone disease. Children with neuroblastoma are prone to bony metastases. Patients with retinoblastoma are at an increased risk for osteosarcoma. Secondary osteosarcomas and other malignancies can result from treatment of other childhood cancers. Family history of conditions such as Li–Fraumeni syndrome must raise suspicion of any bone lesion. Furthermore, certain benign bone tumors can run in families (e.g., multiple hereditary exostoses). 7. Systemic signs or symptoms: Generally, no significant findings should exist on the review of systems with benign tumors. Fevers, chills, night sweats, malaise, change in appetite, weight loss, and so forth should alert the physician that an infectious or neoplastic process may be involved. Questions to be asked
Physical examination should be documented 1. Skin color 2. Warmth 3. Location 4. Swelling: swelling, in addition to the primary mass effect, may reflect a more aggressive process 5. Neurovascular examination: changes may reflect a more aggressive process 6. Joint range of motion of all joints in proximity to the region in question, above and below 7. Size: a mass greater than 5 cm should raise the suspicion of malignancy 8. Tenderness: tenderness may reflect a more rapidly growing process 9. Firmness: malignant tumors tend to be more firm on examination than benign processes; this applies more to soft tissue tumors than to osseous ones 10. Lymph nodes: certain sarcomas (e.g., rhabdomyosarcoma, synovial sarcoma, epithelioid, and clear cell sarcomas all have increased rates of lymph node involvement)
Plain X-ray Size Site/Location What’s it doing to bone? Host bone response What type of matrix is being made? Cortical changes Soft tissue mass
Site/Location Types of bone Long bone / Flat bone Intramedullary / Eccentric / Cortical lesion Epiphysis / Metaphysis / Diaphysis
The larger the lesion the more likely to be aggressive or malignant Size
Geographic / Moth-eaten / Permeative lesions Define the margin or interface between the host bone and the lesion Narrow zone of transition “clear / well-defined border” Wide zone of transition “difficult to be certain where the lesion starts and stops” What is the tumor doing to bone?
Bone often responds to lesions by making new bone Marginal sclerosis Periosteal new bone formation –Interrupted –Continuous What is the host bone response?
Cartilage matrix –Calcified rings, arcs, dots, pop corn-like Ossified matrix –Bone forming, osteoblastic What type of matrix being made?
Cortical erosion by the tumor and remodeling process of the host bone is the hallmark of –Active –Aggressive –Malignant Is the cortex eroded?
Some bone tumor present with a large soft tissue component –Osteosarcoma –Lymphoma –**Infection Soft tissue mass?
Bone Tumors Bone forming tumors Benign Osteoma Osteoid osteoma Osteoblastoma
Bone Tumors Bone forming tumors Malignant Primary osteosarcoma –Conventional –Non-conventional Secondary osteosarcoma
Osteoid Osteoma A benign osteoblastic tumor Usually cortical lesion in long bones Present with unrelenting pain, worse at night, relieved by NSAIDS May produce deformities of bone and soft tissue
Osteoid Osteoma Radiographic appearance: the “nidus” –central lucent area –peripheral sclerotic area Less than 1 cm
Microscopic: sharply demarcated from surrounding bone (no permeation) thin, anastomosing strands of osteoid and/or woven bone (no cartilage) thicker, more compact bone in older lesions osteoblastic rimming loose intervening fibrovascular tissue (not marrow) Osteoid Osteoma
Larger than 1 cm –much more destructive, progressive –more prone to recurrence –1/5th as common as osteoid osteoma Sites: –predilection for axial skeleton (70%) –may be cortical or intramedullary Osteoblastoma
Aggressive Osteoblastoma same general architecture as osteoblastoma older age group (>30) larger, round to epithelioid osteoblasts variable mitotic rate (may be high) locally destructive Osteoblastoma
Osteosarcoma A malignant neoplasm of bone that produces osteoid Most common 1º malignant bone tumor 2nd decade (60% under 25) Males>females Long bones, especially distal femur
Osteosarcoma Conventional, intramedullary 90% of all osteosarcomas 90% are under age 30 present with pain of 1 to 8 months duration usually serum alkaline phosphatase elevated –not specific (OM, Obl, callus, children) –rise with recurrence or metastasis
Sites: –metaphysis of long bones (the longer the bone, the greater the chance) –distal femur (1/3) –proximal tibia and radius –rare in hands and feet Osteosarcoma Conventional, intramedullary
Radiographic appearance: –mixed lytic and sclerotic –large, infiltrating metaphyseal lesion –Codman’s triangle –erodes cortex and extends into soft tissue –fluffy or “cumulus cloud” densities Osteosarcoma Conventional, intramedullary
Osteosarcoma Skip Lesion
Osteosarcoma Although usually in the long bones, may occur in other places: Craniofacial Small bones Extraskeletal (soft tissue)
Osteosarcoma Histology Infiltration and destruction of normal bone