Study Notes on Bone Tumors from Thai Red Cross Society

Thai Red Cross Society

  • The document originates from the Thai Red Cross Society.

Bone Tumors Overview

  • Focus on bone tumors, particularly the Queen Savang Vadhana Memorial Department at the QSMH Hospital, represented by Dr. Komkrich Wattanapaiboon, MD. in the Oncology and Spine Unit.

Types of Bone Tumors

  • Carcinoma:

    • Definition: "Malignant neoplasm of epithelial cell origin, derived from ectoderm or endoderm."

  • Sarcoma:

    • Definition: "Malignant neoplasm of the mesenchymal tissue" (mostly derived from mesoderm).

Classification of Bone Tumors

  • Primary Bone Tumor:

    • Types: Benign, Malignant, Tumor-like lesion, Metastatic bone disease.

Incidence of Bone Sarcoma

  • Average Incidence:

    • Represents approximately 0.2% of all neoplasms.

    • 0.8 new cases per 100,000 population annually.

  • Specific Types Incidence:

    • Osteosarcoma: 35.1%

    • Chondrosarcoma: 25.8%

    • Ewing’s Sarcoma: 16.0%

    • Chordoma: 8.4%

    • Pleomorphic Sarcoma and Fibrosarcoma: 5.6%

  • Age Correlation:

    • Less than 20 years old: More likely to have osteosarcoma and Ewing’s sarcoma.

    • Over 50 years: More likely to develop chondrosarcoma.

Etiology of Bone Tumors

  • Possible causes include:

    • Unknown factors.

    • Chemical Exposure.

    • Radiation.

    • Viruses.

    • Trauma.

    • Genetic Abnormalities:

    • Tumor Suppressor Genes:

      • Examples include RB (Retinoblastoma), p53 (Li-Fraumeni syndrome), p16INK4a (Familial melanoma), NF1 (Neurofibromatosis), EXT1 and EXT2 (Hereditary multiple exostosis).

Clinical Evaluation of Bone Tumors

  • Initial Evaluation:

    • Plain Film Imaging

    • History and Physical Examination

    • CT Scan and Bone Scan for probably malignant cases.

    • Biopsy for determining tumor type and staging.

    • MRI for advanced imaging and evaluation.

Gender Differences in Bone Tumors

  • Male Predominance: generally seen in most tumors.

  • Female Predominance: observed in cases such as:

    • Fibrous Dysplasia

    • Giant Cell Tumor

    • Hemangioma of Bone

    • Aneurysmal Bone Cyst

    • Parosteal Osteosarcoma

Clinical Presentation of Bone Tumors

  • Common Symptoms Include:

    • Pain

    • Mass or Swelling

    • Pathological Fracture

    • Deformity

    • Incidental Findings through imaging.

Detailed History for Clinical Evaluation

  • Duration of Symptoms:

    • Pain: Assessment for rest pain, night pain, progressive increase in pain.

    • Mass: Noting progression over time.

    • Pathological Fracture: Mechanism of injury and pre-fracture pain evaluation.

    • Initial Findings: Encouraging assessment of past medical and surgical history, and chemical or radiation exposure.

Precursor of Malignancy in Bone

  • High-Risk Conditions:

    • Ollier Disease (Enchondromatosis)

    • Maffucci Syndrome

    • Familial Retinoblastoma

    • Rothmund-Thompson Syndrome (RTS)

  • Moderate Risk Conditions:

    • Multiple Osteochondromas

    • Paget's Disease

    • Radiation Exposure

    • Osteitis

Low-Risk Precursor Conditions

  • Low-Risk Examples:

    • Fibrous Dysplasia

    • Bone Infarcts

    • Chronic Osteomyelitis

    • Metallic and Polyethylene Implants

    • Osteogenesis Imperfecta

    • Giant Cell Tumor

    • Osteoblastoma and Chondroblastoma

Benign Lesions with Potential for Malignant Transformation

  • Descriptions of various benign lesions and their potential malignant counterparts:

    • Enchondroma may lead to Chondrosarcoma

    • Osteochondroma leads to Chondrosarcoma

    • Fibrous Dysplasia can progress to Fibrosarcoma, Pleomorphic Sarcoma, or Osteosarcoma

    • Osteomyelitis with chronic draining sinus tract can result in Squamous Cell Carcinoma and Fibrosarcoma

Radiographic Evaluations

  • Enneking’s Questions for Assessment:

    • Location of the lesion

    • Effects of the lesion on the bone

    • Bone's response to the lesion

    • Characteristics within the lesion

    • Patient’s age

    • Presence of other lesions

Locations of Lesions

  • Key Locations:

    • Epiphysis: E.g., Adamantinoma, Osteoid Osteoma

    • Metaphysis: E.g., Osteochondroma, Ewing Sarcoma, Osteosarcoma

    • Diaphysis: E.g., Fibrous cortical defect, Adamantinoma, Round cell tumors

Bone Lesion Descriptions

  • Discusses types of lesions based on radiographic features like:

    • Geographic: Well-defined with a sclerotic margin.

    • Moth-Eaten: Lesion margins showing perforated appearance.

    • Permeative: Invasive lesions that disrupt surrounding bone.

Further Exploration of Lesion Characteristics

  • Investigates what lesions do to bones including:

    • Soft Tissue Extension: Distinction between benign containment versus malignant involvement with soft tissues.

  • Periosteal Reactions: Described by types like uninterrupted, interrupted, and various appearances such as onion-skin or Codman's triangle.

Assessments of Intra-lesion Components

  • Analysis of what is within the lesions such as:

    • Abnormal calcifications

    • Chondroid and Osteoid matrix characteristics (e.g., popcorn-like appearance).

Age Distribution of Bone Malignancies

  • Specific ages correlated with various malignancies:

    • 1st decade: Ewing’s sarcoma

    • 2nd-3rd decade: Osteosarcoma

    • 4th-5th decade: Chondrosarcoma, Metastasis

    • 6th decade onward: Multiple Myeloma, Metastasis

Diagnosis and Treatment Approaches

  • Conscious of Signs of Malignancy:

    • Cortical destruction, wide transitional zones, soft tissue masses, periosteal reactions

  • Introduces principles of biopsy ensuring minimal disruption for future surgeries.

Classifying Tumors

  • Categorizes benign/malignant based on behavior and necessary surgical margins (e.g., wide excision for aggressive tumors).

  • Staging and Treatments for Malignant Bone Tumors: (as per Enneking Classification)

    • Examples: IA, IB, IIA, IIB, III based on tumor grade and site with associated treatment strategies.

Common Benign Bone Tumors

  • Detailed descriptions of prominent benign tumors: e.g., Osteochondroma, Enchondroma, Osteoid Osteoma, Unicameral Bone Cyst, Fibrous Dysplasia, Giant Cell Tumor, etc.

    • Include location, treatment, radiographic presentations, and potential for malignancy.

Common Malignant Bone Tumors

  • Discusses the most significant malignant bone tumors such as Osteosarcoma, Chondrosarcoma, Ewing’s Sarcoma, and Multiple Myeloma.

    • Each section includes:

    • Common locations

    • Patient demographics

    • Symptoms

    • Radiographic findings

    • Treatment approaches

Metastatic Tumors in Bone

  • Describes metastatic bone tumors being most common in adults, often originating from cancers of the breast, prostate, lung, kidney, or thyroid.

    • Identifies common sites for metastasis and presents typical symptoms associated with them and their treatment methodologies.