1. Assoc. Prof. Melih Güven Yeditepe University Hospital Department of Orthopaedics and Traumatology BONE TUMORS

2. Learning Objectives • Classification of benign bone tumors • Charasteristic clinical and radiological features of most common benign bone tumors • Definition of tumor like lesions • Classification of malign bone tumors • Charasteristic clinical and radiological features of most common malign bone tumors • Charasteristic features of metastatic bone tumors • Surgical applications in benign and malign bone tumors

3. Bone tumors • General knowledge • Benign tumors • Tumor like lesions • Malign tumors • Metastatic bone tumors

4. General approaches • Initial referral • Pain • Deeply, sharp and increased over time • Localized sensitivity and rush • Pathologic fracture • Deformity • Incidental finding

5. General approaches • First stage evaluation • Anamnesis • Duration and level of pain, number and duration of the lesions, age, loss in weight, fever, weakness • Physical examination • Site and size of the lesion, mobility, sensitivity,LAP • Radiological evaluation • Codman triangle, onion skin view, sunrise view • Laboratory findings • ALP, serum Ca level, ESR, LDH, protein electrophoresis

6. Bone Tumors Imaging • Solitary or multiple lesions? • What type of bone is involved? • Which part of the bone is involved? • Are the margins of the lesion well defined? • Is there any bony reaction? • Does the lesion contain calcification?

7. General approaches • Second stage evaluation • CT • Bone scintigraphy – Tc 99m • Anjiography • MRI • PET – CT

8. General approaches • Second stage evaluation • Biopsy • Closed • Fine needle aspiration biopsy • Trochar biopsy • Needle biopsy under CT control • Open • Incisional biopsy • Excisional biopsy • Frozen section biopsy (intraoperative)

9. Staging • Staging of benign bone tumors (Enneking) • Stage I: Latent • Dense capsule, no reactive zone • Spontaneous healing • Stage II: Active • Dense capsule, adhesions between capsule and surrounding soft tissue; reactive zone present • No spontaneous healing

10. Staging • Staging of benign bone tumors (Enneking) • Stage III: Agressive • Irregularity is present at the border of the tumor, thin capsule • Dense reactive zone and edema • Tumor can grow up quickly, no restriction

11. Staging • Staging of malign bone tumors (Enneking) • G :G1: Low potential of metastasis , G2: High potential of metastasis • T : Intracompartmantal (T1) or extracompartmantal (T2) • M : M0: No metastasis, M1: Metastasis present IA G1 T1 M0 IB G1 T2 M0 IIA G2 T1 M0 IIB G2 T2 M0 IIIA G1-G2 T1 M1 IIIB G1-G2 T2 M1

12. General classification • Tumors with osseous origin a-Benign:  Osteoma, Osteoid osteoma, Osteoblastoma b-Malign:   Osteosarcoma • Tumors with cartilaginous origins a- Benign :Chondroma, Osteochondroma, Chondroblastoma, Chondromyxoidfibroma b- Malign :  Chondrosarcoma

13. General classification • Tumors with bone marrow origins Ewing’s sarcoma Reticulumcellsarcoma Lymphosarcoma Multiple myeloma • Gaint cell tumors Gaint cell bone tumors (osteoclastoma)

14. General classification • Tumor like lesions (Fibrous, cystic) Simple bone cyst Aneurysmal Bone Cyst Fibrouscorticaldefect (Non-ossifyingfibroma) Eosinophilicgranuloma FibrousDysplasia Desmoplasticfibroma

15. Treatment • If possible, extremity preserving surgery • Functional extremity • External body view • Psychological copmpliance • Sociocultural compliance

16. Surgical treatment 1.Intracapsular excision: - Benign, latent lesions 2.Marginal excision: - Surgical borders contain also reactive zone of the tumor - Benign, active lesions

17. Surgical treatment 3.Wide resection: - Surgical borders contain surrounding healthy tissue - Benign, agressive lesions; malignant low grade lesions 4.Radical resection: - Tumor resection with whole compartment contents - Malignant high grade lesions 5. Amputation

18. Adjuvanttherapies • Chemotheraphy • Neoadjuvant (8-12 weeks) • Adjuvant (6-12 months) • Radiotheraphy • Local adjuvants: • Fenol, hydrogen peroxid, liquid nytrogene, bone cement, alcohol, coterisation, hot water (80°C)

19. BENIGN BONE TUMORS

20. Osteochondroma

21. Enchondroma

22. Enchondroma • Ollier disease • Maffuci syndr.

23. Osteoid osteoma

24. Osteoblastoma

25. GiantCellTumor(Osteoklastoma)

26. Chondroblastoma

27. Benign bone tumors • Osteochondroma • Multiple herediter osteochondromatisis • Enchondroma • Osteoid osteoma • Osteoblastoma • Giant cell tumor • Chondroblastoma

28. TUMOR LIKE LESIONS

29. Simple Bone Cyst

30. Aneurysmal Bone Cyst

31. Eosinophilicgranuloma

32. Fibrouscorticaldefect (Non-ossifyingfibroma)

33. Fibrousdysplasia mlgn 5 yıl sonra

34. Tumorlikelesions • Simple bone cyst • Aneurysmal bone cyst • Eosinophilic granuloma • Fibrous cortical defect (Non-ossifying fibroma) • Fibrous dysplasia

35. MALIGNANT BONE TUMORS

36. Osteosarcoma Birkaç ay sonra

37. Chondrosarcoma

38. Ewing’ssarcoma

39. Multiple myeloma

40. Chordoma

41. Malignant Bone Tumors • Osteosarcoma • Chondrosarcoma • Ewing’s sarcoma • Multiple myeloma • Chordoma

42. METASTATIC BONE TUMORS

43. Metastatic Bone Tumors • Most common malignancy of the skeleton • Pain (most common), limitation of movement, pathologic fracture, spinal cord compression, hypercalcemia • Breast most common in woman, prostate and lung most common in man

44. Metastatic Bone Tumors • Spreading; • Direct • Indirect • Lenfogenous • Hematogenous • Location of metastasis; - vertebra % 69 - pelvis %41 - femur % 25 - cranium %14 Batson venous plexus

45. Breast met. Kidney met. Prostat met. Prostate met. ob ol Lung met.

46. Metastatic Bone Tumors • Diagnosis; • Bone scintigraphy (Tecnesium 99m) • Radiographs • Computarised tomography (CT) • MRI • PET-CT (F-18 PET) • Biopsy Standart methods

47. Metastatic Bone Tumors • Treatment • Chemotherapy • Radiotherapy • Tumor excision ? • Limb salvage surgery • Preventive surgery for pathologic fracture

48. ThankYou …