Brief revision regarding orthopaedic bone tumours principles, classification and Management priniciples

1. Dr Ranjith Kumar Yalamanchili
MS(Ortho)

2. Introduction :
• Neoplasia : It is defined as a mass of tissue
formed as result of abnormal, excessive,
uncoordinated, autonomous and purposeless
proliferation of cells.
• Term Neoplasia includes both Benign and
Malignant.

3. History :
• Gross in 1879 presented a paper on sarcoma of long bones
where he has clearly mentioned amputation as the
treatment of choice.
• Codman in 1926 provided statistical proof of prognosis of
musculoskeletal tumours
• Blood Good in 1928 recommended resection and bone
transplantation in order to restore function. He is
considered as father of limb sparing surgery.
• In 1930 Radiotherapy came in to light for treatment of
metastasis and primary musculoskeletal tumours
• Coley in 1936 attempted chemotherapy using
streptococcus pyogenes which he called as TOXIN THERAPY.
• Moore and Bohlman in 1943 introduced Ëndoprosthesis in
treating GCT of femur.

4. FEATURES BENIGN (DIFFERENTIATED) MALIGNANT (UNDIFFERENTIATED)
MACROSCOPIC FEATURES
Boundaries Encapsulated or well
circumscribed
Poorly circumscribed and irregular
Surrounding tissue Often compressed Usually invaded
Secondary Changes Occur less often Occur more often
MICROSCOPIC FEATURES
Pattern Usually resemble tissue of origin No resemblance
Nucleo – Cytoplasmic
Ratio
Normal Increased
Pleomorphism Absent usually Often present
Anisonucleosis Absent Generally present
Hyperchromatism Absent Often present
Growth Rate
Usually Slow Rapid
Metastasis Absent Frequently Present
Contrasting Differences between Benign and Malignant Tumours

5. Routes of Metastasis :
• Haematogenous Spread : Most common spread in
musculoskeletal tumours
• Lymphatic Spread – rare in musculoskeletal tumours.
• Seen in Rhabdomyosarcoma, Synovial sarcoma, Malignant
fibrous histiocytoma .
• Direct Implantation :
– Through surgeons scalpel, needles, sutures, FNAC, diagnostic or
excision biopsy
• Spread through Cerebro Spinal Fluid :
– malignant tumours of ependyma and leptomeninges rarely
spread through CSF to vertebrae.

6. Classification of Tumours
1. WHO Classification :
widely accepted and is based on histogenesis
and histological criteria.
2. Classification based on origin of tumours
3. Classification based on site of lesions.

7. Modified WHO Classification of BONE TUMOURS **
** www.springer.de.catalog/nsten/who
• 1. Bone forming tumours :
Benign :
Osteoma
Osteoid Osteoma
Osteoblastoma
Intermediate
Aggressive
Osteoblastoma
Malignant
Osteosarcoma
Conventional osteosarcoma
Telangiectatic osteosarcoma
Juxta cortical or Parosteal
Osteosarcoma
Periosteal Osteosarcoma

8. 2. Cartilage forming Tumours
• BENIGN :
• Chondroma
• Enchondroma
• Osteochondroma
• Chondroblastoma
• Chondromyxoid fibroma
• MALIGNANT :
• Chondrosarcoma
• Juxtacortical
chondrosarcoma
• Mesenchymal
chondrosarcoma
• Clear cell
chondrosarcoma
• De differentiated
chondrosarcoma
• Malignant
chondroblastoma

9. 3. Giant Cell Tumours :
– Osteoclastoma
– Malignant giant cell tumour
– Giant cell tumour in Pagets disease
– GCT occurring in non epithelial region
– Giant cell variants : tumors which histologically show the osteoclastic giant cells
1 - aneurysmal bone cyst
2- osteoclastoma
3- chondroblastoma
4- unicameral bone cyst
5- chondromyxoid fibroma
6- non osteogenic fibroma
7- fibrous dysplasia
8- brown tumor of hyperparathyroidism .

10. 4. Marrow tumours
•Ewing sarcoma
•Reticulosarcoma
•Lymphosarcoma
•Myeloma

11. 5. Vascular Tumours
–Benign :
» Haemangioma
» Lymphangioma
» Glomus Tumour
–Intermediate or inderminate variant :
» Haemangio endothelioma
» Hemangio pericytoma
–Malignant :
» Angiosarcoma
» Malignant haemangio pericytoma

12. 6. Other Connective tissue tumours
• Benign :
» Benign fibrous histiocytoma
» Lipoma
• Intermediate :
» Desmoplastic fibroma
• Malignant :
» Fibrosarcoma
» Liposarcoma
» Malignant mesenchymoma
» Malignant fibrous histiocytoma
» Leiomyosarcoma
» Undifferentiated sarcoma

13. 7. Other Tumours
• Chordoma
• Adamantinoma
• Neurilemmoma
• Neurofibroma
8. Unclassified Tumours

14. 9. Tumour Like Lesions
• Solitary Bone cysts
• Aneurysmal bone cyst
• Juxta articular bone cyst (Intra osseous ganglion)
• Metaphilic fibrous defect ( non ossifying fibroma)
• Eosinophilic granuloma
• Fibrous dysplasia
• Myositis ossificans
• Brown Tumour or hyperparathyroidism
• Intraosseous epidermoid cyst
• Gaint cell granuloma

15. Classification based on origin of tumours
1. Primary Bone tumours : Derived from bone
2. Metastatic bone Tumours : Due to Mets from :
–Breast Lytic + Blastic lesions
-Kidney Lytic
–Prostate Blastic
- Adrenal Lytic
–Thyroid Lytic
- Intenstine Lytic
- Lung, Liver Lytic
- Urinary Bladder, Uterine Cervix Lytic lesions
3. Tumour Like Lesions : Non neoplastic Conditions that resemble
tumours. Eg : Solitary Bone cyst, Aneurysmal Bone cyst, Fibrous
Dysplasia, Brown`s tumour.

16. Classification based on origin of tumours
1. Primary Bone tumours : Derived from bone
2. Metastatic bone Tumours : Due to Mets from :
B –Breast Lytic + Blastic lesions
K -Kidney Lytic
P –Prostate Blastic
A- Adrenal Lytic
T –Thyroid Lytic
I- Intenstine Lytic
L- Lung, Liver Lytic
University - Urinary Bladder, Uterine Cervix Lytic lesions
• {Mnemonic : B.K.PATIL University}
3.

17. Classification based on site of Origin
1. Epiphyseal
Osteoclastoma, Chondroblastoma
2. Metaphyseal
Osteioid osteoma, Osteochondroma,
Osteoblastoma, Bone cysts, Osteogenic Sarcoma
3. Diaphyseal
Ewing`s sarcoma, Multiple myeloma,

18. General Concepts in Tumour Terminology
• True Capsule :
• Surrounds a benign lesion and is composed of
compressed normal cells and mature fibrous tissue.
• Pseudocapsule :
• Compressed tumour cells.
• Fibrovascular zone of reactive tissue with an
inflamamtory component that interdigitates with normal
tissue and contains satellite lesions.

19. • Compartment :
It refers to bone or muscle of origin;
– For Muscle, compartment is that within its Fascia.
– For Bone :
• Intracompartmental implies Bone tumour within the
cortex
• Extracompartmental implies a bone tumour that
destroys the cortex and spreads in to the surrouding
tissue.

20. • Skip Metastasis :
• A skip metastasis, is defined as a tumor nodule that is
located within the same bone as the main tumor or on the
opposing side of joint but not in continuity with it.
• High grade sarcomas have the ability to break through
the pseudo capsule and metastasize within the same
compartment.
– MRI Scan better identifies them.

21. Satellite lesion
Tumour nodule
within reactive zone.
Intra Osseous Skip Mets :
Embolization of tumour
cells within the marrow
sinusoids.
Transarticular Skip Mets :
Occur via periarticular
venous anastamosis – Very
poor prognosis

22. GRADING and STAGING of TUMOURS
• To determine prognosis and choice of treatment.
GRADING :
• It is defined as macroscopic and microscopic degree of
differentiation of tumour
• BORDER`s GRADING :
– GRADE I : Well differentiated; <25% Anaplastic cells
– GRADE II : Moderately Differentiated; 25-50% Anaplastic cells
– GRADE III : Moderately differentiated; 50-75% Anaplastic cells
– GRADE IV: Poorly differentiated; >75% Anaplastic cells

23. Enneking`s Grading of Tumours
• G0 Histologically benign
(well differentiated and low cell to matrix ratio)
• G1 Low grade malignant
– (few mitoses, moderate differentiation and local spread
only); Have low risk of metastases
• G2 High grade malignancy
– (frequent mitoses, poorly differentiated); High risk of
metastases

24. STAGING OF TUMOURS :
• STAGING is defined as extent of spread of tumour.
– It is determined by clinical examination, Investigations and
pathological studies.
– Common staging systems are
1. ENNEKING `S STAGING SYSTEM
2. AJCC SYSTEM
3. TNM STAGING ( Union International Cancer centre Geneva
Staging System )

25. ENNEKING`s STAGING OF BENIGN
TUMOURS
1. Latent—low biological activity; well marginated;
often incidental findings (i.e., nonossifying
fibroma)
2. Active—symptomatic; limited bone destruction; may
present with pathological fracture (i.e., aneurysmal
bone cyst)
3. Aggressive—aggressive; bone destruction/soft tissue
extension; do not respect natural barriers (i.e., giant
cell tumor)

26. • GTM classification described by Enneking is
adopted by Musculoskeletal Tumour society
and is based on surgical grading (G), location
(T), lymphnode involvement & metastasis (M)
Enneking`s :staging of malignant tumours
STAGE GRADE SITE
I A Low – G1 Intracompartmental T1
I B Low – G1 Extracompartmental T2
II A High G2 Intracompartmental T1
II B High G2 Extracompartmental T2
III A Any grade with regional or distal
Metastases
Intracompartmental T1
III B Any grade with regional or distal
Metastases
Extracompartmental T2

27. American joint committee on cancer system bone
sarcoma classification (AJCC Classification)
The AJCC system for bone sarcomas is based on tumor grade, size, and presence and
location of metastases.

29. TNM STAGING (Union International Cancer
centre Geneva Staging System)
• T – Primary Tumour – T0 to T4
– In Situ lesion T0 to largest and most extensive T4 primary
tumour
• N – Nodal involvement – N0 to N3
– No lymph nodes involvement N0 to wide spread nodal
involvement N3
• M – Metastasis – M0 to M2
– No Metastasis M0 to distant metastasis M2

30. CLINICAL PRESENTATION :
• Pain :
– Initially may be activity related, but in case of malignancy
there could be progressive pain at rest and at night.
– In benign tumours, pain may be activity related when it is
large enough to compress surrounding soft tissue or when
it weakens bone.
– A benign Osteioid osteoma may cause night pain initially
that classically gets relieved with Aspirin.

31. • In case of soft tissue sarcomas patients may come
with mass rather than pain but in some exceptions
like nerve sheath tumours, they have pain and
neurological conditions.
• Age : It is the most important denominator
because most musculoskeletal tumours occur within
specific age ranges.
• Sex : Very few tumours show sex prediliction.
• Eg GCT is commoner in females.
• Family History : may be present in tumours like
exostosis/ von recklenghausen`s disease.

32. INVESTIGATIONS
Serological investigations :
• 1. Complete Blood Picture :
– Haemoglobin : to rule out anaemia that may be due to
replacement of bone marrow by neoplastic process.
– ESR : raised in mets, Ewing`s sarcoma, lymphoma,
leukemias
• 2. Increased prostate specific antigens with
prostatic acid phosphatase levels in a case of
blastic lesions of x ray is the diganostic of Mets
secondary to Prostate Carcinoma

33.  3. Serum alkaline phosphatase (ALP)
 Biological marker of tumour activity.
 Increases significantly when tumour and metastasis are
highly osteogenic.
 ALP levels decline after Surgical removal of primary
tumour and elevates if metastasis aggravates.
 Good prognostic tool.
• Increased in following conditions: -
– Osteoblastic bone tumors (metastatic or osteogenic sarcoma)
– 5-Nucleotidase and GGT ( Gamma glutamyl Trasferase ) are elevated
in liver pathology along with Alkaline phosphatase, where as in bone
pathologies only ALP is increased.

34.  4. Antisarcoma Antibodies :
 Monoclonal antibodies can be detected by
immunohistochemical assays.
 Antibodies binding to sarcoma cell surface antigens
have specificity.
 5. Osteocalcin – A : Helpful in diagnosing heavily bone
producing types of tumours.
 6. Serum Calcium : Hypercalcemia is often due to Mets,
Myeloma, Hyperparathyroidism.
 7. Abnormal Serum protein electrophoresis along with
bence jones proteins in urine is classical of Multiple
myeloma

35. Flow Cytometry
• A sample of cells are treated with special antibodies
that stick to the cells only if certain substances are
present on their surfaces.
• The cells are then passed in front of a laser beam. If
the cells now have antibodies attached to them, the
laser will cause them to give off light, which can be
measured and analyzed by a computer.
• Flow cytometry can help determine type of those
abnormal cells and help in diagnosing a tumour early.

36. INVESTIGATIONS: RADIOGRAPHS
• Phemister's Law = the most common site of
infection & tumours is the fastest growing site
of the long bone
• To see a lucent lesion in bone, an estimated 30
to 50 % of the bone must first be lost
[Harris & Heaney, N Engl J Med 1969]

37. Radiographic Evaluation
• Five important parameters in evaluating a
tumour on a X RAY are
1. Anatomic site
2. Borders
3. Bone destruction
4. New Matrix ( Bone) formation
5. Periosteal reaction

38. A. Anatomic Sites – X ray
• Anatomic site Specific anatomic sites of the
bone give rise to specific groups of lesions.

40. Characteristic Locations
• Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior

41. Characteristic Locations
• Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior

42. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior
Characteristic Locations

43. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine, posterior
Characteristic Locations

44. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, Pelvis
• Osteoblastoma
Spine, posterior
Characteristic Locations

45. • Simple bone cyst
Proximal humerus
• Chondroblastoma
Epiphyses
• Giant Cell tumor
Epiphyses
• Adamantinoma
Tibia
• Chordoma
Sacrum, clivus
• Osteoblastoma
Spine - posterior
elements
Characteristic Locations

47. B. Borders
• The border reflects the growth rate and the response of the
adjacent normal bone to the tumor.
• Most tumors have a characteristic border
• Benign lesions (e.g., nonossifying fibromas and unicameral bone
cysts) have well-defined borders and a narrow transition area that
is often associated with a reactive sclerosis.
• Aggressive or benign tumors (e.g., chondroblastoma and GCTs)
tend to have faint borders and wide zones of transition with very
little sclerosis, reflecting a faster-growing lesion.
• Poorly delineated or absent margins indicate an aggressive or
malignant lesion

48. C. Bone destruction
• Bone destruction is the hallmark of a bone
tumor.
• Three patterns of bone destruction are
described
1. Geographic,
2. Moth-eaten,
3. Permeative.

49. Geographic Bone Destruction
Complete destruction
of bone from
boundary to normal
bone
• Non-ossifying fibroma
• Chondromyxoid
fibroma
• Eosinophilic
granuloma
Non-ossifying fibroma

50. Moth-eaten Bone Destruction
• Areas of destruction with
ragged borders
• Implies more rapid growth
• Probably a malignancy
Examples:
• Myeloma
• Metastases
• Lymphoma
• Ewing’s sarcoma
Multiple Myeloma

51. Permeative Bone Destruction
• Ill-defined lesion with multiple “worm-holes”
• Spreads through marrow space
• Wide transition zone
• Implies an aggressive malignancy
• Round-cell lesions

52. Examples:
• Lymphoma, leukemia
• Ewing’s Sarcoma
• Myeloma
• Osteomyelitis
• Neuroblastoma
Permeative Bone Destruction
Leukemia

53. Patterns of Bone Destruction
Geographic Moth-eaten Permeative
Less malignant More malignant

54. D. Matrix formation
• Calcification of the matrix, or new bone formation,
may produce an area of increased density within the
lesion.
• Calcification typically appears as flocculent or
stippled rings or clusters.
• The appearance of the new bone varies from dense
sclerosis that obliterates all evidence of normal
trabeculae to small, irregular, circumscribed masses
described as "wool" or "clouds."

55. • Calcification and ossification may appear in
the same lesion.
• Neither type of matrix formation is diagnostic
of malignancy.

56. Tumor Matrix
• Osteoblastic
– Fluffy, cotton-
like or cloud-
like densities
– Osteosarcoma

57. Cartilaginous :
– Comma-shaped,
punctate, annular,
popcorn-like
as Enchondroma,
chondrosarcoma,
chondromyxoid
fibroma
Tumor Matrix
Chondrosarcoma

58. Expansile Lesions of Bone
Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia

59. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone
Renal cell carcinoma

60. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone

61. Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
Expansile Lesions of Bone

62. E. Periosteal reaction
• Periosteal reaction is indicative of malignancy
but not pathognomonic of a particular tumor.
• Any widening or irregularity of bone contour
may be regarded as periosteal activity.

63. Solid Periosteal Reactions
Chronic osteomyelitis
• Single solid layer or multiple
closely apposed and fused
layers of new bone attached
to the outer surface of
cortex resulting in cortical
thickening.
• It is uniterrupted or
continous.

64. Types of Solid Periosteal Reaction
• 1. SOLID BUTRESS
• Seen in Aneurysmal bone cyst, chondromyxoid fibroma
• 2. Solid smooth or Elleptical layer
• Seen in Osteoid osteoma and osteoblastoma
• 3. Undulating type :
• Seen in long standing varicosities, periosteitis, chronic
lymphaoedema.
• 4. Single lamellar reaction :
• Seen in Osteomyelitis, Stress Fractures, Langerhans cell
histiocytosis.

65. Interupted Periosteal Reactions
• Commonly seen in
Aggressive/malignant
tumours.
– onion-peel ( lamellated)
– Ewings sarcoma
– Gouchers disease
– Sunburst
– Codman’s triangle
Ewing sarcoma

66. – Sunburst TYPE OF periosteal
reaction :
Fine lines of increased
density representing newly
formed specules of
bone radiate laterally from and
at right angles to
the surface of the shaft giving a
typical
sun ray appearance.
Osteo-sarcoma

67. Codman’s triangle :
– When the tumour breaks
through the cortex and
destroys the newly formed
lamellated bone, the remnants
of the latter on both ends of
the break through area may
remain as a triangular structure
known as codman triangle.
Also seen in Osteosarcoma,
Ewings sarcoma,
Chronic Osteomyelitis
Osteo-sarcoma

68. Periosteal Reactions
Solid onion-peelSunburst Codman’s
triangle
Less malignant More malignant

69. Radiographic Features in a Benign vs.
Malignant

70. Clues by density of lesions
Sclerotic Cortical Lesions
• Osteoid osteoma
• Brodie’s abscess

71. • Osteoid osteoma
• Brodie’s abscess
Sclerotic Cortical Lesions

72. Mnemonic for Luscent bone lesions =
FOGMACHINES
Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumour
Metastasis/ Myeloma
Aneurysmal Bone Cyst
Chondroblastoma/ Chondromyxoid Fibroma
Hyperparathyroidism (brown tumour)/
Haemangioma
Infection
Non-ossifying Fibroma
Eosinophilic Granuloma/ Enchondroma
Simple Bone Cyst

73. • Metastatic lesions
– Lung
– Renal
– Thyroid
• Multiple myeloma
• Primary bone tumor
Lytic Lesions in Adults

74. • Metastatic lesions
– Lung
– Renal
– Thyroid
• Multiple myeloma
• Primary bone tumor
Chondrosarcoma
Lytic Lesions in Adults

75. • Lymphoma
Blastic Lesions in Children

76. • Metastatic disease
• Breast –female
• Prostate –male
• Lymphoma
• Paget’s disease
• Fluorosis
Prostatic Ca.
Blastic Lesions in Adults

77. • Metastatic disease
• Breast –female
• Prostate –male
• Lymphoma
• Paget’s disease
• Fluorosis
Blastic Lesions in Adults

78. • Metastatic disease
• Breast –female
• Prostate –male
• Lymphoma
• Paget’s disease
• Fluorosis
Blastic Lesions in Adults

79. Sled runner tracks in
Olliers disease
Mafuccis syndrome – olliers +
multiple angiomas

80. Jail house pattern seen in
Haemangioma on X Rays
thickened, vertically
oriented trabeculae
Polka dot pattern is
seen in cross sections
of CT scan.

81. • It delineates intra and extra
osseous extent of tumour.
• It can reliably distinguish
between infection and tumor.
• CT scan identifies accurately area of cortical break through, soft
tissue extension, medullary spread and proximity of the tumour to
neurovascular bundle and evaluating integrity of cortex
• To differentiate solid and cystic lesions.
• Most sensitive investigation to detect Pulmonary mets.
CT scan:-

82. • Best imaging
– to localise the nidus of an osteiod osteoma,
– to detect a thin rim of reactive bone around an aneurysmal bone cyst,
– to evluate calcification in a suspected cartilagenous lesion and
– to evaluate endosteal cortical erosion in a suspected chodrosarcoma.
• To differentiate between the neoplastic mass and inflammatory
condition : Neoplastic masses displace soft tissue fat planes
where as they are obliterated in inflammatory conditions.
• It cannot differentiate benign from malignant tumours
accurately.
• Except in detecting pulmonary mets, Contrast CT is better than
plain CT.

83. • It has better contrast
discrimination than any other
modality.
• Helps in detecting skip lesions
• Assesses the tumor relationship
with adjacent soft tissue, joints
and blood vessels.
• It can visualize bone marrow
content and demonstrate
intramedullary extension of
neoplasm.
MRI:-

84. • It is the investigation of choice in local staging of
musculoskeletal tumours.
• On MRI, it is not possible to accurately
differentiate benign from malignant tumours. But
if the following criteria are present, lesion can be
considered as a malignant one :
– 1. Mass with irregular Border
– 2. Non homogenous signal intensity with extra
compartmental extension
– 3. Peri tumoral edematous reaction.
– 4. Soft tissue mass situated deep to fascia and
measuring more than 5 cm in greatest diameter is likely
to be a sarcoma.

85. • It uses radioactive glucose to locate cancer by observing high
glycolysis rates in a malignant tissue metabolism.
• This glucose contains a radioactive atom that is absorbed by the
cancerous cells and then detected by a special receptacle.
• It has low specificity as the FDG ( Fluoro labelled deoxy
glucose) can also accumulate in benign aggressive and
inflammatory lesions.
• Also helpful in evaluating the tumour after chemotherapy.
• Micromets are better visulaised.
PET- Positron Emission
Tomography

86. Most reliable means of determining vascular anatomy.
• Reactive zone is best seen on early arterial phase,
while the intrinsic vascularity is best seen on late
venous phase as a tumour blush.
• Transcatheter embolisation is done as a definitive
treatment in some benign vascular tumours.
Angiography :

87. Angiography demonstrating
vascularity of a tumour
Embolization of a vascular
lesion, performed at least 6
hours
prior to surgery, is expected
to significantly reduce
intraoperative blood loss.

88. • Technetium (99mTC) bone scans are used.
• It is an indicator for mineral turnover.
• Whenever there is altered local metabolism in remodeling bone,
increased vascularity or mineralization , the isotope uptake is
enhanced mainly in reactive zone surrounding the lesions.
• Confirms epiphyseal spread of tumour.
• Helps in detecting multiple lesions like multiple
osteochondroma, enchondroma.
• Where as a MRI helps in detecting skip lesions
Nuclear Imaging -Bone scan Scinitigraphy :

89. Bone scan showing HOT
SPOTS over proximal
humerus and ribs
It detects the presence of
skeletal metastasis and
delineates it from primary
else where in the body.

90. • Bone scinitigraphy tends to show larger area of
extension of medullary involvement of tumour
as the radio active agent also localises the area
of hyperemia and edema adjacent to tumour.
• Nuclear imaging is advantageous only to
identifying whether skeletal involvement is
solitary or multiple.

91. • Not routinely used in diagnosis of sarcoma; as it
better differentiates only bony cystic lesions.
• However Ultrasound is used in guided
percutaneous biopsy.
• In patients treated with prosthetic implants, USG
is the modality that depicts early recurrence as
MRI produces blurred and artifact images due to
metallic implants.
Ultrasound:

92.  Used for definitive diagnosis.
• Principles of biopsy:
 Opted only after all other investigations are performed.
 A biopsy can be done by FNAC, core needle biopsy, or an
open incisional procedure.
 FNAC may be 90% accurate at determining malignancy;
however, its accuracy at determining specific tumor type is
much lower.
– Trephine or core biopsy is recommended and often yields
an adequate sample for diagnosis.
– Complications are greater with incisional biopsy; but least
likely to be associated with a sampling error, and provides
the sample for additional diagnostic studies, such as
cytogenetics and flow cytometry.
Biopsy

93. – Core biopsy is preferred if limb spraying is an option as it entails
less contamination than open biopsy.
– A small incisional biopsy can be performed if core biopsy
specimen is inadequate.
– Performed under torniquet (possibly) - the limb may be elevated
before inflation but should not be exsanguinated by compression
bandage.
 Longitudinal incisions preferred as transverse excision are
extremely difficult or impossible to excise with the specimen.
 NV bundle not exposed. Dissection through muscle (not
between) to prevent contamination of tumour.

94.  Approach for open biopsy is made through region of definitive
surgical excision. If a drain is used, it should exit in line with
the incision so that the drain track also can be easily excised en
bloc with the tumor. Wound is closed tightly in layers.
 Meticulous haemostasis is arrested by use of bone wax/ Poly
Methyl Metha Acrylate(PMMA) to plug the cortical window.
 Always sample the tissues from periphery of lesion which
contains most viable tissue.
 Never biopsy a periosteal reaction / codmans traingle as it
contains a new reactive bone and could be false negative.

95. • If hole must be made in bone during biopsy, defect should be
round or oval to minimize stress concentration, which
otherwise could lead to pathological fracture.
•Torsional strength is not affected by length of defect. Always
attempt to keep defects less than 10% of bone diameter.
•When biopsy size is greater than 20% of bone diameter, torsional
strength decreases to 50%.

96. Examples of poorly performed biopsies
Biopsy resulted in irregular defect in bone, which led to pathological
fracture

97. Examples of poorly performed
biopsies
Transverse incisions
should not be used
Needle biopsy track
contaminated patellar
tendon
Multiple needle
tracks contaminate
quadriceps tendon

98. Drain site was not placed in line with
incision
Needle track placed posteriorly,
location that would be extremely
difficult to resect en bloc with
tumor if it had proved to be
sarcoma

99. • Biopsy should be done only after clinical, laboratory,
and radiographic examinations are complete.
• Completion of the evaluation before biopsy aids in
planning the placement of the biopsy incision, helps
provide more information leading to a more accurate
pathological diagnosis, and avoids artifacts on
imaging studies.
• If the results of the evaluation suggest that a primary
malignancy is in the differential diagnosis, Biopsy is
not done unless it is possible to operate the case in the
centre.

100. Criteria for prophylactic fixation of
metastatic tumours of long bones
• Surgical Fixation should not be proceeded until
primary neoplasm of bone has been ruled out with
biopsy.
• Goals of fixation
– maximize ability for immediate mobilization and weight-
bearing
– protect the entire bone in setting of systemic or metastatic
disease
• Type of fixation depends on location of lesion and type
of disease
– eg. femur
• cephalomedullary nailing for peritrochanteric lesions
• hemiarthroplasty for femoral neck and head lesions

101. Harington's criteria
of prophylactic fixation
• > 50% destruction of diaphyseal cortices
• > 50-75% destruction of metaphysis (> 2.5 cm)
• Permeative destruction of the subtrochanteric
femoral region
• Persistent pain following irradiation

102. Mirel`s criteria of fixation

103. General principles &Technique for En Bloc
Tumour excision
Tourniquet
– For fear of embolic expression, exsanguinations of
the extremity is not adviced, instead the limb is
raised for 10 minutes prior to applying the
tourniquet.

104. Advantages of Tourniquet
• Prevention of tumour embolisation
• Ease of distinguishing neoplastic tissue from
normal tissue
• Hemostasis of neovasculature
• Quicker surgery
• More precise resection
• No enormous blood transfusion

105. Incision
• A long vertical incision well above and below the
visible limits of the tumour.
• Incision should include the biopsy scar and drain exit
tract in an elliptical fashion.
• The plane should be developed through the normal
tissues keeping a certain amount of normal tissue
surrounding the tumour.
• The main vessel and nerve involvement in tumour
mass should be judged and cleared well away from
the tumour. If their seperation causes one to enter the
reactive zone, this does not become an ideal resection

106. Wound contamination
• Incidence of recurrence is approximately doubled in
case of a wound contamination due to the malignant
tissue.
• If contaminated the two options for a surgeon are :
– To give up the procedure and consider amputation and
– To meticuously wash the wound to the same fashion as is
done for a compound fracture and then proceed with a
planned resection.

107. • Curettage resection and restoration of function by
limb salvage procedures or amputation is primary
form of surgical correction.
• Based on surgical plane of dissection in relation to
tumour, Enneking formulated following types of
resection.
1) Intralesional Resection
2) Marginal resection
3) Wide (Intracompartmental) resection
4) Radical (Extracompartmental) resection
SURGICAL OPTIONS

108. • An intralesional margin is one in which the plane of surgical
dissection is within the tumor.
• This type of procedure is often described as “debulking”
because it leaves behind gross residual tumor.
• This procedure may be appropriate for symptomatic benign
lesions when the only surgical alternative would be to sacrifice
important anatomical structures.
• This also may be appropriate as a palliative procedure in the
setting of metastatic disease.
1) Intralesional Resection :

109. • As musculoskeletal tumors grow, they
compress the surrounding tissues and appear to
become encapsulated.
• This surrounding reactive tissue often is
referred to as the pseudocapsule.
• Intralesional resection is through the
psuedocapsule of the tumor directly in to the
lesion. Macroscopic tumour is left behind.
Curettage is intralesional proceedure.

110. CURETTAGE
• Cortical window with rounded margins is made
• When possible, the window is sized larger than
the tumour so that the entire tumour is readily
seen.
• The rounded margins reduce the risk of
subsequent fracture.
• Large curetts should be used to remove the
lesional tissue.

111. Curettage
• Tumour margin should be treated with
cryotherapy, PMMA cementage or phenol –
alcohol cauterisation, argon beam coagulation
in case of aggressive tumours.
• If curettage weakens the bone, graft using
allograft or autograft with or with out internal
fixation is indicated.

112. • A marginal margin is achieved when the closest plane of dissection
passes through the pseudocapsule.
• This type of margin usually is adequate to treat most benign lesions
and some low-grade malignancies.
• In high-grade malignancy, however, the pseudocapsule often
contains microscopic foci of disease, or “satellite” lesions.
• A marginal resection often leaves behind microscopic disease that
may lead to local recurrence if the remaining tumor cells
do not respond to adjuvant chemotherapy or radiation
therapy.
2) Marginal Resection :

113. • Despite an increased risk of local recurrence, a marginal
resection may be preferable if the alternative is a more
mutilating procedure.
• Improvements in preoperative radiation therapy and
neoadjuvant chemotherapy have made marginal
resections an acceptable alternative to amputation in some
selective circumstances.
• In Marginal resection, dissection passes through the
pseudo capsule & reactive zone. Entire structure of origin of
tumour is not removed. A margin of atleast 5-7 cm above and below
limit of increased bone activity of bone scan is removed.

114. • Intracompartmental
• Wide margins are achieved when the plane of dissection is in
normal tissue.
• Although no specific distance is defined, the Resection
includes removal of entire tumour, + Reactive zone & cuff
of normal tissue.
• If the plane of dissection touches the pseudocapsule at any
point, the margin should be defined as being marginal and not
wide.
• Although sometimes impossible to achieve, wide margins are
the goal of most procedures for high-grade malignancies.
3) Wide Resection :

115. 4] Radical :-
Extracompatmental:
Radical margins are achieved when all the compartments that
contain entire tumor and structure or origin of lesion are
removed en bloc.
The plane of dissection is beyond the limiting fascial & bone
borders.
For deep soft-tissue tumors, this involves removing the entire
compartment (or multiple compartments) of any involved
muscles.

116. For bone tumors, this involves removing the entire
bone and the compartments of any involved muscles.
 Radical operations were previously the procedures
of choice for most high-grade neoplasms;
However, with improvements in imaging studies,
radical procedures now are rarely performed because
equivalent oncological results usually can be obtained
with wide margins .

117. ENNEKING`s Classification of Surgical
Procedures for Bone Tumors
Margin Local (Mode of
resection)
LIMB SALVAGE
OPTIONS
Amputation(Mode of
amputation)
Intralesional Curettage or
debulking
Debulking amputation
Marginal Marginal excision Marginal amputation
Wide Wide local excision Wide through bone,
amputation
Radical Radical local
resection
Radical disarticulation

118. Enneking`s
Classification of
Resection of
tumours.

119. 1] Limb Salvage Proceedures
2] Amputations
SURGICAL OPTIONS:

120. • It is designed to accomplish removal of a malignant tumour &
reconstruction of the limb with an acceptable oncologic, functional
& cosmetic result.
• It is sub amputative wide resection with preservation of the limb &
its function.
 Indications :
 Stage IA Stage IIA & Stage IIIA (All intracompartmental
tumours)with good response to pre-operative chemotherapy
 Skin should be uninvolved and free
 There should be feasibility of keeping a cuff of normal tissue
surrounding the tumour
 Upper extremity lesions are more suitable for limb sparing surgery
 Tumours with good pre-operative chemotherapy response
Limb salvage procedures

121. Advantages of limb salvage proceedures :
• long term survival rates of patients have improved from
approximately 20% to 70%.
• The function of the salvaged limb is better than that of the
amputation but not normal function.
Limb salvage procedures vs Amputation

122. Disadvantages of limb salvage proceedures:
 Limb salvage is more extensive procedure with greater
risk of infection, wound dehiscence, flap necrosis,
blood loss & DVT.
 More chances to undergo multiple future operations
for the treatment of complications.
 After initial salvage upto 33% of long term survivors
may ultimately require an amputation.
Limb salvage procedures vs Amputation

123. Guidelines:
 No major neurovascular tumour involvement.
 Wide resection of the affected bone with normal
muscle cuff in all directions.
 Enbloc removal of all previous biopsy sites & all
potentially contaminated tissues.
 Resection of bone 3-4 cms beyond abnormal uptake
as determined by CT /MRI /BONE SCAN.
 Resection of the adjacent joint & capsule
 Adequate motor reconstruction &soft tissue
coverage.
Limb salvage procedures

124. 1. Major neurovascular involvement.
2. Pathological fractures spread tumour cells through fracture
hematoma increasing risk of recurrence.
3. Inappropriate biopsy sites contaminate normal tissue planes and
jeopardizes local tumour control.
4. Infection flares with metallic implants and thereby
jeopardises effect of chemotherapy..
5. Skeletal immaturity : Predicted limb length discrepency should not
be >6-8cm. In such cases expandable prosthesis be used. Upper limb
reconstruction is independent of skeletal maturity.
6. Extensive muscle involvement.
Contraindications: Limb salvage procedures

125. 1. Resection of the tumour
To avoid local recurrence.
2. Skeletal reconstruction
Technique of reconstruction is independent of resection.
3. Soft tissue & muscle transfers.
To cover and close resection site and to restore motor power.
Distal tissue transfers not used for possibility of contamination.
Stages of Limb salvage procedures

126. • Reconstruction of bone defect may be done by
1] Osteoarticular allograft reconstruction
2] Allograft-prosthesis composite reconstruction
3] Endoprosthetic reconstruction.
4] Allograft arthrodesis
5} Rotationplasty
6} Turnoplasty
Surgical reconstructive options :

127. • Possibility to replace ligaments, tendons & intraarticular structures
• Osteoarticular allografts may have a role as a temporary measure to
preserve an adjacent physis in an immature patient, when the
alternatives include amputation or sacrifice of both physes.
• A proximal tibial osteoarticular allograft could be used in an immature
patient in an attempt to preserve the distal femoral physis until skeletal
maturity.
• This could be converted later to an endoprosthetic reconstruction when
it becomes necessary
• Complications :-non-union at graft –host junction, fatigue
fracture ,articular collapse, degenerative joint
disease
1. Osteoarticular allograft reconstruction:

128. 2.Allograft-prosthesis composite reconstruction:
Main indication for an allograft-
prosthesis composite is an inadequate
length of remaining host bone to secure
the stem of an endoprosthesis. Tumor
prosthesis is used for reconstruction
with allograft for fixation to the
remaining host bone.
Case scenario : osteosarcoma of
`proximal humerus.
X ray shows tumor extending down to
distal diaphysis.

129. Intraoperative photograph after wide
resection of tumour.
Humeral allograft is prepared to accept
stem of tumor prosthesis
Allograft is fixed to bone
with medial and lateral
plates.

130. Prosthesis is
cemented into
allograft.
Postoperative
radiograph.

131. • It also provide long-term function for
some patients.
• Endoprosthetic reconstruction provides the
advantage of predictable immediate
stability that allows for quicker
rehabilitation with immediate full weight
bearing.
• Most endoprostheses are modular,
allowing for incremental limb lengthening
as an immature patient grows.
3.Endoprosthetic Reconstruction:

132. • Polyethylene wear is still a limiting factor for
articulating surfaces, but the inserts are easily
replaceable in most prostheses.
• Fatigue fracture can occur at the rotating hinge.
• Fatigue fracture at the base of the intramedullary stem
where it attaches to the body of the prosthesis is more
problematic. In this location, extraction of the
remaining stem can be extremely difficult.

133. 4. Resection Arthrodesis – Ennekings shirney

134. 5. ROTATIONPLASTY :

135. Winkelmann classified ROTATIONPLASTY
into five groups, as follows:
1. Group AI
– Lesion in distal femur.
– The distal femur, knee joint, and
proximal tibia are resected; the lower leg is
rotated 180 degrees; and the tibia is joined to the
remaining femur.
Rotationplasty :

136. • The distalmost femur, knee joint, and proximal tibia
are resected. After rotation of 180 degrees, the distal
tibia is joined to the distal femur.
2. Group AII—Lesion in the proximal tibia.

137. • The upper femur and hip joint are
resected, and the leg is rotated
180 degrees. The distal femur is
joined to the pelvis so that the knee
functions as the hip, and the ankle
functions as the knee.
3. Group BI—Lesion in the proximal femur
sparing the hip joint and gluteal muscles

138. • The upper femur, hip joint,
and lower hemipelvis are
resected, and the leg is rotated
180 degrees.
The remaining femur
is joined to the remnant of the
ilium so that the knee functions
as a hinged hip joint and the
ankle functions as the knee.
4. Group BII—Lesion in the proximal femur with
involvement of hip joint and contiguous soft tissue

139. • The entire femur is resected.
• The tibia is attached to the pelvis using an
endoprosthesis.
5. Group BIII—Lesion in the mid Femur

140. • "TuRN-up PLAsTy" of the tibia refers to the replacement of a femur
by substituting the iniverted tibia and fibula. This procedure has
been utilized to avoid total ablation of a lower extremity and to
provide a thigh stump for a prosthesis.
• A metallic hip prosthesis is used at turned up end of the tibia.
• The first description of the operation was by Sauerbruch in 1922.
His first case was a girl of 13 years with an ununited fracture of the
femur with chronic osteomyelitis and considerable loss of substance
of the shaft in which he did a resection of the femur distal to the
trochanters and attached the distal tibia to it.
6. Turn-up-plasty *** :
*** Anals of Orthopaedic Surgery, Total Resection of Femur with "Turn-up Plasty" of Tibia and Prosthetic
Replacement of Hip Joint; HENRY S. WIEDER, JR., M.D., JESSE T

143. Two types of prosthesis are used:
• 1. modular
• 2. custom made
7. PROSTHETIC ARTHROPLASTY

144. Custom made
prosthesis to
accomodate large
proximal femoral
defects after resection

145. • A tailor- made metallic prosthesis for a particular patient with
specific measurements is called custom prosthesis.
• Designed using 3D computer modeling & CAD – CAM
technologies.( Computer Assisted Designs and computer
assisted manufacturing )
Custom mega prosthesis

146. • For pediatric patients, future limb-length inequality must be
considered.
• For patients who are near skeletal maturity, the reconstructed
limb can be lengthened 1 cm at the initial procedure.
• Also, epiphysiodesis of the contralateral limb can be done at
the appropriate age to preserve limb-length equality (or to
minimize inequality).
• For younger patients, however, other options should be
considered.
• Although amputation and rotationplasty were previously
considered the only reasonable treatments for very young
patients with bone sarcomas, use of expandable prostheses
currently is gaining support.
Paediatric Consideration:

147. • The surgical technique, postoperative course, rehabilitation,
function, and complications for implantation of this device is
similar to that of other endoprostheses .
• The device is unique, however, in that it uses energy stored in
a compressed spring to allow for future expansion of the
prosthesis as the child grows.
Repiphysis Expandable Prosthesis

148. Electromagnetic expansion of
Repiphysis expandable
prosthesis.

149. • Amputation provides definitive surgical treatment when limb
sparing is not a prudent one.
• Common amputations in malignant tumours:
– Proximal humerus : fore quarter amputation
– Distal femur : hip disarticulation
– Proximal tibia : mid thigh amputation
AMPUTATIONS :

150. Ennekings Classification of
Amputations

151. • Levels of
Above knee
amputation :

152. • Adjuvant chemotherapy:
– To treat presumed micrometastasis
• Neo adjuvant[induction]
– Before surgical resection of the primary tumour
Advantages:
– It controls micro metastasis and improves survival rate.
– Chemotherapy makes limb salvage surgery easier.
– Decreases tumor size and vascularity.
– The response to Chemotherapy can be evaluated after
surgery.
Chemotherapy

153. • Here the chemotherapy is intituted after the primary
tumour has been controlled by alternative treatment
such as surgery or radiotherapy.
• The rationale is the microscopic metastatic disease
can be eradicated.
• Majority of the regimen used is High Dose
Methotrexate.
Adjuvant chemotherapy

154. • Chemotherapy that is given before local
resection is considered neoadjuvant
chemotherapy.
• The most common reason for neoadjuvant
therapy is to reduce the size of the tumor so
as to facilitate more effective surgery.
Neoadjuvant therapy

155. Neoadjuvant chemotherapy
Advantages Disadvantages
• Early institution of systemic
therapy against
micrometastases
• Less chance of drug
resistant clones
• Reduces tumour size
sparing limb salvage
chances
• Less chance of spread of
viable tumour during
surgery
• Delays definitive control of
bulk disease and chances
for systemic dissemination.
• Risk of local tumour
progression with loss of
limb sparing option
• Psychological effect of
retaining tumour

156. Adjuvant chemotherapy
Advantages Disadvantages
• Removal of bulk tumour
decreases tumour burden
and increases growth rate
of residual disease making
s-phase specific agents
more active.
• Decreased probability of
selecting drug resistant
clone in primary tumour.
• Dealy of systemic therapy
for micrometastases.
• Possible spread of tumour
by surgical manipulation.
• No preoperative in vivo
assay of cytotoxic response.

157. GRADE EFFECT
I Little or No response of tumour identified
II Areas of necrosis and tumour cells seen.
III Scattered foci of tumour cells seen.
IV No Tumour cells seen.
HUVO`s Histologic grading of effect of preoperative
chemotherapy on primary Bone tumour

158. GRADE EFFECT
I No viable tumour cells
II Single tumour cells or clusters <0.5cm
III Viable tumour cells <10%
IV Viable tumour cells 10-50%
V Viable tumour cells >50%
VI No response
Salzer-Kuntschik `s Histologic grading of effect of preoperative
chemotherapy on primary Bone tumour

159. • With Megavoltage radiotherapy tumor cell can be destroyed.
• High voltages are administered in short sessions.
• Radiation therapy should be started immediately after
diagnosis before surgery to prevent metastasis .
• Chemotherapy increases the susceptibility of tissues to
irradaition.
• Protect all normal tissue biopsy scars to prevent radiation
necrosis.
• Distribute the dose in accordance with distribution of tumor.
RADIOTHERAPY

160. Diagnosis
Neoadjuvant chemotherapy + Radiation
Resection/ surgery Repeat Chemo + Radiation
Adjuvant + irradiation +chemo Histological Grading
Sequence of treatment:

161. Gene therapy in sarcomas :
• Targeting Osteocalcin promoter.
• Osteocalcin is produced both in Osteoblastic[100%]and fibroblastic[70%]
Osteosarcoma.
LIQUID BRACHYTHERAPY :
– Injecting Intra arterial infusion of chemotherapeutic drugs with
brachytherapy
– It is in Phase 2 trials currently.
• Cryotherapy is used in curettage after resection of primary
tumour to prevent chances of recurrence.
• PMMA, Phenol, liquid nitorgen commonly used
cryoprecipitates.
Recent advances

162. Internal or Sealed source chemotherapy.
• Brachy means close/short distance.
• Source is placed near to the target tissue through
multiple catheters placed over tumour bed.
• High dose can be delivered to the target tissue..with
minimal side effects.
Brachy therapy:

163. • A portion of tumour is implanted in to a sarcoma
survivor and removed after 14 days.
• Sensitized lymphocytes from survivors are infused in
to patient. These cells selectively kill the cancer cells.
Immunotherapy

164. Extracorporeal Irradiation
• En-bloc resection, extracorporeal irradiation, and
re-implantation is done in limb salvage for bony
malignancies.
• After en-bloc resection, the segment is wrapped
in a wet sterile drape to minimise air gaps,
placed in two sealed sterile plastic bags and
wrapped in another sterile drape.
• This is delivered for radiotherapy.

165. Extracorporeal Irradiation
• Meanwhile, the operative site is prepared for re-
implantation and marginal biopsies taken.
• On return the specimen is removed from the
inner plastic bag and soaked in iodine solution.
• It is cleared of unnecessary soft tissue leaving
important muscle insertions for re-attachment
and then re-implanted

166. Cementoplasty
• Patients with osteolytic tumours (metastasis, multiple
myeloma, lymphoma) located to the vertebral body,
acetabulum and condyles and causing local pain,
disability and with a risk of compression fracture are
excellent indications.
• Used in cases of palliative care to stabilise the lytic
lesion.
• For vertebroplasty, a 10-G and 15-G beveled needle
(for thoracic/lumbar and cervical level,
respectively) should be used.
• Cement injection should be done under real-time
imaging.

167. LASER ABLATION for Benign Tumours
• Because of the small size of the ablation zone produced, laser
is mostly used for small tumours or in case of Radio frequency
contraindications (metallic implants).
• Osteoid osteomas are the best indication.
• The laser fibre (400 to 600 µm) is inserted always coaxially
into the tumour under CT-guidance through a spinal needle
and a laser beam directed to ablate the tumour.

168. Direct intra arterial chemotherapy
• Usually in chemotherapy is given intra
venously, but direct intra arterial
administration there by localising the drug
more pertaining to the affected tumour gives
better results.

169. ISOLATED LIMB
PERFUSION METHOD
Effective way of delivering
chemotherapy to the affected
limb alone reducing systemic side
effects.
With a steinmann pin over iliac
bone to anchor Eschmark
torniquet in order to occlude
proximal blood vessels.
Cannulation of vessels and
delivering the drug by ensuing
warmth and perfusion of the
limb.

170. Oncologist BoneTumours
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
Histopathologist
Molecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit
MUSCULOSKELETAL
TUMOURS are Evolving in to
a multi disciplinary
approach

171. References :
• Campbell’s Operative Orthopaedics – 11th & 12th edition
• Samuel Turek Text Book of Orthopaedics: 2nd edition
• Bone and Cancer: Felix Bronner
• Adam Greenspan- Differential diagnosis in orthopaedic oncology, 2nd edition
• Mercers Orthopaedic Surgery Vol II 9th edition and 11th edition
• WHO Manual 2001 reprint for Classification of Musculoskeletal Tumours
• Wheeless`Textbook of Orthopaedics.
• www.uptodate.com/musculoskeletal tumours
• Anals of Orthopaedic Surgery, Total Resection of Femur with "Turn-up Plasty"
of Tibia and Prosthetic Replacement of Hip Joint; HENRY S. WIEDER, JR., M.D.,
JESSE T
• Musculoskeletal cancer surgeries – treatment of sarcomas and allied diseases
– Martin M. Malawer
• American Academy of Orthopaedic Surgeons – Text book of Orthopaedic
knowledge update 8 series.
THANK YOU

172. Buzzwords: in Bone Tumours
• Ground glass fibrous dysplasia
• salt & pepper appearance Hyperparathyroidism,Paraganglionoma
• punched-out lesion eosinophilic granuloma, multiple
myeloma
• soap bubble Giant cell tumour
• Popcorn balls cartilage tumours
• Sled runner tracks Ollier's & Mafucci's
• Sunburst spiculation osteosarcoma
• Pseudo Rosette Ewings sarcoma
• Chicken wire calcifications Ewings sarcoma, Chondroblastoma
• Onion Peel appearance Ewings sarcoma, Gouchers disease
• Codmans Triangle Osteosarcoma, Ewings sarcoma,
Chronic osteomyelitis
• Patchy / Mottled calcification Chondrosarcoma
• Polka Dot Pattern CT finding in Haemangioma ( Cross
section, trabeculae)
• Jail House appearance X ray finding in a haemangioma
(thickened, vertically oriented trabeculae
• Double density Sign Osteioid Osteoma – Bone scan feature