医学精品课件：外科TUMOURs of BONE lx.ppt

1、TUMOURS OF BONE,liang xi 梁熙 The first affiliated hospital of chongqing medical university,Definition bone tumor：all tumors which affected bone , originate from bone or from other tissue, are bone tumor,Benign Malignan 1. Primary bone tumors are rare, less than 2000 cases reported every year in USA.

2、Most of them are sarcomas. 2. Secondary (metastatic) tumors are more common than primary malignancy of bone.,GENERAL ASPECTS,epidemiology 1. age: osteosarcoma -adolescent、children giant cell tumor-adult 2. common region of tumors,Primary bone tumors,一. Symptom 1. no symptoms the tumors than growth s

3、lowly have no symptoms until pathologic fractures 2 . pain, deep, aching pain, which, although not sharp or severe, is distressing because of its constancy. Pain that persists at night and is unrelieved by rest is suggestive of malignancy Mild, dull, aching pain that suddenly becomes severe followin

4、g minimal or no trauma suggests a pathologic fracture. 3. fever,clinical manifestation and diagnosis,4. The history should include a search for such constitutional symptoms as loss of appetite or weight, and previous malignancy, which suggest metastasis. A positive family history is common in patien

5、ts with multiple enchondromas or osteochondromas,.,二. signs Swelling for malignant tumors, the margins of the swelling are not well-defined . Mass 1) for malignant tumors, the margins of the mass are not well-defined 2) If the mass is painful and attached to bone, it is likely to be malignant. 3) if

6、 the mass is attached to bone but painless, the lesion is more often benign unless it is a soft tissue tumor. High skin temperature Superficial vein is engorge (prominent) Tenderness,6. impairment of joint function Impaired function is occasionally the major complaint, especially if the tumor is nea

7、r a joint. Nearby nerves may be compressed 7. The signs of compression spinal core- paralysis peripheral nerve- sensation and motion artery - ischemic vein - stagnant blood,7) Cachexia loss weight, anemia,3、imaging ： 1) X-ray osteoclasia/osteolysis bone formation tumor-reactive bone, neoplastic bone

8、 Codman triangle sunburst (sun-ray) appearance onion-skin appearance osteolysis tumor destruction of bone,2) CT to get the message of the relation of tumor and around tissue lesions involving cortical bone are best imaged by a computed tomography (CT),3) MRI if the soft tissue is involved in marrow

9、lesions, primary tumors of soft tissue, and soft tissue extensions of osseous tumors are better imaged by magnetic resonance imaging (MRI).,Codman triangle new bone formation under the corners of the raised periosteum (Codmans triangle),Codman triangle,sunburst (sun-ray) appearance,Ossify ：new bone

10、formation,osteolysis tumor destruction of bone,4) nuclide bone scan :The bone scan is a critical tool for detecting distant osseous metastases and periosteal involvement of contiguous soft tissue tumors.,4、 Laboratory studies ： Ca、P、ACP、ALP erythrocyte sedimentation rate （ESR） is most frequently ele

11、vated in metastatic and small round-cell tumors, such as Ewing sarcoma. alkaline phosphatase （ALP) is usually elevated when bone is being broken down and remodeled. electrophoreses of Serum and urine are useful if myeloma is suspected: Bence Jones protein ( multiple myeloma ),5、biopsy：confirm diagno

12、sis 1) needle biopsy 2) Open biopsy,6. the principle of diagnosis,1) clinical feature, 2) imaging appearance 3) biopsy,are taken into consider to make diagnosis,Surgery grade G grading G0 benign G1 low potential malignancy juxtacortical osteosarcoma G2 malignancy osteosarcoma, synovial sarcoma T :su

13、rgical site T0 : tumor is enwraped with fibrous cyst or reactive bong T1 : tumor is in the muscular septa or membrane or fascia T2: exceed the muscular septa or membrane or fascia M : lymphatic metastasis or distant metastasis M0： no local and distant metastasis M1： distant metastasis,Differentiate

14、benign and malignant bone tumors,benign malignant trauma： motivation pain： (-) severe Swelling： solid diffusibility tenderness： (-) positive dysfunction： (-) (+) Superficial vein engorge (-) (+) Skin redness (-) (+) bone Destruction (-) (+) Periosteal reaction (-) (+) Soft tissue infiltration (-) (+

15、) Mass in soft tissue (-) (+),Treatment,1) Operation 2) chemotherapy, 3) radiotherapy, 4) immunotherapy, 5) Chinese/traditional medicine,chemotherapy,radiotherapy,immunotherapy,chemotherapy,radiotherapy,immunotherapy,2. Chose treatment plan by surgery grade. amputation should be very careful,only re

16、section without chemotherapy, 5-yeat survival rate is 15%-20%, With regular chemotherapy, 5-year survival rate currently is about 60% Osteosarcoma and Ewing sarcoma.,With the regular chemotherapy and radiotherapy, Techniques for limb salvage procedures have improved steadily.,1.operation （1）curetage

17、 + graft indication: endogenous benign tunors （2）resection + graft indication: exogenous benign tumors,Curetage+graft,Resection +graft,（3）limb-saving surgery： indication: low malignant tumors, early diagnosed malignant tumors plan : regular chemotherapy or/and radiotherapy + resection + graft and re

18、construction or + joint replacement,Amputation: palliative treatment amputation should be very careful (1) indication: advanced disease, aiming at pain-relief and a better life. (2)the safe margin of amputation is 10cm away from tumor to avoid stump recurrence.,Benign,一 Solitary bone cyst,Solitary b

19、one cyst (SBC) is a common lesion of the immature skeleton characterized by an intramedullary fluid- filled cavity that forms in the metaphysis, juxtaposed to or near the physis.,Solitary bone cyst,Clinical features symptoms and signs: Most lesions are asymptomatic, but patients may present with pai

20、n, swelling, and deformity following pathological fracture.,Solitary bone cyst,X-ray: the lesion presents as a geographic intramedullary lucency. The cortex is often markedly thinned and the bone contour frequently expanded.,bone cyst of femur,bone cyst,Treatment operation: curettage + bone graft,二

21、Osteoid osteoma,1. clinical features symptoms and signs: (1) Children and adolescents(5-25 age) are most requently affected, which may exist for many years without change. (2) common region of lesion: the femur and tibia. In the spine, the lesion often causes a painful scoliosis,Osteoid osteomas,sym

22、ptoms and signs : (3) painful lesions in which the pain is described as deep, boring, constant, nocturnal, and frequently relieved by aspirin or other nonsteroidal anti-inflammatory drugs. (4) no sign, no tenderness, no swelling,Osteoid osteomas,Radiographically (1) Xray the lesion is an area of ver

23、y dense bone surrounding a central lucent area or nidus that is less than 1.5 cm in diameter .,(2) CT If reactive bone obscures the nidus on plain radiographs, a CT scan may be necessary to disclose it.,biopsy,Treatment 1. take medicine 2. operation: curettage If the agents do not provide pain relie

24、f, complete excision of the nidus along with the sclerotic bone should be applied. 3. the prognosis is good,三 Osteochondroma,One of the most common bone neoplasms. It is a cartilage-capped projection of bone from the metaphysis of a long bone near the growth plate. Any bone preformed in cartilage ca

25、n be affected.,Osteochondroma,clinical features: 1. mass: the lesion is a hard, immovable, smooth mass that is firmly fixed to bone without tenderness unless it has been traumatized. 2. dysfunction of nerve and joint: nerve is compressed and the joint is blocked by mass.,Osteochondroma,3. X-ray: It

26、is frequently discovered as an incidental finding on a radiograph taken for another reason. The usual radiographic appearance is a pedunculated bony protuberance from the metaphysis of a long bone that points away from the nearby joint.,Osteochondroma,The radiographic appearance of the lesion is dia

27、gnostic, but removal may not be necessary unless the lesion is painful or there is suspicion of malignancy. Malignant change is heralded by growth or pain in a previously static osteo-chondroma.,Treatment observation: indication: Asymptomatic lesions 2. Resection: indication: symptomatic exostosis,四

28、 Enchondromas,clinical fearures: 1. region of lesion: hands and feet Arise within the medullary cavity of bone, most frequently in the small tubular bones of the hands and feet. 2. asymptomatic unless complicated by a pathologic fracture.,Enchondromas,3.pain. Enchondroipas in larger bones, such as t

29、he femur and humerus, may produce dull, aching pain.,4.x-ray Although discovery of the lesion as an incidental osteolytic radiographic finding is common.,Treamment Observation: Radiographs at 3 to 4month intervals for asymptomatic lesions. If no growth is noted during the first year or two, the pati

30、ent need return only if pain develops in the area. Painful lesions without cortical erosion should also be followed.,2.opreation: Treatment is curettage and removal of the tissue filling the cyst, including the lining.,Pre op,PO,Giant cell tumors,一、outline 1. giant cell is osteolysis tumor with vari

31、able growth potential originate from cancellous bone, it is potential malignancy or malignancy. 2. Adult is the most population Consist of cell：giant cell( osteoclast), matrix cell grading：grade I benign grade 2 potential malignancy grade 3- malignancy,Site Lower end of the femur upper end of the ti

32、bia lower end of the radius upper end of the humerus,Giant cell tumors,Pathology Epiphysial region and extend to the joint surface Destroy bone substance and new bone formation - the bone end becomes expand Pathology fracture,Giant cell tumors,Pathology Consists of abundant undifferentiated oval or

33、spindle shaped cells The actual cell of origin is uncertain It metastasises to the lungs,Giant cell tumors,Clinical feature 1. Pain : vague pain 2. swelling: 3. Tenderness on firm palpation 4. pathological fracture,Giant cell tumors,Radiographs Show destruction of the bone substance, with expansion

34、of cortex “Soap-bubble” appearance Grow eccentrically Extend as far as the the articular end of the bone,Giant cell tumors,Treatment 1.Excision part and whole bone :such as clavicle or fibula. 2.Curettage followed by packing bone graft :such as femur 3.Arthroplasty 4.Amputation 5.Radiotherapy may in

35、duce malignant,五 Fibrous dysplasia,Normal bone is replaced by fibrous tissue. The mass of fibrous tissue growth inside the bone and erodes the cortices of the bone from medullary cavity.,Fibrous dysplasla,Clinical features: 1.The diagnosis is generally made in the first three decades of life, with a

36、 slight female predominance. 2.The most common sites include the ribs, proximal end of femur, and tibia.,Fibrous dysplasla,3. pain, swelling, deformity, pathological fracture.,Fibrous dysplasla,4. x-ray 1）FIBDYS appears as a geographic, intramedullary lesion with a ground glass appearance. 2) The de

37、nsity of the lesions varies with the amount of immature bone :produced, Cortical thinning and expansion of the bone contour is common. 3) calcification may be seen. Extensive involvement of the bone can lead to significant deformities, such as shepherds crook deformity of the proximal femur.,Treatme

38、nt curetage +graft + fixation( fracture),Malignant,一 Osteosarcoma,Predominantly a tumour of adolescence The commonest site are the lower end of the femur ,the upper end of the tibia ,and the upper end of humerus-most active growth is occurring It begins in the metaphysis.,Osteosarcoma,Pathology Aris

39、e from primitive bone-forming cell There will be neoplastic new bone or osteoid tissue Mestastasises early by blood stream, especially to the lungs and sometimes to other bone,Osteosarcoma,Clinical features 1. Pain 2. Swelling 3. Superficial vein is engorge (prominent) 4. Tenderness 5. The overlying

40、 skin is warmer than normal because of the vascularity of the tumour 6. The skin appears stretched and shiny,Osteosarcoma,X-ray 1. Show irregular destruction of the metaphysis. latter the cortex appears to have been burst open at one or more place. 2.There is usually evidence of new bone formation u

41、nder the corners of the raised periosteum (Codmans triangle),Osteosarcoma,3. Occasionally well marked radiating spicules of new bone are seen within the tumour (sun ray appearnce) 4.There may be profuse formation of new bone 5. A chest radiograph may show pulmonary metastases,Codmans triangle,Sun ra

42、y appearnce,Sun ray appearnce,biopsy：confirm diagnosis 1) needle biopsy 2) Open biopsy,Osteosarcoma,Treatment Chemotherapy is usually commenced before surgical treatment. To control local recurrence and distal metastatic,1. limb-saving surgery： indication: low malignant tumors, early diagnosed malig

43、nant tumors plan : regular chemotherapy or/and radiotherapy + resection + graft and reconstruction or + joint replacement,2. Amputation: palliative treatment amputation should be very careful (1) indication: advanced disease, aiming at pain-relief and a better life. (2) the safe margin of amputation

44、 is 10cm away from tumor to avoid stump recurrence.,Ewing Sarcoma,Ewing sarcoma is originate from protocell.,outline： originate cell-protocell age-10-20 year sites-diaphysis Clinical features ： pain low-grade fever swelling tenderness warm skin WBC、ESR heighten,X-ray The radiographic appearance of m

45、ottled bone destruction and reactive “onionskin“ periosleal bone formation also simulates infection.,Treatment chemotherapy surgery radiotherapy,metastatic tumor of bone,outline： age originate disease Clinical features： severe pain primary disease loss weight、anemia Laboratary test X-ray nuclide bone scan,Treatment: 1. manage the primary tumor chemotherapy, radiotherapy, operation 2、metastatic lesion treatment- fixation of fracture amputation 3、symptom treatment-relieve pain,谢 谢 ！,