NEOPLASMA of NEOPLASMA of MUSCULOSKELETAL MUSCULOSKELETAL

TISSUESTISSUES(bone)(bone)

ANDRI R. WINOTOANDRI R. WINOTOdr. Spdr. SpOTOT(K)(K) Hand and Microsurgery Reconstruction Hand and Microsurgery Reconstruction

Sub Sub Department of Orthopedic and TraumatologyDepartment of Orthopedic and Traumatology

dr. dr. Kariadi Kariadi General HospitalGeneral Hospital

Medical School of Medical School of DiponegoroDiponegoro University University

Classification (Aegerter,1975)Classification (Aegerter,1975)

I.Reactive Bone I.Reactive Bone LesionLesion

A.OsteogenicA.Osteogenic

1. Osteoid osteoma1. Osteoid osteoma

2. Osteoblastoma2. Osteoblastoma

B.CollagenicB.Collagenic

1. Subperiosteal 1. Subperiosteal cortical defectcortical defect

2. Non-osteogenic 2. Non-osteogenic fibromafibroma

II.Hamartomas II.Hamartomas Affecting BoneAffecting Bone

A. OteogenicA. Oteogenic

1.1. OsteomaOsteoma

2.2. OsteochondromaOsteochondroma

B. ChondrgenicB. Chondrgenic

1.1. EnchondromaEnchondroma

C. CollagenicC. Collagenic

1.1. AngiomaAngioma

2.2. Aneurysmal bone Aneurysmal bone cystcyst

III.True Neoplasms III.True Neoplasms of Boneof Bone

A. OsteogenicA. Osteogenic

1.1. OsteosarcomaOsteosarcoma

2.2. Parosteal sarcParosteal sarc

B. ChondrgenicB. Chondrgenic1. Benignchondrobla

stoma2. Chondromyxoid

fobroma3. Chondrosarcoma

C. CollagenicC. Collagenic

1.1. FibrosarcomaFibrosarcoma

2.2. AngiosarcomaAngiosarcoma

D. MyelogenicD. Myelogenic

1.1. Ewing’s tumorEwing’s tumor

2.2. Reticulum cell Reticulum cell sarcsarc

3.3. Hodgkin’s diseaseHodgkin’s disease

E. Osteoclastoma E. Osteoclastoma (GCT)(GCT)

DiagnosisDiagnosis

Clinical historyClinical historyPhysical signsPhysical signs

Biochemical findings (lab)Biochemical findings (lab)

Radiographic featuresRadiographic featuresScintigraphy (bone scan)Scintigraphy (bone scan)

Computed tomograpphyComputed tomograpphy

Arteriography (angiography)Arteriography (angiography)

MRIMRI

BiopsyBiopsyMicroscopic appearanceMicroscopic appearance

Primary NeoplasmsPrimary Neoplasms and and Neoplasma-like LesionsNeoplasma-like Lesions

of Boneof Bone

Classifications:Classifications: World Health World Health

Organization, Organization, Lichtenstein, Aegerter.Lichtenstein, Aegerter.

Primary neoplasmsPrimary neoplasms 1% of all age groups1% of all age groups

Secondary neoplasmsSecondary neoplasms

Types of Specialists:Types of Specialists: Orthopaedic surgeonOrthopaedic surgeon RadiologistRadiologist PatologistPatologist Medical oncologistMedical oncologist

General ConsiderationsGeneral Considerationsincidence, pathogenesis, clinical features, incidence, pathogenesis, clinical features,

diagnosis, treatmentdiagnosis, treatment

Incidence:Incidence:

osteosarc-during childhoodosteosarc-during childhood

GCT- during adult lifeGCT- during adult life

Site incidenceSite incidence

metaphyseal regionsmetaphyseal regions

Neoplastic cells do not Neoplastic cells do not destroy bone, their destroy bone, their presence incites local presence incites local osteoclastic resorption of osteoclastic resorption of bonebone

I. Reactive Bone LesionI. Reactive Bone Lesion

II.Hamartomas Affecting BoneII.Hamartomas Affecting Bone

A.OteogenicA.OteogenicOsteomaOsteoma

osteochondromaosteochondroma

osteochondromaosteochondroma

RATE OF GROWTHRATE OF GROWTH(Lodwick)(Lodwick)

Grade 1Grade 11a. Sclerotic margin1a. Sclerotic margin

without complete without complete cortical cortical penetrationpenetration

1b. Sharp margin, non-sclerotic 1b. Sharp margin, non-sclerotic margin without total margin without total cortical penetrationcortical penetration

1c. Poorly defined margin, 1c. Poorly defined margin, totally penetrated the totally penetrated the cortexcortex

Grade 2Grade 2geographic lesion + moth-eaten geographic lesion + moth-eaten and/or permeative destructionand/or permeative destruction

Grade 3Grade 3motheaten and/or permeative motheaten and/or permeative destruction onlydestruction only

PERIOSTEAL REACTIONSPERIOSTEAL REACTIONS

Radiographic FeaturesRadiographic Features

Osteolysis: bone resorptionOsteolysis: bone resorption

Osteosclerosis: bone Osteosclerosis: bone depositiondeposition

ExpansionExpansion

Codman’s triangleCodman’s triangle

Onion skinOnion skin

Sunburst appearanceSunburst appearance

Pathological fracturePathological fracture

OsteosarcomaOsteosarcoma

chondrosarcoma

D.D. MyelogenicMyelogenic

Ewing’s tumorEwing’s tumor

SURGICAL STAGES

Stage IA G1, T1, M0 Low grade, intracompartmental lesion, without metastasis

Stage IB G1, T2, M0 Low grade, extracompartmental lesion, without metastasis

Stage IIA G2, T1, M0 High-grade, intracompartmental lesion, without metastasis

Stage IIB G2, T2, M0 High-grade, extracompartmental lesion, without metastasis

Stage IIIA G1 or G2, T1, M1

Intracompartmental lesion with metastasis

Stage IIIB G1 or G2, T2, M2

Extracompartmental lesion with metastasis

SurgicalStaging System (SSS)SurgicalStaging System (SSS)William F. EnnekingWilliam F. Enneking

Stage I: (G1,T1,Mo)Stage I: (G1,T1,Mo) Low-grade, intracompartmental, Low-grade, intracompartmental,

metastase (-) metastase (-) Stage IB:(G1,T2,Mo)Stage IB:(G1,T2,Mo)

low-grade, extracompartmental, low-grade, extracompartmental, metastase (-)metastase (-)

Stage IIA:(G2,T1,Mo)Stage IIA:(G2,T1,Mo) High-grade,intracompartement. High-grade,intracompartement.

Metastase (-)Metastase (-) Stage IIB:(G2,T2,Mo)Stage IIB:(G2,T2,Mo)

High-grade,extracompartment. High-grade,extracompartment. Metastase (-)Metastase (-)

Stage IIIA: (G1 or G2,T1,M1)Stage IIIA: (G1 or G2,T1,M1) Intracompartment, Intracompartment,

metastase (+)metastase (+) Stage IIIB:(G1 or G2,T2,M2)Stage IIIB:(G1 or G2,T2,M2)

Extracompartment, Extracompartment, metastase(+)metastase(+)

Principles of TreatmentPrinciples of Treatment

Accurate diagnosisAccurate diagnosis

Benign neoplasms and non-Benign neoplasms and non-malignant lesion: surgically malignant lesion: surgically (excision, curettement, bone (excision, curettement, bone grafting)grafting)

Malignant primary neoplasms: Malignant primary neoplasms: surgical ablation, eradication, surgical ablation, eradication, with or without radiotherapy with or without radiotherapy and adjuvant chemotherapyand adjuvant chemotherapy

Enneking’s staging systemEnneking’s staging system

Limb-sparing, extremity saving, Limb-sparing, extremity saving,

Limb-salvagingLimb-salvaging

Types of Specialists:Types of Specialists:Orthopaedic surgeonOrthopaedic surgeonRadiologistRadiologistPatologistPatologistMedical oncologistMedical oncologist

CONCLUSIONCONCLUSION

•EARLY DETECTION

(VERY EXPENSIVE)

•LATE must be AMPUTATION

(paliative treatmant)

•SO

•PREVENTION

•HEREDITARY

•SOSIAL PROBLEM