Bone Tumors And Software

LEARNING GOALS

After completing the course, students should be able to:

1. State and analyze the importance of combining clinicians - medical imaging - pathologists in the diagnosis and treatment of a osteosarcoma.
2. Describe and analyze age characteristics in the diagnosis of bone tumors.
3. Describe and analyze characteristics of tumor location in the diagnosis of bone tumors.
4. Describe and analyze characteristics X-ray in the diagnosis of bone tumors.
5. Grasp the subgroup of software u.
6. Staging is the soft tissue tumor and its treatment.

Bone Tumor

OUTLINE

Bone tumors are rare.

Bone Tumors and Lesions

General characteristics

The diagnosis and classification of tumors and osteosarcoma-like lesions are complicated and difficult, and controversial because:

• Mesenchymal cells are very versatile and bone formation is very dynamic, so even in an osteosarcoma there are many different types of tissues and cells. Therefore, the demarcation of the boundaries is sometimes very difficult.
• There are many associated lesions in the same tumor. Beside the tumor tissue, it is possible to see the reactive tissue, the following remodeling tissue caseation, bleeding, surgery or fracture pathological,…
• During development, the tumor may have transient phases or differentiate at first in one direction and then in another.
• Many osteosarcomas have a histological origin of unknown origin. For example, macrocytoma, “dental enamel,…”
• In many cases, it is difficult to determine whether it is a true tumor or a tumor-like lesion, congenital malformations For example, osteosarcoma, heal bones, bone tumor ...
• Many types of tumors are benign or malignant in nature, difficult to identify, but are soft tissue invasive, with the potential for recurrence and metastasis. For example: macrocytoma, mucinous fibrocartilage, chondroblastoma, etc. We are classified as borderline malignant.
• Increasingly, the true nature of many tumors is identified and some new ones are found For example, benign and malignant histiocytomas, etc.
• Many diseases of the bone (inflammation, metabolic disorders, endocrine disorders, etc.) have clinical - radiographic and sometimes microscopic findings resembling an osteosarcoma. For example, von Recklinghausen's disease of the bone due to tumor or parathyroid hyperplasia.
• Clinical symptoms are often not many, less specific; X-ray images are difficult to evaluate and cause confusion, especially for non-osteopathologists.
• However, most bone tumors follow some very strict rules, so based on clinical - X-ray (especially age, location, radiographic grade) is predictable and differential diagnosis of most bone tumors.
• Because each tumor and osteoma-like lesion has a very different treatment and prognosis, it is always necessary to combine the three clinicians – medical imaging – pathologist for diagnosis and treatment.

1. Classification of tumors and osteosarcoma

It can be said that every bone tumor specialist has his own classification. We divide osteomas into three groups:

• Benign tumor: slow-growing tumor and stops after a while, often coincides with the period of skeletal growth arrest, benign microscopic.

• Benign, non-malignant tumors: of non-cartilaginous and histiocytic origin.
• Benign, sometimes malignant: derived from cartilage and histiocytosis.

Table 30.1. Medical classification and osteosarcoma

(2) Malignant borderline tumor: has a benign microscopic appearance, but the tumor tissue grows slowly and continuously, can break bones, invade soft tissues and metastasize distantly (rare).

(3) Malignant neoplasm: non-stop progressive, invasive and metastatic tumor Microscopic malignancy may or may not be obvious.

2. Epidemiology

Primary osteoma is rare, malignant type is more common than benign and borderline malignant; males are more common than females. Osteosarcoma accounts for 1% of all cancers. The three most common types are osteosarcoma, osteochondroma and macrocytoma accounting for 61% of osteosarcomas; followed by chondrosarcoma, chondrosarcoma and lymphoma. These six types account for 80% of total osteosarcoma. The most common tumor-like lesions are bony aneurysms, isolated osteophytes, and fibrous dysplasia.

The most common tissue-forming origin from cartilage and bone tissue accounts for about two-thirds of the total, followed by marrow tissue, fibrous tissue, etc.

Primary osteosarcoma most commonly occurs between the ages of 10 and 30 (68%), corresponding to the age of strong bone growth. Osteosarcoma is very rare under the age of 10 years and the incidence declines significantly after the age of 40 years. Benign tumors are common in adolescence. Malignant tumors under the age of 25 are osteosarcoma, Ewing's sarcoma. Malignant neoplasms in the elderly are plasma myeloma, choriocarcinoma and especially metastatic carcinoma. Other tumors in middle-aged adults. In general, osteosarcomas occur within an age range of 20 years and are strongly correlated with osteoblast pattern and rate of bone growth.

Bone tumor most occur in the extremities (84%) and the limb girdle (7%), i.e. the bones formed by endochondral bone formation. Osteosarcoma very rarely occurs in the periosteum and the bones formed by periosteal osteoblastogenesis (2.7%). In the extremities, the tumor was most commonly found near the knee (2/3) and distal to the elbow (16%), corresponding to the head - head of the skeleton with strong growth. Two tumors at the ends of long bones that occurred at two different ages were medulloblastoma (20-40 years old) and chondroblastoma (under 20 years old).

Malignant neoplasms originate in the bony-cartilaginous-fibrous tissue in the head region of long flat bones. Myeloma in the trunk or head of long bones and flat bones. Benign tumors are usually located in the head region of the long bones, except for benign tumors in the craniofacial bone. The bones of the torso and the limb belts are the sites of chondrosarcomas. Tumors in the posterior arch of the spine are usually benign (osteoblastoma, bony aneurysm), in the vertebrae are usually metastatic carcinomas, plasma cell myeloma or eosinophilic granulomas, and benign vascular tumors.

3. Clinical

Bone tumors cause swelling, swelling, pain, if close to the joints will cause swelling and pain in the joints, there may be collateral circulation, pathological fractures and loss of limb function. Benign tumors are slow-growing, < 3 cm in size, with the exception of vascular benign neoplasms. The tumor is relatively slow-growing, locally invasive, and is usually 3 to 5 cm in size. Malignant tumors are usually larger than 3 cm, with extensive bone destruction, local invasion, and distant vascular metastases.

Fast-growing malignancies with the worst prognosis are Kahler's disease (multiple cytoplasmic myeloma), Ewing's sarcoma, and osteogenic sarcoma. Currently, thanks to multiple chemotherapy, the prognosis of osteosarcoma has been greatly improved.

Slow-growing malignancies are chondrosarcomas, paracortical sarcomas, chordomas, and enamel tumors of long bones. Bone lymphoma progresses more slowly, the prognosis is better than that of lymph nodes. In contrast, fibrosarcoma of bone has a worse prognosis than soft fibrosarcoma.

Some benign tumors such as chondroma (one, many places), chondrosarcoma (one, many places), benign histiocytosis (fibrous), ... can turn malignant.

4. Medical school pictures

Conventional X-ray: Although often nonspecific, conventional radiography is a very useful and inexpensive method. Careful analysis of radiographic features helps to suggest benign/malignant nature, suggests diagnosis, and in most cases helps to differentiate from soft tissue tumours.

The diagnostic predictive value is greater when combined with clinical data, especially about age and location of which bone is affected. The following characteristics should be studied:

* Your location:

X-rays help determine the location on the bone, indicating whether the tumor is growing from the marrow, cortex or periosteum. If it is in long bones, indicate whether the tumor is in the head, the head of the body or the body of the bone, etc. Location is a very important factor to help suggest diagnosis and differential diagnosis.

* X-ray characteristics of tumor tissue

Bone formation pictures: some tumors belong to the osteogenic group or originate from bone tissue (benign bone tumor, osteosarcoma, osteogenic sarcoma, paracortical sarcoma, periosteal sarcoma, ...) and some metastatic carcinomas (from the prostate gland, carcinoma). thyroid papillae, mammary gland, etc.).

• Pictures of calcium absorption: tumors belonging to the cartilaginous group or producing cartilage tissue (benign and malignant tumors of the cartilage, some osteosarcomas, etc.).
• Bone destruction pictures: Most primary and secondary osteosarcoma are osteolytic: X-ray grade according to LODWICK: includes three grades I, II, III:

IA: “Bulk” osteolysis with solid contours of bone; the cortical bone is intact or only partially destroyed.

IB: Osteonecrosis “mass” without contour of solid bone or cortical bulging more than 1 cm.

ICs: “Bulk” osteolysis with complete cortical destruction.

II: “Bulk” osteolysis combined with “termite eating” and/or “penetrating, pervasive” pattern.

III: “Termites eat” or/and “spreading, penetrating” osteolysis.

There is a correlation between X-ray grade and histological grade and prognosis of the tumor.

Table 30.2. Values of bone tumor lesions

“Cubic” bone resorption: benign neoplasms, cystic neoplasms, malignant borderline neoplasms, non-myeloid malignant neoplasms (except for some lymphomas and metastatic carcinomas).

“Small hole” bone destruction: Medullary malignancies, some metastatic carcinomas, sometimes fibrosarcomas, hemangiomas.

Bone destruction by termites, weevils, and silkworms eating mulberry leaves: Medullary malignancies, especially Kahler's disease, some metastatic carcinomas.

• The transition zone between tumor tissue and healthy bone tissue: Careful examination of this area indicates the growth rate of the tumor, its benign nature in most cases, and the body's response.
• Periosteal reaction: Due to tumor stimulation, periosteum can form reactive bone into onion shell, solar flare, Codman's triangle, ... often observed in osteosarcoma, Ewing's sarcoma, etc.

* Other X-ray features:

• Malignant tumors can destroy the cortex and invade the soft tissue. X-ray image is the observable shadow in the software, can clearly see the bone formation (burnt grass in osteogenic sarcoma), calcium absorption image (fireworks, hair curls, snowballs in chondrosarcoma) ),…
• Pathological fractures, can bones
• Dimensions of u

* Disadvantages of conventional X-rays

• Lesions are only visible on radiographs when the bone mass has lost more than 30%. Very small osteolytic lesions and leapfrost metastases were not detected.
• It is not detected if the lesion is in the bone marrow until it has spread into the cortical bone.
• It is difficult to determine the extent to which the tumor has penetrated the soft tissue and spread within the canal.
• The actual damage is always larger than what is seen on the X-ray. Arteriogram:

Allows investigation of the extent and distribution of blood vessels in the tumor, which are essential parameters for chemotherapy and radiation therapy as well as compression or invasion of tumor tissue into the arteries, especially when combined with imaging. magnetic resonance effect. This is important in choosing a surgical method.

Supersonic

Not valid in the diagnosis of osteosarcoma. If the tumor invades soft tissue, ultrasound helps to determine the extent of muscle and vascular invasion and the solid or fluid nature of the tumor tissue.

Computed tomography (CT) X-ray

• Evaluation of the extent of the extent of intra- and extra-osseous lesions is helpful in staging and selecting the type of surgery.
• Shows cortical resorption, subcortical bone resorption, inconspicuous fractures, involvement with surrounding soft tissue, particularly calcium infiltration and ossification. CT is useful in detecting small calcium spots in chondrocytes and thin reactive bone contours in bony aneurysms.
• After contrast injection, evaluate the vascular distribution of the tumor and correlate with neurovascularity.

CT cannot replace conventional radiographs in the diagnosis of primary or secondary osteosarcoma. However, CT assesses bone lesions and the extent of spread into soft tissue better and helps to detect and better evaluate lesions of the axial group (vertebral, pelvic, ...) that are difficult to see on conventional X-ray films. wish. Chest CT helps to survey metastatic lesions to stage bone tumors, monitor progression and evaluate treatment results.

Magnetic resonance imaging

• For early detection and diagnosis, optimal for soft tissue exploration. Provides flow signal without contrast agent, making vascular assessment convenient and easy. Although not specific, it shows signals of dominant tissue (fibrous, fat, hemorrhage, necrosis, fluid, viable tumor tissue,...).
• Multiple survey planes (circular view, inclined section, axial section, axial view, tilt reconstruction, floating reconstruction) help the surgeon see the lesion accurately; indicate the size, shape, limits, peri-tumor edema, and invasion.
• Allows visualization or exploration of tumor extension in bone, soft tissue, joint, along ligaments, and metastases. When there are artificial joints, magnetic resonance imaging can still detect tumor recurrence if present.
• This method does not allow accurate identification of fracture lines or bone destruction, mineralization like computed tomography.

The role of CT and MRI is mainly for staging, and secondary to detecting and qualitative tumors. Lesions seen on CT and MRI are often slightly larger than they actually are.

Flashing map

Scintigraphy is a sensitive but nonspecific method for the diagnosis and staging of osteosarcomas. Scintigraphy with the most sensitive and inexpensive Technetium-99m-methylene diphosphonate (99Tc) for the detection of bone metastases. Scintigraphy with Gallium is better at identifying primary cancers.

If the map flickers normally (cold spot), then the tumor is benign. If an abnormality (hot spot) is present, it cannot be distinguished as inflammatory, benign, or malignant. This method is useful to identify the sites of fibrocystic polyostosis, multifocal osteochondroma, multifocal chondrosarcoma, vascular benign neoplasm, X-cell histiocytosis.

5. Histopathology

When diagnosing a osteosarcoma, the differential diagnosis must be inflammation of the bone and vice versa. Biopsy is required for diagnosis before treatment. The biopsy tissue sample should be sufficient, in the active tumor tissue, multiple sites if possible, avoiding bleeding necrosis or reactive inflammatory tissue surrounding the tumor.

In case the tumor is removed, it is sent to the surgery room specializing in bone pathology.

The survey of macroscopic features helps the experienced surgeon to guess the benign nature of the tumor, predict the histological type of the tumor thanks to the penetration, color, density, composition, etc.

In most cases, the definitive diagnosis is based on examination of the microscopic features of the osteosarcoma but should always be guided by clinical data.

– X-ray – macroscopic and performed by a pathologist specializing in bone pathology.

Immunohistochemistry techniques are useful in identifying some of the most malignancies, which are undifferentiated sarcomas, rhabdoid or round cell sarcomas, etc., needed for treatment.

Table 30.3. Bone tumor stage and treatment

6. Staging and Treatment

Over the past three decades, thanks to multiple chemotherapy (radiotherapy has achieved good results (especially for osteosarcoma) and accurate staging based on modern medical imaging, the current trend is performing limb-sparing surgery for malignancies (see Table 30.3).

U SOFTWARE

OUTLINE

In a broad sense, soft tissue includes tissues of the body other than bones. However, in the common sense, internal organs, epithelial-covered tubules, epidermis, bone marrow, nerve ganglia, and lymph nodes are excluded. Soft tissue includes the remaining tissues surrounding the bones of the head, neck, body and limbs, including internal soft tissues such as fibrous tissue, fatty tissue, muscle tissue, blood vessels, lymphatic vessels, tendon-joint membranes, nerve support tissue peripheral nervous system, etc. Soft tissue comes from the medial lamina, except for Schwann cells, which come from the ectodermal-neuroblast.

The diagnosis and classification of tumors and soft tissue tumors are difficult, delicate and complicated because:

• The mesenchymal cell that differentiates to form soft tissues is a very pluripotent cell, many other cell types (cell histocytes, synovial cells, etc.) have the ability as a fibroblast to produce fibers. hammock, yarn
• More and more new tumor types are discovered and standardized. An example is soft tissue malignancy.
• Many lesions are not known to be reactive or an actual tumor. For example, fibroma, tendon membrane macrocytoma, also known as nodular tendonitis - joint.
• In many cases, it is difficult to distinguish a tumor-like lesion from a true tumor.

For example, hemangiomas, lesions are classified as fibromas.

• In many cases, it is difficult to distinguish between a benign lesion and a sarcoma

For example, fibroids in the abdominal wall, ...

Therefore, the following classification is of a simple and practical nature (see Table 30.4). U software is divided into three groups:

Table 30.4. Classification of tumors and tumour-like lesions of the software

(1) Benign tumor

– Benign tumor, sometimes malignant: fibrous histiocytoma, neurofibromatosis in many places

– Benign tumors, not malignant: other benign tumors.

(2) Borderline malignancies

(3) Malignant tumor

Benign tumors and soft tissue lesions are very common, with benign tumors 5-10 times higher than malignant tumors. Soft tissue malignancies are rare, accounting for 1% of all body malignancies.

The most common benign tumors are benign lipomas, vascular benign tumors. Tumors and neoplasms of osteochondrosis occurring and growing in the soft part, not attached to the skeleton, are very rare. Epidermoid nodules are very common but are not soft tissue tumours. Smooth muscle tumors (benign, malignant) are very rare in the soft tissue (usually in the uterine viscera, gastrointestinal tract, ...). Granulomatous (benign, malignant), soft cystic malignancies are very rare, of unknown cell origin, possibly from neuroblastoma, myoblast or paraganglioma with endocrine function.

Mucinous tumor is a very rare, (usually cardiac) tumor that progresses slowly by invasion, without metastasis. It is necessary to make a differential diagnosis with mucinous degenerative lesions, with other tumors with mucinous tissue (striated muscle sarcoma, lipomatous fibrosarcoma, ...) which are more common.

Most of the soft tissue malignancies from the time of appearance, the most common types are histiocytosis, fibrosarcoma, dermoid sarcoma, rhabdomyosarcoma, and lipomatous sarcoma. The most malignant soft tissue tumors are rhabdomyosarcoma, mesenchymal mesothelioma, histiocytosis, and vascular sarcoma. Malignant tumors with the best prognosis are fibrodermoid sarcomas, fibrosarcomas, etc., but the local recurrence rate is high. Fat sarcoma, synovial sarcoma, and smooth muscle sarcoma are intermediate in grade between these two groups.

The most diverse and malformed malignant tumors are rhabdomyosarcoma, histiocytoma, mesenchymal mesenchymal sarcoma, poorly differentiated lipomatous sarcoma, and smooth muscle sarcoma. Malignant neoplasms with few abnormal cells are mucinous sarcoma, dermoid fibrosarcoma, fibrosarcoma, and meningeal sarcoma. Fibrous sarcomas are often difficult to distinguish from fibroids.

Clinically, the location and progression of the tumor greatly help in the diagnosis. For example, fibrosarcoma, fibrosarcoma, and adult rhabdomyosarcoma are most common in the lower extremities. Meningeal sarcomas are usually proximal soft knee joint while smooth muscle sarcomas and fatty sarcomas are common retroperitoneal.

Biopsy should be performed when clinically suspected to be a soft tissue tumor, no immediate intention to remove the tumor should be made unless extensive resection in normal tissue is warranted in all respects 2 cm from the tumor and always try histopathology. Local anesthesia should not be given and be careful when aspiration, needle biopsy, etc. can cause tumor spread.

In the diagnostic work of pathology, the following points should be kept in mind:

• Adequate clinical data should be provided, gross and tissue samples must be sufficient
• Tissue samples should be diagnosed by two pathologists familiar with soft tissue tumors
• The diagnosis of rare tumors needs to be very cautious and consulted with the pathology - clinical - medical imaging department.

STAGEMENT OF SOFTWARE AND PROCESSIONAL UTIS

Staging is performed using a combination of physical examination, analysis of X-ray images, scintigraphy, computed tomography, nuclear magnetic resonance and microscopy.

Table 30.5. Staging and Management of Software Tumors