Bone tumors occur with the uncontrolled division and growth of bone cells. After this division, they appear as swelling and mass in the extremity. Unlike soft tissue tumors, the first clinic in bone tumors is often extremity pain. The presentation may be pain, swelling, pathological Fracture or incidentally captured radiological image may be the first reason for referral. The character of pain in bone tumors is often night pain, which increases with movement. The majority of bone tumors are benign bone tumors and are not life-threatening.
Benign bone tumors;
Benign bone tumors are named according to the tissues they originate from,
>Bone tumors related to bone formation; osteoid osteoma, osteoblastoma,
Bone tumors that involve cartilage formation; osteochondroma, enchondroma, chondroblastoma
Bone tumors with fibrous tissue formation; Non-ossifying fibroma (NOF), fibrous dysplasia, osteofibrosis dysplasia,
Cystic Lesions; Aneurysmal bone cyst, Simple bone cyst,
Benign bone tumors with aggressive behavior; giant cell bone tumor, eosinophilic granuloma, chondromyxoid fibroma,
We can also name the most common malignant bone tumors according to the tissues they originate from, the most frequently observed bone tumors are;
Multiple Myeloma,
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Ewing Sarcoma,
Osteosarcoma,
Condorssarcoma
Benign Bone Tumors;
Osteoid Osteoma;
It constitutes approximately 10% of benign bone tumors, 75% is observed between the ages of 5-24 and 65% is observed in long bones, although osteoid osteoma is most commonly observed in the proximal femur. More than 50% of the lesions are observed in the femur and tibia.
Osteoid osteoma is also clinically typical, in 75% of cases it is typical to have pain that wakes them up at night, and this pain is usually relieved with salicylate-derived painkillers taken at night. This pain may vary depending on the bone and location where the lesion is observed. Involvement in long bones may cause extremity dysfunction, and when this lesion is observed in areas close to the joint, it may give a clinic resembling a synovitis attack, especially in the knee joint. In cases with vertebral involvement, scoliosis may be observed, especially due to muscle spasm caused by pain. The diagnosis can be clarified by the structures observed radiologically as characteristic of osteoid osteoma surrounded by a sclerosed structure called <1cm small nidus. The differential diagnosis of osteoid osteoma includes osteoblastoma, stress fractures, and bone abscess. In its treatment, removal of the nidus is the basis of the treatment. Removal of the nidus can be done by open-closed methods, and conservative treatment and medical treatment can be applied in areas that are difficult to localize surgically.
Osteoblastoma;
It constitutes 3% of benign bone tumors. Although they are lesions that may be similar to osteoid osteoma, their most important difference from osteoid osteoma is that the lesions are larger. They are lesions most commonly observed between the ages of 10 and 30. Although they are observed in long bones, they are also more frequently observed in the axial skeleton (vertebra). Unlike osteoid osteoma, these lesions may be painless, but may not respond to salicates when there is pain. The treatment is surgical removal of the lesion. The probability of recurrence in these lesions is between 15-20%.
Enchondroma;
They are benign tumors originating from hyaline cartilage. They are the most common tumors of the hand bones, and when seen in large numbers, they may indicate Ollier disease. Although the probability of turning into malignant tumors is very low when seen alone, the risk of malignancy in enchondromas (Mafucci syndrome) observed together with soft tissue hemangioma is high, especially after the age of 40. While the lesions are more active in pediatric patients, the lesions become more inactive in these patients as they reach adulthood.
These lesions, which have a mottled appearance on plain radiographs, are not a soft tissue component in MRI, unlike chondrosarcoma. In these lesions, the lesion does not show stable growth and is not a cause of pain. It can be followed, but if the lesion causes pain, grows, or causes damage to the cortex in the bone where it is located, surgical treatment is another treatment option.
Soft tissue sarcomas include muscle, joint soft tissue, fatty tissue, etc. These are tumors that begin to form in soft tissues. Unlike bone tumors, soft tissue sarcomas are K findings often appear as swelling that begins on soft tissues. Since they are formations that are not accompanied by pain, they are often misdiagnosed as sports injuries and benign soft tumors. Although soft tissue sarcomas are not common tumors, they constitute approximately 1% of all cancers in adults and 15% of tumors in children. Sarcomas, which have many subtypes, are generally named according to the tissues they originate from. Those originating from fat are called liposarcoma, those originating from joint soft tissue are called synovial sarcoma, those originating from fibrous tissue are called fibrosarcoma, those originating from smooth muscle are called leimyosarcoma, those originating from skeletal muscle are called rhabdomyosarcoma, etc. >
It is not clear what causes most sarcomas, but genetic factors, some previous viral infections, and high doses of radiation received for other reasons can be considered among the causes of sarcomas that may develop.
As mentioned before, soft tissue. In all tumors and sarcomas, the first symptom is a painless mass. Diagnosis is often made late because the mass does not cause pain at first and only appears as soft tissue swelling. Such masses grow and cause muscle, nerve, and vascular compression in the surrounding tissue, causing symptoms such as pain and numbness.
The diagnosis of soft tissue sarcomas is often made when the patient notices the swelling. The swelling begins, after the physician's examination, the necessary radiological examinations are performed and the diagnosis is made. The first thing to do in the radiological examinations is to take conventional region radiographs. While these radiographs do not directly show the soft tissue sarcomas themselves, they can determine the bone damage that may have been caused by this mass, whether this soft tissue tumor has penetrated into the bone, whether the mass is present. It gives information about whether it contains any calcification. The most commonly used imaging in the radiological examination of soft tissue sarcomas is magnetic resonance imaging (MRI). With MRI, information is obtained about the size of the mass, its location, the behavior of the mass, and its neighborhood with the surrounding soft tissues (vessels and nerves). is listened to. In these imaging studies, lesions larger than 5 cm, deep-seated lesions, and aggressive lesions are considered to be more likely to be malignant. Computed tomography (CT) is another radiological examination used, it is used to clearly reveal how much soft tissue sarcomas, which are thought to cause bone damage in conventional radiographs, damage the bone, and more often, because these tumors have the potential to spread to other body organs (lung, abdomen). It is used to investigate whether the mass has spread (e.g., pelvis).
Biopsy After radiological examination, it is not necessary to determine the exact name of the existing mass, to understand whether this mass is benign or malignant, and to plan the surgery to be performed. It is an impossible practice. Biopsy is a short-term procedure often performed under anesthesia (local-general-sedation) with a small needle (picture 1). Depending on the behavior of the mass, the biopsy can be performed closed (with a needle) or in some cases it can be performed openly in the operating room with a 3-4 cm incision. Regardless of the appropriate method, biopsy must be performed in accordance with biopsy rules. Biopsies that are not performed in accordance with the rules may lead to a misdiagnosis and may also change the type of surgery to be performed later, so it is most appropriate to have the biopsy performed by the doctor who will perform the surgery.
After the biopsy, another evaluation to be made before surgery in soft tissue sarcomas is whether the tumor has spread to other organs. It is a general body scan for diagnosis, for which positron emission tomography (PET) CT can often be used.
After all these evaluations and examinations, it is necessary to perform staging to clearly determine the surgery to be performed, whether the pathology taken for staging is aggressive or not, whether the tumor is Its size on MRI, whether it is deeply located, whether it has spread to other organs or not is important.
(see the staging presentation for detailed information) is important in determining the stage to be performed and the type of treatment to be applied afterwards.
Treatment;
There must be a multidisciplinary team for the treatment of soft tissue sarcomas. This team should include an orthopedic surgeon, radiation oncologist, medical oncologist and pathologist. The main goal in the treatment of soft tissue sarcomas is to first achieve local control of the tumor and then prevent distant spread, without impairing the quality of life and extremity function. While the treatment for soft tissue sarcomas may vary depending on the type, grade and stage of the tumor, the first treatment is surgical removal, if possible. Surgery should be well planned and the tumor should be removed from its location with wide clean surgical margins. The development of reconstructive surgery options and the ability to perform vascular and nerve transfers and repairs have enabled extremity-sparing surgeries to be performed more frequently in the removal of these tumors. However, in cases where a large amount of muscle, nerve and vascular tissue in that extremity needs to be removed in order to safely remove the tumor, amputation is still a surgical option, although it is less structured.
Radiotherapy;
Radiotherapy is a treatment option that should be added to surgery to prevent regional recurrence in the treatment of soft tissue sarcomas, depending on the type and stage of the tumor. Radiotherapy can be applied before or after surgery for very large mass tumors observed in the soft tissue.
Chemotherapy;
The place of chemotherapy in the treatment of soft tissue sarcomas is controversial. Chemotherapy can be added to the treatment in tumors that are massive, aggressive, high-grade and have a high probability of metastasizing.
WHAT ARE SOFT TISSUE SSARCOMAS?
Malignant Fibrous. Histiocytoma;(MFH)
MFH is a soft tissue sarcoma with a pleomorphic structure. MFH originates from fibroblastic and histiocytic cells. These tumors, which are more common in men, are frequently observed between the ages of 50-70. Unlike other forms, the angiomatoid form of MFH is observed more frequently in the 20s. The main treatment is surgical resection. Radiotherapy can be added in patients with close surgical margins and chemotherapy can be added in those with high grades. Local recurrence decreases to 10% with combined treatments. While metastasis is around 10% in superficially located MFHs, it is more common in deep-seated MFHs.
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