Dr Herry Setya Yudha Utama SpB. FInaCS. MHKes. ICS: BENIGN BONE TUMOR and handling / TUMOR JINAK PADA TULANG

BENIGN TUMOR BONE and handling

Definition of tumor or neoplasm is an umbrella term used to describe the growth of mass (solid / solid) or abnormal tissue in the body. This mass arises as a result of an imbalance of growth and regeneration of cells or tumor is a collection of abnormal cells formed by cells that grow continuously are not limited to, not coordinated with the surrounding tissue and are not useful for the body.

The incidence of some neoplasms bekaitan bone with age. Anatomic locations also have specificity, ie the most common occurring in long metaphysical areas, namely the distal femur, proximal tibia and proximal humerus. Based on the research found that the biggest trigger the occurrence of bone tumors are genetic factors. The initial symptoms are common in the form of prolonged pain in the bones. This pain may arise as a result of trauma impact, but could not. Not infrequently found patients initially it did not feel pain, but swelling of the bone. Interestingly, this tumor potential attack patients under the age of 20 years.

Classification of bone tumors, namely primary and secondary (metastatic). Primary bone tumors are divided into benign tumors (benign) and malignant tumors (malignant). In Indonesia alone, the term refers to a tumor over benign tumors. tumors are benign, does not always mean 'harmless', although most are usually harmless. A benign tumor (benign tumor) can still evolving, and could cause damage to the tissues, nerves or organs nearby. Depending on the location and magnitude, the tumor can still be a serious illness and life-threatening, such as brain tumors.

Benign neoplasms of bone ditatalaksanai with excision or curettage. Bone defect was closed with bone grafts. When you disturb the surrounding tissue, the doctor may suggest surgical removal (surgery). Currently surgical techniques have been developed rapidly, even involving laser surgery technology, or cryosurgery (freezing) tumors.

CHAPTER II

Anatomy and physiology BONE

Anatomy and physiology SYSTEM MUSKULOSKLETAL (BONE)

Muskuloskletal system is supporting the body shape and take care of the movement. The main component of connective tissue system is muskuloskletal. This system consists of bones, joints, skeletal muscles, tendons, ligaments, Ø exchanges, and a dedicated network that connects these structures.

EMBRYOLOGY BONE

Formation and bone development is a process of morphologic (cartilage) efisis plate is not the same as hyaline cartilage and articular cartilage because cartilage epiphyseal plates have vascular structures, zones, biochemical marrow that give a unique picture of the matrix. In the early phases of embryonic bone development (at weeks 3 and 4), to form three germ layers, the ectoderm, mesoderm, and endoderm. This layer is a network that is multipotential and will form the mesenchyme which then differentiate to form cartilage tissue. In the fifth week of embryonic development, the bulge formed limb (limb bud) in which there are also mesenchymal cells that are going to the formation of bone and cartilage.

Bone development into two phases:

1. the fifth week of embryonic development of cartilage formed prakartilago. There are three types of cartilage, which is hyaline cartilage, cartilage fibrin, and elastic cartilage

2. Upon the seventh week of embryonic development, bone will be formed in two ways:

a. Directly:

In this process the bone is formed directly from the bone membrane in sheet form, for example the facial bones, pelvis scapula, and skull. In reinforcement of this kind can be found in one or more membrane ossification center. Ossification process is characterized by the formation of osteoblasts which are canoes of trabecular bone which spread radially.

b. Indirectly:

In this process the bone is formed from cartilage. Cartilage ossification process occurs in two ways:

Ö central ossification = In this situation bone ossification ossification occurs through endokondral

Ö peripheral ossification ossification = In this situation perikondrium or ossification occurs under the periosteum. Undifferentiated mesenchymal peripheral regions in the form of sheet formation osteblas Formatting peristeum place in it.

AS BONE STRUCTURE AND ORGAN

Bones forming the framework for supporting and protective body and become a place of attachment of the muscles that move the body frame. Bone is a well-structured network and has five major functions of bone function:

1. Establish a body frame

2. As pengumpila and the attached muscles.

3. As part of the body to protect and maintain the tools (such as the brain, spinal cord, heart and lungs).

4. As a place to organize and deposits of calcium, phosphate, magnesium, and salt.

5. room amid certain bone as an organ that has other additional functions, namely a haemopoietic tissue to produce red blood cells, white blood cells and platelets.

The main component of bone tissue is mineral and organic tissue (collagen and proteoglycans). Calcium and phosphate form a salt crystals (hydroxyapatite), which is buried in a matrix of collagen and proteoglycans. Organic matrix of bone is also called osteid. Approximately 70% of osteoid collagen type I, which is rigid and gives high on the bone. Another organic material compiled in the form of bone proteoglycans. Almost all hollow bones melt. The structure thus maximizing the strength of the bone structure of the material is relatively small or light. Additional strength is obtained from the composition of collagen and mineral in bone tissue.

Bone tissue can be woven or lamellar form. Shaped woven bone seen rapid growth origin, such as fetal perekembangan time or after the occurrence of subsequent fractures of this state will be replaced by a more mature bone lamellar form.

In adults, bone GROWTH Ø webbing found in the ligament or tendon insertions. BONE interstitial growth can not occur in the bone. Therefore, interstitial growth occurs through the process of ossification in the cartilage endokondral.

There are two locations of growth cartilage in the long bones, namely:

1. articular cartilage. The growth of long bones occurs at the articular cartilage and is the only place for the bone to grow in the epiphyseal region. In short bone, bone growth occurs in the whole area of bone.

2. epiphyseal plate cartilage. Epiphyseal plate cartilage and diaphysis metaphysical gives the possibility to grow lengthwise. In this area there is a balance of growth between the two processes, namely:

F The process of growth. Interstitial growth of the epiphyseal plate cartilage allows the bones thickening

F Process classification. Death and replacement of cartilage on the metaphysical surface area occurs through the process of ossification endokondral.

ANATOMY OF BONE

Broadly speaking, the bone is divided into six:

1. the long bone (long bone), such as the femur, tibia, fibula, ulna, and humerus. Boundary area is called diaphysis and areas adjacent to the epiphyseal line called metaphysical. This area is very frequently found abnormalities or disease because this area is an area of active metabolic and contains many blood vessels. Damage or developmental abnormalities in the epiphyseal plate area will cause abnormal bone growth.

2. bones (short bone), for example, carpal bones

3. lamellar bone (flat bone), for example, the parietal bones, ribs, scapula, and Spelvis.

4. bones takberaturan (irregular bone), for example, vertebrate bones

5. sesamoid bones, such as the patellar bone.

6. bones Sutures (suture bone) no skull roof.

Bone consists of compact bone on the outside of which is called the cortex and the inner part (endosteum) that are shaped spongy trabecular and the outside is covered by the periosteum. Periosteum is thicker in children than in adults, which enables faster bone healing children dibangdingkan adults.

Bone histology

Based on histological, bone growth Ø divided into the two types:

1. bones of immature (non-lamellar bone, woven bone, bone fiber), formed in embryonic development and is not seen again at the age of 1 year of immature bone tissue contains a lot of collagen

2. bones mature (mature bone, bone lemelar), there are two types, namely cortical bone (corikal bone, dense bone, compact bone) and trabecular bone (cancellous bone, trabecular bone, spongiosa).

Histologically, differences in mature and immature bone, especially in the number of cells, tissue collagen, and mucopolysaccharides. Diaphysis or shaft is the center of the cylindrical bone. This section is composed of cortical bone that has a great strength. Metaphysical part of the bone is widened near the tip of the rod end of the bone. This area is mainly composed of trabecular bone or spongy bone containing red marrow. There is also a section of red marrow and epiphyseal bone and diaphysis. In children, red marrow fills most of the inside of the long bones but later replaced by yellow marrow in line with the more mature the child. In adults, the activity of hematopoietic be limited to the sternum and iliac crest bone although others still potentially active again when needed.

Yellow marrow is found in adult bone diaphysis primarily comprised of over fat cells. Metaphysical also sustains the joints and provides a large area for attachment of tendons and ligaments of the epiphysis. Epiphyseal plate is the area of longitudinal growth in children. This section will disappear in adult bone. Part of the epiphysis of long bones near the joints adhesion united with matafisis so that bone growth stops. The entire layer of bone covered by a fibrous layer called peristeum, which contains cells that can play a role in the process berfloriferasi and transverse growth of long bones.

Most long bones have nutrient artery. The location and the integrity of the vessels that determine the success or failure of the process penyebuhan a broken bone. Specific histology of the epiphyseal plate or growth plate is an important factor to understand injury in children. The top layer of cells that is located near the area called the epiphyseal resting cells. The next layer is a zone of proliferation. In this zone of active cell division occurs and where the start of a long bone growth. Active cells is driven towards the trunk bone, into the area of hypertrophy, where these cells swell, become weak and become metabolically inactive. Epiphyseal fractures in children often occurs at this place and the injury may extend into the area of calcification provincional. In the area of this provisinonal kalsfikasi cells start to become hard and resemble normal bone. When the area started to become hard and proliferation of bone resembling normal. If the damaged area of proliferation, growth can be halted due to retardation of longitudinal growth of the limbs or deformities profresif when only

CELL PHYSIOLOGY

BONE

Bone is a dynamic tissue that tersusu three types of cells: osteoblasts, osteocytes, and osteoclasts.

1. osteoblasts, build bone with type I collagen and proteoglycans as bone matrix or osteoid tissue through a process called ossification. When the network is being actively produce osteoid, osteoblasts mensekresikasikan large number of alkaline phosphatase and phosphate into bone matrix. Most of the alkaline phosphatase will enter the blood stream so that the levels of alkaline phosphatase in the blood may be a good indicator of the rate of bone formation after suffering a broken bone or in the case of cancer metastasis to bone.

2. osteocytes, bone cells mature is acting as a path for the exchange of chemical through the dense bone.

3. Osteoclasts are large multinucleated cells that allows the bone mineral and matrix can diabsopsi. Osteoblasts and osteocytes Unlike, megikis osteoclast bone. These cells produce proteolytic enzymes which break the bone matrix and some acids that dissolve bone mineral calcium and phosphate released into the blood stream.

Under normal circumstances, the bone formation and the absorption at a constant rate, except during childhood growth that occurs more frequently than the absorption of bone formation. This process is essential for normal function of bone. This situation can make the bones may respond to pressure meningkata and preventing fractures, bone shapes can be customized to bear the increased mechanical strength. The amendment also helps maintain bone strength in the aging process. Organic matrix degenerates sehigga can already make relatively bones become weak and fragile. The new bone formation requires a new organic matrix that gives additional strength to the

BONE BIOCHEMISTRY

Bone structure changed very slowly Ø bone. especially after a period of bone growth ends. After this phase of bone remodeling occurs more frequently in the form of microscopic changes due to the activity of bone as an organ fisiolgis biochemical bone. Bone composition consists of 33% organic substances and inorganic substances 67%

1. substance of bone consists of bone cells and the intracellular organic substance or collagen matrix and is the largest part of the bone matrix (90%), while the rest is hyaluronic acid and chondroitin sulfuric acid.

2. Substance consisting primarily of inorganic calcium and phosphate and the rest is magnesium, sodium, hydroxyl, carbonate and fluoride. Bone alkaline phosphatase enzyme is produced by osteoblasts that are likely to have an important role in the production of organs before the calcified bone matrix

BONE METABOLISM

Some of hormone regulated bone metabolism. Ø Increased levels of parathyroid hormone has a direct and immediate effect on bone mineral, which causes calcium and phosphate diabsobsi and move into the serum. In addition, increased levels of the hormone paratriroid slowly causing increase in the number and activity of osteoclasts resulting in dimeneralisasi. Elevated levels of serum calcium in hyperparathyroidism may also cause the formation of kidney stones. Calcium and phosphate metabolism are closely related. Bone containing 99% of serum phosphate body. Calcium several important functions in the body.

An important function of calcium in the body:

1. the blood clotting mechanism does

2. neuromuscular impulse transmission

3. 's acid-base balance

4. Permeabilatas cell memberan

5. As the adhesive (adhesiveness) between cells

6. Providing rigidity and mechanical strength of bone setting calcium ion concentration and extracellular fluid is very important in the process of acid-base homeostasis.

Some of the organs involved in the regulation of calcium ion homeostasis include kidney, intertinal, and bone. On the state of calcium ion concentration exceeds the range (levels) in normal extracellular fluid (> 11mg/dl), organ intertinal with calcitriol will seek to reduce the absorption of extracellular calcium ions. Kidney calcium ion release then let out with urine so that the levels of calcium ions in the extracellular may decline. Assist in the reduction in bone calcium ion concentration by osteoclasts and locking and expenditure of calcium ions from bone matrix by osteoblasts. ] In the circumstances of calcium ion concentration below the range (levels) in the extracellular fluid of normal (<8.5 mg / dl), intestinal organs with calcitriol will seek to boost the absorption of calcium from the extracellular. The kidneys then maintain calcium ions that do not come out with urine so that the extracellular calcium ion levels can remain stable. Bones help level the increase in the concentration of calcium ions in the mechanism simulation penigkatan calcium ion release and storage of bone by osteoclasts.

Vitamin D affects bone deposition and absorption. Vitamin in large amounts can cause bone absorption as seen in the high levels of parathyroid hormone. If there is no vitamin D, parathyroid hormone will not cause bone absorption. Vitamin D helps small amounts of bone calcification, such as by increasing the absorption of calcium and phosphate by the small intestine. Estrogen stimulates osteoblasts. The decline in estrogen after menopause reduces osteoblastic akrtivitas, which causes a decrease in the organic matrix of bone. Generally, bone calcification is not affected by osteoporosis that occurs in women before age 65 years. However, the reduced matrix organiklah which is the cause of osteoporosis.

CHAPTER III

BENIGN TUMOR BONE

D EFINISI

Tumor of bone is a bone disorder that is neoplastic. Tumors in the strict sense means a bump, while any new and abnormal growth called a neoplasm.

A tumor dalah new cell growth, abnormal, progressive, where the cells never become mature. With another term that is often used "Bone Tumors", ie abnormal bone growth that can be benign or malignant.

Tumors can be benign or malignant. Malignant tumors can be either primary bone derived from elements of the bone itself or secondary metastasis (infiltration) malignant tumors of other organs to the bone.

1. Benign tumors (benign)

Benign tumors (benign) do not invade and destroy tissue (collection of interconnected cells that form a similar function within an organism) are adjacent, but was able to grow locally enlarged. Usually after surgical removal (benign tumors), tumors of this type will not appear again.

2. Malignant Tumors (Malignant)

More of this type of tumor known as cancer, which has the potential to invade and destroy adjacent tissues, either by direct growth in adjacent tissue (invasion) or cause the occurrence of metastasis (migration of cells to distant sites).

INCIDENCE

From all primary bone tumors; 65.8% are benign and 34.2% are malignant. This means that out of every three bone tumors are malignant one. Malignant bone tumors ranks eleventh of the entire existing malignant tumors and only 1.5% of all malignant tumors of organs. Comparison of bone tumor incidence in men and women are equal.

Primary benign bone tumor most commonly found are osteoma (39.3%), osteokondroma (32.5%), kondroma (9.8%) and the rest by other benign bone tumors.

Osteogenic sarcoma (48.8%) is a primary malignant bone tumor most frequently found, followed by giant cell tumor (17.5%), kondrosarkoma (10%) and the rest is other malignant bone tumors.

Table Incidence of benign and malignant primary tumors in bone:

Benign Tumors		Malignant Tumors
Type	Incidence	Type	Incidence
Osteoma	39.3%	Osteogenic sarcoma	48.8%
Osteokondroma	32.5%	Giant cell tumor	17.5%
Kondroma	9.8%	Kondrosarkoma	10%
Other benign tumors	18.4%	Other malignant tumors	23.7%

WHO classification of tumors of bone

Determined according to the WHO classification based on histological criteria. In determining whether a tumor is benign or malignant is to consider the nature - the nature of the tumor, the origin of the cell as well as histological examination. Cells - cells derived from the mesoderm of the musculoskeletal but then differentiate into osteoclasts, chondroblasts, fibroblasts, and myeloblasts. Therefore, we recommend a bone tumor classification based on the origin of the cell, ie be osteogenic, kondrogenik, or mielogenik. Some things are important with respect to the determination of classification, ie:

1. pervasive networks do not always have a home network.

2. There is no clinical or pathological relationship in a special category

3. Often there is no relationship between benign and malignant disorders with elements - network elements, such as osteoma and osteosarcoma.

Classification based on origin of cell neoplasms of bone , among others:

v Primary

1. tumor tissue origin of bone (Osteogenik)

Tame: Osteoma .

Osteoid o steoma .

Osteoblastoma benign.

Malignant: Osteosarcoma .

Parosteal o steosarkoma .

2. tumor tissue origin cartilage (Kondrogenik)

Tame: K ondroma .

Osteokondroma .

Kondroblastoma benign.

Fibroma k ondromiksoid .

Malignant : Kondrosarkoma

Kondrosarkoma juksta cortical

3. Tumor origin of connective tissue (Fibrogenik)

Tame: Non Ossifying fibroma ..

Lipoma.

Malignant: Fibrosarkoma

Mesenkimoma malignant.

Liposarkoma.

Not differentiated sarcomas.

4. Tumor origin of bone marrow (mielogenik)

Malignant: Ewing's Sarcoma .

Limfosarkoma bone.

Reticulo sarcoma of bone.

M i eloma multip el.

5. Tumor vascular origin

Tame: Hemangiomas.

Lymphangioma.

Glomus tumor.

Intermediate: Hemangio-endotelioma.

Hemangio-perisitoma.

Malignant: angiosarcoma.

6. tumors of bone other his

Tame: Giant cell tumor .

Neurilemoma.

Neurofibroma.

Malignant: Kordoma .

Adamantinoma .

v Secondary / Metastatic

Tumors that originate from other organs that spread to the bone.

C ontoh: tumor / lung cancer that spread to the bone, where the tumor cells resemble cells of the lung and is not a bone cell.

Are included in the category of secondary bone tumors are:

Metastatic tumors .

Tumors derived from the results of the adjacent neoplasm issue .

Tumors that are the result of injury or harm to the transformation of a benign tumor that had been there before.

Classification according to TNM , namely:

Ø T = tumor stem

TX tumors can not be achieved .

T0 primary tumor was not found .

T1 tumors are confined in periost .

T2 tumors penetrate periost .

T3 tumors into the surrounding organs or bone structure .

Ø regional lymph nodes N =

N0 tumors are not found in the lymph nodes .

N1 tumor in the regional lymph nodes .

Ø M = Distant metastases

M 0 not found distant metastases .

M 1 distant metastasis .

BENIGN TUMOR BONE

Benign tumors of bone tissue origin

Osteom a (Ivory exostosis)

Clinical picture:

Osteoma is a benign tumor most commonly found of all benign bone tumors, mainly in the age of 20-40 years. It is small but can be large without causing symptoms - specific symptoms.

Location

The disorder is mostly found in the bones of the skull such as the maxilla, mandible, palate, sinuses paranasalis, and may also be in the bones - long bones such as the tibia, femur, falangs are usually multiple.

Osteoma is round with a clear boundary in the absence of bone destruction. In tangential view of osteoma looks like a dome.

Pathology

Osteoma is a specific process at least in the sinuses and kalfarium small lesions enlarged and have identical radiographic picture of the year - except ketahun increase in size. It signifies not develop lesions of multiple processes. lesions can be found in compact bone with Haversian system or on trabecular bone with marrow called spongiosteoma. The structure is composed of mature bone tissue is dominated by the structure - lamellar structure with a very slow growth.

Treatment

When small is not cause complaints and no special action is required. When it is cosmetics or can provide interference suppression are causing complaints surrounding kejaringan, excision should be performed.

Osteoid Osteoma

Benign osteoblastic tumor composed of osteoid core with high vascularization and bone is a benign tumor with limited growth potential.

Osteoid Osteoma is a benign tumor that is rarely found, especially at the age of 10-25 years. Male - male versus female 2: 1. Most prominent symptom is pain in a particular area and usually become heavy at night. The pain usually disappears by administering low-dose salicylates, and NSAIDs.

Location

The most frequent location of the long bones such as the femur, tibia, and the rest of the area - other areas such as the spine.

Radiologically

In the x-ray photograph found radiolusen.yang area is called the nidus with less than 2 cm in diameter diaphysis area surrounded by an area of dense sclerosis, and thickening of cortical bone formation is a reaction. Nidus can be located in the cortex or periosteal bone intramedular gap in the metaphysical or diaphysis of long bones (epiphysis is very rare). For intrakortikal lesion diagnosis also can be more difficult when there is expansion of intra-articular or occur in spinal.

Pathology

The disorder consists of a mobile network with a high degree of vascularization of bone tissue and immature osteoid tissue

Treatment

Effective treatment is removing the entire network of open partial excision of the nidus with bone and placement of bone graft material. After the evaluation of the x-ray examination should be done to assess whether excision is performed accurately. Impaired bone integrity causing long convalescence.

Osteoid osteoma image

Radiological features found radiolucent nidus area and pathological features are found where the red circle trabecular bone .

Differential Diagnosis

Sclerosing Osteomeilitis, Brodie abscess, periostitis, Bone Cyst. Important differential diagnosis is intracortical osteosarcoma.

Osteoblastoma Tame (Giant Osteoma osteoid)

Tumor size larger than osteoid Osteoma, more rarely and most often in the bones vertebra.1 more than 1.5 cm in size. osteoid osteoma is a difference with osteoblastoma not produce prostaglandins / prostaciklin that cause tissue reaction.

Overview Clinical

These tumors are usually found mainly in young adults and is more common in men - men from the women. Symptoms of pain inflicted lighter than osteoid osteoma and more rare. This disorder is only 2.5% of all benign bone tumors.

Location

Can the long and short bones with a predilection for the vertebrae and bones - other flat bones, such as the ilium, ribs, finger bones and leg bones. .

Radiology

Looks osteolytic areas with edges that are not / slightly sclerotic. Picture similar to bone abscess. Radiolucent lesion found radiodensities type matrix. Lesion size greater than 2 cm.4 photo shows the location of the eccentric MRI and cortical tissue expansion.

Radiological features found radiolucent lesion with matrix tiperadiodensities, the MRI found cortical tissue expansion.

Pathology

Preview histology is similar to osteid osteoma, but temperament is more aggressive, with a size greater than 2 cm. Not obtained at sclerotic bone. Osteoblast and osteoclast like giant cell associated with osteoid spicules and accompanied by fibrous sruma shows prominent vascularity.

Picture of giant cells associated with osteoid spicules .

Therapy

Operative excision. When lesions are needed bone graft to fill in the excised bones.

• aneurysmal bone cyst

Aneurysmal bone cyst is a benign tumor that rarely affects the spine elements of the vertebral body itself. The tumor may affect the further growth, appeared with tenderness and in some cases, and neurological symptoms. Causes less known. Recommended treatment is excision and curettage of the lesion and decompression of the spinal elements when needed.

• Giant cell tumor

Giant cell tumors are benign but locally aggressive lesion on a metaphysical can be malignancy. Giant cell tumors can be metastatic and can even cause death. Giant cell tumors are less commonly understood in the vertebral body (the front of the spine) and although usually benign, can become aggressive and sometimes - sometimes spread elsewhere. Most often appears at the age of 20-40 years and varied. More often in women than men - men. Therapy usually is operative with resection (complete) enblok as the most preferred option. There are several other roads where radiation and tumor immobilization would improve operating risk and outcome of these tumors requires careful preoperative planning - careful and approach before the start of the surgical procedure.

• Eosinophilic granuloma

Eosinophilic granuloma is a benign lesion of bone that appeared with pain and on radiological picture found "vertebra plana" ie vertebral collapse or depletion. The tumors can occur alone or as of a syndrome that involves a lot of bones and other parts. The decision must be individualized therapy for the treatment. Many of these tumors can be treated without surgery by administering low doses of radiation.

Benign tumors of cartilage tissue origin

K ondroma

Also called enkondroma, m erupakan benign neoplasm of bone with a frequency of 9.8% of all benign bone tumors, derived from cartilage tissue. majority of experts consider it as a hamartoma tumor. These benign tumors are usually found at the age of young adults , but can also be at any age. Symptoms usually a painless lump.

Enchondromatosis multiple forms rather than enchondroma is also known as Ollier's Disease. When enchondromatosis accompanied with multiple hemangiomas in soft tissue called the Mafucci Syndrome.

Location

This tumor most commonly affects the small tubular bones (acral skeleton) on the hands and feet, sometimes in larger bones, such as femur, hemerus, tibia, fibula, radius and ulna. In the long bones found in the metaphysical and the distal or proximal diaphysis.

Radiology

It appears as a radiolucent lesion on intramedular zone with possible patches of circular shape classification. This suggests that the presence of mature hyaline cartilage. No reactive new bone formation. If no cortical erosion on a large tubular bones., Indicating the occurrence of malignant degeneration.

Radiological features with radiolucent lesions on zonaintramedular, pathologic features are low cellu l arity, lobularity vague, and focal calcified.

Pathology

P no biopsy specimens obtained at 3 characteristic lesions include vague l o bularity, abundant cartilaginous matrix with focal calcified and low cellularity. Alternatively There is the formation of mature cartilage without signs - signs pleomorf, mitosis or symptoms - symptoms of other malignancies. Often found in the miksoid changes on the network. If found enkondromatosis accompanied by multiple hemangiomas on the soft tissues, the disorder is called Maffucci syndrome. Changes towards malignancy in enkondromatosis more often than solitary enkondroma. Sign - a sign of malignancy usually occurs after the age of 30 years at the premises of symptoms such as pain, enlargement of the tumor which arrived - arrived and erosion of the bone cortex.

Therapy

Treatment is not always necessary. When tumors grow large or reveal any pathologic fracture through the tumor should be removed and then filled with tissue curettage of bone from elsewhere. , then the lesion cavity is filled with bone graft.

Prognosis

A da possibility of malignant degeneration, especially when the tumor is obtained on a large or long bones in the pelvis, of approximately 20-25%. Suspected changes direction when the tumor is malignant pain porch.

Osteokondroma / Osteocartilagenous exostosis

Is a benign bone neoplasm most frequently obtained. By some experts considered not neoplasms, but as a hamartoma (new growth, where the cells can be grown).

Overview Clinical

There in young adults with complaints of lump hard and painful, growing very slowly.

Location

Found on the long bone metaphysis primarily in the distal femur, proximal tibia and proximal humerus (35%), pelvis and scapula. tumors are solitary with a wide base or as small as and when multiple stalks known as diafisial aklasia that is hereditary and inherited dominant mutant gene.

Radiology

The shape there are two kinds , namely :

1. Sessile / pedunculated .

2. Having a broad base (sessile) .

Plain photo illustration shows bone growth outside the area stemmed metaphysical. Form of uniform lesions, cartilage with calcification. Corteks and connected by cord lesions.

Picture an f bibs plain suggests that stemmed metaphysical areas, calcified cartilage, pathological features found in the mature trabecular cells were uniform.

Pathology

T erdapat trabecular mature cortical bone with cartilage cells are uniform. Thickness of less than 1 cm. Several small islands are the same shape.

Therapy

When the complainant because the tumor presses the nearby structures such as tendons, nerves, then performed excision.

Prognosis

All right. Complications of malignant degeneration (be Kondrosarkoma) of approximately 1%.

Multiple Osteochondromatosis / diaphyseal Aclasis

Is a congenital disease, is a hereditary autosomal dominant. Acquired osteochondroma are scattered in several places. Picture of radiology and pathology is similar to that solitary osteochondroma. On multiple forms, the possibility of malignant degeneration increases to approximately 10%.

• Periosteal condroma

Jarana there is growth that appears on the inner lining of the periosteum. Cartilage swelling of the bone and soft kejaringan be a symptom for patients. When patients find no calcified cartilage, lesion itself is not visible on x-ray, but the bone surface can be uneven and mencembung. MRI may be mengungkapakan usuran actual tumors. Histologically contains a lot of cartilage cells.
treatment has a tendency to relapse, the best way hádala with removal of the tumor with marginal excision. Recurrent lesions may look more aggressive but the lesion may be malignant unchanged.

Kondroblastoma benign (Codman's tumor)

Is a rare benign bone and often at the age of 10-25 years, some authors state more often found in men than women with a ratio of 2:1. And is one of the two incomplete differentiation of bone neoplasms with soft, similar noplasma is chondromiksoid fibroma. incidence of approximately 10% of all bone neoplasms. Ladman 1931 kondroblastoma classify as a variation of Giant cell tumor.

Tumor growth was very slow. Symptoms of pain is the main symptom symptoms, especially in the joints. There are authors who consider that 50% of these tumors can be malignant.

Location

Kondromablastoma benign derived from epiphyseal region and evolve towards the metaphysical. Tumor mainly found in the long bones, particularly the proximal epiphysis of the tibia, distal femur and proximal humerus.

Radiological

On plain X-ray is clearly visible on the bone rekfaksi kanselosa can widen out from the epiphyseal line. Eccentric shape with a thin cortex but penetration out rare. Tumor boundaries are irregular, not firmly accompanied with flecks of calcification as a picture of the deposition of calcium. There is no evidence of metastasis adanyanya, and cortex intact.

Radiological features with radiolucent area round / oval eccentric layout, with the pathological features of spindle-shaped lobe or cell stella.

Pathology

Pathological picture is very typical of the area lobulasi or spindle-shaped cells with tissue miksoid stella and kondroid separated from the intercellular tissue contains more cells with bentuls Pindle with some multinucleated giant cells with different shapes. May be found pleomorf cells.

Treatment

This could potentially be a malignant tumor that is not enough to just do curettage alone but also required local excision. Another option that has been reported and replace Polymethymethacrylate or implatasi fat for treatment after curettage and cauterisasi chemical (phenol), cryotherapy with liquid nitrogen.

Non Ossifying fibroma / Non Osteogenik fibroma

Is a benign lesion that is considered by most experts as a reactive lesion, not a true neoplasm. These lesions are self-limiting obtained in children and young adults between the ages of 5 to 20 years. Large lesions covering most of the diameter of the bone is indicated by the presence of a pathological fracture.

Location

Usually the long bones, especially the bones of the lower extremities. Usually the metaphysical or metadiafisis of long bones, especially the distal femur, distal tibia and fibula.

Overview Clinical

Not result in a complaint, found by chance.

Radiological

T ampak as osteolytic area with trabeculation, thus providing an overview multikuler with sclerotic edges. Lesions are usually on the lateral part of the bone and cortical section slowly expands. Clinical importance than these lesions is that the lesion may be in over-diagnosis and over-treatment later. In fact, when the lesion is unknown nature, it actually does not require therapy.

Preview radiologisdaerah osteolytic with trabeculation, pathologic features are uniform spindle cells.

Pathology

A curette aringan of the results reveals a small area yellowish, weakly visible at a magnification of uniform spindle cells and some giant cells.

Therapy

In adulthood these tumors will disappear by itself.

Benign cystic tumor of bone

• Fibrous cortical defect

Fibrous cortical defect or cortical desmoid fibroma is a small hemartomatous often seen on the lower extremities in children metaphysical in its infancy. Multiple and can be as much as 25% in asymptomatic normal children showed lesions at the age of 5 years. The lesions will disappear as a result of bone remodeling before bone maturity. Excessive pressure on the spine can become symptomatic and may also lead to inhibition of the activity of the isotope bone scan.

In the case of fibrous cortical defect microscopic examination showed benign fibroblasts with areas sometimes - sometimes histiocytes, foam cells and giant cells benign. The radiographic picture is also typical for this disease. A biopsy is usually not necessary. This is stage 1 lesions and can usually be observed.

DIAGNOSIS

To establish the diagnosis of bone tumors needed a few things, namely:

History

History is important to know the history of disorders or previous trauma. It should also be asked whether there is a family history of similar disease eg diafisial aklasia that are hereditary.

A few things to note in history are:

1. Age

Age of patients is very important to know as much bone tumors that have a quirk in the age of occurrence, such as osteogenic sarcoma found in children up before the young adults, kondrosarkoma at the age of 40 years, giant cell tumor is rare under the age of 20 years.

2. Lama and progression (progression) tumor

Benign tumors usually grow slowly and if there is rapid development in a short time or a benign tumor that suddenly becomes big it needs suspected malignancy.

3. Pain

Pain is the main complaint in malignant tumors. The presence of pain showed signs of rapid expansion and suppression of tumor into the surrounding tissue, hemorrhage or degeneration.

4. Swelling

Sometimes patients complain of a swelling, which arises slowly in periods of prolonged or sudden.

Clinical examination

The things that are important to the clinical examination are:

1. Locations

Some types of tumors have a classic location and places a particular predilection as in the epiphysis, metaphysis bone, or attack certain bones of the skull, for example osteoma in the area, osteogenic sarcoma in the metaphysical area, osteoblastoma in the vertebrae.

2. Great, shape, boundaries and nature of the tumor

Tumors are less likely a benign tumor, whereas tumors are likely malignant tumors. Important note also form tumors if accompanied by dilation of the blood vessels or ulcers that are characteristic of a malignant tumor. The signs of joint effusion may be found in tumors adjacent to joints.

3. joint movement disorders

In large tumors around the joints will give interference with the movement of the joints.

4. muscle spasm and stiffness of the spine

If there is a tumor in the spinal area, either benign or malignant, can provide spasm / stiffness of the spine muscles.

5. pathological fracture

Some complications of malignant tumors may provide a pathological fracture due to bone fragility occur so that the patient will present with fractures.

Neurological Examination

If there are symptoms in patients with neurological disorders, the neurological examination needs to be done carefully to determine whether these disorders arise because of the emphasis on certain nerve tumors.

Radiological examination

Is one of the most important examinations in the diagnosis of bone tumors. Plain done locally on the location of the lesion or photo survey the entire bone (bone survey) if the suspected presence of a tumor that is metastatic or primary tumor to the bone parts.

Plain radiographs of the spine may give you an idea:

• Location of tumors: epiphysis, metaphysis, diaphysis or in certain organs.

• Characteristically solitary or multiple.

• Type the affected bone.

• Limit firm tumors / no, containing calcifications / no.

• Form cystic or solid.

Other radiological examination to do, namely:

ü Radionukleida scanning , this test is usually used on small lesions such as osteoma.

ü CT scan, can provide information about the presence of a tumor or whether intraosseous ekstraoseus.

ü MRI, can provide information on whether the tumor is located in the bone or not, whether the tumor expands into the joints or soft tissues.

Laboratory Studies

§ Blood, include: LED examination, hemoglobin, serum alkaline phosphatase, serum protein electrophoresis, serum acid phosphatase that provide diagnostic value in malignant bone tumors.

§ Urine , critical examination is the examination of protein Bence Jones .

Examination of biopsy

The goal is to obtain sufficient material for histological examination, to help establish the diagnosis, and tumor staging (determining malignancy). The timing of the biopsy is very important because it can affect the results of radiological examinations are used in staging. If a CT-scan was made after biopsy, it would appear bleeding in the soft tissues that give the impression of an image of a malignancy in soft tissue.

Known two biopsy methods, namely:

o Biopsy closed, using FNAB (Fine Needle Aspiration Biopsy) to perform sitodiagnosis. Is one way to do a biopsy on the tumor diagnosis.

The advantages of FNAB is:

· No need of care.

· The risk of minor complications.

· Preventing the spread of tumors.

· Quickly get results.

o Open biopsy, a biopsy is the method through operative measures. The advantage is that it can be taken a larger network for histological examination and inspection ultramikroskopik, reduces errors and reduces the tendency of the network making the diagnostic distinction of benign and malignant tumors such as between enkondroma and kondrosarkoma, osteoblastoma and osteosarcoma. Open biopsy should not be done when it may cause difficulties in subsequent surgical procedure, such as the resection en bloc .

DIAGNOSIS

It should be done with extreme caution because of other disorders such as infections, myositis osifikans, hematoma can provide an overview of clinical and radiological picture resembling a malignant bone tumor. Abnormalities that may provide the clinical and radiological picture resembling a tumor, among others:

1. subperiosteal hematoma or soft tissue that will provide lump with pain.

2. Osteomyelitis can give symptoms such as malignant tumors or malignant osteosarcoma, Ewing.

3. fracture stress; This will provide an overview of symptoms of pain and fracture.

4. Myositis osifikans.

5. gouty arthritis.

MANAGEMENT

In benign tumors are usually not too difficult compared with malignant tumors. In malignant tumors of the necessary co-operation and consultation between oncology surgeons, orthopedic surgeons, radiologists, pathologists and prosthetic and rehabilitation experts.

v Benign Tumors

On a clear benign tumors, such as non-ossifying fibroma, a small osteokondroma usually no special action is required. If the kind of doubt it is necessary to tumor biopsy.

v Suspicious malignant tumors

If a suspected lesion in the primary tumor as a malignancy then the patient should be treated for a complete examination, blood tests, lung photo, either with plain film imaging and CT-scans and tumor biopsies.

Operation

Excision of the tumor by surgery can be performed by several techniques, namely:

Ø intralesional or intrakapsuler

This technique is done by excision / curettage of the tumor, is not recommended in malignant tumors and are usually done in groups of tumors low grade tumor , such as giant cell tumor.

Ø marginal excision

Is spending tumors outside of the capsule. This technique is mainly performed on the tumor is benign or malignant type of low grade malignancy .

Ø Wide excision (excision en-bloc )

Removed intact tumor tissue surrounding the tumor is accompanied by a pseudo-capsule or tissue outside the tumor reacts. Wide excision performed on malignant tumors and are usually combined with chemotherapy or radiotherapy in pre / post surgery.

Ø Operation radical

Do like the wide excision and coupled with spending the whole bones and joints and tissues as an integral part. This method is usually a limb amputation on it and sliding joints spending on it.

With proper staging and chemotherapy to control the spread of the tumor, amputation can be avoided by a technique called limb-sparing surgery (limb saving procedure) in the form of wide excision is accompanied by the replacement of limbs by using bone graft or protesis tailored to members The motion specifically made individually.

Radiotherapy

With high-energy radiation is a way to eradicate malignant tumors are radiosensitive and can also act as an initial treatment before surgery is performed. The combination of radiotherapy can be given together with chemotherapy. Radiotherapy is performed in circumstances in-operable , for example the presence of metastasis or local circumstances do not allow for surgery.

Chemotherapy

Is an additional treatment in malignant tumors of bone and soft tissue. The drugs used are methotrexate, adriamycin, cyclophosphamide, vincristine, sisplatinum. Chemotherapy is usually performed on pre / post surgery.

CHAPTER IV

CONCLUSION

Tumor of bone is a bone disorder that is neoplastic. With another term "Bone Tumors" is the abnormal growth of bone that can be benign or malignant.

From all primary bone tumors; 65.8% are benign and 34.2% are malignant. This means that out of every three bone tumors are malignant one. Comparison of the incidence of tumors of bone in men and women are equal.

Classification based on origin of cell neoplasms of bone , namely: primary (osteogenic, kondrogenik, fibrogenik, mielogenik, tumor vascular origin, other bone tumors) and secondary / metastatic (t umor derived from other organs that spread to the bone ).

To establish the diagnosis of bone tumors needed a few things, namely: history taking, clinical examination, neurological examination, radiological examination, laboratory tests, and biopsy examination.

Methods of treatment on bone neoplasms among others with surgery, radiotherapy, and chemotherapy. There are several techniques of operation, namely: intralesional or intrakapsuler, marginal excision, wide excision, and radical surgery.