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Hi, everyone. I'm doctor. And today I'll be giving you a presentation on the radiological essentials of prescribing bone tubes. Um I would be using these objectives. So by the end of the presentation, I hope that today we'll be able to understand the key radiological features of bone tumors, identify the key differences between benign and malignant characters of tumors that you can see radiologically on x-rays and systemically describe bone tumors on x-rays. I think x-rays are common things we do in hospitals at the bedside. They uh they easily accessible in most centers even in low income countries these days. I think that is quite important. There are key features that can be found on x rays that I think are important to identify and discuss for bone use. And we will be, we will also talk briefly about correlating these radiological findings with the clinical scenarios you find yourself in because the lesion could mean a different thing in a younger age group, in a woman or in someone with certain comorbid conditions. By way of introduction BB, bone tumors are cancerous growths that develop within bone and surrounding structures. They could be benign or malignant imaging plays a critical role in diagnosing and I in the management of bone use. So how they are diagnosed and picked up, they can often be diagnosed and picked up on basic imaging like ra radiographic x-rays and the monitoring. It's management and subsequent follow up can be quite guided by x-rays. Like with everything radiology, it's quite important to have this systematic descriptions methods. It is important for communication. It's important in having conversations with colleagues. It's important in research and it is important in documentation. So by to, to have a better sense of things, we can see that bone, there are different ways in which bone tumors can be classified. The only way that they can be classified is based on their biological behaviors. Are they benign or are they malignant? The benign tumors being non aggressive, being slow growing, being well defined and malignant tumors being quite aggressive. They are ill defined, they have ill defined margins on x rays and they have the ability to metas metastasize to either surrounding bone tissues, to surrounding soft tissues around the bone or to other organs within the body. The other way apart from the biological behavior that bone tumors can be classified is by the tissue of origin where exactly that is malignant cells from. Sometimes they are bone forming cells. So we in examples would be osteosarcomas or osteoid osteomas. It could be cartilage forming where we have chondrosarcomas and uh and chondromas. It could be fibrous tissue where we have fibrous, there could be a fibroid fibrous origin with fibrosarcomas and no, no, no nonossifying fibroma. And there could be tissue. There could sometimes be tissues that are not of it, uh that do not belong to any of these classes. And we see a sarcoma or sometimes sometimes the bone itself because of his nature and because of his vascularity tends to be a very common site for metastasis. So we could see we could take biopsies and see that these malignancies, these growths are from distant tissues like liver. It could be from the lungs, it could be from the prostate. Also with in the same age group, see a illdefined or well-defined bone tumor growth around the bone and give you an idea. It's a pediatric patient. This could likely be an osteosarcoma S sarcoma in adults. It could more likely you could start thinking, ok. Could this be have been a Met Me metastasis from somewhere else? Could this be a chondrosarcoma? The when this, when you do these X rays and you, you're faced with these lesions? One thing that, that you should always bear in mind is that as long as you use a systematic approach, it could be easy to makes things a lot easier to have an idea of what's going on. So with the systematic approach, the first thing would be location, what part of the bone is this? Uh f would be a type of book. Where exactly is this, is this a skull? Is this a long bone? Is this the spine? This is a pelvic bone. I can give you an idea of what could be the source of this tumor. Uh Bone, bone tumors tend to first spread locally. So, or if it's a metastasis from one or the most likely first point of call would be surrounding bone and tissue. So it's a prostate. It could likely be the lumbar or the sacral or the pelvic bones it spread to or if it's just called it could, could it be a surrounding bone tumor? Could it be meningeal tumor? Could it be a tumor? Brain tumor? Could it could be something around it. So, just knowing what bone is, give us a good idea and where, what part of the bone is it affected? Can aid in description, just telling someone that look, I've seen a lesion around the metaphysis of the bone, the diaphysis of the bone. If it's, if of a bone are spreading between all these three layers will give us a very good idea of what's going on. And then the next very, quite important thing would be the margins and the matrix. Is it well or I defined this will give us an idea of, is this an o lesion? Is it chondroid lesion? Is it a benign lesion? Is it a malignant lesion? Just by the the margins with benign lesions, we tend to see well defined margins. With malignant lesions, we tend to see poorly defined margins. And sometimes there's a mixed picture where it could have been either the tissue, an atypical growth or a tissue or benign lesion has subsequently become malignant. Next is the surrounding um periosteal reaction. So, with uh per reactions can give us an idea of what's going on. This. Uh usually the reactions of the surrounding bony tissue, the reactions of the surrounding cat reaction of the of the, of the surrounding tissue to this abnormal rapidly growing tumor and they react. So the periosteum which is an outer layer that lines that which is the outer layer of the bone, we tend to see, we tend to readjust and so this is rapidly growing tumor. So that's what we 10. So the patho of the perio reaction can give us an idea of what's going on. Some common descriptions. You see will be the only one of so was appearance for a airs or an O respectively. The next thing would be is the soft tissue involvement. This can also be seen in the x rays. Has it extended to the soft tissue. It is a mass extension. It's affecting the surrounding muscles, the cartilage, the bones, is it extending to surrounding bones? Is it exper to surrounding organs? And then the patient age group in a child, you could, like I mentioned earlier, you could start thinking that could this be an having sarcoma in an adult, you could start saying, oh, in someone who is elderly above 65 you said, OK. Could this be a secondary bone metastasis coming from somewhere else? I don't know if you can see this clearly. I'll try to use a the script or. Mm. So this just, there's something called a, called a radiological evaluation. It's called for bone tumors. It gives us an idea of what is God is it, It's, it's a radiological guide to differentiate between benign bone tumors and um malignant bone tumors. It gives an idea that look, this lesion is highly suggestive of benign tumor. This lesion is highly suggestive of malignant tumor. And I think understanding this form is essential because this is the key thing I II hope that anyone listening will take you away from this video. Just understanding the essentials. The first point would be what is the character of the tumor? Does it appear osteolytic? Does it appear osteoblastic or with osteolytic lesions? We are seeing that there is a decreased lucency between the bone with osteo osteoblastic lesion. We have seen an increased lucency. Osteolytic lesions are usually identify loss of bone tissue, a loss of surrounding bone tissue as a result of the mass as a result of the tumor and osteoblastic lesion show a rapid growth or rapid green on, on bone tissue around the muscle lesion with osteo with osteolytic lesions. These tend to usually be benign lesions as a rule of thumb and osteoblastic lesions. All mixed lesions tend to be to be highly suggestive. Oh, um malignant use next would be a day um the content of the tumor. So sometimes you could see tumors with high molarization around the bone. This can be looked at as areas of lucency or areas of increased lucency around the bone. This could if mineralization is absent, that's likely also a sign of an lesion on the bone benign tumor. And if there's high mineralization around the bone, it is very suggestive of and uh of a Malign. So if you can see the image here, we can see areas that was still pelias just around the tibia, the proximal end of the tibia. You can see this is the edge of the bone. It just gives you an idea that look, could this be a benign lesion? Could this be a malignant lesion? Next is the cortical breach. So, mm, if cortical erosions are, if, if the bone cortic themselves are still intact, there's minimal cortical erosion, that's highly so of a benign tumor that hasn't, there is no rapidly spreading beyond the margins of the bone. If there has been cortical bridge, if there's cortical erosion, then most likely we are seeing a tumor that is malignant. And this again is something that can be picked up radiologically from the x-ray. If you can look at it, these are the cortices of the bone in the proximal tibia in this image, you can see that mm there's been minimal Cortico bridge. Although the corti the cortices have thinned out like around here and around this area, it hasn't extended beyond the cortices. The cortices are still impact thinned out. Next is how, how does it look? Is it well defined? Is it ill defined? What exactly are the edges of it? So you can see here that you can still identify that this is the protocol tumor. It still has the appearance of the protal tibia. And the the growth of the lesion itself appear quite well defined. You can see this edge of the lesion. It appears well-defined. Even looking at the lateral view of the image, you can see that the edge of the lesion still appears well defined around the proximal edge of the tube. And then uh next would be, are there any soft tissue masses around? If, if the soft tissue mass is very present? Likely that is also suggestive of a malignant lesion because it's shown extension of the growth uh growth of that tumor into surrounding soft tissue, which indicates aggressiveness which in r indicates rapid growth, it's highly indicative of a malignant tumor. The next thing is that other pathological fractures because of these rapid growths and weakness of the causes is extension into surrounding tissues. Malignant tumors tend to have an increased risk of fractures. If there are any surrounding fractures around this lesion, you've seen that again is very, very highly subjective of the malignant group two. And is this only pera reaction I try I mentioned and explained pera reaction earlier. Mm um So if there is, if there is quite a lot of periosteal reaction again, it is in is an indica indication that the periost itself is quite reactive due to the rapid acceleration and growth of C. So this could be very highly suggestive of a malignant tumor. I hope that this has been quite helpful. The rest criteria, the regular evaluation score for bone tumor radiological evaluation score for bone tumors is quite an important criteria. It's quite something that is, it gives you, it gives cc conditions like a guide or general approach to bone tumors that than the look, this could likely be a malignant tumor and this could be benign. Well with this graph um with this x-ray which um is referenced from Wikipedia, we can see some of the common bone tumors are the glands. Um We, what we've described before, you can see some tumors that are malignant. Here is an osteosarcoma. It's difficult to see because the edges are quite ill defined. There is lots of surrounding soft tissue. You can see that there's soft tissue involvement and a perio reaction around the lesion. You can also see that with the cortices, it's it's bridge to cortices. The cortices are still not, is not intact. So with those sarcomas, they are no bone tumors, you can tell that look that's what's going on next for. Uh And also the lesions themselves are blastic. You can see that this isn't reduced, less, actually is an increase is there isn't reduced ency, this is an osteoblastic lesion. The next would be um A I will give a classic example of a benign tumor. We see a simple unicameral bone cyst. So, bone cyst are benign lesions. It is well defined just at the proximal edge of the of the fibular. Here, the cortices haven't been breached still. In fact, there's no surrounding periosteal reaction. There's an area of, there's this is a lesion with an area of really lucency within the bone. So in you can compare and contrast this to the bone cyst and the osteosarcoma where we are seeing an il lesion as opposed to this, which means that it looks like a mix areas of mild areas of pros in between, but that's an o lesion. So in comparison, this is mo mo one is a a clearly benign lesion most of the time and then the other is a osteo lesion, osteoplastic lesion, high surge of malignancy. So these are my references. I hope that this has been able to give at least the basic idea of the essentials of bone tumors. In some of our, in my next presentation, I'll be talking more extensively about this, looking at the different types of bone tumors, looking at how we can apply the risk criteria to this and exploring this in more detail. Thank you.