Tumor ganas tulang
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Tumor ganas tulang
Sylvia Rachman
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Membedakan tumor ganas & jinakMembedakan tumor ganas & jinak
• Destruksi korteks• Reaksi periosteal• Orientasi / aksis lesi• Zona transisi
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Destruksi korteksDestruksi korteks
Kortikal diganti oleh :• fibrous• chondroid• lesi tulang rawan
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Zona TransisiZona Transisi
• zona transisi sempit: jinak• zona transisi luas: ganas/agresif• zona sclerotik: jinak
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Zona transisi
• Zona transisi sempit
– batas yang tajam dan well-defined dan merupakan
sebuah tanda pertumbuhan yang lambat.
• Zona transisi lebar
– batas yang ill-defined dengan zona transisi yang luas
merupakan sebuah tanda pertumbuhan yang agresif.
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• Reaksi periosteal:
• Sun ray appearance
• Lamelar
• Seperti renda / irreguler.
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Jenis-jenis Reaksi Periosteal
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Foto polos
• Foto polos tulang memberikan gambaran tentang:
– Lokasi lesi
– Soliter atau multiple
– Jenis tulang yang terkena
– Sifat-sifat tumor
• Batas
• Uniform atau bervariasi, menyebabkan destruksi, memberikan reaksi
pada periosteum, jaringan lunak di sekitarnya terinfiltrasi.
– Sifat lesi
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Tulang Tulang
• Tumor ganas primer: 30%• Tumor ganas tulang sekunder: 70 %
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Lokasi Tumor Tulang Potongan Longitudinal
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Pola destruksi tulang• Geografik
– Batas yang tegas dan tajam. Proses yang kurang agresif, pertumbuhan
yang lebih lambat, dan jinak. Zona transisi sempit.
• Moth-eaten
– Batas compang-camping. Pertumbuhan yang cepat. Probabilitas
tinggi malignansi.
• Permeatif
– Lesi Ill-defined dengan gambaran ‘worm-holes’. Menyebar melewati
sumsum tulang. Zona transisi lebar. Lesi agresif keganasan round
cell.
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UmurUmur
• 1-30 th: – Ewing Sarcoma– Osteosarcoma
• 30-40 th: – Fibrosarcoma dan malignant fibrous histiocytoma– Giant cell tumor ganas – Reticulum cell sarcoma– Parosteal sarcoma
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• > 40 th:– Metastase– Myeloma– Chondrosarcoma
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OsteosarkomaOsteosarkoma
• Urutan ke-2 tumor tulang ganas primer• Frekuensi 2 kali chondrosarcoma dan 3 kali
Ewing sarcoma• 75 % timbul pada usia 10-25 th dengan
perbandingan pria - wanita 2:1• Gejala pembengkakan dan nyeri• Metafise femur distal, tibia proximal dan
humerus proximal
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• 3,5 – 7% terjadi di vertebra, 5% sclerotic, 25% litik, 25% campuran
• Metastase ke paru• Metastase ke tulang dapat terjadi, jarang bila
dibandingkan Ewing sarcoma
Gambaran radiologi: • Lesi permeatif tulang panjang bagian metafise• Reaksi periosteal: sun ray, segitiga Codman• Pembengkakan jaringan lunak sekitar lesi
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Reaksi periosteal perpendicular. (a) Diagram menunjukkan reaksi periosteal terspikulasi atau hair-on-end (panah). (b). Diagram menunjukkan reaksi periosteal radial atau sunburst
(panah). (c) Radiograf anteroposterior pada pasien dengan osteosarcoma yang menunjukkan reaksi periosteal perpendicular pada bagian proksimal femur
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Segitiga Codman. (a) Diagram menunjukkan peninggian periosteum (panah) membentuk sudut dengan korteks. (b) Radiograf lateral pada pasien dengan osteosarcoma yang
menunjukkan peniggian periosteum yang membentuk segitiga Codman (panah panjang). Perhatikan pembentukan tulang baru yang diinduksi tumor
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Ewing SarkomaEwing Sarkoma
• Sinonim :– Endothelioma tulang– Endothelial myeloma
• Insiden:– 7 % dari seluruh tumor tulang primer.– Nomor 4 tersering (setelah myeloma, osteosarcoma,
chondro sarcoma)• Usia: 10 - 25 th, jarang dibawah 5 th dan diatas 30 th
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• Perbandingan pria dan wanita 2 : 1• Rasa nyeri dan bengkak daerah lesi• Mirip proses peradangan (anemia, leukositosis, LED
meningkat)• Tulang panjang dari ekstremitas bawah (femur, tibia, tibula)
Gambaran radiologi:• Lesi permeatif di diafise• Reaksi periost onion skin• Fraktur patologis 5 %• Tumor tulang yang sering metastase ke tulang
dibandingkan tumor tulang lain
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Fibro SarkomaFibro Sarkoma
• Usia: 30 – 50 th• Lokasi: femur, tibia (50%) humerus (metafise)• Lesi: medulare (sentral), periosteal• Insiden: 2% seluruh tumor tulang ganas• Gejala: bengkak, nyeri, 1/3 kasus dengan fraktur
patologi, dapat terjadi sequestrasi
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Radiologik• Lesi destruksi medular (litik) eksentris• Pembengkakan jaringan lunak lebih hebat dari
tulang• Segitiga Codman bisa terjadi tapi jarang• Menjalar ke sistem limfatik
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Narrow zone of transition: NOF, SBC and ABC
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Giant Cell TumorGiant Cell Tumor
• 80% jinak, 20% ganas• Sinonim: osteoclastoma• Insiden: 5 – 8% tumor tulang ganas, 15% tumor tulang
jinak• Jinak predominant untuk wanita, ganas biasanya laki –
laki• Usia: 20 – 40 th• Rasa nyeri dan gangguan gerak sendi• Femur distal, tibia proksimal, radius distal, humerus
proksimal (os sacrum 8%)
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Radiologik• Lesi di metafise meluas kearah subartikuler
pada epifise sudah menutup• Lesi lusen eksentris• Sifat ekspansif dengan soap bubble appearance• Kadang–kadang sulit membedakan antara jinak
dan ganas
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Parosteal SarkomaParosteal Sarkoma
• Tumbuh sangat lambat (beda dengan sentral osteo sa)
• Usia: 30 – 40 / 50 thRadiologik• Sangat radioopak, homogen, juxtacortical• Sering di fossa poplitea femur
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Reticulum Cell SarcomaReticulum Cell Sarcoma(Non Hodgkin’s Lymphoma Tulang)
• 3 – 5% seluruh tumor tulang ganas• Usia: 20 / 30 – 40 th• Laki – laki lebih tinggi (2 : 1)• Rasa nyeri intermitens• 50% di os telah mengeluh selama 1 th• Lokasi: femur, tibia, humerus
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Radiologik• Destruksi meduler permeatif di diafise – metafise• Reaksi periosteal laminer minimal• Timbul massa jaringan lunak batas tegas
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Multiple MyelomaMultiple Myeloma
• Paling sering diantara tumor tulang ganas• 75%, usia antara 50 – 70 th, laki – laki lebih
tinggi 2 : 1• Rasa nyeri, dapat dihilangkan dengan istirahat• Lokasi: vertebra, calvarium, iga, scapula• Fraktur patologi sering terjadi
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Radiologik• Bone scan lesi “cold area”• Osteoporosis• Punched out lesion• Vertebra plana• Rain drop skull
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ChondrosarcomaChondrosarcoma
• Nomor 3 tersering di tumor tulang ganas• Usia: 40 – 60 th, laki – laki lebih sering 2:1• Rasa nyeri, dengan pembengkakan• Rasa nyeri hebat setelah terjadi fraktur patologis• Lokasi: pelvis, femur proksimal, humerus, iga,
scapula, sternum cranio facial, tibia proksimal, femur distal
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Radiologik• Lesi lusen, bulat atau oval, batas tidak jelas• Lesi di metafise atau diafise• Endosteal scalloping• Popcorn kalsifikasi• Metastase biasa ke tulang
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Metastase TulangMetastase Tulang
• Sering metastase tulang dari keganasan organ lain
• Tumor otak, karsinoma sel basal jarang metastase ke tulang, selain itu mempunyai potensi metastase ke tulang
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Insiden• 70% metastase tulang• 30% tumor ganas tulang• 80% metastase tulang berasal dari payudara,
prostat, paru dan ginjal• Wanita: 70% berasal payudara, lelaki: 60%
prostat, 25% paru• Usia diatas 40 th• Nyeri tulang, sering terjaga dari tidur
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• Metastase tulang dapat melalui:a. Langsung ekstensi dari tumorb.Sistem limfatikc. Hematogen (tersering)
• Lesi litik akibat erosi tekanan dari medula, tidak ada hubungan dengan aktifitas osteoclast
• Lesi blastik akibat reaksi reparasi dari lokal osteoid terhadap tumor.
• Lesi campuran
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Gambaran radiologi : • 80% metastase berlokasi sentral (tulang aksial,
terutama tulang belakang dan pelvis) selain itu di iga, kepala, femur, humerus
• Jarang distal genu dan cubiti• Dasar kelainan adalah perubahan densitas dan
struktur trabekula• 75% bersifat litik berupa moutheaten atau
permeatif 15% osteoblastik, difus 10% lesi berupa soliter
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• Lesi keluar dari tulang berupa ekspansif hebat, biasanya berasal keganasan ginjal dan tiroid
• Corpus vertebra dan pedicle sering sebagai tempat metastase
• Metastase tangan berasal dari karsinoma bronchogenik berupa ekstensif osteolisis
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• Aspek Radioterapi pada tumor tulang primer malignant
Yang sering :
- Osteosarcoma
- Ewing Sarcoma
- Chondrosarkoma
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• Secara klasik, untuk terapi tumor, termasuk tumor tulang yaitu :
- Operasi
- Radiasi dan kemoterapi
- Bisa sendiri-sendiri atau kombinasi
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Tumor tulang sebenarnya tergolong radioresisten, perlu dosis radiasi yang besar dibandingkan dengan tumor yang radiosensitif
Terapi radiasi tumor tulang mendahului amputasi, mempunyai 5 YSR lebih tinggi daripada amputasi saja
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• Pada osteosarcoma :- Penderita membutuhkan terapi operatif berupa amputasi. - Selain terapi operatif pada penderita diperukan terapi adjuvant berupa pemberian kemoterapi dan radioterapi
• Pada Ewing sarcoma :- Sensitif terhadap radioterapi tetapi tidak curable- Kemoterapi lebih efektif daripada radioterapi
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• Terbaik :
- Kombinasi kemoterapi pre operasi + eksisi luas (amputasi)
- Radioterapi dan eksisi lokal
- Kemoterapi selama satu tahun
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• Amputasi sebaiknya dihindari bila ditemukan metastasis di paru
• Dosis radiasi untuk tumor primer sekitar 70 – 80 Gray.
• Untuk tumor sekunder dapat diberikan dosis 30 – 45 Gray
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