Download MBBS Orthopaedics PPT 5 Benign Bone Tumour Lecture Notes

BENIGN BONE

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TUMOURS

CLASSIFICATION

1.BONE FORMING TUMOURS.

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a] BENIGN b]MALIGNANT.

. osteoma . Osteosarcoma

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. osteoid osteoma . juxta cortical

. Osteoblastoma osteosarcoma

. periosteal

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osteosarcoma

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2.CARTILAGE FORMING TUMOURS

a] BENIGN b]MALIGNANT

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. Chondrosarcoma

. osteochondroma

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. chondromyxoid fibroma
. chondroblastoma

3.GAINT CELL TUMOUR

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a] classical benign type (locally aggressive)
b] malignant GCT

4.MARROW TUMOURS

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a] ewings sarcoma
b] myeloma

5.VASCULAR TUMOUR

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A] benign b] malignant
. haemanigoma . angiosarcoma
. lymphangioma
. glomus tumour

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6. CONNECTIVE TISSUE TUMOURS

A] benign

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B] malignant

. desmoplastic fibroma . fibro sarcoma
. lipoma . Liposarcoma

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7.OTHER TUMOURS.
a] chordoma
b] adamantinoma
c] neurofibroma

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8.TUMOR LIKE LESIONS
a] solitary bone cyst
b] aneurysmal bone cyst
c] ganglion

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d] non ossifying fibroma
e] fibrous dysplasia
f] eosinophilic granuloma
g] myositis ossificans
h] brown tumor of hyper parathyriodism.

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Radiographic Features of the Various

Tumors

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Benign:
well circumscribed, narrow zone of transition, no periosteal

reaction, sclerotic border.

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Benign Aggressive:
expansion, thinning of cortex, usually lytic, +/- periosteal

reaction, +/- narrow zone of transition.
Malignant:

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++++periosteal reaction, large zone of transition, permeative,

moth eaten.

BENIGN TUMOUR

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BENIGN AGGRESSIVE TUMOUR

MALIGNANT TUMOUR

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Age of Tumors

<20y - Osteogenic Sarcoma, Ewings.

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20-40y - GCT, Chondrosarcoma, MFH, Lymphoma

In 60 y - Mets, Myeloma, Chondrosarcoma, late

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Osteogenic sarcoma, MFH, Fibrosarcoma.

Sites of Tumors

Diaphyseal: Ewings, Osteoid Osteoma, Mets,

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Adamantinoma, Fibrous Dysplasia

Epiphyseal: Chondroblastoma, GCT,

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Metaphyseal: Osteosarcoma, bone cysts.


OSTEOID OSTEOMA

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This is benign osteoblastic tumor with a well

demarcated nidus of less than 1 cm

surrounded by a distinct reactive bone

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INCIDENCE: 2.6% of all primary bone tumors
Age : 10-25 yrs
Sex: M:F::2:1
Site : long bones usually tibia and femur more

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commonly affected

Clinical feature:
.vague and intermittent pain more at night

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. pain relived by aspirin.
. mild swel ing , tenderness present

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X-ray : central lucency surrounding the nidus with or without

dense calcified center, which is surrounded by reactive

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sclerosis

Treatment : wide enblock resection with removal of

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surrounding sclerotic bone .


BENIGN OSTEOBLASTOMA

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A benign osteoblastoma is an uncommon vascular

osteoid and bone forming tumor .

It is very slow growing and characterized by

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absence of any reactive perifocal bone formation.

INCIDENCE:0.8% of all primary tumors.

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AGE:10-20yrs.

SITE: vertbra ,flat bones usually.

Microscopy - A well circumscribed tumor when it is expanded it is

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delimited by a shell of cortical new bone. Dense sheets of osteoid

and irregularly calcified new bone with intervening vascularized

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background of osteoblastic connective tissue stroma. Giant cells may

be present.

q Clinical Features: Pain, Swelling, Rarely As

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Fractures

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X RAY : Lesion is well circumscribed, radiolucent and expansile in

fusiform fashion . Cortex is preserved with or without calcification.

Malignant transformation has been reported.

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Treatment:
Small to moderate ? Curretage and bone grafting

Recurrent - enbloc marginal excision.

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ENCHONDROMA

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This is a benign cartilaginous tumor centrally located in phalynx.
INCIDENCE:3% of all bone tumors.
AGE:10-50yrs.
SITE: metaphysis is usually involved, it is common in phalanges

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of hand and feet.

PATHOLOGY: tumor surrounded by fibrous capsule neoplastic

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tissue is composed of bluish white translucent cartilage.

primitive mesenchymal cartilage is in periphery, while most

mature is in center of tumor.

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q Signs and symptoms : incidentally diagnosed radio logically,

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pain and enlargement of phalanx.

q X- ray : tumor appears cystic ( loculated or non ? loculated,

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cortex- thin and expanded it may be perforated . No reactive

bone formation.

circumscribed focus of popcorn like densities is characterstic

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of chondroma

Maffucci and ol iers syndrome ? associated with multiple

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enchhondroma.

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Treatment :
small ? curettage and bone grafting
recurrent ? radical resection

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Osteochondroma (exostosis)

It is aberrant developmental anomalies formed of bone and

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cartilage that arise from the periphery of cartilaginous growth

plate

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Most common benign bone tumor

Incidence : 11%

Age : common during growth period

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Sex : M : F :: 1.4 : 1

Pathology : usually lateral out growth of cartilage have all

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histological feature of " epiphyseal plate" in their

cartilaginous cap . Grows until epiphysis fuses

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Histology : deep layer of periosteum (cambium) retains ability

to form catilage and bone. Tumors may be due to perverted

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activity of this layer

Signs and symptoms : symptom less, pain and swelling can

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occur once bursitis or malignant changes occurs

firm to hard, fixed, painless mass overlying bone .

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X- ray :flow out from cortex of metaphyseal area no reaction

of underlying bone .Cartilaginous cap and overlying bursa are

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radiolucent

Malignant change occurs in 1-2%
Treatment :

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? Observation
? Surgery- removal of tumor with resection of extracapsular

margins

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CHONDROMYXOID FIBROMA

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Least common benign cartilaginous bone tumor
Incidence : 0.4%
Age : 10-30 yrs
Site: upper end tibia ,lower end of femur , lower end fibula.
Pathology : collagen fibers abundant in this tumor. Cellular

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population predominantly chondroid and myxoid in this case

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C/F : mild pain ,swelling ,tender mass fixed to bone

X-ray : translucent mass of variable size located eccentrically

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in the metaphysis , with in tumor faint trabecular pattern is

present .

Treatment : excision and bone grafting .

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CHONDROBLASTOMA

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Benign tumor arising in epiphysis consisting of

polygonal chondroblasts, small foci chondroid

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tissue , osteoclast like giant cells and samll foci

of calcification .

Its importance lies in to differentiate from GCT

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q INCIDENCE : 1 %

q Age : 10 -15 yrs

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q Site :upper end humerus ,lower end femur, upper end tibia
q Clinical feature : pain ,swelling ,limitation of movememts
q X ray :lesion eccentric and involves less than one half of entire

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epiphysis .

border of host bone sclerosis present, small puncture

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calcification present

q treatment :currettage and bone grafting .

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On MRI

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GIANT CELL TUMOR

It is an osteolytic lesion arising from epiphysis common in

young adults .

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Incidence : 5 %

Age : 20- 40 yrs (70 %cases )

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Sites : epiphyseal region of long bones , pelvis and sacrum.

Pathology : soft tumor very friable readily bleeding tissue

contains cavitation and small cysts . Color of tumor varies

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from reddish to chocolate brown .

Presence of abundant tumor giant cell and stromal

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hyperplasia is characteristic .

C/F : chronic course , swelling , pain , pathological fracture .
egg cell crackling sensation is characteristic

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X-ray : cortex is expanded and thin , osteolytic lesion ,no

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periosteal new bone formation .

Thin septa of bone traverse the interior and produce " soap

bubble appearance"

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q Treatment :
curettage and bone grafting ? recurrence is 40 %

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Treatment -
Curettage and acrylic cementation

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Curettage and bone grafting

Enblock excision for aggressive tumors

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Benign Cystic lesions -

Unicameral bone cyst

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Age : first 2 decades of life

Sex preponderance : M > F [2:1]

Location : long bones particularly metaphysis

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Types of UBC

1. Active cystic lesion - within 1cm of physis
2. Benign latent cysts ? separated from epiphysis

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Unicameral bone cyst (contd)

Pathophysiology

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Unclear

Focal defect in metaphyseal remodeling

Recent studies show increased activity of lysosomal

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enzymes in cyst fluid

Gerasimov AM et al(1991) Clin Orthop Relat Res.

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Unicameral bone cyst (contd)

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Pathology

Grossly, bone shows fusiform

expansion with thin cortex

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On microscopy, lined by fibrous

membrane < 1mm thick,
composed of fibroblast,

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mesenchymal cel s and lymphocytes

Histology of unicameral bone cyst

Unicameral bone cyst (contd)

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Fig1: simple bone

cyst in proximal

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humerus in 6 yr old

boy

Fig2: simple bone

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cyst in proximal

femur in a 11 yr old

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girl

Source: Greenspan 4th

ed ch 20

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Simple bone cyst in proximal

humerus with fallen leaf sign

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Source: Greenspan 4th ed ch 20

Treatment modalities

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Percutaneous:
Steroid injections-methylprednisolone acetate (Scaglietti

et al 1974 Clin Orthop Relat Res.)

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Other fibrosing agents

Trepenation (Komiya et al 1993 Clin Orthop)

Autologous bone marrow injection

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Open procedure: sub-total resection with or without

bone grafting

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Aneurysmal bone cyst

Age : usual y in 1st to 3rd decade of life .

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Sex : slight female predominance.

Location : any bone may be involved.
Most common is proximal humerus

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Types :

Primary : appears de novo following intraosseous A-

V fistula.

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Secondary : results of cystic changes in GCT,

osteoblastoma

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Aneurysmal bone cyst (contd)

Pathophysiology:

Unclear

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Local circulatory disturbance leading

to increased venous pressure

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Aneurysmal bone cyst (cont.)

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Pathology:

? Grossly, cavitatory

lesion with blood

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fil ed septate spaces

? On microscopy,

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cavernous spaces

separated by

cel ular stroma ?

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fibroblasts,

histiocytes, giant

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Histologic appearance of aneurysmal

cel s

bone cyst

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Source: Campbel 13th ed page 913

Gross appearance of ABC

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Source: pathpedia.com

Radiograph of tibia showing

ABC

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Source: Greenspan 4th ed ch

20

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Aneurysmal bone cyst (contd.)

Other investigation:

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Bone scan : shows dif use or peripheral tracer

uptake with decreased uptake in centre.

Ct scan : helpful in delineating the cyst

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MRI : shows multi loculated cavities & fluid level

Aneurysmal bone cyst (cont.)

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Treatment :

Curettage & bone grafting.

Marginal resection is indicated in expendable bone

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Low dose radiation

Other adjuvants- high speed burr, cement, phenol,

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argon beam coagulation, cryosurgery


Aneurysmal bone cyst (contd)

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Alternative treatment:
Arterial embolization

Sclerotherapy

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Curopsy (Reddy et al Clin Orthop Relat Resp 2014)

Percutaneous doxycycline (Fife et al J Lab clin Med 1997)

Denosumab

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Bisphosphonates

Case 1:

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12 year old female presented with pain and swelling left knee for 3 months.

Diagnosed as ABC and treated with curettage and bone cement.

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Case2:

40 year old male presented with complain of pain

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knee and swelling. First diagnosed as ABC treated

with intra-lesional sclerosant.

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FIBROUS DYSPLASIA

Intrinsic defect of endo-chondral bone maturation results

in incomplete or immature ossification , the absorbed

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bone is replaced by fibrous osseous tissue.

Incidence : 0.8%

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Age : 3-15 yrs .

Site : diaphysis or metaphysis of femur , tibia , fibula.

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Pathology : appearance of immature bone in a sea of fibrous

connective tissue.

immature dysplastic trabeculae are round, plump .

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Multinucleated giant cells +

q Clinical features : in wt. bearing bones marked deformity ,

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pathological # +

" sheperd crook " deformity of proximal femur is commonest

deformity ( 1-30 cms size ).

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Albright syndrome ? precocious puberty , fibrous dysplasia,

brown skin patches.

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X ray : cyst like lesion in diaphysis or metaphysis with

endosteal scalloping with or without bone expansion.

Uniform distribution of dysplastic trabeculae gives ground

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glass appearance.

q Treatment: Aim is to supplement dysplastic bone with bone

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cement and mechanical support by implants to produce

strength to prevent deformity and fracture than to eradicate

disease.

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Ground glass appearance

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Shepherd crook deformity

Conclusion

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Benign cystic lesions can mimic aggressive and malignant lesions of bone

and vice versa

Despite multi-modal approach to diagnosis of bone lesions, HPE remains

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the standard method

Standard treatment of benign cystic remains curettage/resection with

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bone graft despite advent of new treatment .


Thankyou

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MCQ 1

Fallen leaf sign is a feature of
1. Giant cell tumor
2. Unicameral bone cyst

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3. Fibrous dysplasia
4. enchondroma


MCQ 2

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Egg crackling feature is diagnostic of
1. Giant cell tumor
2. Enchondroma
3. Fibrous dysplasia

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4. Unicameral bone cyst

MCQ 3

A 25 years old female presents to us with a swelling

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around knee. On histopathology there is abundance of

giant cell in the backdrop of mononuclear cells. What is

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the most probable diagnosis
1. Fibrous dysplasia
2. Giant cell tumor
3. Aneurysmal bone cyst
4. Unicameral bone cyst

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MCQ 4

Treatment of shown exostosis with no sign of deformity,

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neural or vascular compression and ceased growth is
1. Excision of tumor
2. Observation
3. Radical excision

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4. Radiotherapy + chemotherapy

MCQ 5

A well demarcated bone forming tumor with well

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defined nidus on CT scan is diagnostic of
1. Osteoblastoma
2. Osteoid osteoma
3. Chondroblastoma

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4. enchondroma