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 sarcomab] 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 fibromae] 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 welldemarcated 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 vascularosteoid 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 maybe 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 infusiform 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 reactivebone 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.--- Content provided by FirstRanker.com ---
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 tumorIncidence : 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 theircartilaginous 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 occursfirm 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 tumorIncidence : 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 ispresent .
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 fociof 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 presentq treatment :currettage and bone grafting .
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On MRI
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GIANT CELL TUMORIt 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 lifeSex 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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UnclearFocal 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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PathologyGrossly, 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 lymphocytesHistology 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 oldboy
Fig2: simple bone
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cyst in proximal
femur in a 11 yr old
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girlSource: 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 agentsTrepenation (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 spacesseparated by
cel ular stroma ?
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fibroblasts,
histiocytes, giant
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Histologic appearance of aneurysmalcel s
bone cyst
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Source: Campbel 13th ed page 913
Gross appearance of ABC
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Source: pathpedia.comRadiograph 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 traceruptake 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, cryosurgeryAneurysmal 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 DYSPLASIAIntrinsic 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 fibrousconnective 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 withendosteal 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 producestrength 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 boneand 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 1Fallen leaf sign is a feature of
1. Giant cell tumor
2. Unicameral bone cyst
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3. Fibrous dysplasia4. 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 cystMCQ 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 diagnosis1. 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 + chemotherapyMCQ 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