CASE 5

A 14 year old girl injured her knee in gym class. Since it still hurt 2 weeks later, her physician examined her. Radiographic study
showed a mass destroying her distal femur.

I. Radiologic Finding
II. Gross
III. Histologic finding
IV. OS Differentials

I. RADIOLOGIC FINDINGS

Age Well defined Ill-defined Sclerotic

0-10  EG  EG  Osteosarcoma
 SBC  Ewing
 Osteosarcoma
 Leukemia
10-20  NOF  Ewing Sarcoma  Osteosarcoma
 Osteoblast  Eosinophilic  Fibrous dysplasia
 EG Granuloma  Eosinophilic Granuloma
 SBC  Osteosarcoma  Osteioid osteoma
ABC  Ostepblastoma
 Chondroblast
 CMF
 Fibrous dysplasia
20-40  GIant CT  Giant CT  Enchondroma
 Enchondroma  Osteoma
 Chondrosarcoma  Bone island
 HPT - Brown tumor  Parosteal Osteosarcoma
 Osteoblastoma
40+  Metastases  Metastases  Metastases
 Myeloma  Myeloma  Bone island
 Geode  Chondrosarcoma
All ages  Infection  Infection  Infection
Radio-opacity
The fundamental principle of all radiographic tests that employ x-rays is that different body tissues have a different capacity to block or
absorb x-rays. The following tissue densities produce the usual radiographic image, and they are arranged in order of increasing radio-opacity (i.e.,
whiteness on conventional radiographic film or computerized tomograms, blackness on fluoroscopic screens):
1. Air, as found, for example, in the trachea and lungs, the stomach and intestine, and the paranasal sinuses.
2. Fat.
3. Soft tissues, e.g., heart, kidney, muscles (these are all approximately the density of water).
4. Calcific (due to the presence of calcium and phosphorus), for example, in the skeleton.
5. Enamel of the teeth.
6. Dense foreign bodies, for example, metallic fillings in the teeth. Also radio-opaque contrast media, such as a barium meal in the stomach or
intravascular contrast.
When the density of a structure is too similar to that of adjacent structures, it is possible to use contrast media to enhance or outline its
contours. Contrast media are classified as radiolucent (e.g., air) and radio-opaque (e.g., barium or iodinated contrast media).

Positioning
The views used in plain radiographic images are named for the part of the body that is nearest the film, for example, anterior, right lateral, left anterior
oblique. Alternatively, the terms anteroposterior and postero-anterior are used when the x-rays have passed through the object from front to back (tube in front
of object, film behind) or from back to front (tube behind object, film in front), respectively. Radiographic postioning is highly standardized in order to
facilitate interpretation. Views are selected to highlight the particular areas or structures being examined.

General features of a long bone

Radiographically, the compact substance of the bone is seen peripherally as a homogeneous band of calcific density. A nutrient canal may be
visible as a radiolucent line traversing the compacta obliquely. In some areas the compacta is thinned to form a cortex. The cancellous, or spongy,
substance is seen particularly toward the ends of the shaft as a network of lime density presenting interstices of soft-tissue density. Islands of
compacta are visible occasionally in the spongiosa. The bone marrow and the periosteum present a soft-tissue densityand are not distinguishable as
such.

In many young bones the uncalcified portion of an epiphysial disc or plate can be seen radiographically as an irregular, radiolucent band termed an
epiphysial line. When an epiphysial line is no longer seen, it is said to be closed, and the epiphysis and diaphysis are said to be united or fused. The
radiographic appearance of fusion, however, precedes the disappearance of the visible epiphysial disc as seen on the dried bone.

The term metaphysis is used radiologically for the calcified cartilage of an epiphysial disc and the newly formed bone beneath it.
 ILL DEFINED
Differentials Epidemiology Clinical Pathology Radiology Histology
Ewing’s  Children and  Painful enlarging mass  Diaphysis of long tubular  Moth-eaten destructive  Sheets of uniform small
Sarcoma adolescents  Tender, warm, & swollen bones permeative lucent lesions in round cells slightly larger
 80%: < 20 y.o.  Local pain  Femur and flat bones the shaft of long bones and cohesive than
 Boys more than girls  Soft tissue mass  Gross: Tumor is soft tan  lymphocytes
 Diaphysis of  Pathological fractures white  Scant cytoplasm but
 Fever  Area of hemorrhage and rich in glycogen
necrosis  Fibrous septae
 Little stroma
 Geographic necrosis
Eosinophilic  Pediatric population  Bone pain and swelling  Inflammation and  Destructive bone lesion  Langerhans cells with
Granuloma  Peak incidence between  Localized diffuse back granuloma formation from marrow cavity foled grooved nuclei and
1-3 y.o. pain  Beveled edges moderately abundant pale
 Male predominance:  Diffuse or nonspecific cytoplasm are mixed with
1.5:1 abdominal or chest pain a few eosinophils
Osteosarcoma  All age groups  Painful progressively  Malignant tumor  Codman triangle: proximal  Lacelike pattern of
 Bimodal age enlarging masses  Cancerous cells produce triangular shell of reactive neoplastic bone produced
distribution, 75% < 20y.o. osteioid matrix or bone ny anaplastic malignant
 25% older adults (who mineralized bone  Prominent bone formation tumor cells in an
suffer Paget dse, bone extending to the soft tissues osteosarcoma
infarcts, prior radition)  Abnormal mitotic
figures
Rickets  Epiphyseal plate not yet  Weakening of bones  Distal femur, Proximal  Fluctuation in optical 
closed  Bone of pain tibia density on radiographic
 Bowing of lower limbs   Reveals Calcium loss or
 alterations in bone structure
 Excess of non-mineralized
osteoid

SCLEROTIC
Differentials Epidemiology Clinical Pathology Radiology Histology
Osterosarcoma     
Fibrous  Equal in boys and girls   Benign tumor  Lesions well  Composed of
Dysplasia  Adolescents  Lesions arise during circumscribed curvilinear trabeculae of
 Stops enlarging at the skeletal development intramedullary & vary woven bone that lack
time of growth plate closure greatly in size conspicuous osteoblastic
  Larger lesions expand & rimming with fibrous
distort the bone tissue
 Typical ground glass
appearance & well
defined margination
Eosinophilic  Pediatric population  Bone pain and swelling  Inflammation and  Destructive bone lesion  Langerhans cells with
Granuloma  Peak incidence between  Localized diffuse back granuloma formation from marrow cavity foled grooved nuclei and
1-3 y.o. pain  Beveled edges moderately abundant
 Male predominance:  Diffuse or nonspecific pale cytoplasm are mixed
1.5:1 abdominal or chest pain with a few eosinophils
Osteoid  Children  Local Pain  Common in long bones  Nydus formation  Vascularized
Osteoma  Yound adtuls 5-24  50%  Periosteal formation  Trabecular growth
 No gender predilection  Benign 
Osteoblastoma     

II. GROSS
 Osteosarcoma Microscopic
 Bone
 Represents one of the specialized connective tissues. It is characterized by a mineralized extracellular matrix.
 It is the mineralization of the matrix that sets bone tissue apart from the other connective tissues and results in an extremely hard tissue that is capable of
providing support and protection to the body.
 The mineral is calcium phosphate in the form of hydroxyapatite crystals.
 In addition to its supporting role, bone also provides a storage site for calcium and phosphate.
 Both can be mobilized from the bone matrix and taken up by the blood as needed to maintain normal levels.
 Bone matrix contains type I collagen and, in small amounts, a number of other types of collagen, i.e., types V, III, XI, and XIII.
 Other matrix proteins that constitute the ground substance of bone such as proteoglycan macromolecules, multiadhesive glycoproteins, growth factors, and
cytokines are also present.
 Bone is typically studied in histological preparations by removing the calcium content of the bone (decalcified bone), thus allowing it to be sectioned like other soft
tissues.

ORIENTATION MICROGRAPH:
 The orientation micrograph shows the upper end of a decalcified humerus from an infant.
 The interior of the head of the bone, the epiphysis (E), consists of spongy cancellous bone made up of an anastomosing network of trabeculae (T) in the form of
spicules of bone tissue.
 The outer portion consists of a dense layer of bone tissue known as compact bone (CB). Its thickness varies in different parts of the bone.
 The shaft of this bone, the diaphysis (D), is also made up of compact bone (CB) and in its interior, spongy bone (SB).
 Also within the shaft of the bone is bone marrow (BM), which at this stage of life is in the form of hemopoetic tissue.
 Lastly, cartilage is also a component of the bone where it is present as an articular surface (AS) and as a growth plate (GP). The latter is described in a later
plate.
III. HISTIOLOGICAL FINDINGS

Osteosarcoma Microscopic
 Composed of pleomorphic cells, many with a spindle shape.
 Nuclear hyperchromatism and cellular pleomorphismfeatures of
malignant neoplasms.
*
 There are islands ( ) of reactive new woven bone forming in
response to the infiltration and destruction of normal bone by the
tumor.

Osteosarcoma Microscopic
 The neoplastic pleomorphic cells of osteosarcoma are shown to be
making pink osteoid.
 Osteoid production by a sarcoma is diagnostic of an osteosarcoma.
This osteoid matrix vaguely resembles primitive woven bone.
 Additional microscopic elements of an osteosarcoma include
vascular proliferation, cartilaginous matrix, and fibrous connective
tissue.
 There may be considerable microscopic variation within a single
tumor, and metastases may not exactly resemble the primary site
microscopic appearance.
 Osteosarcoma Microscopic
 Fine lace-like pattern of neoplastic bone produced by anaplastic
malignant tumor cells in an osteosarcoma
 Abnormal mitotic figures
 Multinucleated giant cells

Differentials Epidemiology Clinical Pathology Radiology Histology

Giant Cell  Women  Bone pain  Gross: Hemorrhagic  Thin to no Periosteal  Multinucleated Giant
Tumor  Adults  Soft tissue mass  Locally aggressive formation cell
 Occurs in Epiphysis  Well vascularized
 Pathologic fractures
Chrondosarco  40s and older    
ma
    
    