CHAPTER I

INTRODUCTION

Tumors are abnormally abnormal tissue mass with excessive growth and
no coordination with normal tissue growth and continue to grow in an excessive
manner after the stimulus that causes the change to stop.1
. The incidence of bone neoplasms is less common when compared with
soft-tissue neoplasms. Neoplasm can be said to be fierce if it has the ability to
spread to other places or organs. Primary bone neoplasm is a neoplasm derived
from cells that make up its own bone tissue, it is said to be secondary if it is a
child of spread from other organs.2 The

classification of malignancy is based:2

1. Extent of spread according to TNM is local spread and metastasis
2. Histologic degree of malignancy based on degrees of cell differentiation,
mitotic activity Rapid
3. development of clinical features
4. Bone tissue derived from mesoderm that can differentiate into: Osteoblast,
Osteoclast, Chondroblast, Fibroblast / collagenoblast, Meiloblast
Classification of tumors is based on the origin cells, so divided into groups:2
1. Reactive bone disorders
- OsteogenicOsteogenic :osteoid, benign osteoblastoma
- CollagenicSubperiosteal :cortical defect

2. Hamartoma
- Osteogenic: Osteoma, Kondrogenic
- Osteocondroma : Collagenic
- EndocondromaAngiomaAneurysm :,bone cyst.

3. True bone neoplasm

a. Tumors that make up bone (Osteogenic)
Benign: - Osteoid Osteoma

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 Malignant: -Osteosarkoma
- Osteoblastoma
-Parosteal Osteosarkoma
- Osteoma
b. Tumors that make up cartilage (Kondrogenic)
Benign: -
Malignant kondroblastoma: -Condrosarkoma
-CondromycsoidFibroma
- Enkondroma
-Osteokondroma

c. Tissue tissue tumors (Fibrogenic)

Benign: - Non OssifyingFibroma
Malignant: - Fibrosarkoma

d. . Bone marrow tumor (Myelogenic)

Myeloma plasma cell, Ewing Tumor, Reticulum cell sarcoma,
Hodgkin's disease.
Osteochondroma or eksostosis is a benign tumor of bone with the
appearance of bony prominence bordered firmly as eksostosis arising from
metaphysical, this bony protrusion is covered (covered) by hyaline cartilage.
These tumors are derived from bone components (osteocytes) and cartilage
components (chondrocytes). Osteokhondroma is the second most common benign
tumor (32.5%) of all benign bone tumors and is especially found in adolescents
whose growth is active and in young adults.3

CHAPTER II
LITERATURE REVIEW

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2.1 Definition
Osteokondroma is derived from the word osteon which means bone and
chondroma which means benign tumor or tumor-like growth consisting of hyaline
cartilage matur, so that osteochondroma can be defined as benign tumors in bone
consisting of protrusion of adult bone coated cartilage protruding from the lateral
contour of the endocondral bone. Osteokondroma can also be called as
condrosteoma or osteokartilagenous eksotosis.1 Osteokondroma or also known as
eksostosis can occur in the form of solitary lesion lesions or in the form of
extensive lesions as part of the dominant autosomal multiple hereditary exposure
syndrome. Eksostosis is usually found to exist late in children or in adolescence.3
Osteokondroma is the second most common benign tumor (32.5%) of all benign
bone tumors and is especially found in adolescents whose growth is active and in
young adults. Most of these tumor sufferers are usually asymptomatic
(asymptomatic), a common disorder usually causing mechanical symptoms
depending on the location and size of the tumor.2

Figure 1. Development of osteochondroma, starting from epiphyseal cartilage

As a benign lesion, osteochondroma has no tendency to metastasis. In less
than 1% of solitary osteochondromas, malignant degeneration of the cartilage cap
to the secondary chondrosarcoma has been described and usually characterized by
early growth of the tumor, new painful lesions, or rapid growth of the lesion.1

2.2Etiology
Bone Osteochondroma is most likely caused by either a congenital defect
or a perichondrium trauma that results in a herniation of the growth epiphyseal
fragments of growth through the periosteal bone cuff. Although the exact etiology
of this growth is unknown, some physical peripheries are suspected of having a
herniation of the growth plate. This herniation may be idiopathic or may result
from trauma or deficiency of the perichondrial ring. Whatever the cause, the result

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is an abnormal extension of the metaplastic cartilage that responds to the factors
4
that stimulate the growth plate and thereby produce an exostosis growth.
The islands of cartilage organize into structures similar to epiphysis
Because these metaplastic cartilage is stimulated, there is enchondral bone
formation, and development of the bone stalk occurs. The histology of cartilage
reflects, defined classical zones observed in the growth of the plates ie, the
proliferation zone, columniation, hypertrophy, calcification, and hardening. This
theory is thought to explain the classic findings of osteochondroma associated
with plate growth and develop far from the physical to maintain its medullary
continuity.
Genetic karyotyping has suggested that reproducible genetic disorders are
associated with benign growth and that they can actually represent a true
neoplastic process, not a reactive one. The study is still at an early stage, and
requires further investigation.4

2.3 Epidemiology
2.3.1Frequency
The actual frequency of osteochondroma is unknown because many are not
diagnosed. Most are found in patients younger than 20 years, Male-female ratios
are 3: 1. Osteochondroma can occur in any bone that experiences enchondral bone
formation, but they are most common around the knee.
as in the picture below.

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Figure 2.Epidemiology of osteochondroma.4
Locations
Osteochondromes usually affect the metaphysis area of long bones, and
the often affected bone is the distal end of the femur (30%), the proximal end of
the tibia (20%), and the humerus (2%). Osteokondroma can also affect the bones
of the hands and feet (10%) and flat bones such as the pelvis (5%) and scapula
(4%) although rare. Osteokondroma consists of 2 types of stemmed type
(pedunculated) and type not stemmed (sesile). The affected bone is usually
stemmed while the pelvis is a type of sesile. Tumors are solitary with wide or
small bases such as tanks and when multiple are known as diaphisial aclasia
(multiple hereditary exposure) that are hereditary and predominantly derived
mutant genes.2

2.4 Pathophysiology
Found the presence of hyaline cartilage in the area around the tumor and
there is a shaped eksostosis inside. Large lesions can form a cauliflower with
degeneration and calcification in the middle.
Tumors occur due to abnormal growth of bone cells (osteocytes) and
cartilage cells (chondrocytes) in the metaphysis. Abnormal growth is initially only
will cause a picture of bone enlargement with the cortex and spongiosa are still
intact. If the growing tumor of the meal will appear as a lump resembling
cauliflower with the osteocyte component as its trunk and the chondrocytes
component as its flower.4
Tumors will grow from metaphysis, but the growth of bone is increasingly
prolonged the longer the tumor will lead to diafisis bone. This growth leads to the
classic form of "coat hanger" variation of the osteochondroma that leads away
from the nearest joint. 4

Stage osteochondroma
Osteochondromas are benign lesions and can be grouped by staging based
on the musculoskeletal Tumor Society(MSTS) for benign lesions, as follows: 1
• Stage I - active or static lesions

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• Stage II - active lesions grow
• Stage III - active lesions that develop that locally destructive / aggressive
Osteochondroma average is in stage I or II. However, significant
secondary deformities for mass effects can occur in areas such as joint and
tibiofibular joint joints. Although this classification is not perfect, the lesion may
be considered a stage III lesion,

Figure 3 Solitary osteochondroma. Radiographs show deformation of the distal

tibiofibular joint in patients with solitary osteochondroma.

2.6 Clinical features

These tumors do not produce symptoms that are often found by chance,
but the lumps grow very long and enlarged. When these tumors suppress the
nervous tissue or blood vessels will cause pain. It can also be pain induced by a
pathological fracture in the stalk of the tumor, especially in the thin stalk part.
Sometimes the bursa may grow above the tumor (exotica bursa) and when
inflamed the patient may complain of swelling and pain. If pain arises in the
absence of a fracture, bursitis, or emphasis on the nerves and tumors continue to
grow after the epiphyseal plate closes it must be suspected of malignancy.5
Osteocondromes can cause pseudoaneurysm mainly in a.poplitea and
a.femoralis caused by fractures in the stem of a tumor in the distal region of the

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femur or proximal tibia. Large osteocondromes in the vertebral columns can cause
cytoplasmic angulation and cause symptoms of spondylolithsis. In multiple
hereditary exoccose the complaint may be a multiple and painless mass near the
joint. Generally bilateral and symmetrical.5

Symptoms of pain occur when there is an emphasis on the bursa or

surrounding soft tissues. Pain is usually caused by a direct, mechanical effect, the
mass of osteochondroma in the soft tissue above it. This may result in an
associated sac or bursitis over the exostosis. The irritation of the surrounding
tendons, muscles, or nerves can result in pain. Pain may also result from fracture
of the stem from osteochondroma from direct trauma. Cover bone stalk may be
infarcted or have ischemic necrosis. 5

Figure 4 Clinical Features of Osteocondroma.6

The most common symptoms of osteochondroma is a painless lump near joints.

Knees and shoulders are more often involved. An osteochondroma can be located
beneath the tendon. At that time, broken tissue above the tumor can cause activity
related to pain.

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 An osteochondroma can be located near the nerve or blood vessels, such
as behind the knee. At that time, there may be numbness and tingling in the
extremity. A tumor suppressing the blood vessels can cause periodic changes in
the bloodstream. This can cause loss of pulsation or changes in the color of the
extremities. Changes in blood flow resulting from an osteochondroma are rare.
A hard lump can be found in the area around the lesion.6

2.7 Diagnosis
Radiological examination
There are 2 types of osteochondroma that are stemmed (pedunculated) /
narrow base and not stemmed (sesile) / broad base. In the pedunculated type, in
plain photographs the protrusion of the bone away from the joint with the cortex
and spongiosa is still normal. This protrusion is shaped like a cauliflower with
osteocyte components as the stalk and the chondrocytes component as the flower.
Inhomogene bone protrusion density (opaq on the stalk and flower on the flower).
Sometimes the presence of calcification in the form of opaq spots due to the
component condals that have calcified.7
There is a prominent bony protrusion as a eksostosis arising from
metaphysis but which appears smaller than that found on physical examination
because most of these tumors are covered by cartilage. Tumors can be single or
multiple depending on the type. For radiological examination can use:7
PHOTO POLOS
Plain radiography is an investigation in imaging for osteochondroma. Good-
quality radiographs should be obtained in 2 plane perpendicular to the
characteristic of the lesion completely. Classical radiographic features include
lesion orientation away from the physical and medullary continuity See the image
below.

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Figure 5. AP photo of the distal femur peduncle osteochondroma.

Figure 6.photos Lateralof the distal femoral osteochondroma peduncle. The

orientation is far from the growth plate, and the medullary continuity is clear

Figure 7. Anteroposterior radiograph of osteochondroma sessile humerus.

CT SCAN

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 In certain bones, such as pelvis and shoulder blades, CT scan is a useful
adjunct to localized lesions. Localization of CT can be useful when planning
resection.

Figure 8. CT scans of the pelvis depicting asolitary osteochondroma

large

Figure 9. CT scan of osteochondroma sessile humerus

MRI (Magnetic Resonance Imaging)

MRI is required only in cases of suspected occurrence of malignancy or
relevant soft tissue anatomy needs to be described. MRI is the modality of choice
to assess the thickness of the cartilage cap, as in the figure below. Although not an
absolute indication, the thickness of the cartilage cap is associated with
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 malignancy. Thick cartilage caps> 4 cm are suggestive of malignant degeneration,
especially when they are associated with pain. 7

Figure 10. sessile osteochondroma femur MRI showed cartilage capthickness.

The bone scan, as a rule, is useless in the examination of osteochondromas or for
preoperative planning for resection.

2.8 Diagnosis of appeal

1. Chondrosarkoma
Is a malignant tumor of bone and cartilage. Most commonly found in
pelvic bone, femur, ribs, humerus, and scapula. But it can also be found in
all bones including small bones in the hands and feet.8
Radiological features: large lesions appear irregular with bony edges that
disappear. The tumor contains a calcified area with a picture like popcorn.8

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 Figure 11. Chondrosarkoma

2. Osteosarcoma
is a primary malignant tumor of bone. The location of most tumors is
distal, femur, proximal tibia, and proximal humerus. Tumors can also
attack flat bones such as pelvis, skull, and mandible.8
Radiological features:
● Bone deterioration features
● Sunburst appearance
● Codman triangle

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 Figure 12. Osteosarcoma
2.9 Treatment
If there are symptoms of suppression of soft tissue such as blood vessels or
surrounding nerves or suddenly enlarged tumors accompanied by pain then
immediate surgery is required, especially if this occurs in adults.8

Medical Therapy
No medical therapy currently exists for osteochondroma. The mainstay of
nonoperative treatment is observation because lesions are mostly asymptomatic.
Accidental lesions can be observed, and patients can be reassured.2

Surgical Therapy The

treatment for osteochondroma symptoms is resection. Care should be
taken to ensure that no cartilage or perichondrium lids are left, otherwise there
may be a recurrence. Ideally, the resection line should be through the base of the
stalk, thus, the entire lesion is removed en block. Atypical or very large lesions
should be fully investigated to exclude the possibility of isolated malignancy.
MRI is useful in assessing the thickness of the cartilage cap.8

2.10 Complications Osteochondroma

A. Fraktur
Fraktur on osteochondroma is an unusual complication that is the result of
localized daritrauma and usually involves the base of the stalk lesion.
Osteochondromas peduncle in the knee is most likely for the occurrence of
fracture. Furthermore, callus formation causes bandlike sclerosis on radiographs
to occur with healing. No significant nonunion incidents were reported.
Interestingly, the regression or resorption of solitary osteochondroma that occurs
both spontaneously and after fractures has been reported.4

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C. Vascular Complications Vascular
complications associated with osteochondroma include vascular
abnormalities, stenosis, occlusion, and pseudoaneurysm formation. Clinical
symptoms in cases of vascular compromise include pain, swelling, and rarely
claudication or a palpable pulse mass usually affects young patients. Blood vessel
thrombosis or occlusion can affect either the arterial or venous system and is most
often seen in the vessels of the knee, especially the popliteal or venous arteries.
The pseudoaneurysm-related formation of osteochondroma was first reported by
Paul in 1953. The site of this disorder complicates mainly concerning the femoral
artery, brachialis, and posterior tibial artery, the popliteal artery. This
complication affects young patients near the end of normal bone growth and
occurs with solitary lesions and some with the same frequency.4

D. NeurologicalNeurological
sequelaecompromise can be attributed to the second (base of the spine or
skull) of osteochondromas occurring in the vertebrae or on the cranial basis.
Peripheral lesions can suppress nerves, cause dop foot, and peroneal nerve
involvement of osteochondromal fibula has been reported most frequently. The
involvement of the radial nerve has also been described. Osteochondromas
occurring at the base of the skull, spine, rib or head may cause cranial nerve
deficit, radiculopathy, spinal stenosis, cauda equina syndrome, and
myelomalacia.4

2.11 Prognosis
For solitary osteochondroma, the outcome and prognosis after surgery is
excellent, with excellent local control and a local recurrence rate of less than 2%.
Thus, prognosis is usually one of complete recovery . The worse outcome is
usually related to the morbidity associated with the exposure required to remove
the lesion or associated with secondary bone deformity, but the latter is usually
observed in the hereditary form of some diseases.4

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 CHAPTER III
CONCLUSION
Osteochondroma is the most common bone tumor, and the radiographic
appearance of the lesion consists of cortical bone and shows medullary continuity
with the underlying bone often pathognomonic. Sleary osteochondromes
involving anatomical complex areas (spine or pelvis) are often better assessed
with CT or MRI to detect marrow characteristics and cortical continuity. Many
complications associated with osteochondromas include fractures, vascular
compromise, neurologic sequelae, the formation of top exchanges, and malignant
transformations. This complication is more common in patients with multiple
lesions (HME) as opposed to solitary osteochondromas. Imaging usually allows
identification and differentiation of the cause of symptoms. Malignant

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transformation for chondrosarcoma occurs in about 1% of solitary lesions and 3%
-5% of patients with HME

REFERENCES

1. Newman, MA 2002. Dorland: Medical dictionary. Jakarta: EGC

2. Appley, AG & L. Solomon. 2002. Appley System Of Orthopedics And

Fractures. Oxford: ELBS

3. Robbins & cotran. 2005. Basic Pocket Pathology for Disease (735-736).
Jakarta: EGC

4. Allan, G & Blonchi, S, et al. 2004. Paediatric Musculoskeletal Disease.

Cambridge: Cambridge University Press.

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5. Schmall, GA et al. 2008. Hereditery Multiple Osteochondroma. Seattle:
NCBI Book Shelf.

6. Dickey, ID 2011. Solitary Osteochondroma. Eastern maine medical center.

www. Medscape. Com. Retrieved date: August 1, 2012.

7. Murphey, M. Et al. 2000. Imaging of osteochondroma: Variant

complication with radiologic corelation.

8. Weiner, DS 2004. Paediatric Orthopedic For Primary Care Physician 2nd

ed. New York: Cambridge University Press.

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