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Benign
Osteoid osteoma
Osteoblastoma
Malignant
Osteosacroma
Osteoid osteoma
A small, active, discrete, painful, benign bone lesion
Predominant group : < 30 years old male
Site : any bone except skull
Only occur in bone form by endochondral
ossification
Common site:femur and tibia (50%)
Spine posterior elements
Run a self limiting course
Pain subside as lesion matures lasting 18-30 months
Lesion healed by 3-7 years
But usually required surgery for pain relief
Osteoid osteoma
Pathology
Nidus usually < 1 cm
diameter
nidus
central nodule of woven
bone and osteoid with
osteoblastic rimming
reactive zone
area of thickened bone
and fibrovascular tissue
Clinical features
Pain worst at night
Palpable superficial tender swelling
If lesion in spine backache ,
scoliosis (10% of cases)
Investigation
X-ray
CT diagnosis
Bone scan hot spot
X-rays
Plain X ray
This is belong to a
immatured skeletal
with solitary cortical
lesion
within proximal
diaphysis of fibula.
It is a geograohic lytic
lesion surrounded by
sclerotic bone and
cortical thickening.
It has bone producing
characterize matrix
With no soft tissue
Management
NSAID
Typically relieve with aspirin
May take 3-4 years for symptoms to
resolve
Prophylatic internal fixator may be
needed
10-15% recurrence rate with
percutaneous radiofrequency
ablation
Surgery (Definitive treatment)
Intraoperative localisation with
CT
Then excised nidus or destroyed with
percutaneous radiofrequency coagulation.
Percutaneous inserion of biopsy needle under
CT scan guide
Tissue biopsy to prove needle is properly
Osteoblastoma
Similar to osteoid osteoma but bigger
>1cm
Cell origin : osteoblast
Age and gender : 10-20 years M>F
Bone affected: spine ,jaw, limb
Investigation
X-ray
Radioisotope reveal hot area
X ray
Plain X ray
This is belong to a
matured skeletal with
solitary cortical lesion
within distal femoral
metaphyseal.
It is a well demarcated
osteolytic lesion which
contain small flecks of
ossification and sclerotic
rim.
Nidus > 2cm
It has bone producing
characterize matrix
Management
Not respond to aspirin
Curettage or marginal excision
Bone grafting
X-ray of rush
Radiographic differential for
osteoblastoma
osteosarcoma
Aneurysmal bone cyst (ABC)
osteomyelitis
osteoid osteoma
Osteoid Osteoma Osteoblastoma
Unilateral
Affected limb is short
Bent if growth plate is asymmetrically affected
Fingers and toes contain multiple
enchondromata
X-ray
Radiolucent streaking
Extending from physes into
metaphysis (appearance of
incomplete ossified cartilage
trapped in bone)
Multiple enchondromata in hand
and feet
Bent femur, slow Multiple chondromas
growth
Maffucis Disease
Development of multiple enchondromas
and soft tissue haemangiomas
Skin and viscera
Appear during childhood
Boys = Girls
Strong tendency of malignant change
(bone lesions or soft tissues)
Should be monitored throughout the life
Cartilage Producing
Bone
Tumour
(Malignant )
Chondrosarcoma
Peak incidence 30-60 years old
Male : Female 2 : 1
Slow growing
Various forms
Location in bone
Develop without precedent (primary) or by
malignant change in pre-existing benign lesion
(secondary)
Predominant cell type in tumour
Majority fall into:
Central tumour
Peripheral tumour
Juxtacortical tumour
Clear-cell tumour
Sites
Pelvis 30%
Femur 20%
Femoral head 10%
Ribs 10%
Clinical features
Deep, dull, achy pain
Pain at night
Nerve dysfunction
Limitation of joint movement
Pathologic #
Central Chondrosarcoma
Tumour develops in medullary cavity
Most common at proximal end of the
femur or innominate bone of pelvis
X-ray
Expended, radiolucent area in bone
Flecks of increased density
Aggressive lesions may take on a globular
appearance with scalloping or destruction of
cortex
Pale glistening cartilage tissue found in
medullary cavity
Haemorrhagic tissues
Peripheral
Chondrosarcoma
Arises in cartilage cap of an exostosis
(osteochondroma)
*Exostoses of pelvis and scapula more
susceptible than others to malignant
change
X-ray
Bony exostosis
Often surmounted by clouds of patchy
calcification in the otherwise unseen
lobulated cartilage cap
Fluffy calcification and poorly outlined
typical cartilaginous calcifications
round with a clear center
a part of the lesion is made of high-signal lobules, but the lesion is
heterogeneous.
The dedifferentiated part takes up strongly contrast medium after
injection
Juxtacortical (periosteal) chondrosarcoma
Lesion appears as an excrescence on the
surface of one of the tubular bone
Arises from the outermost layer of cortex
deep to periosteum
X-ray
Comprise features of both chondrosarcoma
and periosteal osteosarcoma
Flecks of calcification
Sunray streaks
New-bone formation at margin of stripped
periosteum
Anteroposterior
radiograph
revealing a well
formed sclerotic
periosteal
reaction in
metaphysis of
the distal femur
Axial CT revealing
tumour contained
calcified densities
characteristic of the
external bone
surface
associated with a
thickened cortex
Axial T1-weighted MRI showing a sharply
delineated mass with low to intermediate
signal intensity in the bone surface of the
metaphyseal region
Gadolinium-enhanced T1-weighted
MRI with peripheral and septal
enhancements. No intramedullary
extension or edema was identified.
Clear-cell chondrosarcoma
There is doubt as to whether this is really a
chondrosarcoma
Resembles an aggressive chondroblastoma
(typical location in the head of femur rather
than metaphysis)
Slow growing, eventually metastasise
X-ray
Usually osteolytic, expansile lesion
May be focally calcified
Often a sharp interface between tumor and
surrounding bone
Overlying cortex is usually thin, but intact
Pathology
High-grade tumours are more cellular
There may be obvious abnormal features
of the cells
Plumpness
Hyperchromasia
Mitoses
Treatment
Present the ideal case for wide excision
and prosthetic replacement
Amputation is preferable, provided the
lesion can be removed without exposing
the tumour OR causing unacceptable loss
of function
Removal of the affected part of the bone
and some healthy tissue around it
Replaced with the prosthesis or bone graft
Tumours tend to metastasise late
therefore attempt wide local excision
initially
Resistant to chemotherapy and
Low-grade chondrosarcoma in an arm or leg, curettage
with cryotherapy is an option.
Arthroscopy
- establish whether articular surface
has been broached
Biopsy
Differential Diagnosis
Aneurysmal bone cysts (ABC)
Hyperparathyroidism (Brown Tumor)
Fibrous cortical defect(FCD)
Treatment
Extended curettage
Is a technique of intralesional excision where the margins of
the excision are extended by a surgical, chemical, or thermal
adjuvant.
Adjuvant options include phenol, liquid nitrogen, high-speed
burr, cementation with polymethylmethacrylate, and argon-
beam coagulation. The technique described here uses a
combination of high-speed burr, argon-beam coagulation, and
cementation
decreased recurrence rates and significantly less surgical
morbidity
For well-confined, slow growing lesions with benign histology
85%-90% success rate of local control
M>F
- Throbbing
- Localized
- Intermittent
- Worse at night
Others:
- Fever
- Sweating
- Leucocytosis
Imaging
1. X-ray:
peel effect )
3. Radioisotope scan
Treatment
Option:
Clinical
Asymptomatic
Usually discovered after a pathological fracture
or as an incidental finding of xray
Radiographic features
Well defined, central osteolytic area
with thin sclerotic margin
Metaphysis in young & move towards
diaphysis with growth
Symmetric expansion with thinning of
cortex and bone expansion
Falling leaves (pathological fracture
with fallen cortical fragment in base of
empty cyst is pathognomonic)
Treatment
Non operative
Immobolise alone proximal humerus
lesion with pathologic fracture
Aspiration / methylprednisolone acetate
injection active cysts in the proximal
humerus
.
Operative
Curretage and bone grafting +/-
internal fixation based on tumour
location- symptomatic latent cyst that
have not responded to steroid
injections.
Operative
-Aggressive curretage and bone grafting
symptomatic
ABC without acute fracture
METASTATIC CANCERS
OF BONE
EPIDEMIOLOGY
Approximately 1.2 million patients present with
cancer each year in the United States. Of these,
50% have metastases to bone.
CT Scan
Decrease pain
Restore function (eg. weightbearing)
Maintain/restore mobility
Limit surgical procedures
Minimize hospital stay
Treatment
Control of pain and metastatic
activity
Treatment of fractures
Prophylactic fixation
Spinal stabilization
Numbers of Bauers
Survivorship at 1 year
positive criteria
45 50%
23 25%
1 or None Majority survived for < 6
months
Multipl
e
Myelo
ma
(March as Myeloma Action
Month)Burgundy ribbon by
International Myeloma
Introduction
Is a malignant B cell lymphoproliferative disorder of marrow which the plasma
cell predominating.
Multiple myeloma causes cancer cells to accumulate in the bone marrow, where
they crowd out healthy blood cells. Rather than produce helpful antibodies, the
cancer cells produce abnormal proteins that can cause kidney problems.
The effects on bone marrow cell proliferation and increased osteoclastic activity
Osteoporosis
Myelomatosis: appearance of discrete lytic lesions throughout skeleton
2. Radiation exposure
Large dose exposure with long latent peroid
3. Epidemiologic factors
Occupational exposure to petroleum product has higher
incidence ; wood workers & leather workers
4. Genetic abnormalities
Tranlocations t (11;14),t( 4;14)
Deletion of 13q
5. Oncogenes
overexpression of myc and ras growth promoting oncogenes
Bone marrow
Bone marrow biopsy
aspirate
demonstrating sheets
demonstrating
of malignant plasma
plasma cells of
cells in multiple
multiple myeloma.
myeloma.
Note the blue
cytoplasm,
eccentric nucleus,
Morphologic Features
Normal
M band/spike
In Myeloma patient
Peripheral Blood picture of Multiple Myeloma
Bone marrow picture
Staging
Management
Incurable disease, its chronic
relapsing and remitting.
Treatment aims:
Controlling disease
Prolonging survival
Maximizing quality of life
Management
Pain control
Chemotherapy
Melphalan with prednisolone
Melphalan with prednisolone and thalidomide
Melphalan with prednisolone and bortezomib
Stem cell transplantation
Induction followed by high-dose therapy with autologous stem cell
transplantation (ASCT) is the standard treatment.
Induction therapy :
Bortezomib-dexamethasone
The addition of a third agent (eg, thalidomide, doxorubicin, lenalidomide or
cyclophosphamide) has shown higher response rates.
Peripheral blood progenitor cells are the preferred source of stem cells,
rather than bone marrow.
Criteria:
-No organ metastasis
-No pathological fracture
-Solitary skeletal metastasis
-No lung cancer
-The primary tumor is breast carcinoma, renal
cell carcinoma, lymphoma, or myeloma
Prognosis:
-The one-year survival rate can be estimated from the number of the
above
criteria that are positive:
-45 positive criteria one-year survival 50%
-23 positive criteria one-year survival 25%
-01 positive criteria one-year survival 0%
References
https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3302920
/
https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3036978
/
https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3036978
/
https://
www.ncbi.nlm.nih.gov/pubmed/7740944
Apleys System of Orthopaedics and