MS, DNB, MNAMSASSISTANT PROFESSOR

MAMC & SUSHRUTA TRAUMA CENTERNEW DELHI

DESCRIBING GROSS SPECIMENA: Identify the part: Knee / prox. femur/ prox. tibia/ pelvis /scapula. Epiphyseal / Metaphyseal / Diaphyseal. Physeal plate visible? – Immature pt.

B:Describe the abnormality: Nature: solid / soft & friable /cystic / varigated Matrix: bony / cartilaginous / fibrous Secondary changes: central necrosis/ hemorrhage

/ cystic change Cortical destruction, periosteal elevation Intramedullary spread Tumor margin / capsule: well defined / illdefined Extension: into soft tissue / joint; invasion /

infiltration to surrounding tissue

C: Give provisional diagnosis.

Age: 20-40. Epiphyseometaphyseal in adults -

Metaphyseal in adolescents. Common location: around knee (50%),

distal radius Xray: Geographic lytic lesion, thinned & ballooned out cortex.

Gross pathology: Large red - grey - brown tumor Soft & friable Areas of cystic degeneration / necrosis & blood filled cavities

GIANT CELL TUMOR

HISTOPATHOLOGY:•Uniform oval mononuclear stromalcells : mesenchymal origin; neoplastic•Appear to grow in a syncytium

•Numerous osteoclast-type giant cells: reactive

•Necrosis, hemorrhage, hemosiderindeposition and reactive bone

formation

•Relatively few mitotic figures in relation to the dense cellularity of the tumor

GIANT CELL VARIANTSIncludes the tumors which show giant cells in histology-

A. ABC B. Brown tumor C. Chondromyxoid fibroma, chondroblastoma D. Desmoplastic fibroma E. Epulis – Giant cell reparative granuloma F. Fibrous dysplasia, non ossifying fibroma G. Giant cell rich osteosarcoma H. Benign fibrous histiocytoma

Giant cell……

Physiological: MegakaryocytePathological Langhans : fused epitheliod cells. Peripherally arranged 7-21 nuclei. TB,

histoplasmosis, sarcoidosis, other mycobacteria

Foreign body: fused macrophages. Numerous nuclei scattered in cytoplasm

Aschoff : Rheumatic heart disease

Reed Sternberg: Hodgkin’s lymphoma

Touton : xanthoma, xanthogranuloma, dematofibroma

Viral: Warthin Finkeldy (measles), resp syncitial virus, parainfluenza

Tumor

OSTEOSARCOMA Bimodal age distribution: Primary 10-20, secondary 50-70. 75% around knee Bone forming tumor arising from bone Several subtypes – By location (Central or Juxtacortical)MulticentricityDegree of differentiation: well to dedifferentiatedHistologic variance:

osteoblastic/chondroblastic/fibroblastic/telangictatic/small cell Associated with Retinoblastoma (rb gene), Li Fraumeni

syndrome (p53 gene), Rothmund Thomsen syndrome.

GROSS PATHOLOGY: Metaphyseal Tan-white solid tumor fills

most of the medullary cavity of the metaphysis and proximal diaphysis

Expanding & infiltrating through the cortex, lifts the periosteum (Codman’s triangle) and forms soft tissue masses on the side of the bone

Areas of hemorrhage and central necrosis.

HISTOPATHOLOGY: Pleomorphic and anaplastic cell

population- large hyperchromaticnuclei, mitotic figures

Abundant fibrous/ chondroidmatrix

Formation of pink homogenous osteoid by neoplastic cell: characteristic.

The neoplastic bone has a coarse, lacelike architecture but is also deposited in broad sheets or as primitive trabeculae.

Osteoblastic, chondroblastic or fibroblastic types

Osteoclast-like giant cells may be present

CHONDROSARCOMA

Age: 30-60 Primary or Secondary ( Enchondromatosis [Ollier 50%,

Maffucci 100%], diaphyseal aclasis 20%, osteochondroma 0.25%)

Pelvis (30%), Femur (20%) Types: Conventional, mesenchymal, clear cell,

juxtacotical, dedifferentiated Most common malignant bone tumor of hand

GROSS PATHOLOGY: Large bulky tumor Made up of lobules of gray-white

/somewhat translucent glistening tissue. Tumor permeating throughout the

medullary cavity, growing through the cortex, and forming a relatively well-circumscribed soft tissue mass.

At center – necrotic/liquefied/cystic. Gelatinous appearance secondary to myxoid changes in matrix.

May show calcification. The adjacent cortex is thickened or

eroded, and the tumor grows with broad pushing fronts into the surrounding soft tissue.

HISTOPATHOLOGY:• Tumor cells produce

cartilaginous matrix; well, moderate or poorly differentiated.

• May have only minor or focal atypia

• Intracytoplasmic hyaline globules common in low grade tumors

EWING’S SARCOMAJames Ewing 1921GROSS PATHOLOGY: Diaphyseal in long bones;

also pelvis, rib, scapula White tan grey mass like

brain; or red like red currant gelly if hemorrhagic

With necrosis & hemorrhage Cortical destruction Invasion to soft tissue

around, no capsule

HISTOPATHOLOGY:

• Homogenous & denslypacked undifferentiatedsmall round blue cells likelymphocytes; regular nuclei, infrequent mitoses, scant clear cytoplasm.

• Abundant glycogen: PAS + diastase digestible

• Rare Homer- Wright pseudorosettes (7-8 tumor cells arranged in a circle about a central fibrillaryspace)

D/D : Small Round Cell Tumor Ewing’s: mic2 overexpression - CD99/013 . t(11;22)(EWS-FLI-1). NSE +

PNET (Primitive neuroectodermal tumor): CD99/013. S100, chromogranin, synaptophysin; > 20% Homer Wright rosettes

Lymphoma (reticulum cell sarcoma, NHL): CD 45, LCA

Small cell carcinoma: keratin, synaptophysin, chromogranin

Mesenchymal chondrosarcoma Neuroblastoma: neurofilament. S100, chromogranin, synaptophysin.

Alveolar rhabdomyosarcoma: actin, desmin, vimentin, MyoD1, myogenin

Leukemia

OSTEOCHONDROMAGROSS PATHOLOGY: Mushroom shaped Cartilage-capped bony outgrowth Cartilage cap usually regular and

thin Sessile / Pedunculated Pedunculated : attached to skeleton

by bony stalk; medullary cavity of the osteochondroma and bone are in continuity

Diaphyseal aclasis: multiple heriditary exostosis

Trevor’s disease: Epiphyseal side osteochondroma

Painful osteochondroma: Fracture Bursitis Malignant transformation: fluffy calcification in the

cartilage cap, thickness of cartilage cap > 1 cm.

CHRONIC OSTEOMYELITIS Sequestrum is the necrotic

bone that is embedded in the pus/infected granulation tissue.

Involucrum is the new bone laid down by the periosteumthat surrounds the sequestra.

Cloaca is the opening in the involucrum through which pus & sequestra make their way out.

Types of sequestrum….. Tubular: long bone Annular: amputation stump Ring: around pin tracts Flake, coke, rice grain: tubercular Button: histiocytosis Feathery: syphilis Match stick: sickle cell Coloured: fungal Black: gun shot Bombay: exposed bone after open fracture

TUBERCULAR SPONDYLITIS (POTT’S) SPINE

Paradiscal Loss of height

of vertebra Caseating

necrotic tissue Bone necrosis;

sequestra Sclerosis

Kyphotic deformity Internal gibbus Severe cord compression

Granuloma or LH giant cell is notpathagnomonic of TB…!

• Foreign body granuloma.• Fat necrosis.• Fungal infections.• Sarcoidosis.• Crohns disease.

MADURA FOOT Foot looks like tumor Multiple nodules & sinus

Multiple circumscribed abcesses; extensive granulation tissue around.

Bone destruction

• Granulomatous fungal disease; involve subcutaneous tissue after traumatic inoculation; later spread to deep structures.

• Causes local tissue destruction including boneTypes: • Actinmycetoma: Actinomadura sps, Nocardia• Eumycetoma: Aspergillus sps,

• Discharge colored granules: Red (Actinomadura pelletieri), white / yellow (Actinomadura madurae, Pseudoallescheriaboydii), black (Exophiala jeanselmei, Madurella mycematis)

• Pus contains sulfur granules, a tangled mass of branching bacteria (Splendore Hoppelli body)