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bone tumours .osteoid osteoma, osteosarcoma, chondroma
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MODERATOR-DR. S. S. THAKUR
BONE TUMOR
• A bone tumor, is a neoplastic growth of tissue in bone. Abnormal growths found in the bone can be either benign or malignant.
• Bones are classified according to their shape-• Long bone• Flat bone• Short bone.
Long bone anatomy• Diaphysis: long shaft of bone• Epiphysis: ends of bone• Epiphyseal plate: growth plate• Metaphysis: b/w epiphysis and diaphysis• Articular cartilage: covers epiphysis• Periosteum: bone covering (pain sensitive)• Sharpey’s fibers: periosteum attaches to underlying
bone• Medullary cavity: Hollow chamber in bone
- red marrow produces blood cells- yellow marrow is adipose.
• Endosteum: thin layer lining the medullary cavity
Diaphysis
Epiphysis
Metaphysis
• Histology of bone tissueCells are surrounded by matrix.
- 25% water- 25% protein- 50% mineral salts
4 cell types make up osseous tissueOsteoprogenitor cellsOsteoblastsOsteocytesOsteoclasts
• Osteoprogenitor cells:- derived from mesenchyme- unspecialized stem cells- undergo mitosis and develop into osteoblasts- found on inner surface of periosteum and endosteum.
Osteoblasts:
- bone forming cells- found on surface of bone- no ability to mitotically divide - collagen secretors
Osteocytes:
- mature bone cells- derived form osteoblasts- do not secrete matrix material- cellular duties include exchange of nutrients and waste with blood
• Osteoclasts- bone resorbing cells- bone surface- growth, maintenance and bone repair
Abundant inorganic mineral salts:- Tricalcium phosphate in crystalline form called
hydroxyapatite Ca3(PO4)2(OH)2
- Calcium Carbonate: CaCO3
- Magnesium Hydroxide: Mg(OH)2
- Fluoride and Sulfate
Osteoprogeniter cells &Osteoblast
Osteoclast
Precursors of malignancy in bone
• High Risk• Ollier disease (Enchondromatosis)• and Maffucci syndrome• Familial retinoblastoma syndrome• Rothmund-Thomson syndrome (RTS)• Moderate Risk• Multiple osteochondromas• Polyostotic Paget disease• Radiation osteitis
• Low Risk• Fibrous dysplasia• Bone infarct• Chronic osteomyelitis• Metallic and polyethylene implants• Osteogenesis imperfecta• Giant cell tumour• Osteoblastoma and chondroblastoma
Classification of primary tumour involving bones
Histological type
Benign Malignant
Hematopoietic Myeloma
Malignant lymphoma
Chondrogenic Osteochodroma chondrosarcoma
Chondroma
Chondroblastoma
Chondromyxoid fibroma
Histological type
Benign Malignant
Osteogenic Osteoma Osteosarcoma
Osteoid osteoma
osteoblastoma
Unknown origin Giant cell tumour
Ewing tumour
Giant cell tumour
admantinoma
Histological type
Benign Malignant
Histiocytic origin
Fibrous histiocytoma
MFH
Fibrogenic Metaphyseal fibrous defect
Dysplastic fibroma
Fibrosarcoma
Notochordal Chordoma
Vascular Hemangioma Hemangioendothelioma
Hemangiopericytoma
Lipogenic Lipoma Liposarcoma
Neurogenic Neurilemmoma
Distribution of bone tumors in long bones
• Epiphyseal lesions: • Chondroblastoma • Giant cell tumor
• Metaphyseal intramedullary lesions: • Osteosarcoma • Chondrosarcoma • Aneurysmal bone cyst
• Metaphyseal lesions centered in the cortex: • Nonossifying fibroma (NOF) • Osteoid osteoma
• Metaphyseal exostosis: • Osteochondroma
• Diaphyseal intramedullary lesions: • Ewing’s sarcoma • Lymphoma • Myeloma • Fibrous dysplasia • Enchondroma • Diaphyseal lesions centered in the cortex: • Adamantinoma • Osteoid osteoma
Sites of Tumors
Important Facts• 0.001% of all cancers• MC benign tumor--- Osteochondroma; Osteoid
Osteoma• MC Skeletal malignancy– Metastasis.• MC Bone tumor in Pediatric age group & adults-
Osteosarcoma• MC in < 10 y--- Ewing’s sarcoma• MC Primary bone tumor – Multiple Myeloma
PRESENTING SYMPTOMS Patient may present with• An abnormal radiographic finding detected during evaluation of unrelated problem• PAIN:- is most frequent symptom • MASS:- rate of enlargement is important• -Fluctuating mass can be cyst,ganglion or hemangioma• -Family H/O masses near the joint may be indicator of Ollier’s disease or Maffucci
Syndrome• NEUROLOGICAL SYMPTOM:- found in few patients such as sacral tumors & with tumors
located near the nerve causing compression of nerve,especially common in sciatic notch ,inguinal canal & popliteal fossa
• UNEXPLAINED SWELLING OF THE LOWER EXTREMITY:- found in pelvic• tumors which are painless & without a palpable mass & cause swelling due to
compression of iliac vein.
PHYSICAL EXAMINATION• Evaluation of patient’s general health• TUMOR MASS should be measured & its location,shape,
consistency,mobility,tenderness,local temp & change with position should be noted.
• SKIN & SUBCUTANEOUS TISSUE :• Small dialated superficial veins overlying the mass are produced
by large tumors• Café-au-lait spots & subcutaneous neurofibromas indicate Von
Recklinghausen’s disease• A venous malformation Maffucci Syndrome• REGIONAL LYMPH NODES: sign of metastatic disease• Atrophy of surrounding musculature should be recorded,also
neurological deficits & adequacy of circulation.
HISTORY OF THE PATIENT• AGE:- most imp information,bcoz of their presentaion in sp age
group.• 1st decade- usually ABC ,SBC• 2nd decade-Chondroblastoma,osteosarcoma,Ewings• 3rd decade- GCT• 4th decade- chondrosarcoma• 5th decade- Multiple myeloma• SEX:- less imp than age• RACE:- little imp, Ewings rare in african descent• H/O any exposure to radiation Tt or Carcinogens- bone seeking
radionucleotide can cause sarcoma.• Various chemical carcinogens- zinc beryllium silicate, beryllium oxide.• Currently the most worrisome & controversial is Nickel which is used
in many orthopedic devices.
LABORATORY TEST• Alkaline phosphatase – Higher .
• PTH test: Lower.
• Serum phosphorus: Higher
• Ionized calcium and serum calcium: Higher .
INVESTIGATIONS• X-RAY• CT SCAN• MRI• TECHNETIUM BONE SCAN-This type of scan uses a
very low radioactive material (diphosphonate) to see whether or not the cancer has spread to other bones and the damage suffered by the bone.
• PET- uses radioactive glucose to locate cancer. This glucose contains a radioactive atom that is absorbed by the cancerous cells and then detected by a special camera.
BIOPSY• The biopsy is the most conclusive test because it confirms if
the tumor is malignant or benign, the bone cancer type (primary or secondary bone cancer), and stage.
• According to the tumor size and type (malignant or benign) and the biopsy's purpose (to remove the entire tumor or only a small tissue sample), there are two types of biopsies used in bone cancer diagnosis. These are: needle biopsy and incisional biopsy.
• 1. Needle biopsy: During this procedure, a small hole is made in the affected bone and a tissue sample from the tumor is removed.
• There are two types of needle biopsies:• Fine needle aspiration: During this procedure, the tissue
sample is removed with a thin needle attached to a syringe. • Core needle aspiration: During this procedure, the surgeon
removes a small cylinder of tissue sample from the tumor with a rotating knife like device.
• 2. Incisional biopsy: During this procedure, the surgeon cuts into the tumor and removes a tissue sample.
BONE FORMING TUMOURS
• Benign: Osteoma, Osteoid Osteoma,
• Benign Aggressive: Osteoblastoma
• Malignant: Osteogenic Sarcoma
Osteoma
• Benign, asymptomatic, slow-growing osteogenic lesion.
• Age/Sex: 40-50 yr, M:F = 2:1.• Bones involved: flat bones of the skull and
face; may protrude in the paranasal sinus.• Parosteal location.• Gardner’s syndrome.
Ivory like bony mass
Figure 2: The lesion consists of dense and lamellar cortical bone with a focal area of active bone modeling.
Figure 3: Photomicrograph of the more solid area of the lesion to demonstrate the cellular woven character of the bone.
Osteoid osteoma• Signs/Symptoms:
• Pain, characteristically more intense at night, relieved by NSAID and eliminated by excision
• Scoliosis
• Age:• 10-30 years
• Sex:• M > F (2:1)
• Anatomic Distribution:• Nearly every location, most frequent in femur, tibia,( Over 50%) humerus,
bones of hands and feet, vertebrae and fibula• Metaphysis / Diaphysis (cortical) of long bones• Vertebral lesions may be associated with scoliosis.
Small central osteolytic nidus surrounded by dense bone
The small, reddish central nidus is surrounded by a thick layer of sclerotic bone
Wedge shaped nidus which is surrounded by dense sclerotic bone.
New osteoid and bone formation by plump osteoblasts. The stroma is cellular and well vascularized
Osteoid osteoma with anastomosing trabeculae of woven bone
Osteoblastoma • Also called as Giant osteoid osteoma.
• Osteoblastoma is similar to osteoid osteoma with more aggressive behavior.
• D/D from osteoid osteoma- *Pain
*Absence of reactive bone * Large size
• Location : – In spine or major bones of lower extremity
Well differentiated radiopaque/radiolucent lesion
Osteoblastoma.-The histologic appearance is identical
to that of osteoid osteoma.
Recurrent osteoblastoma.-The appearance is similar to that of osteoid osteoma
Osteosarcoma
• Most frequent primary malignant bone tumour.• Age/Sex :10-25 yrs & >40 , M:F = 3:2• Predisposing conditions: Paget’s disease Radiation exposure Chemotherapy Benign bone lesion Foreign bodies Trauma
Codman’s triangle: “Sunray “ appearance
Tumor is located at the typical metaphyseal site. The tumor shown in A is largely restricted to bone, whereas that illustrated in B is accompanied by massive soft tissue extension.
‘skip metastasis’ located in the upper half of the femur. The primary tumor was located in the lower metaphysis of the same bone
The malignant bone is more basophilic and has more irregular borders than the preexisting bone trabeculae.
Osteosarcoma showing characteristic basophilic thin trabeculae of neoplastic bone with an appearance that is reminiscent of
fungal hyphae
Lace-like osteoid deposition is very characteristic of this neoplasm.
Osteoblastic osteosarcoma with finely ramifying matrix between tumor cells
Microscopic variants
Telangiectatic :
• Blood filled cystic space and thus radiologically appears as pure lytic lesion.
• Pathological fractures.• Grossly the lesion simulate aneurysmal bone
cyst.• Detection of malignant stroma in the septa
that separate the bloody cysts.
Telangiectatic osteosarcoma.
Telangiectatic osteosarcoma. A The low-power architecture closely simulates the appearance of an aneurysmal bone cyst
B Malignant osteoid is present in the septa
Telangiectatic osteosarcoma. Spaces containing blood are separated by septa. The cells appear malignant even at this level
of magnification
Fibrohistiocytic
Small cell variant:
• Uniform small size tumour cells.• Diffuse pattern of growth.• Simulate Ewing’s sarcoma and malignant
lymphoma.
Anaplastic
Well differentiated intramedullary
.This tumor is microscopically so bland looking as to be often underdiagnosed as a benign lesion.
In contrast to fibrous dysplasia
1- this tumor shows radiographic evidence of cortical destruction.
2-Microscopically, atypia is minimal but still present.3-The invasive growth pattern.
Variants defined on the basis of topographic, clinical and radiographic features:
Juxtacortical (parosteal)• Slightly older age group• Juxtacortical position in the metaphysis of
long bones.
Juxtacortical osteosarcoma of upper femur. There is only minimal involvement of the cortex
Juxtacortical osteosarcoma large extracortical component
Juxtacortical osteosarcoma--Moderately atypical spindle tumor cells grow between irregularly shaped bone trabeculae
Parosteal osteosarcoma-The spindle cells demonstrate minimal atypia, and the bone appears to arise directly from the spindle
cells.
Periosteal osteosaocoma• Grows on surface of long bones.• Upper tibial shaft or femur.
Periosteal osteosarcoma. The white shining appearance is due to the high content of cartilage
periosteal chondrosarcoma. There is a predominance of myxochondroid areas
Bone formation in the center of a cartilaginous lobule in periosteal osteosarcoma
Osteosarcoma of jaw:• Patients affected are slightly older (average age, 34 years),• And most lesions show a prominent chondroblastic
component.• The most common sites of involvement are the body of the mandible and the alveolar ridge of the maxilla.
Osteosarcoma in Paget’s disease.• Osteosarcoma are of the polyostotic type• Pelvis, humerus, femur tibia & skull.• Large number of osteoclasts alternating with atypical
osteoblast.
Histochemistry, IHC & molecular genetics
• Strong alkaline phosphatase activity.• Vimentin, S-100, keratin & EMA.• Osteonectin, osteocalcin, osteopontin.
Prognostic factors• Paget’s disease• Irradiation• Specific bone involvement• Multifocality• Various types• Microscopic variants• Serum elevation of alkaline phosphatase• Aneuploidy• Post chemotherapy tumour necrosis• RB gene• HER2/neu expression• P-glycoprotein.
CARTILAGE FORMING TUMOURS• Benign: Enchondroma,
Peri-osteal Chondroma, Osteochondroma.
• Benign Aggressive: Chondromyxoid Fibroma, Chondroblastoma.
• Malignant: Chondrosarcoma.
Chondroma• Benign tumor of mature hyaline cartilage• Age – 20-50 yrs• Usually solitary,30% are multiple.• Bones involved: small bones of hand & feet.• Asymptomatic, pain & swelling.Enchondroma is the most common tumor of
the bones of the hand
Enchondromas
• Begin in spongiosa of diaphysis, from which they expand and thin cortex
• Unusual in ribs and long bones
Juxtacortical Chondroma
• Much less common than enchondroma• Involve parosteal region of long bone or small bone of hand
or foot
2 syndromes characterized by multiple chondromas:
• Ollier’s disease
• Maffucci’s syndrome
• Both disorders have 25% risk of malignant transformation to chondrosarcoma
Maffucci syndrome-Innumerable chondromas are seen concentrated in the distal aspect of the extremity
Juxta-cortical - The tumor produces a semispherical expansion of the involved bone.
Enchondroma-The tumor has a typical lobulated appearance
Osteochondroma
• Also known as exostosis.• Most frequent benign cartilaginous tumour.• Age/sex - <20yr, M:F=3:1• Bones involved: lower femur, upper tibia,
upper humerus and pelvis.• Location: Metaphysis
• Probably not a true neoplasm.
• Inactivation of both copies of the EXT gene in the growth plate chondrocytes.
• Presents as slow growing mass, painful.
• <1% cases show malignant transformation.
A- Large osteochondroma of femur with a bilobed appearance. B Cut surface of osteochondroma of ribthick cartilaginous cup
Projection with cortex continuous with underlying bone; may be pedunculated; cartilaginous cap with frequent
calcification
Microscopic-Mature bone is covered by a well-differentiated cartilaginous cap.
Microscopic
Chondroblastoma
• Rare benign cartilage producing tumour.• Age/Sex : 2nd decade M:F=2:1.• Bones involved: Distal femur ,proximal
humerus and tibia.• Location: Epiphysis• Pain is constant .
Typical sharply delineated lytic appearance of chondroblastoma of humeral head
Gross appearance of chondroblastoma of upper end of the humerus, associated with aneurysmal bone cyst-like changes
Chondroblastoma. A- Small tumor cells of round shape are accompanied by scattered osteoclasts.
B-Immunoreactivity for S-100 protein in the neoplastic component.
Chondroblast: Prominent Indented NucleusEosinophilic Cytoplasm Thick Cell Membrane
Uniform Appearance of Cells
Chondroblastoma with eosinophilic chondroid matrix, giant cells, and mononuclear cells
Imagine the cells present without the nuclei: The thickened cell membranes would give a chicken wire fence appearance
Chondromyxoid Fibroma
• Benign tumour of cartilaginous origin.• Age/Sex: 20-30 yr/ M:F=2:1• Bones involved: Long bones>flat bones
>vertebrae.• Location: Metaphysis.• Localised pain with or without tenderness
Sharply delimited chondromyxoid fibroma of lower femoral metaphysis in a young boy.
A-Chondromyxoid fibroma of proximal femur extending into soft tissue B-The tumor has a lobulated appearance, in which myxochondroid islands alternate with more cellular foci.
Chondromyxoid fibroma- (A) An irregularly shaped hypocellular center is surrounded by a cellular spindle
cell stroma. (B) The lobules contain tumor cells with small nuclei
and eosinophilic cytoplasmic extensions within a myxoid background
Chondrosarcoma
• Second most common malignant tumour of bones. • Arise de novo or from pre-existing benign
cartilagenous tumour.• Divided into two major categories:
*Conventional chondrosarcoma *Chondrosarcoma variants
Conventional chondrosarcoma
• 30 – 60 yr of age.• M>F• Divided according to location: *Central *Peripheral *Juxtacortical
-Typical chondrosarcoma of femurI-ill defined margins; fusiform thickening of shaft; perforation of cortex
Typical chondrosarcoma
Peripheral Variant:• Tumour is present on the surface of bone.• May arise de-novo or from cartilaginous cap
of preexisting osteochondroma.
Peripheral chondrosarcoma of femur resulting in a huge exophytic mass
Juxtacortical(periosteal) variant:• Location:
– shaft of long bone (most often femur)• Cartilaginous lobular pattern with areas of:
– spotty calcification – endochondral ossification
• Closely related to periosteal osteosarcoma.
Microscopic
• Wide range of differentiation and graded into: – well differentiated – moderately differentiated – poorly differentiated
Well-differentiated chondrosarcoma. The tumor has a distinctly lobulated quality
Well differentiated- High-power appearance of grade 1 chondrosarcoma. A few doubly nucleated cells and
moderate atypia .
Moderately differentiated - High-power appearance of grade 2 chondrosarcoma with necrosis . The nuclei are crowded and
hyperchromatic
Poorly differentiated
Grading system• Grade I : lesions contain hyaline cartilage manifested by
sparse cellularity. The cells typically contain dark, pyknotic nuclei. <20% of cells contain large nuclei and fine nuclear chromatin. Mitosis is absent.
• Grade II: A) lesion are slightly more cellular and >20% nuclei are larger than nucleus of mature lymphocyte. Binucleate cells are easily found. Mitosis is absent.
B) cellular lesions with numerous binucleated cells and nuclear atypia. Mitosis is present but not more than
1/ 10hpf.• Grade III: Mitosis atleast >=2 / 10 hpf
• The main differential is of low grade (Grade 1) chondrosarcoma and enchondroma.
• Features consistent with chondrosarcoma are:*Pain attributable to lesion *Age greater than 50*Cortical destruction and a soft tissue mass*Periosteal reaction and thickening*Endosteal erosion>2/3 cortical thickness on a CT scan*Size greater than 5 cm
Chondrosarcoma variants
Dedifferentiated chondrosarcoma:• Worst prognosis.• Age/sex: sixth decade/ M:F =1:1.• Bones involved: pelvis, femur.• Poorly differentiated sarcomatous component
at periphery of otherwise typical low-grade chondrosarcoma – usually central type – can be peripheral
Gross appearance of dedifferentiated chondrosarcoma of pelvic bone -
Microscopic
• Dedifferentiation: – may be in initial lesion – more often in specimens from recurrent tumor:
• microscopic appearance of this component may be: – rhabdomyosarcoma – fibrosarcoma – osteosarcoma – pleomorphic sarcoma with MFH-like features
The edge of an island of well-differentiated cartilage (upper left) is surrounded by highly pleomorphic sarcoma containing tumor giant cells
Chondrosarcoma is juxtaposed with high-grade malignant fibrous histiocytoma
Clear cell variant:• Behaves as low-grade malignancy • Can undergo dedifferentiation• Age/Sex : 30-40 yrs/M:F= 2.5:1• Location: proximal end of femur and humerus.
Clear cell chondrosarcoma with faint lobulation, woven bone, and clear cells
Mesenchymal variant:
• Usually second or third decade of life • Great variability in clinical course.• Location:
– most commonly: • jaw • pelvis • femur • ribs • spine
Shows an island of well-differentiated cartilage in the center
Cellular, hemangiopericytoma-like component
TUMOUR LOCATION AGE/M/F SALIENT PATHOLOGIC FINDING
OSTEOMA FACIAL BONE
40-50/2:1 MINERALIZED COMPACT BONE
OSTEOID OSTEOMA
CORTEX OF LB
10-30/2:1 “NIDUS” OF IMMATURE BONE SURROUNDED BY SCLEROTIC BONE.
OSTEOBLASTOMA
VERTEBRAE,CORTEX OF LB
10-30/2:1 IDENTICAL TO OSTEOID OSTEOMA BUT LARGER AND OFTEN NO SCLEROSIS
OSTEOSARCOMAA-CONVENTIONAL .B-LOW GRADE CENTRAL
METAPHYSIS OF LB
10-25/3:2
A-OSTEOID FORMED DIRECTLY BY MALIGNAT CELLS
-B- MILDLY ATYPICAL FIBROBLASTIC PROLIFERATION+THICK BONE TRABECULAE
TUMOUR LOCATION AGE/M/F SALIENT PATHOLOGIC FINDING
C-TELANGIECTATIC
METAPHYSIS
BLOOD FILLED SPACE+FIBROUS SEPTAE+HIGHLY MALIGNANT OSTEOID
D-PAROSTEAL
CORTEX OUTSIDE PERIOSTEUM
30-60 YRS MILDLY ATYPICAL FIBROBLASTIC PROLIFERATION+THICK BONE TRABECULAE
E-PERIOSTEAL
CORTEX INSIDE PERIOSTEUM
ABUNDAND CARTILAGE MATRIX +VARIABLE MALIGNANT OSTEOID
TUMOUR LOCATION AGE/M/F SALIENT PATHOLOGIC FINDING
CHONDROMA
HANDS ,FEET,RIBS ,FEMUR
10-40/1:1 VARIABLY CELLULAR HYLINE CARTILAGE
OSTEOCHONDROMA
METAPHYSISOF LBS
10-30/1:1 CARTILAGE CAPPED BONY PROTRUSION
CHONDROBLASTOMA
EPIPHYSISOF LBS
10-20/2:1 CHONDROID LIKE MATRIX, S-100 POSITIVE CELLS WITH GROOVED NUCLEI
CHONDROMYXOID FIBROMA
METAPHYSIS OF LBS
10-30/1:1 HYPOCELLULAR CHONDROMYXOID LOBULES SURROUNDED BY MORE CELLULAR SPINDLE CELL AREAS
TUMOUR LOCATION AGE/M/F SALIENT PATHOLOGIC FINDING
CHONDROSARCOMA
PELIVIS. RIBS ,FEMUR
/3:1
A- CONVENTIONAL
METAPHYSIS 20-80 VARIABLY CELLULAR HYLINE CARTILAGE WITH PERMEATING BONE
B-DEDIFFERENTIATED
METAPHYSIS >30 CONVENTIONAL CHONDROSARCOMA+HIGH GRADE SPINDLE CELL SARCOMA
C- MESENCHYMAL
METAPHYSIS 20-50 UNDIFFERENTIATED SMALL TUMOUR CELLS
WITH +HYLINE CARTILAGE
E- CLEAR CELL EPIPHYSIS 20-70 CONVENTIONAL CHONDROSARCOMA +ABUNDANT LARGE CLEAR CELLS
THANKYOU
PRESENTED BY – DR NARMADA PRASAD TIWARI