Bone & JointBone & JointTumorsTumors

Periostal reactionsPeriostal reactions Response to RAPIDLY growing

lesions

1. Spiculated "hair-on-end"

2. Onion-skinning

Codman's triangleCodman's triangle

Periostal reactionsPeriostal reactions Response to SLOW growing lesions

focal cortical thickening

I. Cartilaginous I. Cartilaginous

TumorsTumors OsteochondromaOsteochondromaSolitary EnchondromaSolitary EnchondromaChondrosarcomaChondrosarcoma

OsteochondromaOsteochondroma

Osteocartilaginous exostosisOsteocartilaginous exostosis Most common benign tumors or Most common benign tumors or

tumorlike lesions of bone, tumorlike lesions of bone, In almost any bone preformed in In almost any bone preformed in

cartilage, cartilage, particularly long tubular particularly long tubular bonesbones, ,

Presents as a solitary cartilage-Presents as a solitary cartilage-capped bony outgrowth protruding capped bony outgrowth protruding from the bone surface near the from the bone surface near the metaphysis.metaphysis.

The most common location of The most common location of an osteochondroma is in the an osteochondroma is in the region of the region of the kneeknee, , particularly the lower particularly the lower

metaphysis of the femur or the metaphysis of the femur or the upper metaphysis of the tibia. upper metaphysis of the tibia.

occasionally in a flat boneoccasionally in a flat bone such as a rib, clavicle, ilium, or such as a rib, clavicle, ilium, or

vertebravertebra. .

PathologyPathology A sessile or stalked, A sessile or stalked,

cartilage-capped, bony cartilage-capped, bony protusion which extends protusion which extends from the metaphysial regionfrom the metaphysial region

MicroscopicallyMicroscopically bony protusionbony protusion a cap of mature cartilage a cap of mature cartilage

- bony protusionbony protusion- a cap of mature cartilagea cap of mature cartilage

Solitary EnchondromaSolitary Enchondroma

Central Chondroma Central Chondroma Composed of mature hyaline Composed of mature hyaline

cartilagecartilage Develops in the medullary cavity Develops in the medullary cavity

of a single boneof a single bone Third to sixth decades of life Third to sixth decades of life

average age : between 30 and 40 average age : between 30 and 40 years.years.

The most common location is The most common location is in the bones of the in the bones of the handhand: : About one-third of all cases About one-third of all cases

occur in the phalanges. occur in the phalanges. Sometimes: Sometimes:

the bones of the foot the bones of the foot long tubular bone (the humerus or long tubular bone (the humerus or

femur) femur) pelvic bonespelvic bones shoulder girdles. shoulder girdles.

Radiology:Radiology: A central, or slightly eccentric, A central, or slightly eccentric,

well-circumscribed or "bubbly" well-circumscribed or "bubbly" radiolucent lesion, radiolucent lesion,

finely or densely stippled with finely or densely stippled with calcification.calcification.

Pathology:Pathology: Microscopically, small neoplastic Microscopically, small neoplastic

cartilage cells with single small cartilage cells with single small nucleinuclei

May form lobules or facets May form lobules or facets May be partially calcifiedMay be partially calcified

- - lobules or facets lobules or facets - partially calcified- partially calcified

EnchondromatosisEnchondromatosis(Ollier’s Disease)(Ollier’s Disease)

Chondrosarcoma Chondrosarcoma

A malignant cartilaginous tumorA malignant cartilaginous tumor The third to sixth decades of life The third to sixth decades of life

(average age of 45 years) (average age of 45 years) Slightly more common in males than Slightly more common in males than

femalesfemales

Chondrosarcoma may originate in the Chondrosarcoma may originate in the medullary cavity medullary cavity (central (central chondrosarcoma)chondrosarcoma) about 75% of cases or by malignant about 75% of cases or by malignant

transformation of a preexisting transformation of a preexisting enchondromaenchondroma particularly in patients with particularly in patients with enchondromatosisenchondromatosis, ,

May originate in a juxtacortical May originate in a juxtacortical location location (peripheral chondrosarcoma)(peripheral chondrosarcoma) by sarcomatous change in the cartilage by sarcomatous change in the cartilage cap of an osteochondroma.cap of an osteochondroma.

Location: Location: flat bones of the pelvis flat bones of the pelvis the large limb bonesthe large limb bones

femur femur 25% 25% humerushumerus

the ribsthe ribs

Radiology:Radiology: Radiolucencies (irregular or Radiolucencies (irregular or

circular or bubbly) circular or bubbly) Calcification (granular or Calcification (granular or

lobular radiopaque areas)lobular radiopaque areas) Destruction of the inner cortex, Destruction of the inner cortex, Enlargement of bone contours, Enlargement of bone contours, Focal periosteal reaction,Focal periosteal reaction, Penetration of the cortex.Penetration of the cortex.

Chondrosarcoma

ChondrosarcomChondrosarcomaa

ChondrosarcomaChondrosarcoma

MicroscopyMicroscopy a lobular cartilaginous a lobular cartilaginous

architecture,architecture, highly cellular, highly cellular, more than one nucleated cell per more than one nucleated cell per

lacuna, lacuna, occasionally reveals tumor giant occasionally reveals tumor giant

cells or clear cells, cells or clear cells, with increasing grades of with increasing grades of

malignancy, has marked malignancy, has marked variation in nuclear and cellular variation in nuclear and cellular size and shape. size and shape.

ChondrosarcomaChondrosarcoma

II. Bone-FormingII. Bone-Forming TumorsTumors

- - Osteoid OsteomaOsteoid Osteoma

- Osteoblastoma- Osteoblastoma

- Osteogenic Sarcoma - Osteogenic Sarcoma

Osteoid OsteomaOsteoid Osteoma

A distinctive, small (<2 cm), solitary, A distinctive, small (<2 cm), solitary, benign, tumorlike lesion of bone benign, tumorlike lesion of bone

It is composed of osteoid tissue It is composed of osteoid tissue intermixed with woven bone and intermixed with woven bone and surrounded by reactive bony surrounded by reactive bony sclerosis. sclerosis.

Osteoid osteoma most often occurs Osteoid osteoma most often occurs in children and young adults. in children and young adults.

A frequent presenting symptom of A frequent presenting symptom of this condition is night pain, often this condition is night pain, often relieved by relieved by aspirinaspirin, with localized , with localized tenderness in the painful area. tenderness in the painful area.

Osteoid osteoma is commonly Osteoid osteoma is commonly located in a located in a femurfemur or or tibiatibia, ,

Radiology:Radiology: A representative x-ray picture A representative x-ray picture An osteoid osteoma shows a well An osteoid osteoma shows a well

circumscribed, small, round or circumscribed, small, round or oval, radioluscent or radiodense oval, radioluscent or radiodense lesion (the nidus) lesion (the nidus)

May be located in or near the May be located in or near the cortex and surrounded by densely cortex and surrounded by densely sclerotic bone.sclerotic bone.

Osteoid OsteomaOsteoid Osteoma

MicroscopyMicroscopy The nidus:The nidus:

narrow trabeculae of osteoid or narrow trabeculae of osteoid or newly formed bone produced by newly formed bone produced by osteoblasts + vascularized stroma osteoblasts + vascularized stroma

surrounded by a sclerotic mature surrounded by a sclerotic mature bone.bone.

Osteoid OsteomaOsteoid Osteoma

OsteoblastomaOsteoblastoma Osteoblastomas are larger (> 2 cm) Osteoblastomas are larger (> 2 cm)

than osteoid osteomas than osteoid osteomas Mainly osteolyticMainly osteolytic

do not evoke reactive bone sclerosisdo not evoke reactive bone sclerosis Higher recurrence rate (~10%)Higher recurrence rate (~10%) Characterised by immature osteoid Characterised by immature osteoid

production production Commonly in the cancellous bone of Commonly in the cancellous bone of

the spine (posterior elements) and the spine (posterior elements) and skullskull

Osteogenic SarcomaOsteogenic Sarcoma

Osteosarcoma: Osteosarcoma: a malignant tumor a malignant tumor of bone of bone

Most common primary bone Most common primary bone tumor after myelomatumor after myeloma

In young people under 20 years In young people under 20 years of ageof age

Male / Female : 2/1 Male / Female : 2/1

Peak beyond 40 years of age:Peak beyond 40 years of age: Secondary to preexisting disease Secondary to preexisting disease

Paget's disease (Paget's sarcoma)Paget's disease (Paget's sarcoma) Previous radiation (irradiation Previous radiation (irradiation

sarcoma) sarcoma) Other conditionsOther conditions

Osteosarcoma may occur in any bone Osteosarcoma may occur in any bone The most frequent location is near The most frequent location is near

the the kneeknee (~50-60% of cases) (~50-60% of cases) most commonly in the distal end of the most commonly in the distal end of the

femur femur the upper end of the tibia, the upper end of the tibia, upper end of the humerus, upper end of the humerus, pelvis, pelvis, upper end of the femur. upper end of the femur.

Bone-forming cells produce Bone-forming cells produce alkaline alkaline phosphatasephosphatase The serum alkaline phosphatase is The serum alkaline phosphatase is

markedly elevated in many patients with markedly elevated in many patients with osteosarcoma.osteosarcoma.

Radiology of a long bone usually Radiology of a long bone usually show a large, ill-defined tumor. show a large, ill-defined tumor.

The bone-producing (osteoblastic) The bone-producing (osteoblastic) lesion is located in the medulla near lesion is located in the medulla near the metaphysisthe metaphysis

Lifts up the periosteum (periostal Lifts up the periosteum (periostal reaction)reaction) often producing "often producing "Codman's triangleCodman's triangle", an ", an

angle between the outer cortex and the angle between the outer cortex and the elevated periosteum, elevated periosteum,

Sun-rays patternSun-rays pattern Less common : Less common :

destructive (osteolytic) lesions with a destructive (osteolytic) lesions with a "moth eaten" appearance of the cortex. "moth eaten" appearance of the cortex.

OsteosarcomaOsteosarcoma

OsteosarcomaOsteosarcoma OsteosarcomaOsteosarcoma

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Osteosarcoma: Osteosarcoma: Lung metsLung mets

MicroscopyMicroscopy Proliferating malignant Proliferating malignant

spindle- cell stromaspindle- cell stroma Osteoid or immature boneOsteoid or immature bone

OsteosarcomaOsteosarcoma

OsteosarcomaOsteosarcoma

III.III. Tumors of Other or Tumors of Other or Unknown Histogenesis Unknown Histogenesis

Ewing’s sarcomaEwing’s sarcoma Giant Cell TumorGiant Cell Tumor

Ewing's SarcomaEwing's Sarcoma

A malignant, small, round-cell A malignant, small, round-cell tumor of bone tumor of bone

Composed of uniform, densely Composed of uniform, densely packed, tumor cells with round packed, tumor cells with round nuclei and indistinct cellular nuclei and indistinct cellular bordersborders

The histogenesis of Ewing's The histogenesis of Ewing's sarcoma remains controversialsarcoma remains controversial

Mainly in children Mainly in children second decade of life second decade of life average age of 13-14 years average age of 13-14 years

Male/Female : 2/1 Male/Female : 2/1 The most common presenting The most common presenting

symptom of Ewing's sarcoma is symptom of Ewing's sarcoma is bone bone painpain, , swelling, tenderness, and heat in swelling, tenderness, and heat in

the affected part, slight fever, and the affected part, slight fever, and elevated erythrocyte elevated erythrocyte sedimentation rate, which all sedimentation rate, which all together may together may mimic osteomyelitismimic osteomyelitis..

Ewing's sarcoma may occur in Ewing's sarcoma may occur in any bone but most frequently any bone but most frequently involves involves long boneslong bones. . Femur (27%), pelvic bones (18%), Femur (27%), pelvic bones (18%),

tibia and fibula (17%), humerus tibia and fibula (17%), humerus (10%), scapula (6%). (10%), scapula (6%).

Radiology:Radiology: A mottled A mottled "moth eaten""moth eaten"

destructive lesion in the diaphysis destructive lesion in the diaphysis periosteal reactive new bone periosteal reactive new bone

sometimes formed in concentric sometimes formed in concentric layers and producing an layers and producing an ""onion skinonion skin"" appearance, and often accompanied appearance, and often accompanied by a soft-tissue mass.by a soft-tissue mass.

Ewing's sarcomaEwing's sarcoma

Microscopically, Microscopically, uniform, densely packed, tumor cells uniform, densely packed, tumor cells

with a single, round or oval nucleus, with a single, round or oval nucleus, indistinct cellular borders, and a size indistinct cellular borders, and a size and appearance somewhat resembling and appearance somewhat resembling lymphocytes lymphocytes ((small round blue cellssmall round blue cells)). .

The tumor cell cytoplasm The tumor cell cytoplasm characteristically contains characteristically contains PAS-positive PAS-positive glycogen granules. glycogen granules.

The tumor cells grow in sheets, The tumor cells grow in sheets, sometimes with sometimes with central necrosiscentral necrosis, but , but without pattern, such as the without pattern, such as the rosettesrosettes typically formed by metastatic typically formed by metastatic neuroblastoma. neuroblastoma.

Giant Cell Tumor Giant Cell Tumor

An aggressive benign tumor An aggressive benign tumor Composed of :Composed of :

well vascularized stroma well vascularized stroma plump, spindly, and oval tumor cells plump, spindly, and oval tumor cells multinucleated tumor giant cellsmultinucleated tumor giant cells

Over the age of 20: Over the age of 20: most commonly in the third decade most commonly in the third decade

of life of life slight female preponderanceslight female preponderance

The skeletal location: The skeletal location: 50% of cases occur near the 50% of cases occur near the kneeknee

most commonly in the distal end of most commonly in the distal end of the femur or the upper end of the the femur or the upper end of the tibia. tibia.

The x-ray picture : The x-ray picture : Large, eccentric, oval, Large, eccentric, oval, Radioluscent destructive lesion Radioluscent destructive lesion

centered in the epiphysis, centered in the epiphysis, Cortical erosion and thinning, Cortical erosion and thinning, Expanding the bone contours Expanding the bone contours

without a border.without a border.

Giant Cell TumorGiant Cell Tumor

Giant Cell TumorGiant Cell Tumor

Microscopy:Microscopy:

1.1. plump, spindly, and oval plump, spindly, and oval stromal cells stromal cells

2.2. multinucleated tumor giant multinucleated tumor giant cells which are formed by cells which are formed by fusion of the stromal cellsfusion of the stromal cells

Differential diagnosis: Differential diagnosis: reparative granulomasreparative granulomas brown tumors of brown tumors of

hyperparathyroidism hyperparathyroidism the lytic phase of Paget's diseasethe lytic phase of Paget's disease aneurysmal bone cystaneurysmal bone cyst

IV. Miscellaneous IV. Miscellaneous Tumors and Tumor-like Tumors and Tumor-like Lesions of BoneLesions of Bone

Multiple MyelomaMultiple Myeloma ChordomaChordoma Myositis OssificansMyositis Ossificans

Multiple Myeloma Multiple Myeloma

Multiple myeloma is a malignant Multiple myeloma is a malignant tumor of plasma cells tumor of plasma cells

Characterized by Characterized by multiple lytic destructive lesions of multiple lytic destructive lesions of

bone, bone, immunoglobulin abnormalities immunoglobulin abnormalities

(monoclonal gammopathy), (monoclonal gammopathy), bone marrow failure, bone marrow failure, recurrent infections, recurrent infections, hypercalcemia, hypercalcemia, amyloid deposits, amyloid deposits, renal insufficiency. renal insufficiency.

Over 40Over 40 years of age and with an years of age and with an average age of 60 years. average age of 60 years.

Multiple myeloma most often involves Multiple myeloma most often involves the the vertebral column, ribs, and skullvertebral column, ribs, and skull although virtually any, or all, bones although virtually any, or all, bones can be affected. can be affected.

The most common symptom is bone The most common symptom is bone painpain, ,

Other symptoms Other symptoms bone marrow failure (anemia, bleeding), bone marrow failure (anemia, bleeding), recurrent infections, recurrent infections, serum hyperviscosity, serum hyperviscosity, hypercalcemia, hypercalcemia, renal failure of multifactorial pathogenesis renal failure of multifactorial pathogenesis

(myeloma nephropathy, associated (myeloma nephropathy, associated amyloidosis, nephrocalcinosis). amyloidosis, nephrocalcinosis).

Radiology:Radiology: Skull, ribs, or other affected bones Skull, ribs, or other affected bones Multiple lytic Multiple lytic "punched out""punched out"

lesions. lesions. Osteopenia/Osteoporosis Osteopenia/Osteoporosis

Multiple MyelomaMultiple Myeloma

Microscopy: Microscopy: Bone marrow. Bone marrow. Plasma cell tumorPlasma cell tumor::

an eccentric, round, hyperchromatic an eccentric, round, hyperchromatic nucleus sometimes with a nucleus sometimes with a "cartwheel" distribution of chromatin "cartwheel" distribution of chromatin

frequent double or triple nuclei, frequent double or triple nuclei, abundance of cytoplasm with a abundance of cytoplasm with a

purple (basophilic) color and an purple (basophilic) color and an occasional perinuclear "halo", occasional perinuclear "halo",

distinct cell borders. distinct cell borders.

Multiple MyelomaMultiple Myeloma

ChordomaChordoma

A malignant tumor of the A malignant tumor of the notochordnotochord

Arises towards either end of the Arises towards either end of the vertebral column, most often in vertebral column, most often in the the sacrococcygealsacrococcygeal regionregion but also but also in the spheno-occipital region. in the spheno-occipital region.

Fifth to eighth decades of life, Fifth to eighth decades of life, average age : 50 yearsaverage age : 50 years slight female preponderance.slight female preponderance.

Clinical x-rays :Clinical x-rays : large soft tissue mass large soft tissue mass lytic destruction of the lytic destruction of the

sacrococcygeal bone.sacrococcygeal bone. Pathology Pathology

Grossly, Grossly, large, soft, lobulated, gelatinous large, soft, lobulated, gelatinous

tumor tumor extends from the sacrum and extends from the sacrum and

expanding into the pelvic cavity. expanding into the pelvic cavity. Microscopically,Microscopically,

large and vacuolated, so-called large and vacuolated, so-called physaliferous (bubbly/drop-like) cells.physaliferous (bubbly/drop-like) cells.

ChordomaChordoma

Myositis Ossificans Myositis Ossificans A nonneoplastic tumor-like lesion A nonneoplastic tumor-like lesion Trauma to skeletal muscle Trauma to skeletal muscle

hemorrhage hemorrhage distrophic distrophic calcification calcification heterotropic heterotropic ossificationossification

It must be distinguished from It must be distinguished from extraosseous osteogenic sarcoma. extraosseous osteogenic sarcoma.

Clinical x-rays: Clinical x-rays: peripherally calcifying (ossifying) peripherally calcifying (ossifying)

lesion located in the soft tissues or lesion located in the soft tissues or next to bone. next to bone.

Microscopically, Microscopically, newly formed bone newly formed bone matures toward the periphery of matures toward the periphery of

the lesion, the lesion, whereas the center or interior of whereas the center or interior of

the lesion is cellular and poorly the lesion is cellular and poorly differentiated. differentiated. The presence of peripheral maturity The presence of peripheral maturity

and central immaturity of the lesion and central immaturity of the lesion is called "zoning phenomenon" and is called "zoning phenomenon" and is characteristic of myositis is characteristic of myositis ossificans but lacking in osteogenic ossificans but lacking in osteogenic sarcoma.sarcoma.

Myositis OssificansMyositis Ossificans

Joint TumorsJoint Tumors

Synovial tumors Synovial tumors Benign tumors Benign tumors

Tenosynovial giant cell tumor Tenosynovial giant cell tumor Localized tenosynovial giant cell tumor Localized tenosynovial giant cell tumor Diffuse tenosynovial giant cell tumor Diffuse tenosynovial giant cell tumor

(extraarticular pigmented villonodular synovitis, (extraarticular pigmented villonodular synovitis, florid tenosynovitis)florid tenosynovitis)

Malignant tumors Malignant tumors Synovial sarcoma Synovial sarcoma

Biphasic (fibrous and epithelial) synovial sarcoma Biphasic (fibrous and epithelial) synovial sarcoma Monophasic (fibrous or epithelial) synovial Monophasic (fibrous or epithelial) synovial

sarcomasarcoma Malignant giant cell tumor of tendon sheathMalignant giant cell tumor of tendon sheath

8-10% of all sarcomas 8-10% of all sarcomas All agesAll ages Location:Location:

extremitiesextremities especially the lower extremities especially the lower extremities

around the kneesaround the knees Misdiagnose Misdiagnose benign tumor benign tumor

small size, slow growth, and small size, slow growth, and well-defined appearancewell-defined appearance

Synovial sarcoma in the anterior left upper thigh and/or inguinal region Synovial sarcoma in the anterior left upper thigh and/or inguinal region