Giant osteoid osteoma of tibial shaft: A rare case report

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Giant osteoid osteoma of the tibial shaft is a rare entity.
Though this tumor is seen commonly in axial skeleton, so far
no conclusive report has been published on its periosteal
involvement of tibial shaft diaphysis.

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Giant osteoid osteoma of tibial shaft: A rare case report

  1. 1. Giant osteoid osteoma of tibial shaft: A rare case report
  2. 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 8 5 e2 8 8 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme Case Report Giant osteoid osteoma of tibial shaft: A rare case report Raju Vaishya a,*, Shameem Ahmad Khan b, Ashok Kumar c a Prof., Sr Consultant, Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi 110076, India Registrar, Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi 110076, India c Ortho OT Nurse, Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi 110076, India b article info abstract Article history: We report a rare case of diaphyseal, giant osteoid osteoma of tibial shaft. Detailed review of Received 20 July 2012 literature of giant osteoid osteoma is presented. This entity is more clearly defined and its Received in revised form differentiating features with other mimicking lesions are presented. 11 August 2012 Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Accepted 13 August 2012 Available online 27 August 2012 Keywords: Giant osteoid osteoma Osteoblastoma Diaphyseal Non-steroidal anti inflammatory drugs Introduction Giant osteoid osteoma of the tibial shaft is a rare entity. Though this tumor is seen commonly in axial skeleton, so far no conclusive report has been published on its periosteal involvement of tibial shaft diaphysis. The lesion generally produces few symptoms in spite of its relatively large size. Radiologically, it presents as a lytic lesion of bone; however, varying degrees of calcification and peripheral sclerosis may give it a bizarre appearance. Its awareness is necessary as it may be confused clinically with other benign and malignant tumors of the bone. This benign bone tumor requires local excision as its definitive treatment.1 Case report A 16 year old boy presented with a 2 years history of dull aching pain (intermittent) and swelling of left middle 3rd leg. There was temporary relief with Non-Steroidal Anti Inflammatory Drugs (NSAIDs). There was no other associated symptoms or family history of similar problem. * Corresponding author. Tel.: þ91 9810123331. E-mail address: raju.vaishya@gmail.com (R. Vaishya). 0976-0016/$ e see front matter Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.08.006
  3. 3. 286 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 8 5 e2 8 8 On examination, he has had a bony hard, tender swelling of about 6 cm  5 cm present on the anterior aspect of middle third of left leg, seems to be arising (and attached) from the tibial shaft. Local temperature over the swelling was slightly raised. Ipsilateral ankle, knee and hip movements were normal and there was no other abnormal swellings found in other parts of the body. All the laboratory parameters were within normal limits, including ESR and CRP. X-rays, showed an eccentric radiolucent area in the anterior cortex of the mid shaft of the left tibia with slightly ill defined margins and a surrounding area of dense sclerosis and solid periosteal reaction involving the cortex of the bone and some scalloping of the anterior tibial cortex intramedullary (but no extension into it), due to pressure effect of the bony mass (Fig. 1). Computed Tomographic (CT) scan showed an osteolytic diaphyseal cortical-based lesion in the anterior cortex of the left tibia with sparse intralesional trabeculations and perilesional osteosclerosis. Hyperdense foci are also noted in the adjoining part of medullary cavity (Fig. 2). A wide excision and biopsy of the lesion was done by an anterior approach. The lesion was demarcated well by radiography, intra-operatively using image intensifier. The tumor was excised en bloc (Fig. 3). A bony hard tissue of about 7  3  2 cm was excised. It was arising from the periosteal surface of the anterior cortex of mid shaft tibia. On gross examination, there was a single, flat bony piece of tissue, measuring 6.5  3  1.5 cm. Cut surface show central, Fig. 1 e Pre-op X-rays. Fig. 2 e Pre-op CT scan. Fig. 3 e Post-op X-rays showing en bloc resection of tumor.
  4. 4. 287 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 8 5 e2 8 8 irregular, soft, dark brown cavitated area, roughly measuring 3 Â 1.4 Â 0.5 cm (Fig. 4). The microscopic examination showed sections from center of the bone trabeculae of variably mineralized osteoid. Most of these have a prominent osteoblastic rimming. The intervening stroma is composed of loose fibroconnective tissue, with prominent vascularity. Areas of fresh & old hemorrhage are seen. Sections from the periphery show broad trabeculae of mature lamellar bone. The histopathology was considered consistent with a giant osteoid osteoma. Gram and AFB stains with Aerobic, Anaerobic and Fungal cultures were negative. The wound healed by primary intention. The patient was mobilized non-weight bearing for 3 weeks with crutches. At 2 years follow-up the patient had no pain, swelling or any evidence of recurrence clinically or radiologically. The main preoperative complaint of persistent pain resolved completely, post-operatively, without any need for any analgesics. Discussion Fig. 4 e Tumor removed en bloc. Gaint osteoid osteoma was first described as an osteoblasticosteoid tissue-forming tumor by Jaffe and Mayer in 1932.1 Subsequently, Lichtenstein2 reported similar lesions as osteogenic fibromas and Dahlin and Johnson,3 reported them as giant osteoid osteomas (distinguishing them from ossifying fibromas and classical osteoid osteomas). The term osteoblastoma was introduced by Jaffe4 in 1956 and the prefix “benign” was added to stress its benign nature, in contrast to osteogenic sarcoma with which it is frequently confused. Benign osteoblastoma is a very uncommon lesion. Males and Table 1 e Differential diagnosis of benign diaphyseal tumors of tibia. Osteoblastoma 10e30 Spine, femur & tibia shaft Dull pain, scoliosis, neuro deficit (spine) Osteoid osteoma 10e30 Femur, tibia Night pain relived with NSAID Osteosarcoma 10e25 Femur. tibia (around knee) Pain, swelling, malignancy signs Swelling Giant cell tumor (GCT) 20e40 Around knee, distal radius Eosinophilic granuloma 05e20 Back pain Adamantinoma 15e30 Spine, long bone (diaphysis) Tibial shaft (85%), mandible Brodie’s abscess 15e25 Metaphysis around knee Dull aching pain Pain, swelling >2 cm in size, osteolytic lesion þ/À nidus, with sclerosis Central nidus (<1.5 cm) with surrounding sclerosis Aggressive metaphyseal lesion e blastic/ lytic Eccentric, epiphyseal osteolytic lesion Vertebra plana, punched out lesion Multiple, sharply demarcated radiolucent lesions Lytic lesion with a rim of sclerosis Fibro-vascular stroma, primitive woven bone, layer of osteoblasts En bloc resection, extended curettage þ/À bone grafting Usually benign Fibro-vascular tissue with immature bone Excision, curettage, percutaneous RF ablation Wide resection, amputation Always benign, self limiting condition Highly malignant, early pulmonary metastasis Rarely malignant, locally aggressive Malignant osteoid, pleomorphic osteoblasts in multiple layers Multinucleated giant cells in background of stromal cells Langerhan’s cell, eosinophilic cytoplasm Islands of epithelial cells in a fibrous stroma Infected granulation tissue Excision, extended curettage þ/À cementing Low-dose irradiation, curettage & bone grafting Wide resection or amputation Self limiting Curettage/ saucerization Low virulent organism Radio/chemo therapy resistant
  5. 5. 288 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 8 5 e2 8 8 females are affected with equal frequency. The majority of cases occur between 10 and 35 years of age. The youngest patient reported was 5 years, the oldest was 61 years. Although the lesion may involve any bone, the vertebrae, femur and tibia are most commonly affected. Characteristically, giant osteoid osteomas grows to a large size, yet produces few or no symptoms. This is in contrast to osteoid osteoma which is usually small but produces excruciating pain. We believe that this may be explained on the basis that the nidus in a small osteoid osteoma is densely encapsulated by thick bone & not allowing it to expand (‘breathe’), causing severe pain. Whereas, in a giant osteoid osteoma, since the nidus has larger space to expand, there is lesser degree of pain. As a rule, laboratory tests are within normal limits. The radiologic appearance is that of a well-circumscribed osteolytic lesion. The overlying cortex may be thinned or eroded. Depending on the extent of calcification within the tumor, varying degrees of sclerosis are apparent. Although sclerosis about a central nidus may occur, it is seldom as characteristic as in osteoid osteoma. The tumor may vary from 2 to 12 cm in greatest diameter. It appears pinkish-red to purple in color and may be surrounded by variable amounts of sclerotic bone. On cut section the lesion appears friable, gritty and hemorrhagic. Microscopically, osteoid trabeculae are seen lying in loose vascular osteoblastic connective tissue. The osteoid trabeculae are lined by typical osteoblasts which show no evidence of malignancy. Mitoses are rare, thick bony trabeculae may be present at the periphery. Multinucleated giant cells, probably osteoclasts, are also present in variable numbers, and evidence of remote hemorrhage is frequently seen in the poorly cellular connective tissue. Cartilage is never present. Giant osteoid osteoma may be confused with other mimicking lesions of the bone, as discussed in the Table 1 below: According to Dahlin and Johnson,3 “the lesion is essentially osteoid osteoma, but fails to demonstrate aggressiveness”. This concept is also advanced by Lichtenstein,3 who regards osteoma and osteoid osteoma as special types of benign osteoblastoma. The current belief that these lesions represent a primary benign bone tumor was proposed by Jaffe1 in 1935. Prior to that time a non-bacterial inflammatory origin was considered. Recently, there have been several reports describing clinical and roentgenographic healing, and the validity of the classification of this lesion as a neoplasm has been challenged.5 Since both osteoid osteoma and benign osteoblastoma show characteristic osteoblastic proliferation and osteoid formation in a highly vascular stroma, it is conceivable that a locally altered blood supply (for reasons not readily apparent) stimulates osteoblastic activity and results in either lesion. Such a pathogenesis was proposed by Lichtenstein6 for the development of aneurysmal bone cyst, which has a similarly prominent vasculature. This concept may well explain the good results of conservative surgical therapy e local excision or curettage.7 Conflicts of interest All authors have none to declare. references 1. Jaffe HL. Arch Surg (Chicago). 1935;31:709. 2. Lichtenstein L. Bone Tumors. St. Louis: C. V. Mosby Company; 1952. p. 82. 3. Dahlin DC, Johnson Jr EW. J Bone Joint Surg Am. 1954;36A:559. 4. Dahlin DC, Johnson Jr EW. Bull Hosp Jt Dis. 1956;17:141. 5. Moberg E. J Bone Joint Surg Am. 1951;33A:166. 6. Moberg E. Bone Tumors. 2nd ed. St. Louis: C. V. Mosby Company; 1959. p. 97. 7. Ochsner Sr A, Ochsner Jr A. Tumors of the thoracic wall. In: Spain DM, ed. Diagnosis and Treatment of Tumors of the Chest. New York: Grune & Stratton, Inc.; 1960:205.
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