Vol 8 ppt

496 views
376 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
496
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
26
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Vol 8 ppt

  1. 1. Volume 8 Round Cell Tumors of BoneEwing’s sarcoma-----------------Case 169-175 & 861-900Large cell lymphoma------------Case 176-178 & 901-933Hodgkin’s lymphoma-----------Case 179-180 & 934-936Leukemia-------------------------Case 181 & 937-944Plasma cell tumors Solitary plasmacytoma-------Case 182-185 & 946-957 Multiple myeloma------------Case 186-188 & 958-976Metastatic neuroblastoma------Case 189 & 977-983
  2. 2. Round CellTumors Of Bone
  3. 3. Ewing’s Sarcoma
  4. 4. Ewing’s Sarcoma The Ewing’s sarcoma is the second most common primarymalignant bone tumor seen in children and is the fourth mostcommon malignant tumor overall. This tumor is a very primitivemesenchymal sarcoma that has a mysterious etiology. However,with the advent of the electron microscope and immunohisto-chemical studies, most experts today feel that this tumor probablyrepresents a poorly differentiated member of a larger family ofneural tumors, distinct from the neuroblastoma. In 90% of cases,cytogeneticists will find reciprocal translocation in chromosome11 and 22. That also is found in patients with the diagnosis ofprimative neuroectodermal tumor (PNET) and Askin’s tumor.Other round cell tumors that have a similar histological appearanceinclude the embryonal rhabdomyosarcoma, the mesenchymalchondrosarcoma, and the metastatic neuroblastoma. It is veryimportant to separate out the large group of histiocytic lymphomas
  5. 5. seen in an older age group that have a similar appearance withH & E staining. With special staining techniques, most lymphomaswill be positive for leukocyte antigen. Likewise with metastaticembryonal rhabdomyosarcoma, specific immunohistochemicalstudies will reveal muscle markers such as actin, desmin, andmyoglobin not found in the Ewing’s sarcoma. Ninety percent of patients with Ewing’s sarcoma will be from 5to 25 years of age, with males being affected slightly more thanfemales. The two most common locations for Ewing’s sarcoma arethe femur and pelvis, followed by the tibia, humerus and scapula,but it can be found in any location in the body that includesmyelogenous tissue, including the spine, ribs, foot and hand. Radio-graphically, the Ewing’s tumor will be found typically in a meta-diaphyseal location in the medullary canal with very diffuse,permeative lytic destruction of the surrounding cortical structuresthat looks like hematogenous osteomyelitis. Likewise, the clinicalappearance of Ewing’s sarcoma can mimic infectious disease
  6. 6. with elevated temperature, white count and sed rate. Because of thehigh incidence of necrosis with the Ewing’s sarcoma, it is commonto find liquefied necrotic debris in the tumor site that gives theclinical appearance of osteomyelitis. With early breakthrough intothe subperiosteal tissues, the radiographic finding of a reactiveperiostitis is quite common, creating a multilaminated “onionskin”appearance on a routine radiograph. Another characteristic radio-graphic finding is the “hair-on-end” appearance that is createdby reactive new bone formation along the perpendicular periostealblood vessels running between the periosteum and the subadjacentcortex. Prior to 1970, the prognosis for survival in Ewing’s sarcoma wasextremely poor with approximately 10% of patients surviving theirdisease. Currently with the use of adjuvant systemic chemotherapyin non-metastatic Ewing’s sarcoma, the survival prognosis now runsapproximately 70%. However, in about 20% of patients withEwing’s sarcoma that present with metastatic disease to other bones
  7. 7. or to the lung, the survival rate drops to about 30%. Wheneverpossible, the orthopedic oncologist will attempt a wide resection ofthe primary tumor site, a technique similar to that used for osteo-sarcoma. If wide surgical margins are obtained, the chances forsurvival is probably better than if radiation therapy and chemo-therapy had been used without surgery. However, in cases wherethe surgical margins are positive at the time of surgical resection,postoperative radiation therapy is indicated. The chance for localrecurrence with chemotherapy and radiation therapy alone is 20%or higher. A devastating complication of radiation therapy is path-ological fracture that frequently results in intramedullary fixationthat may fail and can result in amputation. Secondary sarcomas canoccur with the use of radiation therapy for Ewing’s sarcoma in 10%of cases. The primative neuroectodermal tumor accounts for 10%of all Ewing’s-like tumors and carries the same prognosis forsurvival. The clinical management for this entity is essentially thesame as for Ewing’s sarcoma.
  8. 8. CLASSICCase #16913 year femaleEwing’s sarcomadistal femur onion skin periostitis
  9. 9. Bone scan
  10. 10. Coronal protondensity MRI
  11. 11. Coronal T-2 MRI
  12. 12. Coronal T-2 MRIshowing multifocaldisease
  13. 13. necroticMacro section Ewing’ssarcoma distal femur viable
  14. 14. Photomic showing pseudo-rosette formations
  15. 15. Same patient withmultifocal involvementproximal humerus
  16. 16. Case #17015 year femaleEwing’s sarcomaproximal tibia
  17. 17. Lateral view
  18. 18. Sagittal T-1 MRI
  19. 19. Axial T-1 MRI
  20. 20. Compress systemPhoto of resected proximal tibia & prosthesis
  21. 21. Placement of rotatinghinge Compress prosthesis
  22. 22. Attachment ofpatellar ligament withdouble tooth washers
  23. 23. X-ray 2 mos post op anchor plug
  24. 24. 5.5 years post opwith excellentosseointegration atbone-prostheticinterface
  25. 25. 11 years post op
  26. 26. Case #17119 year femaleEwing’ sarcomaproximal femur
  27. 27. Bone scan
  28. 28. 1 year later withpath fracture thruradiated bone
  29. 29. Persistent non unionafter IM nailing
  30. 30. X-ray 1 year post opplacement of cementedlong stem custombipolar prosthesis
  31. 31. Case #172 permeative lysis13 year male with“hair-on-end”reactivesubperiosteal newbone formation
  32. 32. Macro section resectedproximal femur
  33. 33. periostiumCloseup macro sectionshowing “hair-on-end” necrosisreactive subperiostealnew bone permeation
  34. 34. periostiumCloseup macro section“hair-on-end” subperiostealreactive bone formation
  35. 35. Photomic Ewing’s sarcoma
  36. 36. Case #173 hair-on-end15 year male Ewing’ssarcoma femur onion skin
  37. 37. Case #174 28 year male with Ewing’s sarcoma pelvis
  38. 38. tumorCT scan
  39. 39. Case #175 14 year male with Ewing’s sarcoma pelvis
  40. 40. iliumMacro section from tumorautopsy specimen acetabulum
  41. 41. Photomic
  42. 42. Case #861 34 year female with Ewing’s sarcoma pelvis
  43. 43. Close up hip
  44. 44. Coronal Gad contrast MRI
  45. 45. Coronal T-2 MRI
  46. 46. Axial T-1 MRI
  47. 47. Axial proton density MRI
  48. 48. Photomic
  49. 49. Case #862 Coronal T-1 MRI tumor 28 year male with Ewing’s sarcoma pubis
  50. 50. tumor Coronal T-2 MRI
  51. 51. tumorT-2 MRI
  52. 52. tumor Coronal T-2 MRI
  53. 53. tumorAxial PD MRI
  54. 54. Photomic
  55. 55. Axial PD MRI following successful chemotherapy
  56. 56. Coronal T-2 MRI post chemo
  57. 57. Case #863 10 year female with Ewing’s sarcoma pelvis
  58. 58. 6 months later
  59. 59. Coronal T-1 MRI
  60. 60. Coronal T-2 MRI
  61. 61. Case #864 19 year male with Ewing’s sarcoma SI area
  62. 62. Axial gad contrast MRI
  63. 63. Axial T-2 MRI
  64. 64. Photomic
  65. 65. Post op cementation
  66. 66. Case #86519 year maleEwing’s sarcomasacrum
  67. 67. Close up
  68. 68. Myelogram showingnerve root pressure
  69. 69. tumorCT scan
  70. 70. Photomic
  71. 71. Case #86612 year maleEwing’s sarcomaL-5
  72. 72. Oblique view
  73. 73. Case #86737 year maleEwing’s sarcomaproximal femur
  74. 74. Coronal T-1 MRI
  75. 75. Photomic
  76. 76. X-ray allograftprior to implantation lateral AP
  77. 77. Post op alloprostheticreconstruction
  78. 78. Case #86814 year maleEwing’s sarcomamid femurBone scan
  79. 79. Coronal protondensity MRIPre chemo
  80. 80. Axial PD MRI pre chemo
  81. 81. Photomic
  82. 82. Axial PD MRI post chemo
  83. 83. Amputation following good chemo response
  84. 84. cementPost op x-ray with modified bipolar reconstruction
  85. 85. Case #869 21 year male with Ewing’s sarcoma pelvis and femur
  86. 86. Coronal T-1 MRI
  87. 87. tumorCoronal T-2 MRI
  88. 88. Coronal T-2 MRI
  89. 89. Case #8707 year maleEwing’s sarcomadistal femur
  90. 90. Bone scan
  91. 91. Sagittal protondensity MRI
  92. 92. tumorAxial T-1 MRI
  93. 93. Photomic
  94. 94. Axial T-2 MRI post chemo
  95. 95. Coronal T-2 MRI post chemo
  96. 96. Case #87113 year maleEwing’s sarcomafemur
  97. 97. 5 years afterradiation & chemowith recurrence &path fracture
  98. 98. Post op x-ray withIM nail for pathfracture
  99. 99. tumor bulgeTotal femur replacement specimen
  100. 100. Custom total femur replacement prosthesis
  101. 101. Placement of custom prosthesis
  102. 102. Post op X-ray
  103. 103. Case #87216 year maleEwing’s sarcomaproximal femur
  104. 104. Lateral view
  105. 105. Coronal T-1 MRI
  106. 106. Coronal T-2 MRI
  107. 107. Axial proton density MRI
  108. 108. Case #873 9 year male with Ewing’s sarcoma tibia
  109. 109. Bone scan
  110. 110. Sagittal T-1 MRI T-2 MRI
  111. 111. Post op reconstructionallograft over IM nail
  112. 112. 8 years later
  113. 113. Case #875 onion skin laminated2.5 year male periostitisEwing’s sarcomadistal tibia
  114. 114. Lateral view entire tibia
  115. 115. Coronal T-1 MRI
  116. 116. Axial T-1 Gad contrast MRI
  117. 117. Case #87617 year male withEwing’s sarcoma tibia
  118. 118. Different view
  119. 119. Post op alloprosthetic allograftreconstruction
  120. 120. Multifocal lesion proxfemur 6 mos later
  121. 121. Case #87719 year female with tumorEwing’s sarcomaproximal humerus hair on end
  122. 122. Post op alloprostheticreconstruction
  123. 123. Case #87839 year maleEwing’s sarcomaproximal humerus
  124. 124. X-ray one year laterwithout treatment
  125. 125. Photomic
  126. 126. Case #879 10 year male with Ewing’s sarcoma scapula
  127. 127. Scapular view
  128. 128. Bone scan
  129. 129. CT scan
  130. 130. Special CT scan scapula
  131. 131. Case #880 9 year male with Ewing’s sarcoma scapula
  132. 132. Case #881 20 year male with Ewing’s of scapula
  133. 133. Soft tumorSpecial soft tissue technique x-ray
  134. 134. Case #882 16 year male with Ewing’s sarcoma clavicle
  135. 135. Case #883 16 year female with Ewing’s sarcoma clavicle
  136. 136. Case #884 7 year female with Ewing’s sarcoma 3rd posterior rib
  137. 137. Case #885 17 year female with Ewing’s sarcoma post 7th rib
  138. 138. Case #886 11 year male with Ewing’s sarcoma rib
  139. 139. Case #88712 year femaleEwing’s sarcomafibula
  140. 140. Macro section fromresected specimen
  141. 141. Scanning lensphotomic
  142. 142. Higher power
  143. 143. Case #88820 year femaleEwing’s sarcomadistal fibula
  144. 144. tumorAxial T-2 MRI
  145. 145. Case #888.1 Ewing’s Fibula 15 yr male with pain and swelling of leg for 3 months
  146. 146. Cor T-1 T-2 Gad
  147. 147. Axial T-1 T-2 Gad
  148. 148. Case #88915 year femaleEwing’s sarcomaproximal fibula
  149. 149. Case #89018 year maleEwing’s sarcomadistal fibula
  150. 150. Bone scan
  151. 151. Case #891 17 year male with Ewing’s sarcoma 4th metatarsal
  152. 152. Coronal T-1 MRI
  153. 153. tumorAxial T-1 MRI
  154. 154. tumorAxial T-2 MRI
  155. 155. Photomic with pseudo-rosettes
  156. 156. CT scan thoracic spine shows multi focal lesion
  157. 157. Coronal CT scan
  158. 158. Case #892 35 year female with Ewing’s sarcoma os calcis
  159. 159. tumor Several months later
  160. 160. tumor T-1 MRI
  161. 161. tumorGad contrast MRI
  162. 162. Case #89321 year maleEwing’s sarcomamid tarsal area
  163. 163. Case #89420 year maleEwing’s sarcoma2nd toe
  164. 164. Case #8955 year femaleEwing’s sarcomaproximal ulna
  165. 165. Lateral view
  166. 166. Axial T-1 MRI
  167. 167. Sagittal T-1 MRI
  168. 168. Coronal T-2 MRI
  169. 169. Photomic
  170. 170. Case #896 50 year female with Ewing’s sarcoma proximal ulna
  171. 171. Case #8972 year old with Ewing’ssarcoma middle finger
  172. 172. Lateral view
  173. 173. Sagittal T-1 MRI
  174. 174. Photomic
  175. 175. Case #898 15 year male with Ewing’s sarcoma thumb
  176. 176. Case #898.1 Parosteal Ewing’s sarcoma 18 year male with lateral knee knee for 3 months
  177. 177. Bone scan
  178. 178. Axial T-1 Axial Gad C+
  179. 179. Coronal STIR Gad C+ Sagittal Gad C+
  180. 180. Case #898.2 Parosteal Ewing’s sarcoma 13 year male with painful mass in forearm for 3 months
  181. 181. Bone scan
  182. 182. Cor T-1 T-2 FS
  183. 183. Sag T-1 Gad
  184. 184. Axial T-2 GadPost chemo T-2 Gad
  185. 185. Case #898.3 Parosteal Ewing’s Sarcoma Humerus 27 yr female with firm tender mass in upper medial arm for 2 mos.
  186. 186. Axial T-2 Gad
  187. 187. Cor T-1 T-2 Gad
  188. 188. Ewing’s Sarcoma Pseudotumors
  189. 189. Case #899 onion skin periostitis11 year femaleosteomyelitis distal femurlooking like Ewing’s sclerosissarcoma
  190. 190. Lateral view
  191. 191. Bone scan
  192. 192. Coronal T-2 MRI
  193. 193. Axial T-2 MRI
  194. 194. Photomic of reactive periostitis
  195. 195. polys lymphsPhotomic showing inflammatory cells
  196. 196. Case #899.1 Ewing’s pseudotumor Osteomyelitis 3/06 7/07 7/07 14 year old male with pain right arm for 17 months
  197. 197. Cor T-1 T-2 Gad
  198. 198. Axial T-1 T-2 Gad
  199. 199. Case #9008 year male with acutefracture thru priorfemoral stress fracture stress periostitis Day of fracture
  200. 200. 3 days after acute fracture Stress periostitis
  201. 201. At 3 weeks lookinglike Ewing’s sarcoma
  202. 202. 6 mos later with solidunion unlike Ewing’ssarcoma
  203. 203. Case #900.1 Stress Periostitis Radius Axial T-2 16 yr male with forearm pain for 6 weeks Gad
  204. 204. Case #900.2 Stress Periostitis Femur May June 10 yr male with pain in thigh for 2 months
  205. 205. Cor T-1 T-2 Sag T-2
  206. 206. Axial T-2 Axial CT
  207. 207. Case #900.5Eosinophillic granulomafibula looking likeEwing’s sarcoma in a5 year male
  208. 208. Lymphoma of Bone
  209. 209. Lymphoma of Bone Lymphoma of bone accounts for approximately 7% of all primarymalignant tumors of bone and can be divided roughly into twoclinical groups: Hodgkin’s lymphoma of bone and non-Hodgkin’slymphoma of bone. Hodgkin’s lymphoma carries a much betterprognosis for survival. It tends to be localized and presents with aradiographic appearance that frequently includes a dense, scleroticresponse. The non-Hodgkin’s lymphomas can be divided intotwo categories. The systemic form, the most common form withgeneralized involvement of the entire lymphatic system includingsoft tissue and bone, carries a poor prognosis. The less commonform that is found in bone and does not have systemic manifestationscarries a better prognosis for survival. To meet the strict criteria fora primary lymphoma of bone, the disease must be contained withinthe skeletal system for at least six months before becomingdisseminated to other lymphatic organs such as lymph nodes and
  210. 210. spleen, at which time the prognosis for survival becomes muchworse. The age group for primary lymphoma of bone is between25 and 50 years. The most common bones involved are the spineand pelvis in 50% of cases. In the extremities, the most commonlocation is the femur followed next by the humerus and tibia withmultiple skeletal sites involved in approximately 25% of cases. Radiographically, the primary lymphoma takes on a permeativelytic appearance in cortical bone in a metadiaphyseal location,but can also involve epiphyseal bone as well. Because of thepermeative nature of the bone destruction, pathologic fractures arecommon, similar to the situation with Ewing’s sarcoma. In bothprimary lymphoma and Ewing’s sarcoma, large soft tissue massescan be found. With H&E staining, the histological appearanceof lymphoma and Ewing’s sarcoma can be quite similar but withspecific immunohistochemical staining techniques, B cell and T cellsubtypes of lymphoma can be identified and clearly separatedfrom Ewing’s sarcoma. As in the case of Ewing’s sarcoma, the
  211. 211. advent of chemotherapy dramatically improved the prognosis forsurvival that, for a solitary primary lymphoma of bone, is similar toEwing’s sarcoma with a 70% five year survival. However, with moredisseminated involvement of multiple bones or other lymphaticorgans, the prognosis drops dramatically to 10-25%. As with Ewing’ssarcoma, the lymphoma of bone is quite sensitive to external beamradiation therapy. However, the complications (including path-ological fracture) are a problem and the orthopedic oncologist willattempt a wide resection of the tumor if possible or, in more extensiveinvolvement, an intralesional approach with a long stem cementedprosthesis with adjuvant bone cement may be indicated to avoidpathological fracture. In cases of systemic involvement with extensivemetastatic disease, patients can be considered for bone marrowtransplantation. The same holds true for Ewing’s sarcoma.
  212. 212. CLASSICCase #17645 year malelymphoma proximalfemur path fracture
  213. 213. Frog leg lateral
  214. 214. signal voidBone scan
  215. 215. tumor Coronal T-1 MRI
  216. 216. tumorCoronal T-2 MRI
  217. 217. Axial T-2 MRI
  218. 218. High power photomic showing folded nuclear forms
  219. 219. Case #176.1 Large cell lymphoma 47 yr old male smoker with 4 mo history of left hip pain
  220. 220. Bone scan
  221. 221. CoronalT-1 T-2
  222. 222. AxialT-1 T-2
  223. 223. Post op recon nailing
  224. 224. Case #176.2 Large cell lymphoma 69 yr female with painful hip for 3 months
  225. 225. Cor CT scan Axial
  226. 226. Case #177 83 year female with lymphoma right pelvis
  227. 227. 6 months later with pathologic fracture
  228. 228. Another 6 mos later
  229. 229. Bone scan
  230. 230. Photomic
  231. 231. Case #17840 year femalelymphoma lowerspineSagittal T-2 MRI
  232. 232. Sagittal T-2 MRIupper spine
  233. 233. Sagittal T-2 MRImid spine
  234. 234. Case #178.1 Lymphoma sacrum 72 year male with LBP for many years
  235. 235. Bone scan
  236. 236. Axial T-1 MRI T-2 Gad
  237. 237. T-1 T-2 Sagittal Gad STIR
  238. 238. Case #901 17 year male with lymphoma acetabulum
  239. 239. tumorCoronal T-1 MRI
  240. 240. tumorAxial T-1 MRI
  241. 241. tumorAxial T-2 MRI
  242. 242. Photomic
  243. 243. Good response fromchemotherapy
  244. 244. Case #902 49 year male with lymphoma pelvis
  245. 245. tumor CT scan
  246. 246. Case #902.1 Lymphoma of pelvis 69 year male with 2 month history of left hip pain
  247. 247. tumorCoronal T-1 T-2 Gad C+
  248. 248. Sagittal T-1 T-2 Gad
  249. 249. AxialT-1 T-2 Gad
  250. 250. Case #90344 year male withlymphoma pelvis
  251. 251. Case #904 31 year male with lymphoma pelvis
  252. 252. Bone scan
  253. 253. Case #90540 year malelymphoma pelvis
  254. 254. Case #90647 year malelymphomadistal femur
  255. 255. Lateral view
  256. 256. Bone scan6 months later
  257. 257. Sagittal T-1 MRI
  258. 258. Sagittal T-1 MRI thru notch
  259. 259. tumorSagittal T-2 MRI
  260. 260. tumorAxial T-2 MRI
  261. 261. Photomic
  262. 262. Case #906.5 49 year male with lymphoma distal femur
  263. 263. Lateral view
  264. 264. Bone scan
  265. 265. Sagittal T-1 MRI
  266. 266. Coronal T-1 MRI
  267. 267. tumorCoronal STIR MRI
  268. 268. Case # 906.6 Large cell lymphoma knee 48 year female with medial knee pain 1 year and history oftorn medial meniscus & 18000 WBC & elevated cholesterol
  269. 269. Bone scan
  270. 270. Sag T-1 Cor T-2
  271. 271. Axial PDFemoral cut Tibial cut
  272. 272. Case #906.7 Lymphoma Bone scan 58 year male with painful swelling above knee for 3 months
  273. 273. Cor T-1 T-2 FS
  274. 274. Axial PD T-2
  275. 275. Sag PD T-2
  276. 276. Case #906.8 Lymphoma Path Fracture Distal Femur 55 yr female with recent severe knee pain & prior breast CA
  277. 277. Axial CT scan Bone scan
  278. 278. Cor T-1 T-2
  279. 279. Case #90723 year femalelymphomadistal femur
  280. 280. Lateral view
  281. 281. Bone scan
  282. 282. Sagittal T-1 MRI
  283. 283. Coronal T-1 MRI tumor
  284. 284. tumor tumorCoronal STIR MRI
  285. 285. Positive silver stain for reticulum fiber
  286. 286. Case #90828 year malelymphoma femur
  287. 287. Macro sectionresected specimen
  288. 288. Photomic
  289. 289. Case #90934 year male withlymphoma prox femur
  290. 290. Frog lateral
  291. 291. Case #91038 year malepathologic fracturelymphoma prox femur
  292. 292. Case #911 Axial T-1 MRI tumor 77 year male with parosteal lymphoma femur
  293. 293. tumorAxial T-2 MRI
  294. 294. Case #91217 year malelymphoma distalfemur
  295. 295. AP view
  296. 296. Coronal T-1 MRI tumor
  297. 297. tumorSagittal T-1 MRI
  298. 298. Case #913 Coronal T-1 MRI 54 year male with HIV lymphoma proximal femur
  299. 299. tumorAxial proton density MRI
  300. 300. Case #914 65 year female ORIF hip fracture prior history of lymphoma 5 yrs ago
  301. 301. 5 years later withOGS at healedfracture site
  302. 302. Bone scan shows multifocal OGS
  303. 303. Case #91541 year malelymphomaproximal tibia
  304. 304. Lateral view
  305. 305. Oblique view3 months later
  306. 306. Pathologic fracturefollowing radiationtherapy at 6 months
  307. 307. Photomic
  308. 308. Custom total kneeprosthesis forreconstruction
  309. 309. Post op x-ray withprosthetic reconstruction
  310. 310. Case #91634 year femalelymphoma prox tibia
  311. 311. Sagittal T-1 MRI
  312. 312. Sagittal T-2 MRI
  313. 313. Case #917 21 year female with lymphoma proximal tibia
  314. 314. Coronal T-1 MRI
  315. 315. tumorSagittal T-1 MRI
  316. 316. Case #91826 year femalelymphoma distaltibia
  317. 317. tumor Coronal T-1 MRI
  318. 318. Sagittal T-1 MRI tumor
  319. 319. tumorAxial T-2 MRI
  320. 320. Case #91929 year femalelymphoma proximalhumerus
  321. 321. Bone scan
  322. 322. Coronal T-1 MRI
  323. 323. tumorAxial proton density MRI
  324. 324. Photomic
  325. 325. Case #920Pathologic fracturelymphoma proximalhumerus in a 64 yearfemale
  326. 326. Bone scan
  327. 327. Coronal T-2 MRI tumor
  328. 328. Case #92138 year female withlymphoma humerus
  329. 329. Bone scan
  330. 330. Coronal T-2 MRI
  331. 331. Case #92227 year malelymphoma distalhumerus
  332. 332. Sagittal T-1 MRI
  333. 333. tumorAxial T-2 MRI
  334. 334. Photomic
  335. 335. Case #923 28 year male with lymphoma proximal ulna
  336. 336. Axial T-1 MRI
  337. 337. Axial T-2 MRI tumor
  338. 338. Case #924 Laminogram x-ray 50 year female with lymphoma proximal ulna
  339. 339. Case #925 Sagittal T-1 MRI tumor tumor 64 year female with soft tissue lymphoma forearm
  340. 340. tumorAxial proton density MRI
  341. 341. Axial T-2 MRI
  342. 342. Case #92670 year female withlymphoma distal radius
  343. 343. Case #927 Tumor defect 20 year male with lymphoma sacrum 1 year post resection and radiation therapy
  344. 344. 2.5 years post op
  345. 345. Case #928 43 year male with lymphoma 11th posterior rib
  346. 346. Resection specimen cut in path lab
  347. 347. Photomic
  348. 348. LymphomaPseudotumors
  349. 349. Case #929 pain 73 year female with radiation osteitis 2nd to radiation therapy for ovarian carcinoma 19 years ago
  350. 350. 9 days later with path fracture looking like lymphoma; biopsy negative for sarcoma
  351. 351. 2 weeks later with progressive collapse
  352. 352. 6 weeks later and more collapse
  353. 353. Coronal T-1 MRI with low signal like a lymphoma
  354. 354. Coronal proton density MRI
  355. 355. Case #929.1 Lymphoma pseudotumor transient osteoporosis25 year male alcoholic and smoker with R hip pain 4 mos
  356. 356. Cor T-1Cor T-2
  357. 357. Axial T1Axial T-2
  358. 358. Case #93052 year maleradiation osteitishumerus 2nd toradiation for softtissue sarcomayears ago now lookinglike a lymphoma
  359. 359. Pathologic fracturelater requiringIM nail
  360. 360. Case #931 54 year male tennis player with stress fracture sacrum
  361. 361. R L Bone scan
  362. 362. CT scan showing fracture callus
  363. 363. pseudotumorCoronal T-1 MRI showing low signal like lymphoma
  364. 364. Coronal T-2 MRI showing high signal from fracture
  365. 365. Case #93222 year malestress fracture thrulateral plateau lookinglike a lymphoma
  366. 366. Bone scan hot like lymphoma
  367. 367. Sagittal T-1 MRIshowing fractureedema lookinglike lymphoma
  368. 368. Case #93332 year femalemastocytosis spine &pelvis looking likelarge cell lymphoma
  369. 369. Femoral mastocytosislooking like lymphoma
  370. 370. Similar lesionsdistal femur
  371. 371. Same changesin humerus
  372. 372. Changes in ribs &humerus
  373. 373. Hodgkin’sLymphoma
  374. 374. CLASSICCase #17940 year maleblastic form ofHodgkin’s lymphomaL-4
  375. 375. Photomic showing Reed-Sternberg cell
  376. 376. Case #180 33 year female with Hodgkin’s disease SI area
  377. 377. Photomic with Reed-Sternberg cells
  378. 378. Case #934 58 year male with blastic form Hodgkin’s lymphoma pelvis
  379. 379. Left iliac lesions
  380. 380. Right iliac lesion
  381. 381. Photomic with Reed-Sternberg cells & eosinophils
  382. 382. Case #93538 year male withblastic form of lymphomaL-3
  383. 383. Case #93651 year malelytic form ofHodgkin’s lymphomaL-4
  384. 384. eosinophilPhotomic with Reed-Sternberg cell
  385. 385. Case #936.1 Hodgkin’s lymphoma 28 year old male with hip pain for past 3 months
  386. 386. Bone scan
  387. 387. Cor T-1 T-2 Gad
  388. 388. Axial T-1 T-2 gad
  389. 389. Case #936.2 Hodgkin’s of Scapula 25 yr male with pain in shoulder 1 year
  390. 390. Cor T-2 Gad
  391. 391. Axial T-2 Axial GadSag T-2 Sag Gad
  392. 392. Leukemia
  393. 393. CLASSIC Case #181 10 year female with hemorrhagic purpura second to acute lymphoblastic leukemia
  394. 394. Transverse radioleucent metaphyseal bands seen in acute lymphoblastic leukemia
  395. 395. Lymphoblasts in peripheral blood smear
  396. 396. Case #93759 year malechronic lymphocyticleukemiaBone scan
  397. 397. Coronal T-1 MRI
  398. 398. Sagittal T-1 MRI
  399. 399. Coronal T-1 MRI
  400. 400. Coronal T-1 MRI
  401. 401. Coronal T-2 MRI
  402. 402. Lymphoblasts seen in marrow smears
  403. 403. Case #9384.5 year maleacute lymphoblasticleukemia
  404. 404. Bone scan
  405. 405. Axial T-2 MRI
  406. 406. Lymphoblasts in peripheral blood smeer
  407. 407. Case #93940 year male5 year history ofchronic lymphocyticleukemia with chronicreactive periostitis
  408. 408. Lateral view
  409. 409. Case #94014 month female withacute lymphoblasticleukemia femur showinglaminated periostitis
  410. 410. Casswe #94143 year male with tumorchronic granulocyticleukemia with focallesion in femur
  411. 411. tumorAnother view
  412. 412. Case #941.1 Acute lymphocytic leukemia 3/06 4/06 6/0612 year female with wrist pain and elevated sed rate 3 mos
  413. 413. 6/06Coronal T-1 T-2 Sagittal T-2
  414. 414. Case #9424 year femaleacute lymphocyticleukemia withlaminated periostitisfibula
  415. 415. Case #9434 year maleacute lymphocyticleukemia hand
  416. 416. Case #94440 year femalechronic lymphocyticleukemia withosteoporotic codfishshaped vertebral bodies
  417. 417. AP view
  418. 418. Plasma Cell Tumors
  419. 419. SolitaryPlasmacytoma
  420. 420. Solitatary Plasmacytoma To fit the strict criteria for the diagnosis of a solitary plasmacytoma,the patient should present with a single bony involvement, asdemonstrated by a bone skeletal survey, and remain free of otherbony site involvement for at least six months after the initialdiagnosis. Unfortunately, in approximately 70% of cases, thesolitary form of the disease will disseminate into the more commonform of multiple myeloma. Likewise, in the case of pure solitaryplasmacytoma, the serum protein electrophoresis study iscompletely normal in 75% of cases with the remaining 25%showing a mild abnormality. The age group for solitary plasma-cytoma is slightly younger than multiple myeloma, typically beforethe age of 40 years. The most common sites of involvementinclude the spine, pelvis and proximal femur with radiographicevidence of a solitary lytic destruction of bone that may take on theappearance of a benign lesion such as a solitary form of fibrous
  421. 421. dysplasia. Because the disease is purely lytic in nature, the boneisotope scan may be negative. Since the disease is considered localized at first, the treatment islocalized with a wide surgical resection and prosthetic replacement,with or without bone cement, followed by local radiation therapyif the margins are positive. No systemic chemotherapy is used untilthe disease becomes more disseminated as demonstrated by increasedlevels of abnormal myeloma protein found by serum electrophoresisstudies. The prognosis for survival is quite good until the diseasebecomes more disseminated which is usually within three yearsafter the initial diagnosis.
  422. 422. CLASSIC Case #182 40 year male with solitary plasmacytoma pelvis
  423. 423. Bone scan showingsignal void
  424. 424. Axial T-1 MRI
  425. 425. Axial T-2 MRI
  426. 426. Photomic showing plasma cells
  427. 427. High power
  428. 428. Case #183 42 year male with solitary plasmacytoma pelvis
  429. 429. Axial T-1 MRI
  430. 430. Axial T-2 MRI
  431. 431. Post op x-ray afterradiation therapy &total hip replacement
  432. 432. Case #18453 year malesolitary plasmacytomaproximal femur
  433. 433. Pathologic fracture one year later
  434. 434. Post op x-ray withcemented long stembiopolar prosthesis
  435. 435. Case #18555 year malesolitary plasmacytomaproximal femur
  436. 436. Case #185.1 Solitary plasmacytoma40 year male withincreasing pain inthigh for 6 mos
  437. 437. Bone scan
  438. 438. Sag T-1 PD FS Cor STIR
  439. 439. Axial T-1T-2 Gad
  440. 440. PO interlocking nailand cementation
  441. 441. Case #94649 year malesolitary plasmacytomaacetabulum
  442. 442. tumor CT scan
  443. 443. Bone scan
  444. 444. Photomic
  445. 445. Steinman pinReconstruction withmetal cage
  446. 446. Cementation over metaland completed THAinside cage
  447. 447. Post op X-ray
  448. 448. Case #947 tumor 32 year male with solitary plasmacytoma acetabulum
  449. 449. Coronal T-1 MRI
  450. 450. Case #94853 year male withsolitary plasmacytomasacrum
  451. 451. R LBone scan shows signal void in tumor
  452. 452. tumorCT scan
  453. 453. Sagittal T-2 MRI tumor
  454. 454. Case #949 52 year male with large solitary plasmacytoma pelvis
  455. 455. CT scan at sacral level
  456. 456. tumorCT scan at lumbar level
  457. 457. Case #950 45 year male with solitary plasmacytoma sacrum
  458. 458. Lateral view tumor
  459. 459. Bone scan shows signal void in tumor site
  460. 460. tumorBone scan
  461. 461. tumorAxial T-2 MRI
  462. 462. Sagittal PD MRI tumor
  463. 463. Sagittal T-2 MRI tumor
  464. 464. Photomic
  465. 465. Case #951 Axial T-1 MRI tumor 56 year male with solitary plasmacytoma sacrum
  466. 466. Sagittal T-1 MRI tumor
  467. 467. Case #952 28 year female with path fracture thru supra acetabular Solitary plasmacytoma
  468. 468. Case #95346 year male withsolitary plasmacytomaproximal femur
  469. 469. Coronal T-1 MRI
  470. 470. Coronal T-2 MRI
  471. 471. Case #95465 year female withsolitary plasmacytomafemur
  472. 472. Post op x-ray withblade-plate fixation
  473. 473. Case #95541 year male withsolitary plasmacytomafemur
  474. 474. Case #95640 year female withsolitary plasmacytomaproximal fibula
  475. 475. Case #957 tumor 24 year male with solitary plasmacytoma scapula
  476. 476. Bone scan showing signal void in center of tumor
  477. 477. tumor CT scan
  478. 478. Multiple Myeloma
  479. 479. Multiple Myeloma Multiple myeloma is considered to be the most common primarytumor of bone, accounting for approximately 45% of all malignantbone tumors. It is usually seen in patients over 40 years of age andis two times more common in blacks than whites. Radiographically,the lytic lesions seen in multiple myeloma are typically punched-outwith fairly sharp margins but no sclerotic response at the peripheryand thus are not frequently picked up on a total body bone isotopestudy. The diagnosis is usually made by a combination of a bonemarrow biopsy and a serum protein electrophoresis that revealsthe elevated monoclonal immuninoglobulin at either the alpha orgamma spike. Bence-Jones protein is found in the urine examinationsecondary to a light chain immuninoglobulin spillover. Three per cent of patients with myeloma have a sclerotic form(seen on the radiographic examination) associated with a peripheralneuropathy. This type of multiple myeloma has a better prognosis
  480. 480. for survival and is referred to as the Poems syndrome. Skeletallesions are more typically seen in the spine and pelvic area andproximal long bones, but rarely seen distal to the elbow or knee. Inaggressive forms of myeloma with extensive bony destruction byosteoclastic erosion, the patients will develop hypercalcemia thatcan result in a semi-comatose state and sometimes is associatedwith nephrocalcinosis. Renal damage also results from excessiveproteins plugging the renal tubules. Pathological fractures arecommon because of excessive osteoclastic activity (osteoclysis)that can be inhibited by drugs such as Aredia. Even though largeconcentrations of imminoglobulin are produced by the malignantplasma cells, the patient’s resistance to infection is markedlyinhibited and surgical complications resulting from infection shouldbe anticipated when operating on patients with this disease. Systemic chemotherapy has greatly improved the prognosisfor survival in this disease. The drugs used include Malphalan andcortisone which have increased the chance for survival to three years.
  481. 481. Local treatment consists of external beam radiation therapy andintramedullary devices, such as long stem prostheses and inter-locking nails supplemented with bone cement, for pathologicalfractures. Excessive bleeding at the time of surgery is typical withmyeloma patients, similar to the problem faced with patients withmetastatic renal cell disease and thyroid carcinoma. It is importantto radiate the entire long bone involved when considering intra-medullary device fixation because of the potential for newer lesionsarising distal to the fixation device at a later date.
  482. 482. CLASSIC Case #186 fracture 65 year male with multiple myeloma pelvis and hips
  483. 483. Photomic showing plasma cells
  484. 484. R LPost op x-ray with THR right & ORIF left
  485. 485. Case #187 72 year male with multiple myeloma skull
  486. 486. Punched outlesions femur
  487. 487. Case #188 Sagittal T-2 MRI 55 year male with multiple myeloma spine
  488. 488. Sagittal T-2 MRIlumbar spine withevidence of cordcompression
  489. 489. Case #95837 year male withmultiple myelomadorsal spine
  490. 490. Lumbar spine
  491. 491. Autopsy specimens
  492. 492. Photomic
  493. 493. Case #95955 year male with multiplemyeloma dorsal spine
  494. 494. Lateral view
  495. 495. CT scan showing tumor in vertebra and vertebral canal
  496. 496. CT of adjacent vertebra
  497. 497. Anterior vertebrectomy specimen
  498. 498. Photomic
  499. 499. Case #96048 year male withmultiple myelomadorsal spine withcord involvement tumorSagittal T-2 MRI
  500. 500. Axial T-2 MRI showing tumor in pedicle & costovertebral joint
  501. 501. tumorAnother axial T-2 cut
  502. 502. Biopsy photomic
  503. 503. Case #96155 year male withmultiple myelomacervical spine andcompression fracture
  504. 504. Post op posteriorspinal fusion andradiation therapy
  505. 505. Case #96238 year male withmultiple myelomalumbar spine
  506. 506. Post op anteriorcurettement andcementation
  507. 507. AP view
  508. 508. Case #96341 year male withmultiple myelomawith collapsed vertebralbody and paraplegia
  509. 509. Lateral view
  510. 510. Case #964 16 year male with multiple myeloma lumbar spine
  511. 511. Case #965 tumor 59 year female with multiple myeloma pelvis
  512. 512. tumorCT scan showing large aneuysmal lesion
  513. 513. tumorAnother CT cut
  514. 514. Post op x-ray with THAwith cement andSteinman pins
  515. 515. Skull x-ray showing multiple punched out lesions
  516. 516. Case #966 72 year female with severe multiple myeloma pelvis
  517. 517. Case #967 59 year female with multiple myeloma skull
  518. 518. Same patient with scapular and humeral lesions
  519. 519. Thumb lesion
  520. 520. Case #967.1 Multiple Myeloma 55 yr male with a painful swollen wrist for 6 months
  521. 521. Case #96855 year female withmultiple myelomawith path fracturefemur
  522. 522. Post op x-ray with cementedlong stem THA
  523. 523. Case #96975 year male withmultiple myelomaand path fracturefemur
  524. 524. Case #970 68 year female with multiple myeloma shoulder area
  525. 525. Same patient withtibial lesions
  526. 526. Punched outfemoral lesions
  527. 527. Punched out humerallesions as well
  528. 528. Path fracture later onwith IM nail fixation
  529. 529. Photomic
  530. 530. Case #97162 year male withmultiple myelomahumerus
  531. 531. Post op cemented Neerprosthesis
  532. 532. Case #97237 year male withmultiple myelomaupper extremitywith punched out lesions
  533. 533. Case #973 48 year female with multiple myeloma shoulder
  534. 534. Bone scan withscapular andrib lesions
  535. 535. Coronal T-1 MRI
  536. 536. tumor Axial T-2 MRI
  537. 537. Case #97472 year male withmultiple myelomalumbar spine
  538. 538. Same patient withpunched out lesionsin femur and ischium
  539. 539. Also punched out lesionsin tibia and fibula
  540. 540. Case #975 29 year male with blastic form of multiple myeloma
  541. 541. Close up
  542. 542. Case #97640 year male with avariant of multiplemyeloma known asfibrogenesis imperfectaossium
  543. 543. Multiple collapsedlumbar vertebra as inmultiple myeloma
  544. 544. X-ray at a later datewith progressive disease
  545. 545. X-ray of pelvis shows diffuse lytic changes
  546. 546. Bone scan
  547. 547. MetastaticNeuroblastoma
  548. 548. Metastatic Neuroblastoma Neuroblastoma is a primitive tumor of childhood taking its originfrom the medullary portion of the adrenal gland or in other parts ofthe sympathetic nervous system and is considered to be the thirdmost common malignancy in childhood. This tumor is usually seenunder the age of five years and typically metastasizes to bonesincluding the vertebra, ribs, skull, femur, pelvis, humerus, tibia, andradius. These patients usually have systemic symptoms includingweight loss, fever, generalized pain and anemia. Radiographically,the lesions in bone have a permeative destructive pattern typicallyin the metaphyseal portion of long bones. Histologically, thecharacteristic feature of the neuroblastoma is a rosette formationwith neurofibrils. However, on routine H&E stains the histology isquite similar to that of rhabdomyosarcoma, non-Hodgkin’slymphoma and Ewing’s sarcoma. Diagnostic studies includecytogenetics that will reveal a chromosomal abnormality in the
  549. 549. number 1 chromosome. A CT scan of the abdomen will frequentlypick up a neoplastic abnormality in the kidneys. Chemotherapy andsometimes bone marrow transplantation is used in the treatmentprotocol for this aggressive, extensive metastatic disease but withonly a a 20-25% chance for survival at five years after diagnosis.
  550. 550. CLASSIC Case #1894 year malemetastatic neuroblastomadistal femur withpathologic fracture
  551. 551. Lateral view showinghair-on-end reactivesubperiosteal boneformation
  552. 552. Bone scan
  553. 553. Bone scan shows abnormalcollection in kidney wherethe primary tumor wasfound
  554. 554. Sagittal T-2 MRIshowing metastatictumor in tibia
  555. 555. tumorAbdominal CT scan showing primary neuroblastoma in the kidney area
  556. 556. Chest x-ray showing multiple pulmonary mets
  557. 557. Femoral biopsy photomic showing rosette pattern
  558. 558. Higher power showing rosette pattern
  559. 559. Case #9777 year male withmetastatic neuroblastomaproximal humerus andpath fracture
  560. 560. Bone scan showingprimary tumor in kidneyand met to shoulder &base of skull
  561. 561. Photomic from humeral biopsy
  562. 562. Case #9789 year male withmetastatic neuroblastomaproximal humerus
  563. 563. Another view
  564. 564. Case #9791 year old female withmetastatic neuroblastomaproximal humerus
  565. 565. Case #9805 year female withmetastatic neuroblastomaproximal femur
  566. 566. Case #98111 year female withmetastatic neuroblastomafemur treated with wideresection and fibular strut& IM nail reconstruction
  567. 567. Macro section fromresected specimenshowing tumor insideand outside the femur
  568. 568. Scanning lens photomic
  569. 569. Higher power photomic
  570. 570. Case #9827 year male withmetastatic neuroblastomadistal femur
  571. 571. Case #9837 month male with largecalcific renal mass whichon biopsy proved to beneuroblastoma
  572. 572. Lateral view

×