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Volume 8 Volume 8 Presentation Transcript

  • 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
  • Round CellTumors Of Bone
  • Ewing’s Sarcoma
  • 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
  • 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, rib, 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
  • 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
  • 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.
  • CLASSICCase #16913 year femaleEwing’s sarcomadistal femur onion skin periostitis
  • Bone scan
  • Coronal protondensity MRI
  • Coronal T-2 MRI
  • Coronal T-2 MRIshowing multifocaldisease
  • necroticMacro section Ewing’ssarcoma distal femur viable
  • Photomic showing pseudo-rosette formations
  • Same patient withmultifocal involvementproximal humerus
  • Case #17015 year femaleEwing’s sarcomaproximal tibia
  • Lateral view
  • Sagittal T-1 MRI
  • Axial T-1 MRI
  • Compress systemPhoto of resected proximal tibia & prosthesis
  • Placement of rotatinghinge Compress prosthesis
  • Attachment ofpatellar ligament withdouble tooth washers
  • X-ray 2 mos post op anchor plug
  • 5.5 years post opwith excellentosseointegration atbone-prostheticinterface
  • 11 years post op
  • Case #17119 year femaleEwing’ sarcomaproximal femur
  • Bone scan
  • 1 year later withpath fracture thruradiated bone
  • Persistent non unionafter IM nailing
  • X-ray 1 year post opplacement of cementedlong stem custombipolar prosthesis
  • Case #172 permeative lysis13 year male with“hair-on-end”reactivesubperiosteal newbone formation
  • Macro section resectedproximal femur
  • periostiumCloseup macro sectionshowing “hair-on-end” necrosisreactive subperiostealnew bone permeation
  • periostiumCloseup macro section“hair-on-end” subperiostealreactive bone formation
  • Photomic Ewing’s sarcoma
  • Case #173 hair-on-end15 year male Ewing’ssarcoma femur onion skin
  • Case #174 28 year male with Ewing’s sarcoma pelvis
  • tumorCT scan
  • Case #175 14 year male with Ewing’s sarcoma pelvis
  • iliumMacro section from tumorautopsy specimen acetabulum
  • Photomic
  • Case #861 34 year female with Ewing’s sarcoma pelvis
  • Close up hip
  • Coronal Gad contrast MRI
  • Coronal T-2 MRI
  • Axial T-1 MRI
  • Axial proton density MRI
  • Photomic
  • Case #862 Coronal T-1 MRI tumor 28 year male with Ewing’s sarcoma pubis
  • tumor Coronal T-2 MRI
  • tumorT-2 MRI
  • tumor Coronal T-2 MRI
  • tumorAxial PD MRI
  • Photomic
  • Axial PD MRI following successful chemotherapy
  • Coronal T-2 MRI post chemo
  • Case #863 10 year female with Ewing’s sarcoma pelvis
  • 6 months later
  • Coronal T-1 MRI
  • Coronal T-2 MRI
  • Case #864 19 year male with Ewing’s sarcoma SI area
  • Axial gad contrast MRI
  • Axial T-2 MRI
  • Photomic
  • Post op cementation
  • Case #86519 year maleEwing’s sarcomasacrum
  • Close up
  • Myelogram showingnerve root pressure
  • tumorCT scan
  • Photomic
  • Case #86612 year maleEwing’s sarcomaL-5
  • Oblique view
  • Case #86737 year maleEwing’s sarcomaproximal femur
  • Coronal T-1 MRI
  • Photomic
  • X-ray allograftprior to implantation lateral AP
  • Post op alloprostheticreconstruction
  • Case #86814 year maleEwing’s sarcomamid femurBone scan
  • Coronal protondensity MRIPre chemo
  • Axial PD MRI pre chemo
  • Photomic
  • Axial PD MRI post chemo
  • Amputation following good chemo response
  • cementPost op x-ray with modified bipolar reconstruction
  • Case #869 21 year male with Ewing’s sarcoma pelvis and femur
  • Coronal T-1 MRI
  • tumorCoronal T-2 MRI
  • Coronal T-2 MRI
  • Case #8707 year maleEwing’s sarcomadistal femur
  • Bone scan
  • Sagittal protondensity MRI
  • tumorAxial T-1 MRI
  • Photomic
  • Axial T-2 MRI post chemo
  • Coronal T-2 MRI post chemo
  • Case #87113 year maleEwing’s sarcomafemur
  • 5 years afterradiation & chemowith recurrence &path fracture
  • Post op x-ray withIM nail for pathfracture
  • tumor bulgeTotal femur replacement specimen
  • Custom total femur replacement prosthesis
  • Placement of custom prosthesis
  • Post op X-ray
  • Case #87216 year maleEwing’s sarcomaproximal femur
  • Lateral view
  • Coronal T-1 MRI
  • Coronal T-2 MRI
  • Axial proton density MRI
  • Case #873 9 year male with Ewing’s sarcoma tibia
  • Bone scan
  • Sagittal T-1 MRI T-2 MRI
  • Post op reconstructionallograft over IM nail
  • 8 years later
  • Case #875 onion skin laminated2.5 year male periostitisEwing’s sarcomadistal tibia
  • Lateral view entire tibia
  • Coronal T-1 MRI
  • Axial T-1 Gad contrast MRI
  • Case #87617 year male withEwing’s sarcoma tibia
  • Different view
  • Post op allographic allograftreconstruction
  • Multifocal lesion proxfemur 6 mos later
  • Case #87719 year female with tumorEwing’s sarcomaproximal humerus hair on end
  • Post op alloprostheticreconstruction
  • Case #87839 year maleEwing’s sarcomaproximal humerus
  • X-ray one year laterwithout treatment
  • Photomic
  • Case #879 10 year male with Ewing’s sarcoma scapula
  • Scapular view
  • Bone scan
  • CT scan
  • Special CT scan scapula
  • Case #880 9 year male with Ewing’s sarcoma scapula
  • Case #881 20 year male with Ewing’s of scapula
  • Soft tumorSpecial soft tissue technique x-ray
  • Case #882 16 year male with Ewing’s sarcoma clavicle
  • Case #883 16 year female with Ewing’s sarcoma clavicle
  • Case #884 7 year female with Ewing’s sarcoma 3rd posterior rib
  • Case #885 17 year female with Ewing’s sarcoma post 7th rib
  • Case #886 11 year male with Ewing’s sarcoma rib
  • Case #88712 year femaleEwing’s sarcomafibula
  • Macro section fromresected specimen
  • Scanning lensphotomic
  • Higher power
  • Case #88820 year femaleEwing’s sarcomadistal fibula
  • tumorAxial T-2 MRI
  • Case #88915 year femaleEwing’s sarcomaproximal fibula
  • Case #89018 year maleEwing’s sarcomadistal fibula
  • Bone scan
  • Case #891 17 year male with Ewing’s sarcoma 4th metatarsal
  • Coronal T-1 MRI
  • tumorAxial T-1 MRI
  • tumorAxial T-2 MRI
  • Photomic with pseudo-rosettes
  • CT scan thoracic spine shows multi focal lesion
  • Coronal CT scan
  • Case #892 35 year female with Ewing’s sarcoma os calcis
  • tumor Several months later
  • tumor T-1 MRI
  • tumorGad contrast MRI
  • Case #89321 year maleEwing’s sarcomamid tarsal area
  • Case #89420 year maleEwing’s sarcoma2nd toe
  • Case #8955 year femaleEwing’s sarcomaproximal ulna
  • Lateral view
  • Axial T-1 MRI
  • Sagittal T-1 MRI
  • Coronal T-2 MRI
  • Photomic
  • Case #896 50 year female with Ewing’s sarcoma proximal ulna
  • Case #8972 year old Ewing’ssarcoma middle finger
  • Lateral view
  • Sagittal T-1 MRI
  • Photomic
  • Case #898 15 year male with Ewing’s sarcoma thumb
  • Case #898.1 Parosteal Ewing’s sarcoma 18 year male with lateral knee knee for 3 months
  • Bone scan
  • Axial T-1 Axial Gad C+
  • Coronal STIR Gad C+ Sagittal Gad C+
  • Case #898.2 Parosteal Ewing’s sarcoma 13 year male with painful mass in forearm for 3 months
  • Bone scan
  • Cor T-1 T-2 FS
  • Sag T-1 Gad
  • Axial T-2 GadPost chemo T-2 Gad
  • Ewing’s Sarcoma Pseudotumors
  • Case #899 onion skin periostitis11 year femaleosteomyelitis distal femurlooking like Ewing’s sclerosissarcoma
  • Lateral view
  • Bone scan
  • Coronal T-2 MRI
  • Axial T-2 MRI
  • Photomic of reactive periostitis
  • polys lymphsPhotomic showing inflammatory cells
  • Case #899.1 Ewing’s pseudotumor Osteomyelitis 3/06 7/07 7/07 14 year old male with pain right arm for 17 months
  • Cor T-1 T-2 Gad
  • Axial T-1 T-2 Gad
  • Case #9008 year male with acutefracture thru priorfemoral stress fracture stress periostitis Day of fracture
  • 3 days after acute fracture Stress periostitis
  • At 3 weeks lookinglike Ewing’s sarcoma
  • 6 mos later with solidunion unlike Ewing’ssarcoma
  • Case #900.5Eosinophillic granulomafibula looking likeEwing’s sarcoma in a5 year male
  • Lymphoma of Bone
  • 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
  • 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
  • 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.
  • CLASSICCase #17645 year malelymphoma proximalfemur path fracture
  • Frog leg lateral
  • signal voidBone scan
  • tumor Coronal T-1 MRI
  • tumorCoronal T-2 MRI
  • Axial T-2 MRI
  • High power photomic showing folded nuclear forms
  • Case #176.1 Large cell lymphoma 47 yr old male smoker with 4 mo history of left hip pain
  • Bone scan
  • CoronalT-1 T-2
  • AxialT-1 T-2
  • Post op IM nailing
  • Case #177 83 year female with lymphoma right pelvis
  • 6 months later with pathologic fracture
  • Another 6 mos later
  • Bone scan
  • Photomic
  • Case #17840 year femalelymphoma lowerspineSagittal T-2 MRI
  • Sagittal T-2 MRIupper spine
  • Sagittal T-2 MRImid spine
  • Case #178.1 Lymphoma sacrum 72 year male with LBP for many years
  • Bone scan
  • Axial T-1 MRI T-2 Gad
  • T-1 T-2 Sagittal Gad STIR
  • Case #901 17 year male with lymphoma acetabulum
  • tumorCoronal T-1 MRI
  • tumorAxial T-1 MRI
  • tumorAxial T-2 MRI
  • Photomic
  • Good response fromchemotherapy
  • Case #902 49 year male with lymphoma pelvis
  • tumor CT scan
  • Case #902.1 Lymphoma of pelvis 69 year male with 2 month history of left hip pain
  • tumorCoronal T-1 T-2 Gad C+
  • Sagittal T-1 T-2 Gad
  • AxialT-1 T-2 Gad
  • Case #90344 year male withlymphoma pelvis
  • Case #904 31 year male with lymphoma pelvis
  • Bone scan
  • Case #90540 year malelymphoma pelvis
  • Case #90647 year malelymphomadistal femur
  • Lateral view
  • Bone scan6 months later
  • 6 months later
  • Sagittal T-1 MRI
  • Sagittal T-1 MRI thru notch
  • tumorSagittal T-2 MRI
  • tumorAxial T-2 MRI
  • Photomic
  • Case #906.5 49 year male with lymphoma distal femur
  • Lateral view
  • Bone scan
  • Sagittal T-1 MRI
  • Coronal T-1 MRI
  • tumorCoronal STIR MRI
  • 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
  • Bone scan
  • Sag T-1 Cor T-2
  • Axial PDFemoral cut Tibial cut
  • Case #906.7 Lymphoma Bone scan 58 year male with painful swelling above knee for 3 months
  • Cor T-1 T-2 FS
  • Axial PD T-2
  • Sag PD T-2
  • Case #90723 year femalelymphomadistal femur
  • Lateral view
  • Bone scan
  • Sagittal T-1 MRI
  • Coronal T-1 MRI tumor
  • tumor tumorCoronal STIR MRI
  • Positive silver stain for reticulum fiber
  • Case #90828 year malelymphoma femur
  • Macro sectionresected specimen
  • Photomic
  • Case #90934 year male withlymphoma prox femur
  • Frog lateral
  • Case #91038 year malepathologic fracturelymphoma prox femur
  • Case #911 Axial T-1 MRI tumor 77 year male with parosteal lymphoma femur
  • tumorAxial T-2 MRI
  • Case #91217 year malelymphoma distalfemur
  • AP view
  • Coronal T-1 MRI tumor
  • tumorSagittal T-1 MRI
  • Case #913 Coronal T-1 MRI 54 year male with HIV lymphoma proximal femur
  • tumorAxial proton density MRI
  • Case #914 65 year female ORIF hip fracture prior history of lymphoma 5 yrs ago
  • 5 years later withOGS at healedfracture site
  • Bone scan shows multifocal OGS
  • Case #91541 year malelymphomaproximal tibia
  • Lateral view
  • Oblique view3 months later
  • Pathologic fracturefollowing radiationtherapy at 6 months
  • Photomic
  • Custom total kneeprosthesis forreconstruction
  • Post op x-ray withprosthetic reconstruction
  • Case #91634 year femalelymphoma prox tibia
  • Sagittal T-1 MRI
  • Sagittal T-2 MRI
  • Case #917 21 year female with lymphoma proximal tibia
  • Coronal T-1 MRI
  • tumorSagittal T-1 MRI
  • Case #91826 year femalelymphoma distaltibia
  • tumor Coronal T-1 MRI
  • Sagittal T-1 MRI tumor
  • tumorAxial T-2 MRI
  • Case #91929 year femalelymphoma proximalhumerus
  • Bone scan
  • Coronal T-1 MRI
  • tumorAxial proton density MRI
  • Photomic
  • Case #920Pathologic fracturelymphoma proximalhumerus in a 64 yearfemale
  • Bone scan
  • Coronal T-2 MRI tumor
  • Case #92138 year female withlymphoma humerus
  • Bone scan
  • Coronal T-2 MRI
  • Case #92227 year malelymphoma distalhumerus
  • Sagittal T-1 MRI
  • tumorAxial T-2 MRI
  • Photomic
  • Case #923 28 year male with lymphoma proximal ulna
  • Axial T-1 MRI
  • Axial T-2 MRI tumor
  • Case #924 Laminogram x-ray 50 year female with lymphoma proximal ulna
  • Case #925 Sagittal T-1 MRI tumor tumor 64 year female with soft tissue lymphoma forearm
  • tumorAxial proton density MRI
  • Axial T-2 MRI
  • Case #92670 year female withlymphoma distal radius
  • Case #927 Tumor defect 20 year male with lymphoma sacrum 1 year post resection and radiation therapy
  • 2.5 years post op
  • Case #928 43 year male with lymphoma 11th posterior rib
  • Resection specimen cut in path lab
  • Photomic
  • LymphomaPseudotumors
  • Case #929 pain 73 year female with radiation osteitis 2nd to radiation therapy for ovarian carcinoma 19 years ago
  • 9 days later with path fracture looking like lymphoma biopsy negative for sarcoma
  • 2 weeks later with progressive collapse
  • 6 weeks later and more collapse
  • Coronal T-1 MRI with low signal like a lymphoma
  • Coronal proton density MRI
  • Case #929.1 Lymphoma pseudotumor25 year male alcoholic and smoker with R hip pain 4 mos
  • Cor T-1Cor T-2
  • Axial T1Axial T-2
  • Case #93052 year maleradiation osteitishumerus 2nd toradiation for softtissue sarcomayears ago now lookinglike a lymphoma
  • Pathologic fracturelater requiringIM nail
  • Case #931 54 year male tennis player with stress fracture sacrum
  • R L Bone scan
  • CT scan showing fracture callus
  • pseudotumorCoronal T-1 MRI showing low signal like lymphoma
  • Coronal T-2 MRI showing high signal from fracture
  • Case #93222 year malestress fracture thrulateral plateau lookinglike a lymphoma
  • Bone scan hot like lymphoma
  • Sagittal T-1 MRIshowing fractureedema lookinglike lymphoma
  • Case #93332 year femalemastocytosis spine &pelvis looking likelarge cell lymphoma
  • Femoral mastocytosislooking like lymphoma
  • Similar lesionsdistal femur
  • Same changesin humerus
  • Changes in ribs &humerus
  • Hodgkin’sLymphoma
  • CLASSICCase #17940 year maleblastic form ofHodgkin’s lymphomaL-4
  • Photomic showing Reed-Sternberg cell
  • Case #180 33 year female with Hodgkin’s disease SI area
  • Photomic with Reed-Sternberg cells
  • Case #934 58 year male with blastic form Hodgkin’s lymphoma pelvis
  • Left iliac lesions
  • Right iliac lesion
  • Photomic with Reed-Sternberg cells & eosinophils
  • Case #93538 year male withblastic form of lymphomaL-3
  • Case #93651 year malelytic form ofHodgkin’s lymphomaL-4
  • eosinophilPhotomic with Reed-Sternberg cell
  • Case #936.1 Hodgkin’s lymphoma 28 year old male with hip pain for past 3 months
  • Bone scan
  • Cor T-1 T-2 Gad
  • Axial T-1 T-2 gad
  • Leukemia
  • CLASSIC Case #181 10 year female with hemorrhagic purpura second to acute lymphoblastic leukemia
  • Transverse radioleucent metaphyseal bands seen in acute lymphoblastic leukemia
  • Lymphoblasts in peripheral blood smear
  • Case #93759 year malechronic lymphocyticleukemia Bone scan
  • Coronal T-1 MRI
  • Sagittal T-1 MRI
  • Coronal T-1 MRI
  • Coronal T-1 MRI
  • Coronal T-2 MRI
  • Lymphoblasts seen in marrow smears
  • Case #9384.5 year maleacute lymphoblasticleukemia
  • Bone scan
  • Axial T-2 MRI
  • Lymphoblasts in peripheral blood smeer
  • Case #93940 year male5 year history ofchronic lymphocyticleukemia with chronicreactive periostitis
  • Lateral view
  • Case #94014 month female withacute lymphoblasticleukemia femur showinglaminated periostitis
  • Casswe #94143 year male with tumorchronic granulocyticleukemia with focallesion in femur
  • tumorAnother view
  • Case #941.1 Acute lymphocytic leukemia 3/06 4/06 6/0612 year female with wrist pain and elevated sed rate 3 mos
  • 6/06Coronal T-1 T-2 Sagittal T-2
  • Case #9424 year femaleacute lymphocyticleukemia withlaminated periostitisfibula
  • Case #9434 year maleacute lymphoblasticleukemia hand
  • Case #94440 year femalechronic monocyticleukemia withosteoporotic codfishshaped vertebral bodies
  • AP view
  • Plasma Cell Tumors
  • SolitaryPlasmacytoma
  • 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
  • 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.
  • CLASSIC Case #182 40 year male with solitary plasmacytoma pelvis
  • Bone scan showingsignal void
  • Axial T-1 MRI
  • Axial T-2 MRI
  • Photomic showing plasma cells
  • High power
  • Case #183 42 year male with solitary plasmacytoma pelvis
  • Axial T-1 MRI
  • Axial T-2 MRI
  • Post op x-ray afterradiation therapy &total hip replacement
  • Case #18453 year malesolitary plasmacytomaproximal femur
  • Pathologic fracture one year later
  • Post op x-ray withcemented long stembiopolar prosthesis
  • Case #18555 year malesolitary plasmacytomaproximal femur
  • Case #185.1 Solitary plasmacytoma40 year male withincreasing pain inthigh for 6 mos
  • Bone scan
  • Sag T-1 PD FS Cor STIR
  • Axial T-1T-2 Gad
  • PO interlocking nailand cementation
  • Case #94649 year malesolitary plasmacytomaacetabulum
  • tumor CT scan
  • Bone scan
  • Photomic
  • Steinman pinReconstruction withmetal cage
  • Cementation over metaland completed THAinside cage
  • Post op X-ray
  • Case #947 tumor 32 year male with solitary plasmacytoma acetabulum
  • Coronal T-1 MRI
  • Case #94853 year male withsolitary plasmacytomasacrum
  • R LBone scan shows signal void in tumor
  • tumor CT scan
  • Sagittal T-2 MRI tumor
  • Case #949 52 year male with large solitary plasmacytoma pelvis
  • CT scan at sacral level
  • tumorCT scan at lumbar level
  • Case #950 45 year male with solitary plasmacytoma sacrum
  • Lateral view tumor
  • Bone scan shows signal void in tumor site
  • tumorBone scan
  • tumorAxial T-2 MRI
  • Sagittal PD MRI tumor
  • Sagittal T-2 MRI tumor
  • Photomic
  • Case #951 Axial T-1 MRI tumor 56 year male with solitary plasmacytoma sacrum
  • Sagittal T-1 MRI tumor
  • Case #952 28 year female with path fracture thru supra acetabular Solitary plasmacytoma
  • Case #95346 year male withsolitary plasmacytomaproximal femur
  • Coronal T-1 MRI
  • Coronal T-2 MRI
  • Case #95465 year female withsolitary plasmacytomafemur
  • Post op x-ray withblade-plate fixation
  • Case #95541 year male withsolitary plasmacytomafemur
  • Case #95640 year female withsolitary plasmacytomaproximal fibula
  • Case #957 tumor 24 year male with solitary plasmacytoma scapula
  • Bone scan showing signal void in center of tumor
  • tumor CT scan
  • Multiple Myeloma
  • 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
  • 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.
  • 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.
  • CLASSIC Case #186 fracture 65 year male with multiple myeloma pelvis and hips
  • Photomic showing plasma cells
  • R LPost op x-ray with THR right & ORIF left
  • Case #187 72 year male with multiple myeloma skull
  • Punched outlesions femur
  • Case #188 Sagittal T-2 MRI 55 year male with multiple myeloma spine
  • Sagittal T-2 MRIlumbar spine withevidence of cordcompression
  • Case #95837 year male withmultiple myelomadorsal spine
  • Lumbar spine
  • Autopsy specimens
  • Photomic
  • Case #95955 year male with multiplemyeloma dorsal spine
  • Lateral view
  • CT scan showing tumor in vertebra and vertebral canal
  • CT of adjacent vertebra
  • Anterior vertebrectomy specimen
  • Photomic
  • Case #96048 year male withmultiple myelomadorsal spine withcord involvement tumorSagittal T-2 MRI
  • Axial T-2 MRI showing tumor in pedicle & costovertebral joint
  • tumorAnother axial T-2 cut
  • Biopsy photomic
  • Case #96155 year male withmultiple myelomacervical spine andcompression fracture
  • Post op posteriorspinal fusion andradiation therapy
  • Case #96238 year male withmultiple myelomalumbar spine
  • Post op anteriorcurettement andcementation
  • AP view
  • Case #96341 year male withmultiple myelomawith collapsed vertebralbody and paraplegia
  • Lateral view
  • Case #964 16 year male with multiple myeloma lumbar spine
  • Case #965 tumor 59 year female with multiple myeloma pelvis
  • tumorCT scan showing large aneuysmal lesion
  • tumorAnother CT cut
  • Post op x-ray with THAwith cement andSteinman pins
  • Skull x-ray showing multiple punched out lesions
  • Case #966 72 year female with severe multiple myeloma pelvis
  • Case #967 59 year female with multiple myeloma skull
  • Same patient with scapular and humeral lesions
  • Thumb lesion
  • Case #96855 year female withmultiple myelomawith path fracturefemur
  • Post op x-ray with cementedlong stem THA
  • Case #96975 year male withmultiple myelomaand path fracturefemur
  • Case #970 68 year female with multiple myeloma shoulder area
  • Same patient withtibial lesions
  • Punched outfemoral lesions
  • Punched out humerallesions as well
  • Path fracture later onwith IM nail fixation
  • Photomic
  • Case #97162 year male withmultiple myelomahumerus
  • Post op cemented Neerprosthesis
  • Case #97237 year male withmultiple myelomaupper extremitywith punched out lesions
  • Case #973 48 year female with multiple myeloma shoulder
  • Bone scan withscapular andrib lesions
  • Coronal T-1 MRI
  • tumor Axial T-2 MRI
  • Case #97472 year male withmultiple myelomalumbar spine
  • Same patient withpunched out lesionsin femur and ischium
  • Also punched out lesionsin tibia and fibula
  • Case #975 29 year male with blastic form of multiple myeloma
  • Close up
  • Case #97640 year male with avariant of multiplemyeloma known asfibrogenesis imperfectaossium
  • Multiple collapsedlumbar vertebra as inmultiple myeloma
  • X-ray at a later datewith progressive disease
  • X-ray of pelvis shows diffuse lytic changes
  • Bone scan
  • MetastaticNeuroblastoma
  • 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
  • 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.
  • CLASSIC Case #1894 year malemetastatic neuroblastomadistal femur withpathologic fracture
  • Lateral view showinghair-on-end reactivesubperiosteal boneformation
  • Bone scan
  • Bone scan shows abnormalcollection in kidney wherethe primary tumor wasfound
  • Sagittal T-2 MRIshowing metastatictumor in tibia
  • tumorAbdominal CT scan showing primary neuroblastoma in the kidney area
  • Chest x-ray showing multiple pulmonary mets
  • Femoral biopsy photomic showing rosette pattern
  • Higher power showing rosette pattern
  • Case #9777 year male withmetastatic neuroblastomaproximal humerus andpath fracture
  • Bone scan showingprimary tumor in kidneyand met to shoulder
  • Photomic from humeral biopsy
  • Case #9789 year male withmetastatic neuroblastomaproximal humerus
  • Another view
  • Case #9791 year old female withmetastatic neuroblastomaproximal humerus
  • Case #9805 year female withmetastatic neuroblastomaproximal femur
  • Case #98111 year female withmetastatic neuroblastomafemur treated with wideresection and fibular strutreconstruction
  • Macro section fromresected specimenshowing tumor insideand outside the femur
  • Scanning lens photomic
  • Higher power photomic
  • Case #9827 year male withmetastatic neuroblastomadistal femur
  • Case #9837 month male with largecalcific renal mass whichon biopsy proved to beneuroblastoma
  • Lateral view
  • Bone scan
  • Bone scan
  • Sag PD T-2