Volume 8        Round Cell Tumors of BoneEwing’s sarcoma-----------------Case 169-175 & 861-900Large cell lymphoma--------...
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 fo...
seen in an older age group that have a similar appearance withH & E staining. With special staining techniques, most lymph...
with elevated temperature, white count and sed rate. Because of thehigh incidence of necrosis with the Ewing’s sarcoma, it...
or to the lung, the survival rate drops to about 30%. Wheneverpossible, the orthopedic oncologist will attempt a wide rese...
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”reactivesubperiostea...
Macro section resectedproximal femur
periostiumCloseup macro sectionshowing “hair-on-end”      necrosisreactive subperiostealnew bone                         p...
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                ...
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...
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                  ...
Cor T-1   T-2   Gad
Axial T-1   T-2   Gad
Case #9008 year male with acutefracture thru priorfemoral stress fracture                                      stress     ...
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 divid...
spleen, at which time the prognosis for survival becomes muchworse. The age group for primary lymphoma of bone is between2...
advent of chemotherapy dramatically improved the prognosis forsurvival that, for a solitary primary lymphoma of bone, is s...
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 m...
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 tis...
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 radi...
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 carcin...
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 fema...
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 presen...
dysplasia. Because the disease is purely lytic in nature, the boneisotope scan may be negative.    Since the disease is co...
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 plasmacyt...
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 approximatel...
for survival and is referred to as the Poems syndrome. Skeletallesions are more typically seen in the spine and pelvic are...
Local treatment consists of external beam radiation therapy andintramedullary devices, such as long stem prostheses and in...
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...
number 1 chromosome. A CT scan of the abdomen will frequentlypick up a neoplastic abnormality in the kidneys. Chemotherapy...
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
Upcoming SlideShare
Loading in …5
×

Volume 8

376 views
337 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
376
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
21
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Volume 8

  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, 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
  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 allographic 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 #88915 year femaleEwing’s sarcomaproximal fibula
  146. 146. Case #89018 year maleEwing’s sarcomadistal fibula
  147. 147. Bone scan
  148. 148. Case #891 17 year male with Ewing’s sarcoma 4th metatarsal
  149. 149. Coronal T-1 MRI
  150. 150. tumorAxial T-1 MRI
  151. 151. tumorAxial T-2 MRI
  152. 152. Photomic with pseudo-rosettes
  153. 153. CT scan thoracic spine shows multi focal lesion
  154. 154. Coronal CT scan
  155. 155. Case #892 35 year female with Ewing’s sarcoma os calcis
  156. 156. tumor Several months later
  157. 157. tumor T-1 MRI
  158. 158. tumorGad contrast MRI
  159. 159. Case #89321 year maleEwing’s sarcomamid tarsal area
  160. 160. Case #89420 year maleEwing’s sarcoma2nd toe
  161. 161. Case #8955 year femaleEwing’s sarcomaproximal ulna
  162. 162. Lateral view
  163. 163. Axial T-1 MRI
  164. 164. Sagittal T-1 MRI
  165. 165. Coronal T-2 MRI
  166. 166. Photomic
  167. 167. Case #896 50 year female with Ewing’s sarcoma proximal ulna
  168. 168. Case #8972 year old Ewing’ssarcoma middle finger
  169. 169. Lateral view
  170. 170. Sagittal T-1 MRI
  171. 171. Photomic
  172. 172. Case #898 15 year male with Ewing’s sarcoma thumb
  173. 173. Case #898.1 Parosteal Ewing’s sarcoma 18 year male with lateral knee knee for 3 months
  174. 174. Bone scan
  175. 175. Axial T-1 Axial Gad C+
  176. 176. Coronal STIR Gad C+ Sagittal Gad C+
  177. 177. Case #898.2 Parosteal Ewing’s sarcoma 13 year male with painful mass in forearm for 3 months
  178. 178. Bone scan
  179. 179. Cor T-1 T-2 FS
  180. 180. Sag T-1 Gad
  181. 181. Axial T-2 GadPost chemo T-2 Gad
  182. 182. Ewing’s Sarcoma Pseudotumors
  183. 183. Case #899 onion skin periostitis11 year femaleosteomyelitis distal femurlooking like Ewing’s sclerosissarcoma
  184. 184. Lateral view
  185. 185. Bone scan
  186. 186. Coronal T-2 MRI
  187. 187. Axial T-2 MRI
  188. 188. Photomic of reactive periostitis
  189. 189. polys lymphsPhotomic showing inflammatory cells
  190. 190. Case #899.1 Ewing’s pseudotumor Osteomyelitis 3/06 7/07 7/07 14 year old male with pain right arm for 17 months
  191. 191. Cor T-1 T-2 Gad
  192. 192. Axial T-1 T-2 Gad
  193. 193. Case #9008 year male with acutefracture thru priorfemoral stress fracture stress periostitis Day of fracture
  194. 194. 3 days after acute fracture Stress periostitis
  195. 195. At 3 weeks lookinglike Ewing’s sarcoma
  196. 196. 6 mos later with solidunion unlike Ewing’ssarcoma
  197. 197. Case #900.5Eosinophillic granulomafibula looking likeEwing’s sarcoma in a5 year male
  198. 198. Lymphoma of Bone
  199. 199. 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
  200. 200. 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
  201. 201. 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.
  202. 202. CLASSICCase #17645 year malelymphoma proximalfemur path fracture
  203. 203. Frog leg lateral
  204. 204. signal voidBone scan
  205. 205. tumor Coronal T-1 MRI
  206. 206. tumorCoronal T-2 MRI
  207. 207. Axial T-2 MRI
  208. 208. High power photomic showing folded nuclear forms
  209. 209. Case #176.1 Large cell lymphoma 47 yr old male smoker with 4 mo history of left hip pain
  210. 210. Bone scan
  211. 211. CoronalT-1 T-2
  212. 212. AxialT-1 T-2
  213. 213. Post op IM nailing
  214. 214. Case #177 83 year female with lymphoma right pelvis
  215. 215. 6 months later with pathologic fracture
  216. 216. Another 6 mos later
  217. 217. Bone scan
  218. 218. Photomic
  219. 219. Case #17840 year femalelymphoma lowerspineSagittal T-2 MRI
  220. 220. Sagittal T-2 MRIupper spine
  221. 221. Sagittal T-2 MRImid spine
  222. 222. Case #178.1 Lymphoma sacrum 72 year male with LBP for many years
  223. 223. Bone scan
  224. 224. Axial T-1 MRI T-2 Gad
  225. 225. T-1 T-2 Sagittal Gad STIR
  226. 226. Case #901 17 year male with lymphoma acetabulum
  227. 227. tumorCoronal T-1 MRI
  228. 228. tumorAxial T-1 MRI
  229. 229. tumorAxial T-2 MRI
  230. 230. Photomic
  231. 231. Good response fromchemotherapy
  232. 232. Case #902 49 year male with lymphoma pelvis
  233. 233. tumor CT scan
  234. 234. Case #902.1 Lymphoma of pelvis 69 year male with 2 month history of left hip pain
  235. 235. tumorCoronal T-1 T-2 Gad C+
  236. 236. Sagittal T-1 T-2 Gad
  237. 237. AxialT-1 T-2 Gad
  238. 238. Case #90344 year male withlymphoma pelvis
  239. 239. Case #904 31 year male with lymphoma pelvis
  240. 240. Bone scan
  241. 241. Case #90540 year malelymphoma pelvis
  242. 242. Case #90647 year malelymphomadistal femur
  243. 243. Lateral view
  244. 244. Bone scan6 months later
  245. 245. 6 months later
  246. 246. Sagittal T-1 MRI
  247. 247. Sagittal T-1 MRI thru notch
  248. 248. tumorSagittal T-2 MRI
  249. 249. tumorAxial T-2 MRI
  250. 250. Photomic
  251. 251. Case #906.5 49 year male with lymphoma distal femur
  252. 252. Lateral view
  253. 253. Bone scan
  254. 254. Sagittal T-1 MRI
  255. 255. Coronal T-1 MRI
  256. 256. tumorCoronal STIR MRI
  257. 257. 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
  258. 258. Bone scan
  259. 259. Sag T-1 Cor T-2
  260. 260. Axial PDFemoral cut Tibial cut
  261. 261. Case #906.7 Lymphoma Bone scan 58 year male with painful swelling above knee for 3 months
  262. 262. Cor T-1 T-2 FS
  263. 263. Axial PD T-2
  264. 264. Sag PD T-2
  265. 265. Case #90723 year femalelymphomadistal femur
  266. 266. Lateral view
  267. 267. Bone scan
  268. 268. Sagittal T-1 MRI
  269. 269. Coronal T-1 MRI tumor
  270. 270. tumor tumorCoronal STIR MRI
  271. 271. Positive silver stain for reticulum fiber
  272. 272. Case #90828 year malelymphoma femur
  273. 273. Macro sectionresected specimen
  274. 274. Photomic
  275. 275. Case #90934 year male withlymphoma prox femur
  276. 276. Frog lateral
  277. 277. Case #91038 year malepathologic fracturelymphoma prox femur
  278. 278. Case #911 Axial T-1 MRI tumor 77 year male with parosteal lymphoma femur
  279. 279. tumorAxial T-2 MRI
  280. 280. Case #91217 year malelymphoma distalfemur
  281. 281. AP view
  282. 282. Coronal T-1 MRI tumor
  283. 283. tumorSagittal T-1 MRI
  284. 284. Case #913 Coronal T-1 MRI 54 year male with HIV lymphoma proximal femur
  285. 285. tumorAxial proton density MRI
  286. 286. Case #914 65 year female ORIF hip fracture prior history of lymphoma 5 yrs ago
  287. 287. 5 years later withOGS at healedfracture site
  288. 288. Bone scan shows multifocal OGS
  289. 289. Case #91541 year malelymphomaproximal tibia
  290. 290. Lateral view
  291. 291. Oblique view3 months later
  292. 292. Pathologic fracturefollowing radiationtherapy at 6 months
  293. 293. Photomic
  294. 294. Custom total kneeprosthesis forreconstruction
  295. 295. Post op x-ray withprosthetic reconstruction
  296. 296. Case #91634 year femalelymphoma prox tibia
  297. 297. Sagittal T-1 MRI
  298. 298. Sagittal T-2 MRI
  299. 299. Case #917 21 year female with lymphoma proximal tibia
  300. 300. Coronal T-1 MRI
  301. 301. tumorSagittal T-1 MRI
  302. 302. Case #91826 year femalelymphoma distaltibia
  303. 303. tumor Coronal T-1 MRI
  304. 304. Sagittal T-1 MRI tumor
  305. 305. tumorAxial T-2 MRI
  306. 306. Case #91929 year femalelymphoma proximalhumerus
  307. 307. Bone scan
  308. 308. Coronal T-1 MRI
  309. 309. tumorAxial proton density MRI
  310. 310. Photomic
  311. 311. Case #920Pathologic fracturelymphoma proximalhumerus in a 64 yearfemale
  312. 312. Bone scan
  313. 313. Coronal T-2 MRI tumor
  314. 314. Case #92138 year female withlymphoma humerus
  315. 315. Bone scan
  316. 316. Coronal T-2 MRI
  317. 317. Case #92227 year malelymphoma distalhumerus
  318. 318. Sagittal T-1 MRI
  319. 319. tumorAxial T-2 MRI
  320. 320. Photomic
  321. 321. Case #923 28 year male with lymphoma proximal ulna
  322. 322. Axial T-1 MRI
  323. 323. Axial T-2 MRI tumor
  324. 324. Case #924 Laminogram x-ray 50 year female with lymphoma proximal ulna
  325. 325. Case #925 Sagittal T-1 MRI tumor tumor 64 year female with soft tissue lymphoma forearm
  326. 326. tumorAxial proton density MRI
  327. 327. Axial T-2 MRI
  328. 328. Case #92670 year female withlymphoma distal radius
  329. 329. Case #927 Tumor defect 20 year male with lymphoma sacrum 1 year post resection and radiation therapy
  330. 330. 2.5 years post op
  331. 331. Case #928 43 year male with lymphoma 11th posterior rib
  332. 332. Resection specimen cut in path lab
  333. 333. Photomic
  334. 334. LymphomaPseudotumors
  335. 335. Case #929 pain 73 year female with radiation osteitis 2nd to radiation therapy for ovarian carcinoma 19 years ago
  336. 336. 9 days later with path fracture looking like lymphoma biopsy negative for sarcoma
  337. 337. 2 weeks later with progressive collapse
  338. 338. 6 weeks later and more collapse
  339. 339. Coronal T-1 MRI with low signal like a lymphoma
  340. 340. Coronal proton density MRI
  341. 341. Case #929.1 Lymphoma pseudotumor25 year male alcoholic and smoker with R hip pain 4 mos
  342. 342. Cor T-1Cor T-2
  343. 343. Axial T1Axial T-2
  344. 344. Case #93052 year maleradiation osteitishumerus 2nd toradiation for softtissue sarcomayears ago now lookinglike a lymphoma
  345. 345. Pathologic fracturelater requiringIM nail
  346. 346. Case #931 54 year male tennis player with stress fracture sacrum
  347. 347. R L Bone scan
  348. 348. CT scan showing fracture callus
  349. 349. pseudotumorCoronal T-1 MRI showing low signal like lymphoma
  350. 350. Coronal T-2 MRI showing high signal from fracture
  351. 351. Case #93222 year malestress fracture thrulateral plateau lookinglike a lymphoma
  352. 352. Bone scan hot like lymphoma
  353. 353. Sagittal T-1 MRIshowing fractureedema lookinglike lymphoma
  354. 354. Case #93332 year femalemastocytosis spine &pelvis looking likelarge cell lymphoma
  355. 355. Femoral mastocytosislooking like lymphoma
  356. 356. Similar lesionsdistal femur
  357. 357. Same changesin humerus
  358. 358. Changes in ribs &humerus
  359. 359. Hodgkin’sLymphoma
  360. 360. CLASSICCase #17940 year maleblastic form ofHodgkin’s lymphomaL-4
  361. 361. Photomic showing Reed-Sternberg cell
  362. 362. Case #180 33 year female with Hodgkin’s disease SI area
  363. 363. Photomic with Reed-Sternberg cells
  364. 364. Case #934 58 year male with blastic form Hodgkin’s lymphoma pelvis
  365. 365. Left iliac lesions
  366. 366. Right iliac lesion
  367. 367. Photomic with Reed-Sternberg cells & eosinophils
  368. 368. Case #93538 year male withblastic form of lymphomaL-3
  369. 369. Case #93651 year malelytic form ofHodgkin’s lymphomaL-4
  370. 370. eosinophilPhotomic with Reed-Sternberg cell
  371. 371. Case #936.1 Hodgkin’s lymphoma 28 year old male with hip pain for past 3 months
  372. 372. Bone scan
  373. 373. Cor T-1 T-2 Gad
  374. 374. Axial T-1 T-2 gad
  375. 375. Leukemia
  376. 376. CLASSIC Case #181 10 year female with hemorrhagic purpura second to acute lymphoblastic leukemia
  377. 377. Transverse radioleucent metaphyseal bands seen in acute lymphoblastic leukemia
  378. 378. Lymphoblasts in peripheral blood smear
  379. 379. Case #93759 year malechronic lymphocyticleukemia Bone scan
  380. 380. Coronal T-1 MRI
  381. 381. Sagittal T-1 MRI
  382. 382. Coronal T-1 MRI
  383. 383. Coronal T-1 MRI
  384. 384. Coronal T-2 MRI
  385. 385. Lymphoblasts seen in marrow smears
  386. 386. Case #9384.5 year maleacute lymphoblasticleukemia
  387. 387. Bone scan
  388. 388. Axial T-2 MRI
  389. 389. Lymphoblasts in peripheral blood smeer
  390. 390. Case #93940 year male5 year history ofchronic lymphocyticleukemia with chronicreactive periostitis
  391. 391. Lateral view
  392. 392. Case #94014 month female withacute lymphoblasticleukemia femur showinglaminated periostitis
  393. 393. Casswe #94143 year male with tumorchronic granulocyticleukemia with focallesion in femur
  394. 394. tumorAnother view
  395. 395. Case #941.1 Acute lymphocytic leukemia 3/06 4/06 6/0612 year female with wrist pain and elevated sed rate 3 mos
  396. 396. 6/06Coronal T-1 T-2 Sagittal T-2
  397. 397. Case #9424 year femaleacute lymphocyticleukemia withlaminated periostitisfibula
  398. 398. Case #9434 year maleacute lymphoblasticleukemia hand
  399. 399. Case #94440 year femalechronic monocyticleukemia withosteoporotic codfishshaped vertebral bodies
  400. 400. AP view
  401. 401. Plasma Cell Tumors
  402. 402. SolitaryPlasmacytoma
  403. 403. 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
  404. 404. 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.
  405. 405. CLASSIC Case #182 40 year male with solitary plasmacytoma pelvis
  406. 406. Bone scan showingsignal void
  407. 407. Axial T-1 MRI
  408. 408. Axial T-2 MRI
  409. 409. Photomic showing plasma cells
  410. 410. High power
  411. 411. Case #183 42 year male with solitary plasmacytoma pelvis
  412. 412. Axial T-1 MRI
  413. 413. Axial T-2 MRI
  414. 414. Post op x-ray afterradiation therapy &total hip replacement
  415. 415. Case #18453 year malesolitary plasmacytomaproximal femur
  416. 416. Pathologic fracture one year later
  417. 417. Post op x-ray withcemented long stembiopolar prosthesis
  418. 418. Case #18555 year malesolitary plasmacytomaproximal femur
  419. 419. Case #185.1 Solitary plasmacytoma40 year male withincreasing pain inthigh for 6 mos
  420. 420. Bone scan
  421. 421. Sag T-1 PD FS Cor STIR
  422. 422. Axial T-1T-2 Gad
  423. 423. PO interlocking nailand cementation
  424. 424. Case #94649 year malesolitary plasmacytomaacetabulum
  425. 425. tumor CT scan
  426. 426. Bone scan
  427. 427. Photomic
  428. 428. Steinman pinReconstruction withmetal cage
  429. 429. Cementation over metaland completed THAinside cage
  430. 430. Post op X-ray
  431. 431. Case #947 tumor 32 year male with solitary plasmacytoma acetabulum
  432. 432. Coronal T-1 MRI
  433. 433. Case #94853 year male withsolitary plasmacytomasacrum
  434. 434. R LBone scan shows signal void in tumor
  435. 435. tumor CT scan
  436. 436. Sagittal T-2 MRI tumor
  437. 437. Case #949 52 year male with large solitary plasmacytoma pelvis
  438. 438. CT scan at sacral level
  439. 439. tumorCT scan at lumbar level
  440. 440. Case #950 45 year male with solitary plasmacytoma sacrum
  441. 441. Lateral view tumor
  442. 442. Bone scan shows signal void in tumor site
  443. 443. tumorBone scan
  444. 444. tumorAxial T-2 MRI
  445. 445. Sagittal PD MRI tumor
  446. 446. Sagittal T-2 MRI tumor
  447. 447. Photomic
  448. 448. Case #951 Axial T-1 MRI tumor 56 year male with solitary plasmacytoma sacrum
  449. 449. Sagittal T-1 MRI tumor
  450. 450. Case #952 28 year female with path fracture thru supra acetabular Solitary plasmacytoma
  451. 451. Case #95346 year male withsolitary plasmacytomaproximal femur
  452. 452. Coronal T-1 MRI
  453. 453. Coronal T-2 MRI
  454. 454. Case #95465 year female withsolitary plasmacytomafemur
  455. 455. Post op x-ray withblade-plate fixation
  456. 456. Case #95541 year male withsolitary plasmacytomafemur
  457. 457. Case #95640 year female withsolitary plasmacytomaproximal fibula
  458. 458. Case #957 tumor 24 year male with solitary plasmacytoma scapula
  459. 459. Bone scan showing signal void in center of tumor
  460. 460. tumor CT scan
  461. 461. Multiple Myeloma
  462. 462. 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
  463. 463. 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.
  464. 464. 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.
  465. 465. CLASSIC Case #186 fracture 65 year male with multiple myeloma pelvis and hips
  466. 466. Photomic showing plasma cells
  467. 467. R LPost op x-ray with THR right & ORIF left
  468. 468. Case #187 72 year male with multiple myeloma skull
  469. 469. Punched outlesions femur
  470. 470. Case #188 Sagittal T-2 MRI 55 year male with multiple myeloma spine
  471. 471. Sagittal T-2 MRIlumbar spine withevidence of cordcompression
  472. 472. Case #95837 year male withmultiple myelomadorsal spine
  473. 473. Lumbar spine
  474. 474. Autopsy specimens
  475. 475. Photomic
  476. 476. Case #95955 year male with multiplemyeloma dorsal spine
  477. 477. Lateral view
  478. 478. CT scan showing tumor in vertebra and vertebral canal
  479. 479. CT of adjacent vertebra
  480. 480. Anterior vertebrectomy specimen
  481. 481. Photomic
  482. 482. Case #96048 year male withmultiple myelomadorsal spine withcord involvement tumorSagittal T-2 MRI
  483. 483. Axial T-2 MRI showing tumor in pedicle & costovertebral joint
  484. 484. tumorAnother axial T-2 cut
  485. 485. Biopsy photomic
  486. 486. Case #96155 year male withmultiple myelomacervical spine andcompression fracture
  487. 487. Post op posteriorspinal fusion andradiation therapy
  488. 488. Case #96238 year male withmultiple myelomalumbar spine
  489. 489. Post op anteriorcurettement andcementation
  490. 490. AP view
  491. 491. Case #96341 year male withmultiple myelomawith collapsed vertebralbody and paraplegia
  492. 492. Lateral view
  493. 493. Case #964 16 year male with multiple myeloma lumbar spine
  494. 494. Case #965 tumor 59 year female with multiple myeloma pelvis
  495. 495. tumorCT scan showing large aneuysmal lesion
  496. 496. tumorAnother CT cut
  497. 497. Post op x-ray with THAwith cement andSteinman pins
  498. 498. Skull x-ray showing multiple punched out lesions
  499. 499. Case #966 72 year female with severe multiple myeloma pelvis
  500. 500. Case #967 59 year female with multiple myeloma skull
  501. 501. Same patient with scapular and humeral lesions
  502. 502. Thumb lesion
  503. 503. Case #96855 year female withmultiple myelomawith path fracturefemur
  504. 504. Post op x-ray with cementedlong stem THA
  505. 505. Case #96975 year male withmultiple myelomaand path fracturefemur
  506. 506. Case #970 68 year female with multiple myeloma shoulder area
  507. 507. Same patient withtibial lesions
  508. 508. Punched outfemoral lesions
  509. 509. Punched out humerallesions as well
  510. 510. Path fracture later onwith IM nail fixation
  511. 511. Photomic
  512. 512. Case #97162 year male withmultiple myelomahumerus
  513. 513. Post op cemented Neerprosthesis
  514. 514. Case #97237 year male withmultiple myelomaupper extremitywith punched out lesions
  515. 515. Case #973 48 year female with multiple myeloma shoulder
  516. 516. Bone scan withscapular andrib lesions
  517. 517. Coronal T-1 MRI
  518. 518. tumor Axial T-2 MRI
  519. 519. Case #97472 year male withmultiple myelomalumbar spine
  520. 520. Same patient withpunched out lesionsin femur and ischium
  521. 521. Also punched out lesionsin tibia and fibula
  522. 522. Case #975 29 year male with blastic form of multiple myeloma
  523. 523. Close up
  524. 524. Case #97640 year male with avariant of multiplemyeloma known asfibrogenesis imperfectaossium
  525. 525. Multiple collapsedlumbar vertebra as inmultiple myeloma
  526. 526. X-ray at a later datewith progressive disease
  527. 527. X-ray of pelvis shows diffuse lytic changes
  528. 528. Bone scan
  529. 529. MetastaticNeuroblastoma
  530. 530. 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
  531. 531. 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.
  532. 532. CLASSIC Case #1894 year malemetastatic neuroblastomadistal femur withpathologic fracture
  533. 533. Lateral view showinghair-on-end reactivesubperiosteal boneformation
  534. 534. Bone scan
  535. 535. Bone scan shows abnormalcollection in kidney wherethe primary tumor wasfound
  536. 536. Sagittal T-2 MRIshowing metastatictumor in tibia
  537. 537. tumorAbdominal CT scan showing primary neuroblastoma in the kidney area
  538. 538. Chest x-ray showing multiple pulmonary mets
  539. 539. Femoral biopsy photomic showing rosette pattern
  540. 540. Higher power showing rosette pattern
  541. 541. Case #9777 year male withmetastatic neuroblastomaproximal humerus andpath fracture
  542. 542. Bone scan showingprimary tumor in kidneyand met to shoulder
  543. 543. Photomic from humeral biopsy
  544. 544. Case #9789 year male withmetastatic neuroblastomaproximal humerus
  545. 545. Another view
  546. 546. Case #9791 year old female withmetastatic neuroblastomaproximal humerus
  547. 547. Case #9805 year female withmetastatic neuroblastomaproximal femur
  548. 548. Case #98111 year female withmetastatic neuroblastomafemur treated with wideresection and fibular strutreconstruction
  549. 549. Macro section fromresected specimenshowing tumor insideand outside the femur
  550. 550. Scanning lens photomic
  551. 551. Higher power photomic
  552. 552. Case #9827 year male withmetastatic neuroblastomadistal femur
  553. 553. Case #9837 month male with largecalcific renal mass whichon biopsy proved to beneuroblastoma
  554. 554. Lateral view
  555. 555. Bone scan
  556. 556. Bone scan
  557. 557. Sag PD T-2

×