Benign aggressive bone
tumors
INTRODUCTION
● aggressiveness of these lesions is between
purely benign and frankly malignant.
● Today in this seminar bri...
Giant Cell Tumor
● Sir Astley Cooper first describe in 1818 emphasizing its
benign nature.
● Dr Paget called it “brown or ...
Incidence
● acc to mayo clinic series 5% of neoplasms
of bone.
● common in some parts of andhra pradesh in
india.
Age groups involved.
● Usually after epiphyseal closure.
● Hence age group involved is 20 to 40
years(70%) with slight fem...
Site of Involvement
Situated mostly at epiphyseo-metaphyseal region of long bones.
AROUND KNEE JOINT 55 %
DISTAL END OF RA...
CLINICAL PRESENTATION
● complains of vague persistent pain over the
swelling at end of long bones…swelling
present from fe...
Clinical Picture
Overlying skin is stretched , shiny
with no engorged veins.
● PALPATION- The swelling is
warm , smooth wi...
ROM at adjacent joint can be restricted due to
mechanical block.
Radiological featuresPlain Radiograph-
● Tumour will show large , sharply
circumscribed area of reduced density
asymmetric...
Computed Tomography
● Helps in confirming the integrity
of cortex and outlining the
tumour extent.
● Subcortical destructi...
M.R.I
● With mri the morphologic analysis
and extent of disease into
surrounding soft tissue can be
assessed .
● As in CT ...
ANGIOGRAPHY
● to check Relationship of major
vessles to large tumors.
● Does not correlate with
grading of tumor.
RADIONUCLIDE SCINTIGRAPHY
● GCT takes up increased uptake of technetium
99.
● Again does not have any correlation with
gra...
Biopsy
This is the final diagnostic tool for diagnosis of gct.
Sample can be taken by
● OPEN INCISIONAL BIOPSY
● FINE NEED...
GROSS APPEARANCE
● Epiphyseal end of long bone will be expanded with
thining of periosteum and cortex, being easily broken...
MICROSCOPIC APPEARANCE
● Multinucleated giant cells and spindle
cells are the main component .
● GIANT CELLS in this tumor...
● The appearance of spindle cells indicates the malignant
potential of tumor.
POINT TO BE NOTED-
● Appearance of giant cel...
GRADING OF GCT
CAMPANACCI RADIOGRAPHIC GRADING
● Grade 1- tumor has well
marinated border of a thin rim
of mature bone, and the
cortex is...
● Grade 2- tumor has relatively
well defined margins, but no
radio opaque rim, cortex is thin
and expanded but is present.
Grade 3- cortex is perforated
with extension of tumor into soft
tissue.
Enneking staging of Giant cell tumor
Based on clinical radiological and histopathological features
Stage 1- LATENT(10 - 15...
Stage 3 (aggressive) : 10 - 15 %
● Symptomatic
● Rapidly growing mass
● Radiologically- Extracapsular, has cortical
perfor...
Note-
TNM Classification system is not applicable to
GCT because anatomically it remains
intracompartmental for a long tim...
Giant Cell Variants
1. Aneurysmal bone cyst
2. Brown tumor of hyperparathyroidism
3. non ossifying fibroma
4. Unicameral b...
MANAGEMENT AND COMPLICATIONS OF
GCT
INTRODUCTION
● Majority of tumors are benign, have 30 to 40
% recurrence and has tendency to
metastasize.
AIM OF TREATMENT
● To eradicate the growth completely at initial operation
● to avoid ablation of limb
● to maintain possi...
● Traditionally
: intralesional curettage/resection with bone graft
:recurrence 35-42 %
● En Bloc resection
: recurrence 1...
● HISTORICALLY TREATMENT CONSISTED OF SIMPLE CURETTAGE
● BUT RECURRENCE RATES > 50%
● FOR DEFECTS AFTER RESECTION OR CURET...
ADJUNCT Tx
●PMMA, Liquid N2, Phenol, l,electrocautery.
–Local extension of margin
–Kill residual foci and remaining tumour...
Bone graft
ADVANTAGE:
• RESTORING NORMAL BIOMECHANICS TO JOINT
SURFACE
•PREVENT FUTURE DEGENERATIVE JOINT DISEASES
•RESTOR...
•DISADVANTAGES
: JOINT MUST BE PROTECTED FOR AN EXTENDED
PERIOD OF TIME TO PREVENT A PATHOLOGICAL
FRACTURES.
● TUMOUR RECU...
Bone cement
•THE ABOVE DISADVANTAGES OVERCOME BY USE OF BONE
CEMENT
•PROVIDES IMMEDIATE STABILITY-HENCE QUICKER
REHABILITA...
Curettage with bone
cementing
En bloc excision
•INITIAL PROCEDURE OF CHOICE AND HERE 2 CM OF NORMAL
BONE IS ALSO EXCISED
•
•DEFECTS ARE FILLED WITH CANC...
resection of tumor in lesions of
sacrificable part
● lower end ulna
● upper end of fibula
● phalanges
● metatarsal rays
RE...
Resection and
reconstruction with
Autograft
•AROUND THE KNEE,A HEMI CONDYLAR OSTEOARTICULAR
ALLOGRAFT RECONSTRUCTION OR A ROTATING HINGE
ENDOPROSTHESIS MAY BE NECESSA...
EXCISION AND RECONSTRUCTION
•FOR GCT AFFECTING LOWER END OF FEMUR OR UPPER END
OF TIBIA
• AFTER EN BLOCK EXCISION RECONSTR...
RADIOTHERAPY- Disappointing recurrence rate of 50-70%.
● malignant sarcomatous transformation ocuured in 7-10 %
cases
CHEM...
RECURRENCE OF LESIONS
● Most local recurrences and pulmonary metastases occur within 3
years or even upto 20 years.
● Pati...
•treatment is same as for primary lesions.
•after biopsy shows that tumor is still
benign,repeat curretage or resection is...
CHONDROBLASTOMA
INTRODUCTION
● Codman in 1931 first described..”Codmans
tumor”
● It is a rare , benign bone tumor of immature
cartilage ce...
● INCIDENCE- less than 1 % of primary bone
tumors.
● AGE
Ranges - 3 to 73 years.
Usually teenagers, before obliteration of...
● SITE
Epiphyseal region of long bone, occasionally extends to adjacent
metaphysis.
● COMMON OCCURRENCE
lower extremity(72...
SIZE - 1 to 6 cm
CLINICAL FEATURES-.
>Pain & swelling – several months.
>May be referred to nearest joint
>Some loss of jo...
RADIOLOGICAL FEATURES
X – RAYS:
>Lytic area –
>Oval or round
< ½ of epiphyseal area.
>Thin rim of sclerosis
>Punctate or s...
● In metaphyseal extension,
i.e tumor crossing growth
plate results in –
Eccentric location &
bulging expansion of
cortex
PATHOLOGY
Gross:
● Usually well demarcated
lesions.
● Capsule – thin, easily
disruptable
● Cut section- Soft, reddish –
pu...
MICROSCOPIC:-
● Islands of chondroblasts
with uniform polyhedral
closely packed cells.
● Background of fibrous
stroma cell...
● Cells – round, plump and active little
immature matrix is present.
● Pericellular lattice-like fine
calcification – “CHI...
DIFFERENTIAL DIAGNOSIS
● Enchondroma
Hand, diaphysis.
● G.C.T.
Eccentrical, soap bubble or trabecular pattern
No calcifica...
● Chondromyxoid fibroma
Site- Metadiaphysis
Septae are present.
TREATMENT AND PROGNOSIS
● Curettage and autologous bone grafting – high recurrence rate (10 –
35%).
● Close follow up & ob...
● Methacrylate adjunct –
when excision impractical & intracapsular curettage
is of high risk of recurrence due to surgical...
Radiosensitivity:
● Radiosensitive tumor
● Not used for uncomplicated cases – potential hazards
of irradiation induced mal...
OSTEOBLASTOMA
INTRODUCTION
● Jaffe and lichtenstein first described it in 1956.
● Rare bone tumor,
● 1 % of all primary bone tumors
● 3 ...
AGE
● Young person 10 to 30 years (80%)
SEX
● Males: female -3:1.
SITE
Vertebral Column 34 %
Extremities 30%
Hands and feet 14%
Skull and facial bones 15 %
● In long bones it occurs in medullary portion of metaphysis.
Rarely juxtacortical or periosteal osteoblastomas are
report...
Clinical features
● Pain- Dull , aching, persistent and localized.
● Slight local tenderness and palpable swelling of incr...
RADIOLOGICAL FEATURES
● lesion is well circumscribed, radiolucent,
eccentric and with an intact surrounding shell
of bone ...
● In vertebrae it is seen as
definitely expansile radiolucent
growth containing granular
radiopacities
● ct scans are bett...
CT SCAN
.
● it can show cotton wool
appearance when
calcification of tumor tissue
has occured...if cotton wool
appearance ...
PATHOLOGY
GROSS
● well circumscribed, 2-10 cm.
● surrounded by shell of cortical bone or thickened
periosteum.
● Haemorrha...
HISTOPATHOLOGY
•Vascular spindle-cell
stroma with abundant
irregular spicules of
mineralized bone and
Osteoid
DIFFERENTIAL DIAGNOSIS
OSTEOBLASTOMA OSTEOID OSTEOMA
1. INCIDENCE one fifth as common as osteoid
osteoma
10% of benign bon...
● OSTEOSARCOMA
No ALP rise in osteoblastoma, stromal cells are not large, but
are relatively uniform.
● GCT
>>more than ha...
TREATMENT
● Curettage and resection.
● bone grafting of defect.
● In spine- if resection causes instability,
instrumented ...
CHONDROMYXOID
FIBROMA
INTRODUCTION
● Rare tumour, least common benign cartilaginous tumors.
● Can be misdiagnosed as chondrosarcoma...as it is
c...
AGE
● 2nd and 3rd decade, rare in children.
SEX
● No predominance.
LOCATION
● metaphyseal region of large tubular
bones.(e...
CLINICAL PICTURE
● In young adults tumor causes mild or no pain,
slowly increasing local swelling and palpable
tender tumo...
RADIOLOGICAL FINDINGS
XRAY
● in long bones
>>Lesion -translucent mass of variable
sizes , located eccentrically in metaphy...
● in case narrow tubular bone
(fibula) or small tubular bone
(phalanx)- generally entire
width of bone is involved
● fusif...
PATHOLOGY GROSS
● Outer surface- covered by thin shell of newly
formed periosteal bone.
● Cut Surface-solid tumor mass of ...
MICROSCOPIC
•Tumor is composed of lobulated
and pseudo lobulated areas of
stellate cells with indistinct
cytoplasmic borde...
TREATMENT
● Curettage is not sufficient, as tumor may recur.
● En Bloc excision and filling cavity with
autogenous bone re...
Curettage and Bone cementing
LANGERHANS CELL
HISTIOCYTOSIS
● Previously called HISTIOCYTOSIS X
● Characterised by widespread dissemination of
reticuloendothelial system.
● Syndrome ...
Orthopaedic surgeon is primarily concerned
with
EOSINOPHILIC GRANULOMA OF BONE
EOSINOPHILIC GRANULOMA
● Self limited benign bone destructive lesion characterised by histocytic
and eosinophilic leucocyt...
Clinical Picture
● Acute onset
● complains of dull aching pain in a limited local area of bone.
● local tenderness , warmt...
RADIOGRAPHY
● Rapidly destructive lytic process
producing punched out
appearance
● In diaphysis of long bones lesions may
have aggressive permeative appearance
with periosteal reactive bone formation.
● Eosinophilic granuloma of
vertebral body
● showing marked flattening of
vertebral body or vertebral
plana
Histopathology
•Diagnosis is made by identification of
langerhans cell.
•Mixture of eosinophils, plasma cells,
histiocytes...
TREATMENT
● Microscopically diagnosis is made by identification of
langerhans cell.
● Recommended treatments incd-
>> cort...
Hand schuller - christian disease
REFRENCES
1. ORTHOPAEDICS PRINCIPLES AND THEI APPLICATION: SAMUEL L TURES
2. CAMPBELLS OPERATIVE ORTHOPAEDICS
3. TEXTBOOK ...
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benign aggressive bone tumors

  1. 1. Benign aggressive bone tumors
  2. 2. INTRODUCTION ● aggressiveness of these lesions is between purely benign and frankly malignant. ● Today in this seminar brief dicussion of such benign aggressive tumors would be done ● GIANT CELL TUMOR ● CHONDROBLASTOMA ● OSTEOBLASTOMA ● CHONDROMYXOID FIBROMA ● LANGERHANS CYST HISTOCYTOSIS
  3. 3. Giant Cell Tumor ● Sir Astley Cooper first describe in 1818 emphasizing its benign nature. ● Dr Paget called it “brown or Myeloid tumour” in 1853. ● WHO- ‘’An aggressive , potentially malignant lesion’’ Its an aggressive lesion characterised by well- vascularised tissue composed of spindle cells and multinucleated giant cells uniformly dispersed throughout the tumour.
  4. 4. Incidence ● acc to mayo clinic series 5% of neoplasms of bone. ● common in some parts of andhra pradesh in india.
  5. 5. Age groups involved. ● Usually after epiphyseal closure. ● Hence age group involved is 20 to 40 years(70%) with slight female predominance (3:2 ). ● Gradual Decrease in after fifth decade.
  6. 6. Site of Involvement Situated mostly at epiphyseo-metaphyseal region of long bones. AROUND KNEE JOINT 55 % DISTAL END OF RADIUS 10-12 % UPPER END OF HUMERUS 7% LOWER END OF TIBIA 3-4 % SMALL BONES OF HAND AND FEET 2% SPINE ,SKULL AND PELVIS 15-17%
  7. 7. CLINICAL PRESENTATION ● complains of vague persistent pain over the swelling at end of long bones…swelling present from few weeks to several months. ● Note- This pain could have increased after pathological fracture which may bring the patient to surgeon for first time.
  8. 8. Clinical Picture Overlying skin is stretched , shiny with no engorged veins. ● PALPATION- The swelling is warm , smooth with variable consistency, predominantly bony and tenderness is present on firm palpation. ● EGG SHELL CRACKLING-ELICITABLE WHEN THERE IS PATHOLOGICAL FRACTURE OR TOO MUCH THINNING OF CORTEX.
  9. 9. ROM at adjacent joint can be restricted due to mechanical block.
  10. 10. Radiological featuresPlain Radiograph- ● Tumour will show large , sharply circumscribed area of reduced density asymmetrically located in the epiphysis, begining subcortically and extending towards metaphysis. ● SOAP BUBBLE APPEARANCE- multilocular and trabeculated appearance of tumor. ● Geographical destruction type of osteolysis. ● cortical thinning. ● no sclerotic rim and new bone formation.
  11. 11. Computed Tomography ● Helps in confirming the integrity of cortex and outlining the tumour extent. ● Subcortical destruction can be well appreciated with a ct scan. ● Limitation- soft tissue extension of tumour and its relationship with adjacent structures cannot be seen .
  12. 12. M.R.I ● With mri the morphologic analysis and extent of disease into surrounding soft tissue can be assessed . ● As in CT SCAN, sub cortical destruction can be well appreciated by multiplanar mri. ● Intramedullary tumors best appreciated in T1 weighted images. ● Extraosseous Tumors best appreciated in T2 weighted images.
  13. 13. ANGIOGRAPHY ● to check Relationship of major vessles to large tumors. ● Does not correlate with grading of tumor.
  14. 14. RADIONUCLIDE SCINTIGRAPHY ● GCT takes up increased uptake of technetium 99. ● Again does not have any correlation with grading of tumor.
  15. 15. Biopsy This is the final diagnostic tool for diagnosis of gct. Sample can be taken by ● OPEN INCISIONAL BIOPSY ● FINE NEEDLE ASPIRATION ● CORE NEEDLE BIOPSY
  16. 16. GROSS APPEARANCE ● Epiphyseal end of long bone will be expanded with thining of periosteum and cortex, being easily broken by handling. ● Composed of ragged , very friable, readily bleeding tissue containing variously sized cavitations and small cysts. ● colour -varies from reddish brown to chocolate color in which vascular tissue predominates , to greyish or mottled where connective tissue is major component. ● no evidence of periosteal new bone formation. ● the inner wall of tumor is lined by a fibrous capsule from which the septae extend inwards to partition the tumor.
  17. 17. MICROSCOPIC APPEARANCE ● Multinucleated giant cells and spindle cells are the main component . ● GIANT CELLS in this tumor are characteristic and specific having size of 10 to 100 microns with centrally placed uniform sized nuclei numbering 15 to 150 max. ● SPINDLE CELLS- They are oval ,elongated and contain relatively large chromatinized nucleus and small acidophilic cytoplasm
  18. 18. ● The appearance of spindle cells indicates the malignant potential of tumor. POINT TO BE NOTED- ● Appearance of giant cells is not diagnostic. Giant cells are also seen in lesions like aneurysmal, unicameral cyst, non ossifying fibroma, chondroblastoma and brown tumor of hyperparathyroidism ● appearance of spindle cells is important.(main neoplastic component)
  19. 19. GRADING OF GCT
  20. 20. CAMPANACCI RADIOGRAPHIC GRADING ● Grade 1- tumor has well marinated border of a thin rim of mature bone, and the cortex is intact or slightly thinned but not deformed.
  21. 21. ● Grade 2- tumor has relatively well defined margins, but no radio opaque rim, cortex is thin and expanded but is present.
  22. 22. Grade 3- cortex is perforated with extension of tumor into soft tissue.
  23. 23. Enneking staging of Giant cell tumor Based on clinical radiological and histopathological features Stage 1- LATENT(10 - 15%) ● Patient is asymptomatic, discovered incidentally. ● May be associated with pathological fractures. ● Radiologically-tumor is intracapsular, with well defined margins and sclerotic rim. no cortical destruction. Stage 2- ACTIVE ( 70-75 %) ● Patient is symptomatic. ● Often associated with pathological fracture. ● Radiologically- intracapsular, has expanded or thinned out cortex ,but there is no breakthrough the cortex.
  24. 24. Stage 3 (aggressive) : 10 - 15 % ● Symptomatic ● Rapidly growing mass ● Radiologically- Extracapsular, has cortical perforation ● Will show intense vascularity on angioram
  25. 25. Note- TNM Classification system is not applicable to GCT because anatomically it remains intracompartmental for a long time within well formed capsule of the periosteum and soft tissue.
  26. 26. Giant Cell Variants 1. Aneurysmal bone cyst 2. Brown tumor of hyperparathyroidism 3. non ossifying fibroma 4. Unicameral bone cyst 5. Fibrous dysplasia 6. Chondroblastoma 7. Giant cell reparative granuloma 8. ossifying fibroma 9. osteogenic sarcoma
  27. 27. MANAGEMENT AND COMPLICATIONS OF GCT
  28. 28. INTRODUCTION ● Majority of tumors are benign, have 30 to 40 % recurrence and has tendency to metastasize.
  29. 29. AIM OF TREATMENT ● To eradicate the growth completely at initial operation ● to avoid ablation of limb ● to maintain possible function
  30. 30. ● Traditionally : intralesional curettage/resection with bone graft :recurrence 35-42 % ● En Bloc resection : recurrence 10% : multiple complications
  31. 31. ● HISTORICALLY TREATMENT CONSISTED OF SIMPLE CURETTAGE ● BUT RECURRENCE RATES > 50% ● FOR DEFECTS AFTER RESECTION OR CURETTAGE,EITHER ALLOGRAFT OR BONE CEMENT USED AS FILLING AGENTS EXTENDED CURETTAGE –USE OF A POWER BURR TO ENLARGE THE CAVITY 1-2 CM IN ALL DIRECTIONS IS NOW CONSIDERED STANDARD
  32. 32. ADJUNCT Tx ●PMMA, Liquid N2, Phenol, l,electrocautery. –Local extension of margin –Kill residual foci and remaining tumour cell ● ASSOCIATED WITH PATHOLOGIC FRACTURES & WOUND HEALING PROBLEMS
  33. 33. Bone graft ADVANTAGE: • RESTORING NORMAL BIOMECHANICS TO JOINT SURFACE •PREVENT FUTURE DEGENERATIVE JOINT DISEASES •RESTORING BONE STOCK
  34. 34. •DISADVANTAGES : JOINT MUST BE PROTECTED FOR AN EXTENDED PERIOD OF TIME TO PREVENT A PATHOLOGICAL FRACTURES. ● TUMOUR RECURRENCE IS DIFFICULT TO DISTINGUISH FROM GRAFT RESORPTION.
  35. 35. Bone cement •THE ABOVE DISADVANTAGES OVERCOME BY USE OF BONE CEMENT •PROVIDES IMMEDIATE STABILITY-HENCE QUICKER REHABILITATION •EASIER DETECTION OF RECURRENCE SEEN AS EXPANDING RADIOLUCENCY ADJ TO CEMENT •KILLS RESIDUAL TMR CELLS THROUGH POLYMERISATION HEAT. ● CYTOTOXIC AGENTS- METHOTREXATE AND ADRIAMYCIN CAN BE INCORPORATED IN BONE CEMENT.
  36. 36. Curettage with bone cementing
  37. 37. En bloc excision •INITIAL PROCEDURE OF CHOICE AND HERE 2 CM OF NORMAL BONE IS ALSO EXCISED • •DEFECTS ARE FILLED WITH CANCELLOUS BONE GRAFTS,FREEZE DRIED ALLOGRAFT OR PROSTHESIS
  38. 38. resection of tumor in lesions of sacrificable part ● lower end ulna ● upper end of fibula ● phalanges ● metatarsal rays RECURRENCE IS ALMOST NILL
  39. 39. Resection and reconstruction with Autograft
  40. 40. •AROUND THE KNEE,A HEMI CONDYLAR OSTEOARTICULAR ALLOGRAFT RECONSTRUCTION OR A ROTATING HINGE ENDOPROSTHESIS MAY BE NECESSARY •FOR AGGRESSIVE LESION OF DISTAL RADIUS,PRIMARY RESECTION AND RECONSTRUCTION WITH A PROXIMAL FIBULAR AUTOGRAFT INDICATED
  41. 41. EXCISION AND RECONSTRUCTION •FOR GCT AFFECTING LOWER END OF FEMUR OR UPPER END OF TIBIA • AFTER EN BLOCK EXCISION RECONSTRUCTION CAN BE DONE BY 1.TURN-O-PLASTY TECHNIQUE 2.ARTHRODESIS 3.ARTHROPLASTY
  42. 42. RADIOTHERAPY- Disappointing recurrence rate of 50-70%. ● malignant sarcomatous transformation ocuured in 7-10 % cases CHEMOTHERAPY- NO EFFECTIVE CHEMOTHERAPEUTIC AGENTS AVAILAIBLE FOR MANAGEMENT OF GCT.
  43. 43. RECURRENCE OF LESIONS ● Most local recurrences and pulmonary metastases occur within 3 years or even upto 20 years. ● Patient should have radiograph of primary tumor site and of the chest at >> 3 MONTHS INTERVAL FOR 1YR >> 6 MONTHS INTERVAL FOR NEXT 2 YRS >>AND ANNUALLY THEREAFTER
  44. 44. •treatment is same as for primary lesions. •after biopsy shows that tumor is still benign,repeat curretage or resection is performed.
  45. 45. CHONDROBLASTOMA
  46. 46. INTRODUCTION ● Codman in 1931 first described..”Codmans tumor” ● It is a rare , benign bone tumor of immature cartilage cells derivation arising in epiphysis consisting of polygonal chondroblast, foci of chondroid, osteoclast like giant cells and small foci of calcifications.
  47. 47. ● INCIDENCE- less than 1 % of primary bone tumors. ● AGE Ranges - 3 to 73 years. Usually teenagers, before obliteration of epiphyseal plate. 90% Reported in 5 to 25 years. ● SEX Male:female 2:1
  48. 48. ● SITE Epiphyseal region of long bone, occasionally extends to adjacent metaphysis. ● COMMON OCCURRENCE lower extremity(72%)...in which 50 % cases have been reported knee Proximal humerus 18% Proximal Tibia 17 % Distal Femur 16 % Proximal femur 16% Ankle bones 9%
  49. 49. SIZE - 1 to 6 cm CLINICAL FEATURES-. >Pain & swelling – several months. >May be referred to nearest joint >Some loss of joint function & muscle wasting. >Joint effusion esp. around knee. >Pathological fractures – rare.
  50. 50. RADIOLOGICAL FEATURES X – RAYS: >Lytic area – >Oval or round < ½ of epiphyseal area. >Thin rim of sclerosis >Punctate or streaky calcification.
  51. 51. ● In metaphyseal extension, i.e tumor crossing growth plate results in – Eccentric location & bulging expansion of cortex
  52. 52. PATHOLOGY Gross: ● Usually well demarcated lesions. ● Capsule – thin, easily disruptable ● Cut section- Soft, reddish – purple, friable, focally fritty tissue. ● Cystic spaces and haemorrhages may be seen.
  53. 53. MICROSCOPIC:- ● Islands of chondroblasts with uniform polyhedral closely packed cells. ● Background of fibrous stroma cells within the islands – PAVING STONE APPEARANCE.
  54. 54. ● Cells – round, plump and active little immature matrix is present. ● Pericellular lattice-like fine calcification – “CHICKEN WIRE” or “PICKET FENCE” pattern are seen. ● Small granular purplish areas of microcalcification. ● Multinucleated Giant cells – scattered in stroma. ● Often prominent, dilated blood vessels at centre & periphery are present.
  55. 55. DIFFERENTIAL DIAGNOSIS ● Enchondroma Hand, diaphysis. ● G.C.T. Eccentrical, soap bubble or trabecular pattern No calcifications Often after closure of growth plate. ● Central chondrosarcoma Slow growth, severe pain & margins not demarcated on xrays.
  56. 56. ● Chondromyxoid fibroma Site- Metadiaphysis Septae are present.
  57. 57. TREATMENT AND PROGNOSIS ● Curettage and autologous bone grafting – high recurrence rate (10 – 35%). ● Close follow up & observation for all till skeletal maturity – in patients , whose potential growth is remaining and lesions abuts the epiphyseal plate, lesions should be followed up and observed, instead of premature or aggressive treatment ● Marginal extra capsular excision – when growth plate not at all at risk, curettage and excision is done. Defect can be obliterated with Autogenous bone graft.
  58. 58. ● Methacrylate adjunct – when excision impractical & intracapsular curettage is of high risk of recurrence due to surgical inaccessibility. ● Curettage followed by cryosurgery: >In case of recurrence or when associated with ABC. >Yields consistent good results with a high cure rate when entire tumor is adequately frozen by liquid nitrogen.
  59. 59. Radiosensitivity: ● Radiosensitive tumor ● Not used for uncomplicated cases – potential hazards of irradiation induced malignant transformation.
  60. 60. OSTEOBLASTOMA
  61. 61. INTRODUCTION ● Jaffe and lichtenstein first described it in 1956. ● Rare bone tumor, ● 1 % of all primary bone tumors ● 3 % of benign bone tumors. It is a Solitary benign progressively growing bone tumor histologically similar to osteoid osteoma , size, clinical and radiological features differentiate it.
  62. 62. AGE ● Young person 10 to 30 years (80%) SEX ● Males: female -3:1.
  63. 63. SITE Vertebral Column 34 % Extremities 30% Hands and feet 14% Skull and facial bones 15 %
  64. 64. ● In long bones it occurs in medullary portion of metaphysis. Rarely juxtacortical or periosteal osteoblastomas are reported. ● In Spine- spinous and transverse process are frequently involved. lesions in body are rare.
  65. 65. Clinical features ● Pain- Dull , aching, persistent and localized. ● Slight local tenderness and palpable swelling of increasing size. ● spinal location > radiculopathy(50%). >rarely produce neurological symptoms . >scoliosis and muscle spasm may appear. ● lesions of extremities may present with wasting and limp.
  66. 66. RADIOLOGICAL FEATURES ● lesion is well circumscribed, radiolucent, eccentric and with an intact surrounding shell of bone . ● centrally there is lytic area >2cm with surrounding sclerosis.
  67. 67. ● In vertebrae it is seen as definitely expansile radiolucent growth containing granular radiopacities ● ct scans are better appreciated for vertebral lesions
  68. 68. CT SCAN . ● it can show cotton wool appearance when calcification of tumor tissue has occured...if cotton wool appearance is seen in lesion...it is diagnostic.
  69. 69. PATHOLOGY GROSS ● well circumscribed, 2-10 cm. ● surrounded by shell of cortical bone or thickened periosteum. ● Haemorrhagic, granular , friable and calcified lesions.
  70. 70. HISTOPATHOLOGY •Vascular spindle-cell stroma with abundant irregular spicules of mineralized bone and Osteoid
  71. 71. DIFFERENTIAL DIAGNOSIS OSTEOBLASTOMA OSTEOID OSTEOMA 1. INCIDENCE one fifth as common as osteoid osteoma 10% of benign bone tumor 2. COMMONEST LOCATION Vertebral column, often posterior element Proximal femur 3.CLINICAL PRESENTATION Pain inconsistent pain persistent , nocturnal 4. RADIOGRAPHY Size > 2 cm no or minimal perifocal osseous reaction size < 2cm, perifocal osseous reaction is marked. 5.HISTOLOGY >Osteoid trabeculae with discontinuous and irregular bone formation, > abundant fibrous stromal reaction, >many multinucleated osteoblastic giant cells >osteoid trabaculae with continuous and regular bone formation. >Scanty stromal reaction >multinucleated osteoblastic giant cells are rare.
  72. 72. ● OSTEOSARCOMA No ALP rise in osteoblastoma, stromal cells are not large, but are relatively uniform. ● GCT >>more than half are located near knee, or distal radius. >>soap bubble appearance.
  73. 73. TREATMENT ● Curettage and resection. ● bone grafting of defect. ● In spine- if resection causes instability, instrumented fusion can be necessary. ● Radiation- some authors have recommended, adjuvant radiation therapy for spinal lesions, as revision surgery is difficult.
  74. 74. CHONDROMYXOID FIBROMA
  75. 75. INTRODUCTION ● Rare tumour, least common benign cartilaginous tumors. ● Can be misdiagnosed as chondrosarcoma...as it is composed of similar cytological features, however radiological and clinical findings are of benign tumor .
  76. 76. AGE ● 2nd and 3rd decade, rare in children. SEX ● No predominance. LOCATION ● metaphyseal region of large tubular bones.(eccentric) ● can also involve thin tubular bones- fibula, phalanx and calcaneus.(usually entire width)
  77. 77. CLINICAL PICTURE ● In young adults tumor causes mild or no pain, slowly increasing local swelling and palpable tender tumor. ● Rarely metastasizes ● In less than 10 years age group- symptoms are more pronounced.
  78. 78. RADIOLOGICAL FINDINGS XRAY ● in long bones >>Lesion -translucent mass of variable sizes , located eccentrically in metaphysis >> on medullary aspect of lesion- margin is scalloped and sclerosed. >>Cortex - Expanded and thinned out, may appear interrupted.
  79. 79. ● in case narrow tubular bone (fibula) or small tubular bone (phalanx)- generally entire width of bone is involved ● fusiform expansion and thinning of both cortices.
  80. 80. PATHOLOGY GROSS ● Outer surface- covered by thin shell of newly formed periosteal bone. ● Cut Surface-solid tumor mass of greyish white or bluish grey color,resembles cartilage and sometimes contain cavities of mucoid tissue ● consistency - usually firm. ● Calcified areas are unusual. ● no bony septa traverse the tumor.
  81. 81. MICROSCOPIC •Tumor is composed of lobulated and pseudo lobulated areas of stellate cells with indistinct cytoplasmic borders,lying within the central portion of lobule and widely separated by mucin like material.
  82. 82. TREATMENT ● Curettage is not sufficient, as tumor may recur. ● En Bloc excision and filling cavity with autogenous bone results in high rate of cure. ● Despite Wide excision , if tumor recurs then additional studies should be done to rule out malignant transformation.
  83. 83. Curettage and Bone cementing
  84. 84. LANGERHANS CELL HISTIOCYTOSIS
  85. 85. ● Previously called HISTIOCYTOSIS X ● Characterised by widespread dissemination of reticuloendothelial system. ● Syndrome constitutes following clinical conditions 1. Eosinophilic Granuloma 2. Hand -Schuller -Christian disease 3. Letterer -Siwe disease.
  86. 86. Orthopaedic surgeon is primarily concerned with EOSINOPHILIC GRANULOMA OF BONE
  87. 87. EOSINOPHILIC GRANULOMA ● Self limited benign bone destructive lesion characterised by histocytic and eosinophilic leucocyte infiltration. Incidence ● Usually in first two decades with peak incidence in 5 to 10 years group. ● solitary lesion usually seen in ribs vertebrae, skull, flat bones and long tubular bones. ● multiple lesions are rare - ocurrance in skull and femur ● diaphysis and metaphysis are commonly involved.
  88. 88. Clinical Picture ● Acute onset ● complains of dull aching pain in a limited local area of bone. ● local tenderness , warmth and swelling over the affected bone. ● pathological fracture of long bone or vertebral collabs can be seen. ● Disease usually progress for few weeks to few months , and recovery is usually spontaneous
  89. 89. RADIOGRAPHY ● Rapidly destructive lytic process producing punched out appearance
  90. 90. ● In diaphysis of long bones lesions may have aggressive permeative appearance with periosteal reactive bone formation.
  91. 91. ● Eosinophilic granuloma of vertebral body ● showing marked flattening of vertebral body or vertebral plana
  92. 92. Histopathology •Diagnosis is made by identification of langerhans cell. •Mixture of eosinophils, plasma cells, histiocytes along with peculiar large mononuclear giant cells (Langerhans cells) with abundant pale cytoplasm and cleaved nuclei. •Necrosis, fibrosis and reactive cells are evident
  93. 93. TREATMENT ● Microscopically diagnosis is made by identification of langerhans cell. ● Recommended treatments incd- >> corticosteroid infiltrations >> radiation therapy >> Curettage with or without bone grafting.
  94. 94. Hand schuller - christian disease
  95. 95. REFRENCES 1. ORTHOPAEDICS PRINCIPLES AND THEI APPLICATION: SAMUEL L TURES 2. CAMPBELLS OPERATIVE ORTHOPAEDICS 3. TEXTBOOK OF ORTHOPAEDICS AND TRAUMA - GS KULKARNI 4. J.B.JS.
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