benign bone tumors

1. BENIGN BONE TUMORS
Dr. Debesh Shrestha
1st year resident
Department of Orthopaedics
GMC

2.  Bone tumors may be defined as a new growth
arising in a bone or derived from cells which
are components of skeletal tissue

3. Characters of benign tumor

5. Radiographic features

6. Benign bone tumors (Revised WHO
classification 1994)
 Bone forming
 Osteoma
 Osteoid osteoma
 Osteoblastoma
 Cartilage forming
 Chondroma
 Osteochondroma
 Chondroblastoma
 Chondromyxoid fibroma

7.  Fibrous tissue
 Fibroma
 Fibromatosis
 Giant cell tumors
 Benign osteoclastoma
 Vascular tissue
 Hemangioma
 Hemangiopericytoma
 Hemangioendothelioma

8.  Other connective tissue
 Fibroma
 Fibrous histiocytoma
 Lipoma
 Other tumors
 Neurofibroma
 Neurilemmoma

10. Osteoid Osteoma
 10% of benign bone tumors
 2nd – 3rd decade of life
 M:F = 3:1
 Lesion <1.5 cm
 Predilection for lower extremity – femur/ tibia
(half the cases)
 Malignant changes not documented

11. Clinical features
 Persistent pain
 Worse at night
 Relieved by NSAIDs (Aspirin)
 When lesion near joint– swelling, stiffness and
contracture
 When lesion in vertebra– scoliosis

12. Diagnosis
 X-ray/CT
 Lesion is small (<1.5 cm) central radiolucent nidus
with surrounding bony sclerosis
 CT is the best to identify nidus
 Technetium bone scan
 Increased uptake by the nidus
 MRI
 Limited role
 Soft tissue changes and surrounding edema

14. Bony trabeculae surrounded by loose fibrovascular
tissue

15. Treatment
1. Medical treatment
2. Percutaneous radiofrequency ablation
3. Open surgical procedures

16. Medical treatment
 If patient is willing and symptoms adequately
controlled
 NSAIDs
 Spontaneous healing in 3-4 years

17. Percutaneous radiofrequency
ablation
 For lesions of pelvis and long bones
 CT guided core needle biopsy after which a
radiofrequency electrode is inserted through
the canula of the biopsy needle
 Temperature of tip -90 degrees for 6 mins
 Outpatient procedure
 Recurrence <10%
 Not indication for vertebral lesions and small
bones of hands and feet (thermal injury)

18. Surgical management
1. Curettage
2. En bloc resection– low recurrence rate but
rarely indicated in long bones (post operative
fracture)

19. Burr-down technique
 Identify nidus by fluoroscopy
 Remove sclerotic bone overlying nidus by
power burr
 Nidus removed using curet
 Cavity treated again with power drill to remove
entire nidus
 Recurrence<10%

20. Osteoblastoma
 Giant osteoid osteoma
 Larger >1.5 cm
 3% of all benign bone tumors
 Young adults (10-25 years)
 M:F = 2:1
 Site : Spine (most common),
metaphysis/diaphysis of long bones, small
bones of hands/feet

21. Clinical features
 Pain
 No night pain
 Not relieved by NSAIDs

22. Diagnosis
 X-ray
 Well demarcated osteolytic lesion
 May contain flecks of ossification
 Surrounding sclerosis (thin)
 CT scan: investigation of choice
 Radioisotope scan: increased uptake
 MRI : soft tissue and intraspinal extension

24. anastomosing bony trabeculae
separated by loose fibrovascular
stroma.

25. Treatment
 Excision and bone grafting
 Local recurrence common
 Malignant transformation reported

26. Chondroma
 Benign lesions of hyaling cartilage
 Common
 Affects all age groups
 Any bone can be involved but mainly affects
phalanges of the hands and feet
 Usually asymptomatic and discovered
incidentally or after a pathologic fracture

27.  Enchondromas: arise in the medullary cavity
 Periosteal/juxta-cortical chondromas: arise on
the surface of the bone (rare)

29. Multiple enchondromatosis
 Ollier disease
 rare
 Multiple enchondromatosis
 Many cartilaginous tumors appear in the large
and small tubular bones and in the flat bones

31.  Maffuci syndrome
 Multiple enchondromatosis occuring in
association with soft tissue hemangiomas
 Individual lesions are similar to solitary
enchondromas
 They have a tendency to become malignant
 25% of patients with Ollier disease are
diagnosed with sarcomas by 40.

32. Diagnosis
 Radiography
 Benign appearing tumors
 Translucent
 Intralesional calcification– irregular
(stippled/punctate/popcorn)
 Small bones of hand hands and feet–
considerable erosion and expansion of the
overlying cortex

34.  Long bones– deep endosteal erosion (>2/3 of
the thickness of cortex) indicates a
chondrosarcoma
 Associated soft tissue mass– indicates
chondrosarcoma

36. Histology
 Consists of mature hyaline cartilage
 Proximally located enchondromas–
hypocelluar
(hypercellularity/ atypia in proximally located
enchondromas indicates chondrosarcoma)
 Enchondromas of hand, juxta-cortical
chondromas and multiple enchondromatosis
may be relatively hypercellular and mild atypia
but still be benign

38. Treatment
 Solitary enchondromas
 observation and serial radiographs
 If asymptomatic and radiographically stable—
no further intervention
 If symptomatic or lesion grows– extended
curettage
 Recurrence is low

39.  Multiple enchondromatosis
 More difficult
 Lesions are not treated individually
 Obvious deformities corrected by osteotomy
 Monitored indefinitely for malignant changes

40. Osteochondroma
 Common
 Development malformations rather than true
neoplasms
 Originate within the periosteum as small
cartilaginous nodules
 Produced by progressive endochondral
ossification of a growing cartilaginous cap

41.  Growth of lesion parallels that of the patient and
stops once skeletal maturity is reached
 Most lesions found during the period of rapid
skeletal growth.
 Single lesion—90%
 Site– may involve any bone formed in cartilage
usually found on metaphysis of long bone
near the physis (distal femur, proximal tibia,
proximal humerus)

42.  Osteochondromas are of 2 types:
1. Pedunculated (more common)
2. Sessile
 Malignant degeneration– 1% for solitary
osteochondroma and 5% for multiple
osteochondromas

43.  Rarely develop in a joint
 Trevor disease (dysplasia epiphysealis
hemimelica) refers to intra-articular epiphyseal
osteochondroma

44. Clinical feature
 Asymptomatic mostly
 Discovered incidentally
 Mechanical symptoms
 Pathological fracture
 Neuropathies due to compression of nerve by
tumor

45. Hereditary multiple exostoses
 Autosomal dominant
 Multiple osteochondromas in bones arising
from osteochondral ossification
 Skeletal deformities and short stature
 Defect in EXT1/EXT2 genes

46. Diagnosis
 X-ray
 Eccentric bony outgrowth from metaphyseal
region of long bone composed of cortical and
medullary portions which are continuous with
the cortex and medulla of the underlying bone
 Cap not visible
 Usually sufficient

49. Treatment
 Small asymptomatic lesions—observation
 Indications for surgical excision:
1. Cosmesis
2. Joint dysfunction
3. Fracture
4. Impingement of nerve, vessels, tendons
5. Malignant change

50. Surgery
 Complete excision of osteochondroma
including the perichondrium
 Recurrence if incomplete removal

51. Chondroblastoma
 Benign tumor of immature cartilage
 Occurs primarily in the epiphysis
 Usually proximal humerus, femur or tibia
 Age– around the end of growth period or in
early adult life
 Male predilection

52. Clinical feature
 Constant pain over the joint
 Tenderness over the adjacent bone

53. Diagnosis
Rounded, well demarcated radiolucent area in the epiphysis
No central calcification
Sometimes the lesion extends across the physeal line
Occasionally the articular surface is breached

54. Large collection of chondroblasts
surrounded by immature fibrous tissue
Scattered giant cells seen

55. Treatment
 Lesion removed after the end of growth period
 options
1. Marginal excision (less satisfactory)
2. Curettage
3. Alcohol or phenol cauterization
 Recurrence if incomplete resection

56. Fibrous dysplasia
 Developmental disorder in which areas of
trabecular bone are replaced by cellular
fibrous tissue containing flecks of osteoid and
woven bone.
 May affect one bone (mono-ostotic), one limb
(monomelic) or many bones (polyostotic)
 Sites– proximal femur, tibia, humerus, ribs and
cranio-facial bones

57. Clinical features
 Small single lesion asymptomatic
 Large mono-ostotic lesions– pain or
pathological fracture
 Polyostotic disease– pain, limp, bony
enlargement, deformity or pathological fracture
 Albright syndrome = fibrous dysplasia + cafe-
au-lait spots + precocious puberty in girls
 Malignant transformation– 0.5% in mono-
ostotic lesion and upto 5% in Albright
syndrome

58. Diagnosis
 X-ray
 Radiolucent cystic areas in the metaphysis or
shaft
 The lucent areas have a hazy or ground glass
appearance (due to fibrous tissue)
 Weight bearing bone may be bent –
shepherd’s crook deformity of proximal femur

60. Osteoid trabeculae that are narrow, curvilinear or
irregularly-shaped are arranged haphazardly in a
background of dense fibroblastic stroma.

61. Treatment
 Small lesions– no treatment
 Large,painful and fracture– curet and graft
 Recurrence may occur

62. Giant cell tumor
 5% of all primary bone tumors.
 Uncertain origin
 appear in mature bone
 Hardly seen before closure of nearby physis
 Most common site: distal femur, proximal tibia,
proximal humerus, distal radius

63. Clinical features
 Young adult
 Pain at end of long bone
 Slight swelling (sometime)
 Hx of trauma not uncommon
 Pathological # 10-15%
 O/E: palpable mass with raised local
temperature

64. Xray
 Radiolucent area eccentrically at end of long
bone, bounded by sub-chondral plate
 Center has soap bubble appearance due to
ridging of surrounding bone
 Cortex is thin and ballooned
 Appearance of cystic lesion in mature bone
extending upto subchondral plate is
characterstic.

66.  Detail staging and extent of tumor can be done
by CT and MRI (imp to establish if articular
surface has been breached or not)
 Biopsy ; essential

67.  Potential to transform into osteosarcoma
 Rarely metastasize into lungs

68. numerous multinucleated giant
cells scattered in a background of uniform
mononuclear cells

69. Treatment
 Benign histology tumor: Curettege and
stripping of cavity with burrs and gouges
followed by swabing with hydrogen peroxide
 Aggressive: excision followed by bone grafting
or prosthetic replacement.

70. Chondromyxoid fibroma
 May occur any bone, more on bone of lower
limb
 Seen in adolescent and young adults
 Discovered on accident or after pathological #
 Malignant change rare

71. Xrays
 Very characteristic
 Rounded or ovoid radiolucent area placed
eccentrically in metaphysis
 In children extend upto physis
 Endosteal margin may be scalloped but
always bounded by dense zone of reactive
bone extending tongue like towards diaphysis
 Cortex asymmetrically expanded

73. Patches of myxomatous tissue + island of
hyaline cartilage + area of fibrous tissue

74. Treatment
 Excision
 Curettage followed by autologous bone
grafting
 Risk of recurrence present
 Care taken to prevent damage to physis or
nearby joint.

75. Simple bone cyst
 aka solitary cyst or unicameral bone cyst
 Appear in childhood.
 Metaphysis of long bone: mostly in proximal
humerus or femur
 It is not a tumor, Heal spontaneosly
 Never seen in adults.
 Discovered after pathological # or incidental
finding on xray.

76. Xray
 Well demarcated radiolucent area in
metaphysis
 often extending upto physeal plate
 Cortex may be thinned and bone expanded.
 Needle inserted into cyst on x-ray control;
straw colored fluid filled will be withdrawn

78. Treatment
 Asymptomatic lesion can be left alone but
cautioned to avoid injury
 Active cyst: aspiration of fluid and injection of
80-160mg methylprednisolone or autologous
bone marrow
 If cyst enlarging with pathological #: clean
cavity by curettege and packed by bone chips
 Recurrence with need of more than one
surgery.

79. Aneurysmal bone cyst
 At any age ,more on young adults
 Any bone, more on long bone metaphysis
 Arises spontaneously or after degenaration or
hemorrhage in some other lesion.
 Pain is most common complain
 Large cyst may cause visible or palpable
swelling of bone.
 Malignant transformation does not occur

80. Xray
 Well defined radiolucent cyst
 Trabeculated and eccentrically placed
 In growing tubular bone, vertebrae and flat
bones
 In adult may confuse with GCT
 Marked ballooning of bone end

82. large cystic spaces separated by septa
containing giant cells and spindle cells.
The spaces may be filled with blood and
lack an endothelial lining

83. Treatment
 Thoroughly curetted and packed with bone
graft
 Recurrence common as graft resorbed
 In recurrence: packing with
methylmethacrylate cement may be effective
 Occasionally heal spontaneously.

84. Osseus Hemangioma
 Consists of vascular channels
(capillary/venous/cavernous)
 Usually middle aged patients
 Spine- common site
 Asymptomatic / back ache
 Treatment– embolization
followed by operation
Coarse vertical
trabeculation
“corduroy
appearance”

85. References
 Campbell’s operative orthopaedics
 Apley’s system of orthopaedics and fractures
 Turek’s orthopaedics applications and their
applications
 www.webpathology.com
 www.radiologyassistant.com