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Vol 9 ppt

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Vol 9 ppt

  1. 1. Contents for Volume 9Bone cysts Unicameral bone cyst-------------Case 190-97 & 984-96 Aneurysmal bone cyst------------Case 198-204 & 997-1039 Epidermoid cyst-------------------Case 205-6
  2. 2. Bone Cysts
  3. 3. Unicameral Bone Cysts
  4. 4. Unicameral Bone Cysts The unicameral or solitary bone cyst is a very common pseudo-tumor seen in bone in children and is the most common cause forpathological fracture in that age group. The bone cyst is consideredto be a hamartomatous developmental process with an unknownetiology. It may be a degenerative process seen in a pre-existingfibrous lesion of bone, such as monostotic fibrous dysplasia, thatoccurs between the ages of 5 and 15 years, more common in boysthan girls, with half the cases in the proximal humerus and half inthe proximal femur. These patients are usually asymptomatic untilthe time of fracture. The cysts are usually located in the metaphysealportion of long bones, immediately adjacent to the growth plateduring the early years when the lesions are considered active. Asthe patient approaches maturity, the cyst will start to migrate awayfrom the growth plate and go into what is referred to as the inactivestage. Radiographically, the lesions are well marginated with a thinsclerotic edge at the periphery. They are centrally located in the
  5. 5. metaphysis with thinning and slight dilatation of the surroundingcortex and no matrix calcification. The cysts are filled with a clear serous fluid with increasedpressure during the active phase that some experts feel may causethe cyst to enlarge by a hydraulic dynamic mechanism. The cyst islined by a fibrous membrane studded with macrophages and,occasionally, foam cells. In some cases, tissue similar to fibrousdysplasia can be found at either end of the lesion. The periostealcovering over the cyst is normal and for this reason, the pathologicalfractures go on to heal without difficulty. Because of the potentialfor repeated pathological fractures, surgeons are tempted to carryout some type of bone grafting procedure during the early, activephase of the disease but become frustrated with a recurrence rate of30-50 per cent. For this reason, the more common and current wayto handle bone cysts in the early age group, before bone maturity,is by simple aspiration with a double needle technique with theinstillation of methylprednisolone into the cyst cavity that inhibits
  6. 6. the macrophage activity and reduces the chance of local recurrence.It slows down the active lytic process of the disease. This injection isusually required on multiple occasions, every 3 to 6 months untilthe patient reaches maturity, at which time the disease tends tobecome inactive. 3 to 8 injections over this period of time may berequired to avoid the necessity of a bone grafting procedure at a laterdate. The success rate is approximately 85%. In patients over the age15 years, steroid injections in the inactive phase of the disease are notbeneficial because the macrophage activity has disappeared. At thispoint, the only acceptable treatment would be a classic bone graftingprocedure to strengthen the bone and reduce the chance of patho-logical fracture in the future. Physicians must be aware of thepossibility that an apparent bone cyst on radiographic examinationmay masquerade as a malignant tumor such as an osteosarcoma. Ifone is unable to obtain fluid at time of aspiration, a biopsy shouldbe performed to rule out this possibility.
  7. 7. CLASSICCase #190 sclerosis10 year femaleunicameral cystproximal humerus
  8. 8. Photomic showing giant cells in cyst lining
  9. 9. X-ray followingcurettement andbone grafting
  10. 10. 6 months after bonegrafting with nearlycomplete loss of graft
  11. 11. 1 year following surgeryand even further lossof graft material
  12. 12. Case #1919 year femaleunicameral bone cystproximal humerus
  13. 13. Injection of cortisone into cyst
  14. 14. Healed 10 mos later
  15. 15. Case #192 9 year male with path fracture thru monostotic fibrous dysplasia
  16. 16. One year later with cystic changes
  17. 17. 3 years later witheven more cysticchanges
  18. 18. Progressive cystic changes at 4 years
  19. 19. Age 16 and healedpath fracture thrunearly pure cyst
  20. 20. Surgical window into large cystic lesion
  21. 21. Fibular strut taken from opposite leg
  22. 22. X-ray opposite legwhere graft was takenreveals anotherfibrous dysplastic lesion
  23. 23. Cyst packed with fibular strut & crest graft
  24. 24. Immediate post opradiograph
  25. 25. 6 months post op
  26. 26. Case #192.1 UBC Prox Humerus 52 yr male with incidental finding right humerus
  27. 27. CT scan Axial prox. poleCor Sag
  28. 28. Bone scan
  29. 29. Cor T-1 STIR Sag gad
  30. 30. Axial T-1 STIR Gad
  31. 31. Case #19315 year femaleunicameral cystilium
  32. 32. Post op x-rayafter bone grafting
  33. 33. Case #195 9 year female with unicameral cyst prox fem epiphysis
  34. 34. Case #196 15 year male with unicameral cyst os calcis
  35. 35. Case #196.1 18 year old female with incidental finding in foot
  36. 36. Sag gadAxial T-1 T-1
  37. 37. Cor T-1 T-2 Gad
  38. 38. PO bone graft
  39. 39. Case 196.1 Pseudo UBC - rheumatoid synovial cyst 60 yr female with long history of stiff and painful ankle
  40. 40. Sag T-1Sag T-2
  41. 41. Cor PD Axial T-2 FS
  42. 42. Case #197 16 year female with unicameral cyst os calcis
  43. 43. Sagittal T-2 MRI
  44. 44. Coronal T-2 MRIshowing fluid-fluidlevel
  45. 45. Case #98414 year male withunicameral bone cystproximal humerus withpathologic fracture
  46. 46. 2 months later withhealing of upper partof cyst and now a newfracture in lower part
  47. 47. 4 months after 1stfracture and the twoparts have joined withgradual healing in asresult of fracture
  48. 48. 3 years later andnearly completehealing withouttreatment
  49. 49. Case #98516 year male withunicameral bone cystproximal humerus withpath fracture
  50. 50. Surgical exposure for placement of fibular bone graft
  51. 51. Scanning lens photomic of curetted lining of cyst showinggiant cell activity and recent hemorrhage from fracture
  52. 52. Café-au-lait noted atsite of fibular graftharvesting
  53. 53. X-ray appearance 3 mosfollowing bone grafting
  54. 54. Case #98611 year male withunicameral bone cystproximal humerus withpath fracture
  55. 55. 18 months later
  56. 56. Post op x-ray aftercurettment and packingwith plaster of Parispellets
  57. 57. 4 months later withgradual resorption ofpellets
  58. 58. 18 months post op andpellets have dissolved
  59. 59. The pellet treatment didnot prevent another fractureseen healing here
  60. 60. Case #98715 year female withpath fracture thruunicameral bone cystproximal femur
  61. 61. 6 months post opfibular strut and fibulaDHS fixation
  62. 62. 3 years post op
  63. 63. Case #988 44 year female with unicameral bone cyst femoral neck
  64. 64. Coronal T-1 MRI
  65. 65. Coronal T-2 MRI
  66. 66. Case #989 9 year male with unicameral bone cyst femoral neck
  67. 67. Photomic showing giant cell activity in cyst lining
  68. 68. 6 weeks post op packing with cancellous allograft
  69. 69. 3 months later with slight recurrence
  70. 70. 9 months post op and even more recurrence
  71. 71. Case #989.116 year female withunicameral bone cystProximal femur
  72. 72. Coronal T-1 MRI
  73. 73. Coronal T-2 MRI
  74. 74. Coronal gad contrast MRI
  75. 75. Case #989.2 21 year female with path fracture thru UBC distal femur
  76. 76. Photomic from bone cyst lining
  77. 77. 2 yrs post op curettement and cancellous bone grafting
  78. 78. Case #989.312 year female withunicameral bone cystdistal femur
  79. 79. Lateral view
  80. 80. Coronal T-1 MRI
  81. 81. Coronal T-2 MRI
  82. 82. Axial T-1 MRI
  83. 83. Axial T-2 MRI
  84. 84. Case #989.4 10 year male with unicameral bone cyst tibia
  85. 85. Post op curettement & cementation with cancellous allograft
  86. 86. Case #989.511 year male withunicameral bone cysttibia
  87. 87. Coronal T-1 MRIshowing multiloculation
  88. 88. Coronal T-2 MRI
  89. 89. Axial T-2 MRI showing fluid-fluid level
  90. 90. Case #989.68 year female withunicameral bone cystproximal tibia
  91. 91. Case #989.75 year female withUBC prox tibia
  92. 92. Lateral view
  93. 93. CT scan
  94. 94. Case #989.811 year female withunicameral bone cystdistal fibula
  95. 95. Case #989.953 year male withunicameral bone cyst4th metacarpal
  96. 96. Bone scan
  97. 97. Coronal T-2 MRI
  98. 98. Case #989.91 6 year female with unicameral bone cyst 5th metacarpal
  99. 99. Case #990 25 year male with unicameral bone cyst thumb
  100. 100. Case #991 22 year male with UBC capitate
  101. 101. Case #99218 year male withunicameral bonecyst distal ulna
  102. 102. Case #992.13 year male withunicameral bone cystdistal radius
  103. 103. Lateral view
  104. 104. Case #99329 year female withunicameral bone cysttalus
  105. 105. Lateral view
  106. 106. Photomic with foam cells and giant cells
  107. 107. Case #993.1 57 year female with mild ankle pain one year without trauma
  108. 108. Sag gad Cor STIR
  109. 109. Axial T-2 Gad
  110. 110. Case #994 16 year female with bilateral unicameral bone cysts
  111. 111. Case #995 36 year female with unicameral bone cyst ilium
  112. 112. Bone scan showing signalVoid in bone cyst
  113. 113. CT scan
  114. 114. Coronal T-1 MRI
  115. 115. Axial T-2 MRI with fluid-fluid level posterior
  116. 116. Case #996 12 year male with unicameral bone cyst ischium
  117. 117. Photomic showing giant cell activity
  118. 118. Post op x-ray after packing with cancellous bone graft
  119. 119. One year later
  120. 120. Aneurysmal Bone Cysts
  121. 121. Aneurysmal Bone Cysts The aneurysmal bone cyst is another clinical entity that presentsas a hemorrhagic pseudotumor in bones in the pediatric age group,most typically in the femur, tibia, pelvis and spine. It has many ofthe characteristic clinical features of the giant cell tumor, except ina younger age group, and is frequently associated with other wellknown neoplastic conditions such as giant cell tumor, chondro-blastoma, osteoblastoma, fibrous dysplasia, or in some cases ofosteosarcoma, especially the hemorrhagic type. It is a very lytic,destructive lesion of bone occurring in patients between the agesof 10 and 20 years. Its characteristic feature is an aneurysmalappearance seen on radiograph that, in the early stages, is extremelydestructive,osteolytic and permeative, taking on the radiographicfeatures of a malignant tumor such as a hemorrhagic osteosarcoma.In two thirds of the cases in the spine, the aneurysmal bone cyst isseen most commonly in the posterior elements, but in one third theywill be seen in the vertebral body. In the case of the giant cell tumor
  122. 122. in the spine, the lesions are almost always found in the vertebral body. At the time of surgical biopsy, the surgeon will note a large amountof hemorrhage in a cystic lesion that has a very friable, mossy liningat the periphery and one sees reactive bone as it forms a shell aroundthe hemorrhagic cyst. Microscopically, the mossy tissue will beloaded with large, reactive-type giant cells and the backgroundstromal tissue will be made up of benign-appearing spindle cells witha large amount of interstitial hemorrhage and reactive bone formation,and even a few mitotic figures will be noted similar to the situationseen in hemorrhagic osteosarcoma. However, in hemorrhagic osteo-sarcoma, the number of mitotic figures would be very large. One mustbe very careful when sampling a biopsy of this type of lesion tomake sure that one obtains multiple specimens, especially from themore fleshy portion of the tumor, looking for the possibility of anadjacent osteosarcoma. As far as treatment is concerned, this is a lesion that tends to in-volute spontaneously as the child matures into the young adult age
  123. 123. group. However, because of early progressive destruction and painassociated with these osteolytic lesions, surgeons will usually curettethe tumor and then repair the defect with bone graft or, in some cases,bone cement and Steinman pins. In the case of large pelvic lesions orlarge spinal lesions that are difficult to resect surgically, intra-arterialembolization is a good technique to stimulate rapid involution of thetumor. Radiation therapy is a very effective in controlling massivelesions of the pelvis and spine, however, one runs the risk of asecondary sarcoma arising 5 to 15 years later.
  124. 124. CLASSICCase #1989 year femaleABC proximal fibula
  125. 125. growth plateResection specimen cut in path lab
  126. 126. blood osteoid Photomic showing giant cells
  127. 127. Case #199 9 year male with ABC proximal humerus
  128. 128. Rapid destruction 3 months later
  129. 129. Surgical photo of outer reactive bone shell
  130. 130. Photomic showing large giant cells
  131. 131. Immediate post op x-ray with bone graft struts
  132. 132. 7 years later
  133. 133. Case #2009 year femaleABC distal tibia
  134. 134. Lateral view
  135. 135. 18 months following simple curettement
  136. 136. Case #200.1 ABC 14 year old male with ankle pain for 3 months
  137. 137. Sag T-1 Cor STIR Sag Gad
  138. 138. Axial T-2 Gad
  139. 139. Surgical curettments
  140. 140. Case #201 12 year male with ABC proximal tibia
  141. 141. Fluid-fluid levelCoronal T-2 MRI
  142. 142. X-ray followingcementation procedure cement
  143. 143. Case #202 17 year male with ABC mid lumbar vertebra
  144. 144. Ct scan
  145. 145. Coronal T-1 MRI
  146. 146. Axial T-2 MRI with fluid-fluid levels
  147. 147. Case #20317 year femaleABC ilium
  148. 148. Increased size6 months later
  149. 149. Axial T-1 MRI
  150. 150. Coronal T-2 MRI
  151. 151. Reconstruction with large bone allograft and recon plates
  152. 152. Case #204 17 year female with ABC ilium
  153. 153. CT scan
  154. 154. 2 years after curettement, embolization and radiation
  155. 155. reactive shell CT scan 2 years post treatment
  156. 156. X-ray at 5 years showing proximal hip migration
  157. 157. Radiation ulceration of skin over lesion
  158. 158. 2 months after myocutaneous flap coverage
  159. 159. 6.5 yrs post radiation with radiation OGS in SI area
  160. 160. Photomic of radiation sarcoma
  161. 161. Case #997 25 year male with ABC pelvis
  162. 162. R Bone scan
  163. 163. Photomic
  164. 164. 2 months later with progressive lysis
  165. 165. CT scan
  166. 166. ABCCT scan lower level
  167. 167. ABCCT scan thru pubic area
  168. 168. ABCCoronal T-1 MRI
  169. 169. Axial T-2 MRI
  170. 170. Arteriogram at time of embolization therapy
  171. 171. 8 months after external beam RT
  172. 172. Post op hemipelvectomy
  173. 173. Case #998 15 year male with ABC acetabulum
  174. 174. Photomic from biopsy specimen
  175. 175. 5 months post op curettement and bone grafting
  176. 176. CT scan 5 mos post curettage
  177. 177. CT at a higher level
  178. 178. Extensive peripheral calcification several mos post RT
  179. 179. CT at a higher level after RT
  180. 180. CT scan of chest reveals multiple metastatic nodules
  181. 181. Photomic of pulmonary lesion biopsy showing OGS
  182. 182. Case #999 19 year female with ABC pelvis
  183. 183. 8 months post RT
  184. 184. Case #1000 17 year female with asymptomatic ABC sacrum
  185. 185. 2 years laterwithout treatment
  186. 186. Another 9 months later
  187. 187. 1.5 years later with burned out inactive lesion without pain
  188. 188. Case #1001 42 year male with burned out ABC ilium
  189. 189. CT scan
  190. 190. Case #1002 11 year male with active ABC pelvis
  191. 191. 4 years later and nearly inactive without treatment
  192. 192. Case #1003 14 year male with ABC ischium
  193. 193. Case #1004 14 year female with ABC pubic area
  194. 194. Case #10058 year male withABC C-2
  195. 195. Bone scan
  196. 196. CT scan with fluid-fluid level
  197. 197. Photomic
  198. 198. 3 years post op posterior fusion
  199. 199. Case #100617 year male withABC T-12
  200. 200. Lateral view
  201. 201. CT scan
  202. 202. Sagittal T-2 MRI
  203. 203. Axial T-2 MRI
  204. 204. Case #100721 year female withABC L-2
  205. 205. Oblique view
  206. 206. Coronal T-2 MRI
  207. 207. Sagittal T-2 MRI
  208. 208. Axial T-2 MRI showing fluid-fluid levels
  209. 209. Case #10084 year male withABC L-5
  210. 210. 3 months post opcurettement alone
  211. 211. Case #1009 CT scan 25 year female with ABC lumbar spine
  212. 212. 5 months post op simple curettement
  213. 213. Case #101013 year male withABC C-4
  214. 214. Case #1011 25 year female with ABC C-7
  215. 215. Case #1012 33 year female with ABC clavicle
  216. 216. Bone scan
  217. 217. Sagittal T-1 MRI
  218. 218. Axial T-2 MRI
  219. 219. Case #l013 12 year female with ABC clavicle
  220. 220. CT scan
  221. 221. Case #1014 11 year male with ABC clavicle
  222. 222. Case #101511 year male withABC distal femur
  223. 223. Lateral view
  224. 224. Coronal T-1 MRI
  225. 225. Axial T-1 MRI
  226. 226. Axial T-2 MRI
  227. 227. 18 months laterwithout treatment
  228. 228. Lateral view
  229. 229. osteoidBiopsy photomic
  230. 230. 3 years after simplecurettement
  231. 231. Lateral view
  232. 232. Case #101647 year female withABC arising from asmall focus of monostoticfibrous dysplasia seen at ABCupper pole of lytic area
  233. 233. fibrous dysplasiaLateral view ABC
  234. 234. Sagittal T-1 MRI
  235. 235. Coronal T-2 MRI
  236. 236. Photomic from curettement specimen
  237. 237. Case #101717 year female withABC proximal femur
  238. 238. Bone scan
  239. 239. Coronal GadContrast MRI
  240. 240. Coronal T-2 MRI
  241. 241. Axial gad contrast MRI
  242. 242. Case #1018 27 year male with ABC distal femur
  243. 243. Lateral view
  244. 244. Sagittal PD MRI
  245. 245. Axial T-2 MRI
  246. 246. Sagittal T-2 MRI
  247. 247. Biopsy photomic
  248. 248. Case #1018.1 ABC second to hyperparathroidism 56 year female with anterior knee pain for 2 years
  249. 249. Sag T-2 PD FS
  250. 250. Axial PD FS Cor PD FS
  251. 251. Case #10195 year female withABC proximal femur
  252. 252. 3 months later with enlargement
  253. 253. Lateral view
  254. 254. CT scan
  255. 255. Case #102012 year female withABC proximal tibia
  256. 256. Lateral view
  257. 257. Coronal T-1 MRI
  258. 258. Sagittal PD MRI
  259. 259. Coronal T-2 MRI
  260. 260. Sagittal T-2 MRI
  261. 261. Scanning lens photomic
  262. 262. Higher power photomic
  263. 263. Case #102114 year male withearly ABC distaltibia
  264. 264. 18 months later
  265. 265. Lateral view
  266. 266. Sagittal T-2 MRI
  267. 267. Coronal T-1 MRI
  268. 268. Axial T-2 MRI
  269. 269. Case #1021.1 Bone abscess - ABC pseudo tumor 04 07 04 0716 yr male with 3 yr history of intermittent pain and swelling at knee
  270. 270. Bone scan
  271. 271. 07Cor T-1 T-2 Gad
  272. 272. Sag T-1 T-2
  273. 273. Axial T-2 Gad
  274. 274. Case #1021.2 Bone abscess - ABC pseudotumor25 yr Indian male with 3 yr history of intermittent aching pain R leg
  275. 275. CT Scan
  276. 276. Sag T-1 PD FS Gad
  277. 277. Axial T-1 T-2 Gad
  278. 278. Case #102215 year female withABC proximal tibiaoblique view
  279. 279. AP view
  280. 280. Case #1023 18 year female with ABC proximal tibia
  281. 281. Surgical specimen attime of excisionalarthrodesis
  282. 282. Macro section
  283. 283. Scanning lens photomic
  284. 284. Case #1024 AP Lat 4 year male with ABC proximal tibia
  285. 285. Case #102517 year female withABC proximal fibula
  286. 286. Resected specimen cut in path lab
  287. 287. Macro section
  288. 288. Case #102613 year male withABC distal fibula
  289. 289. 5 months post opsimple curettement
  290. 290. Case # 1026.119 year female withankle pain 4 mos
  291. 291. Axial T-1 T-2Gad
  292. 292. Sag T-1 PD FS Gad
  293. 293. Case #10277 year female withABC proximal humerus
  294. 294. Biopsy photomic
  295. 295. Rapid progression 6 weeks later
  296. 296. Another 6 weeks and rapid enlargement
  297. 297. Photo just prior to forequarter amputation
  298. 298. Surgical specimen cut open in path lab
  299. 299. Photomic shows features of hemorrhagic OGS
  300. 300. Post op chest x-ray shows pulmonary mets
  301. 301. Case #1028 17 year female with ABC distal humerus
  302. 302. Lateral view
  303. 303. Curettement photomic
  304. 304. Case #102954 year male withburned out inactiveABC proximal humerus
  305. 305. Case #1030 2 year female with ABC distal radius
  306. 306. Lateral view
  307. 307. Case #103111 year female withABC distal radiusCoronal T-1 MRI
  308. 308. Coronal T-2 MRI
  309. 309. Axial T-2 MRI with fluid-fluid level
  310. 310. blood Photomic
  311. 311. Case #1032 5 year male with ABC distal ulna
  312. 312. Lateral view
  313. 313. Case #1033 17 year male with ABC ulna
  314. 314. Surgical appearance
  315. 315. Photomic
  316. 316. X-ray 1 month following simple curettement
  317. 317. 3 more months and further healing in
  318. 318. 3.5 years later and completely healed
  319. 319. Case #103451 year male withABC 2nd metacarpal
  320. 320. Case #1035 20 year male with ABC 1st metacarpal
  321. 321. AP view
  322. 322. Photomic
  323. 323. Case #1036 21 year male with ABC 1st metacarpal
  324. 324. Case #1037 10 year female with ABC distal phalanx
  325. 325. Biopsy photomic
  326. 326. Case #103816 year male withABC 3rd metatarsal
  327. 327. CT scan
  328. 328. Photomic
  329. 329. Case #10398 year female withABC 2nd metatarsal
  330. 330. Case #1039.1 CT scan 16 yr male with painful foot for 4 months
  331. 331. Axial T-1 T-2 FS Gad
  332. 332. Cor T-1 T-2 FS Gad
  333. 333. Sag STIR Gad
  334. 334. Epidermoid Cysts
  335. 335. Epidermoid Cyst The least common cyst in bone is the epidermoid cyst. It isusually seen in the distal phalanx or in the skull. In the case of thedistal phalanx, the lesion usually occurs as the result of a crushingtrauma to the distal phalanx that drives nail bed epithelium downinto the subadjacent bone where it implants and produces an ectopic,squamous epithelial cystic lesion formed by a keratinized outershell. It is filled with clear fluid and creates a surface erosion of theadjacent distal tuft of the phalanx that shows a very characteristicradiographic appearance. The lesions will transluminate with aflashlight. Other lesions that have a similar radiographic appearanceinclude enchondroma, glomus tumors of the distal phalanx andperhaps a neurofibroma. Treatment consists of a simple curettementand packing of the defect with autologous bone graft.
  336. 336. CLASSIC Case #205 35 year female with epidermoid cyst distal phalanx
  337. 337. keratin cyst liningbone Photomic
  338. 338. Case #206 40 year female with epidermoid cyst distal phalanx
  339. 339. Lateral view

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