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Orthopedic Pathologic specimen & Histology

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Orthopedic Pathologic specimen & Histology for orthopedic students

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Orthopedic Pathologic specimen & Histology

  1. 1. MS, DNB, MNAMS ASSISTANT PROFESSORMAMC & SUSHRUTA TRAUMA CENTER NEW DELHI
  2. 2. DESCRIBING GROSS SPECIMENA: Identify the part: Knee / prox. femur/ prox. tibia/ pelvis /scapula. Epiphyseal / Metaphyseal / Diaphyseal. Physeal plate visible? – Immature pt.
  3. 3. B:Describe the abnormality: Nature: solid / soft & friable /cystic / varigated Matrix: bony / cartilaginous / fibrous Secondary changes: central necrosis/ hemorrhage / cystic change Cortical destruction, periosteal elevation Intramedullary spread Tumor margin / capsule: well defined / illdefined Extension: into soft tissue / joint; invasion / infiltration to surrounding tissue
  4. 4. C: Give provisional diagnosis.
  5. 5. GIANT CELL TUMOR Age: 20-40. Epiphyseometaphyseal in adults - Metaphyseal in adolescents. Common location: around knee (50%), distal radius Xray: Geographic lytic lesion, thinned &ballooned out cortex.Gross pathology: Large red - grey - brown tumor Soft & friable Areas of cystic degeneration / necrosis &blood filled cavities
  6. 6. HISTOPATHOLOGY:•Uniform oval mononuclear stromalcells : mesenchymal origin; neoplastic•Appear to grow in a syncytium•Numerous osteoclast-type giantcells: reactive•Necrosis, hemorrhage, hemosiderin deposition and reactive boneformation•Relatively few mitotic figures inrelation to the dense cellularity of thetumor
  7. 7. GIANT CELL VARIANTSIncludes the tumors which show giant cells in histology- A. ABC B. Brown tumor C. Chondromyxoid fibroma, chondroblastoma D. Desmoplastic fibroma E. Epulis – Giant cell reparative granuloma F. Fibrous dysplasia, non ossifying fibroma G. Giant cell rich osteosarcoma H. Benign fibrous histiocytoma
  8. 8. Giant cell……Physiological: MegakaryocytePathological Langhans : fused epitheliod cells. Peripherally arranged 7-21 nuclei. TB, histoplasmosis, sarcoidosis, other mycobacteria Foreign body: fused macrophages. Numerous nuclei scattered in cytoplasm Aschoff : Rheumatic heart disease Reed Sternberg: Hodgkin’s lymphoma Touton : xanthoma, xanthogranuloma, dematofibroma Viral: Warthin Finkeldy (measles), resp syncitial virus, parainfluenza Tumor
  9. 9. OSTEOSARCOMA Bimodal age distribution: Primary 10-20, secondary 50-70. 75% around knee Bone forming tumor arising from bone Several subtypes – By location (Central or Juxtacortical) Multicentricity Degree of differentiation: well to dedifferentiated Histologic variance: osteoblastic/chondroblastic/fibroblastic/telangictatic/small cell Associated with Retinoblastoma (rb gene), Li Fraumeni syndrome (p53 gene), Rothmund Thomsen syndrome.
  10. 10. GROSS PATHOLOGY: Metaphyseal Tan-white solid tumor fills most of the medullary cavity of the metaphysis and proximal diaphysis Expanding & infiltrating through the cortex, lifts the periosteum (Codman’s triangle) and forms soft tissue masses on the side of the bone Areas of hemorrhage and central necrosis.
  11. 11. HISTOPATHOLOGY: Pleomorphic and anaplastic cell population- large hyperchromatic nuclei, mitotic figures Abundant fibrous/ chondroid matrix Formation of pink homogenous osteoid by neoplastic cell: characteristic. The neoplastic bone has a coarse, lacelike architecture but is also deposited in broad sheets or as primitive trabeculae. Osteoblastic, chondroblastic or fibroblastic types Osteoclast-like giant cells may be present
  12. 12. CHONDROSARCOMA Age: 30-60 Primary or Secondary ( Enchondromatosis [Ollier 50%, Maffucci 100%], diaphyseal aclasis 20%, osteochondroma 0.25%) Pelvis (30%), Femur (20%) Types: Conventional, mesenchymal, clear cell, juxtacotical, dedifferentiated Most common malignant bone tumor of hand
  13. 13. GROSS PATHOLOGY: Large bulky tumor Made up of lobules of gray-white /somewhat translucent glistening tissue. Tumor permeating throughout the medullary cavity, growing through the cortex, and forming a relatively well- circumscribed soft tissue mass. At center – necrotic/liquefied/cystic. Gelatinous appearance secondary to myxoid changes in matrix. May show calcification. The adjacent cortex is thickened or eroded, and the tumor grows with broad pushing fronts into the surrounding soft tissue.
  14. 14. HISTOPATHOLOGY:• Tumor cells produce cartilaginous matrix; well, moderate or poorly differentiated.• May have only minor or focal atypia• Intracytoplasmic hyaline globules common in low grade tumors
  15. 15. EWING’S SARCOMAJames Ewing 1921GROSS PATHOLOGY: Diaphyseal in long bones; also pelvis, rib, scapula White tan grey mass like brain; or red like red currant gelly if hemorrhagic With necrosis & hemorrhage Cortical destruction Invasion to soft tissue around, no capsule
  16. 16. HISTOPATHOLOGY:• Homogenous & densly packed undifferentiated small round blue cells like lymphocytes; regular nuclei, infrequent mitoses, scant clear cytoplasm.• Abundant glycogen: PAS + diastase digestible• Rare Homer- Wright pseudorosettes (7-8 tumor cells arranged in a circle about a central fibrillary space)
  17. 17. D/D : Small Round Cell Tumor Ewing’s: mic2 overexpression - CD99/013 . t(11;22)(EWS-FLI-1). NSE + PNET (Primitive neuroectodermal tumor): CD99/013. S100, chromogranin, synaptophysin; > 20% Homer Wright rosettes Lymphoma (reticulum cell sarcoma, NHL): CD 45, LCA Small cell carcinoma: keratin, synaptophysin, chromogranin Mesenchymal chondrosarcoma Neuroblastoma: neurofilament. S100, chromogranin, synaptophysin. Alveolar rhabdomyosarcoma: actin, desmin, vimentin, MyoD1, myogenin Leukemia
  18. 18. OSTEOCHONDROMAGROSS PATHOLOGY: Mushroom shaped Cartilage-capped bony outgrowth Cartilage cap usually regular and thin Sessile / Pedunculated Pedunculated : attached to skeleton by bony stalk; medullary cavity of the osteochondroma and bone are in continuity Diaphyseal aclasis: multiple heriditary exostosis Trevor’s disease: Epiphyseal side osteochondroma
  19. 19. Painful osteochondroma: Fracture Bursitis Malignant transformation: fluffy calcification in the cartilage cap, thickness of cartilage cap > 1 cm.
  20. 20. CHRONIC OSTEOMYELITIS Sequestrum is the necrotic bone that is embedded in the pus/infected granulation tissue. Involucrum is the new bone laid down by the periosteum that surrounds the sequestra. Cloaca is the opening in the involucrum through which pus & sequestra make their way out.
  21. 21. Types of sequestrum….. Tubular: long bone Annular: amputation stump Ring: around pin tracts Flake, coke, rice grain: tubercular Button: histiocytosis Feathery: syphilis Match stick: sickle cell Coloured: fungal Black: gun shot Bombay: exposed bone after open fracture
  22. 22. TUBERCULAR SPONDYLITIS (POTT’S) SPINE  Paradiscal  Loss of height of vertebra  Caseating necrotic tissue  Bone necrosis; sequestra  Sclerosis
  23. 23.  Kyphotic deformity Internal gibbus Severe cord compression
  24. 24. Granuloma or LH giant cell is not pathagnomonic of TB…!• Foreign body granuloma.• Fat necrosis.• Fungal infections.• Sarcoidosis.• Crohns disease.
  25. 25. MADURA FOOT Foot looks like tumor  Multiple circumscribed abcesses; extensive granulation tissue around. Multiple nodules & sinus  Bone destruction
  26. 26. • Granulomatous fungal disease; involve subcutaneous tissue after traumatic inoculation; later spread to deep structures.• Causes local tissue destruction including boneTypes:• Actinmycetoma: Actinomadura sps, Nocardia• Eumycetoma: Aspergillus sps,• Discharge colored granules: Red (Actinomadura pelletieri), white / yellow (Actinomadura madurae, Pseudoallescheria boydii), black (Exophiala jeanselmei, Madurella mycematis)• Pus contains sulfur granules, a tangled mass of branching bacteria (Splendore Hoppelli body)

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