2. BONE TUMOURS
• Bone neoplasms are rare and account for only 0.2%
of all human neoplasms
• Understanding bone tumor classification is necessary
for accurate diagnosis, patient management, and
prognostication.
5. ENNEKING STAGING SYSTEM
• reliable, reproducible, and has prognostic importance for
musculoskeletal sarcomas, especially for those originating in
the axial skeleton.
• Enneking staging system is applicable only to mesenchymal
malignancies.
6. Enneking Staging System for benign
musculoskeletal tumors
• This classification is based on radiographic characteristics of
the tumor-host margin.
• It consists of three categories:
stage 1- latent,
stage 2 - active, and
stage 3 -aggressive.
7. EG: NON OSSIFYING
FIBROMA
STAGE 1 – LATENT :
• Intracapsular
• Usually asymptomatic
• Frequently accidental finding
• Low biologic activity
Radiography:
• Well defined margins with thick
rim of reactive bone
• No cortical destruction or
expansion
• Usually do not require
treatment as they do not
compromise strength of the
bone
• Usually resolve spontaneously
8. STAGE 2 – ACTIVE :
• Also intracapsular
• But actively growing
• Cause symptoms or lead to pathological
fracture
Radiography:
• Well defined margins
• Expansion and thinning of cortex present
• Have thin rim of reactive bone
• Limited bone destruction
• Growth limited by natural barriers
• Negligible recurrence after marginal
resection
• Treatment usually extended curettage
• EX: ANEURYSMAL BONE CYST
9. STAGE 3 – AGGRESSIVE :
• Extracapsular
• Aggressive bone destruction or soft tissue
extension
Radiography:
• Ill defined margins/ borders
• Growth not limited by natural barriers
• 5% may have metastasis
• High recurrence after intracapsular or
marginal resection
• Wide resection preferred
• EG: GIANT CELL TUMOUR
10. ENNEKING SURGICAL STAGING SYSTEM FOR
MALIGNANT MESENCHYMAL TUMORS
GRADES:
low (G1) or high (G2) grade.
Low grade – G1
• Low risk for distant spread (< 25%).
• Low mitotic rates
• Low nuclear to cytoplasmic ratio
• Limited pleomorphism.
High Grade – G2
• Higher incidence of metastasis
• Mitotic figures are seen on histology
• Prominent nucleoli
11. LOCAL EXTENT/ SITE:
• Intracompartmental (T1) / extracompartmental (T2)
• Anatomical compartments have natural barriers, e. g. cortical bone,
articular cartilage, fascial septae, muscle origins, joint capsule etc.
• The adequacy of the surgical margin is determined by this barrier
between the plane of resection and the tumor
• High-grade lesion may require the use of adjuvant therapies to
eradicate tumor cells that would remain after surgical resection.
METASTASIS:
• The presence of metastatic disease denotes a poor prognosis.
12. Stage Grade Site Metastasis
IA Low (G1)
Intracompartmental
(T1)
No metastasis (M0)
IB Low (G1)
Extracompartmental
(T2)
No metastasis (M0)
IIA High (G2)
Intracompartmental
(T1)
No metastasis (M0)
IIB High (G2)
Extracompartmental
(T2)
No metastasis (M0)
III Any (G) Any (T)
Regional or distant
metastasis (M1)
15. Limitations of the Enneking surgical
staging system
• based on the natural evolution of mesenchymal tumors
• thus is not applicable to tumors originating in either the
marrow or reticuloendothelial system.
• Including lymphomas,
multiple myeloma,
plasmacytoma,
Ewing’s sarcoma and other round cell neoplasms,
metastatic carcinomas
16. TNM STAGING OF BONE TUMOURS
Primary tumor (T):
• TX Primary tumor cannot be
assessed
• T0 No evidence of primary tumor
• T1 Tumor ≤8 cm in greatest
dimension
• T2 Tumor >8 cm in greatest
dimension
• T3 Discontinuous tumors in the
primary bone site
Regional lymph node (N)
• NX Regional lymph node cannot
be assessed
• N0 No regional lymph node
metastasis
• N1 Regional lymph nodes
metastasis
Definition of distant metastasis (M)
• M0 No distant metastasis
• M1 Distant metastasis
M1a Lung
M1b Bone or other distant sites
Histologic Grade (G)
• GX Grade cannot be assessed
• G1 Well differentiated, low grade
• G2 Moderately differentiated, high
grade
• G3 Poorly differentiated, high grade
17. AJCC PROGNOSTIC STAGING OF BONE
SARCOMA
Stage
Primary
tumor (T)
Regional
lymph node
(N)
Distant
metastasis
(M)
Histologic
grade (G)
IA T1 N0 M0 G1 or GX
IB T2 or T3 N0 M0 G1 or GX
IIA T1 N0 M0 G2 or G3
IIB T2 N0 M0 G2 or G3
III T3 N0 M0 G2 or G3
IVA Any T N0 M1a Any G
IVB Any T N1 Any M Any G
Any T Any N M1b Any G
18. WHO CLASSIFICATION
• Fifth edition of the WHO classification of tumors of soft tissue and bone
was published in april 2020
• The WHO classification of bone tumors is regarded as the gold standard
reference for diagnosis of bone tumors
Based on following lineage groups:
• Chondrogenic tumors
• Osteogenic tumors
• Fibrogenic tumors
• Vascular tumors of bone
• Osteoclastic giant cell-rich tumors
• Notochordal tumors
• Other mesenchymal tumors of bone
• Hematopoietic neoplasms of bone
21. OSTEOCLASTIC GIANT CELL-
RICH TUMORS
BENIGN:
• Aneurysmal bone cyst
• Non-ossifying fibroma
INTERMEDIATE (LOCALLY
AGGRESSIVE):
• Giant cell tumor of bone
MALIGNANT:
• Giant cell tumor of bone,
malignant
• Plasmacytoma of bone
• Malignant lymphoma
• Langerhans cell histiocytosis
• Erdheim-Chester disease
• Rosai-Dorfman disease
HEMATOPOIETIC
NEOPLASM
22. OTHER MESENCHYMAL TUMORS OF
BONE
BENIGN:
• Chondromesenchymal hamartoma of
chest wall
• Simple bone cyst
• Fibrous dysplasia
• Osteofibrous dysplasia
• Lipoma
INTERMEDIATE (LOCALLY AGGRESSIVE):
• Osteofibrous dysplasia-like
adamantinoma
MALIGNANT:
•Adamantinoma
•Leiomyosarcoma
•Pleomorphic sarcoma,
undifferentiated
•Bone metastases
23. Tumor Entities 2013 WHO Classification 2020 WHO Classification
Benign fibrous
histiocytoma
*
Fibrohistiocytic tumor Removed
Giant cell lesion of the small
bones
†
Osteoclastic giant cell rich
tumor
Removed
Leiomyoma Myogenic tumor Removed
Liposarcoma Lipogenic tumor Removed
24. RADIOGRAPHY OF BONE TUMOURS
• Musculoskeletal tumors are commonly suspected on the basis
of the history and physical examination.
• They are most often revealed on conventional radiographic
examination.
• The imaging of these tumors serves three purposes:
(1) detection,
(2) diagnosis and differential diagnosis, and
(3) staging.
25.
26. AGE
• Certain bone tumors are found almost exclusively in certain
age groups.
• When tumors do occur outside of their typical age group, they
may not appear in the usual locations or may have a different
radiographic appearance.
• In simple bone cysts (so-called unicameral bone cysts), Before
skeletal maturity, they usually arise in the proximal humerus
or proximal femur.
• After skeletal maturity, however, they may be found in the
calcaneus, scapula, or pelvis, among other places; with aging,
they may look somewhat unconventional on radiography.
27.
28. WHETHER A LESION IS SOLITARY OR
MULTIPLE?
• Usually presenting as
solitary lesion
o Fibrosarcoma,
o Malignant fibrous
histiocytoma,
o Ewing sarcoma,
o Chondrosarcoma
o Osteosarcoma.
• Malignancies that are
multifocal
o multiple myeloma,
o metastatic disease
o lymphoma
• Benign bone lesions with
multifocal sites
o Polyostotic fibrous dysplasia,
o Enchondromatosis,
o multiple hereditary
osteochondromata
o Langerhans cell histiocytosis
(eosinophilic granuloma),
o Hemangiomatosis
o Osseous fibromatosis.
29.
30. AUNT MINNIE APPROACH
• It consists of a question and answer:
Q:“How do you know that woman is your Aunt Minnie?”
A: “Because I’ve seen her before and it looks like her”
• This approach relies on familiarity with the typical overall
appearances of a particular lesion.
• This is all very satisfactory if the abnormality under
investigation is classic in appearance, but problems arise if
the lesion has atypical features, arises at an unusual site or
is mimicked by a differing pathology
31. Pattern analysis
• Relies on meticulous recognition of various
radiographic signs.
• Analysis can be best illustrated by answering a series of
five questions:
• Which bone is affected?
• Where in that bone is the lesion located?
• What is the tumour doing to the bone (pattern of
destruction)?
• What form of periosteal reaction, if any, is present?
• What type of matrix mineralisation, if any, is present?
32.
33. Distribution of various lesions
in a vertebra
Benign lesions
predominate in its
posterior elements.
Osteoblastoma
Osteoid osteoma
Aneurysmal Bone
cyst
Osteochondroma
Chondromyxoid
fibroma
Malignant lesions are
seen predominantly in
its anterior part (body)
Lympohoma
Myeloma
Osteosarcoma
Ewing
Chondrosarcoma
Metastases
41. WHAT IS THE LESION DOING TO THE
BONE?
Pattern of Bone Destruction
• Bone destruction is usually the first radiographic sign of
disease and may be the only evidence of pathology.
• Trabecular bone is more easily destroyed than cortical bone.
• Analysis of the interface between tumour and host bone is a
good indicator of the rate of growth in the lesion.
• A sharply marginated lesion usually denotes slower growth
than a nonmarginated lesion.
• The faster the growth, the more “aggressive” the pattern of
destruction and the wider the zone of transition between
tumour and the normal bone
42. • The American skeletal radiologist, Gwilym Lodwick,
described three patterns of bone destruction
associated with tumours and tumour-like lesions of
bone:
• type 1, geographic bone destruction
• type 2, moth-eaten bone destruction
• type 3, permeative bone destruction
44. • In this pattern the growth rate is sufficiently
indolent and the lesion will appear well
marginated with a thin zone of transition.
• The geographic pattern may be further
subdivided into 3 types depending on the
appearance of the margin and the effect on the
cortex
• Type 1A
• Type 1B
• Type 1c
45. TYPE 1A
• The slowest growing of all the
lesions and thereby the least
aggressive, is characterized by a
sclerotic margin.
• The thicker the sclerotic rim, the
longer the host bone has had time
to respond to the lesions
indicating a slow rate of growth
• The vast majority of these lesions will prove to be benign
47. TYPE 1B
• The lesion is well defined
without the sclerotic margin.
• While still relatively slow
growing, the rate is slightly
greater than that of type 1A.
• Again, the majority of
type-1B lesions are benign,
although some malignancies
may on occasion demonstrate this pattern.
48. TYPE 1B – WELL DEFINED,
NON SCLEROTIC MARGIN
• GCT
• enchondroma
• Chondroblastoma
• myeloma,
• Metastatsis
• CMF
• FD
• Chondrosarcoma
49. TYPE 1C
• Margin is less well defined,
indicating a more aggressive
pattern.
• Cortex is also destroyed.
• Few benign tumours exhibit
a type-1C pattern
51. TYPE 2- MOTH EATEN
• Areas of destruction with
ragged borders.
• Less well defined /
demarcated lesional margin
• Longer zone of transition
52. TYPE 3 - PERMEATIVE
• Poorly demarcated lesion imperceptibly merging with
uninvolved bone
• Long zone of transition
LESIONS HAVING MOTH EATEN /
PERMEATIVE :
• Ewing Sarcoma
• Eosinophilic granuloma
• myeloma,
• Metastasis
• Lymphoma
• Osteosarcoma
• Fibrosarcoma
53. Poorly demarcated from normal,
numerous elongated holes/slots
in cortex, run parallel to long axis
of bone
Multiple scattered holes that
vary in size & seem to arise
separately
54. REACTION OF BONE TO TUMOUR
• Limited responses of bone
Destruction: lysis (lucency)
Reaction: sclerosis
Remodeling: periosteal reaction
• Rate of growth determines bone response
◦ slow progression, sclerosis prevails
◦ rapid progression, destruction prevails
55. PERIOSTEAL REACTION
• Periosteal reaction must mineralize to be seen on X ray ( 10
days – 3 weeks)
• Configuration of periosteal reaction
◦ Nature of inciting process
◦ Intensity
◦ Aggressiveness
◦ Duration
56.
57.
58. CONTINUOUS PERIOSTEAL
REACTION
⚫A continuous reaction is likely to represent a benign lesion
that is slow growing and usually indolent.
⚫Intact or expanded cortex
⚫In faster-growing lesions the endosteal resorption will
exceed periosteal opposition and a thin outer “shell”
will be produced
60. CONTINUOUS PERIOSTEAL REACTION WITH
AN INTACT CORTEX.
• The solid periosteal response
may take many forms:
a single lamellar reaction, as
seen with Ewings sarcoma
a solid elliptical or smooth
layer, for example, present in
osteoblastoma and osteoid
osteoma
a solid septated ridge shell
accompanying aneurysmal
bone cyst and chondromyxoid
fibroma
61. DISCONTINUOUS (INTERRUPTED)
PERIOSTEAL REACTION
⚫A discontinuous or interrupted periosteal reaction
indicates that the cortex has been breached
⚫TYPES:
Codmans triangle
Buttress – benign neoplasm
Truncated lamellae
Interrupted spiculae (Sunburst appearance)
66. COMBINED PERIOSTEAL
REACTION
⚫More than one pattern of periosteal reaction may be
manifest in the same case and is called a combined or
complex pattern. This reflects the varying rate of growth at
different sites in the same lesion.
⚫The divergent spiculated periosteal reaction, otherwise known
as “sun-burst” or “sun-ray”, is a typical example of a complex
pattern and is suggestiveof osteosarcoma
67. TUMOUR MATRIX
Tumour new bone is the matrix of intercellular substance
produced by certain tumourcells that can calcify or ossify.
Radiodense tumour matrix is of either osteoid (osteogenic
tumours) or chondroid (chondrogenic tumours) origin.
A radiographic study of the matrix frequently can yield
sufficient findings to differentiate between chondroblastic and
osteoblastic processes and may help in distinguishing between
lesions similar in appearance.
68. Tumour cartilaginous matrix is more amorphous,typically with
calcifications.
stippled or punctate,
ring and arc
flocculent / irregularly shaped
Composition of tumor
tissue—chondroid
matrix. Both
enchondroma (A) and
chondrosarcoma (B) display
a typical chondroid matrix
69. the presence of fluffy, cotton-like densities within the medullary cavity such in this
case of osteosarcoma of the distal femur (A), case of osteosarcoma of the sacrum (B),
or by the presence of a solid sclerotic mass, like in this case of parosteal
osteosarcoma of the femur (C).
Tumour osteoid -
presence of fluffy,
cotton-like densities
within the medullary
cavity
• solid (sharp-edged)
• cloud
• ivory-like
70.
71. Enchondroma: Radiographs showdensechondrogenic calcications in the form of
rings and arcs in the proximal metadiaphyseal humerus. underlying osteolysis is completely
obscured by thecalcifications. There is no scleroticrim and thecortex is intact.
72. Radiographic appearance of osteoid matrix in osteosarcoma. a Lateral radiograph of the
distal femur shows predominantly fluffy osteoid matrix in bone and within the large so
tissue component. b Anterioposterior radiograph shows a predominantly cloudlike
(cumulous) opacity in the proximal humerusand adjacentso tissue
73. SOFT TISSUE MASS
• The presence of a soft-tissue mass is a reliable indicator of an
aggressive or malignant process.
• In contrast, benign bone neoplasms are not associated with
soft-tissue mass, with certain exceptions
desmoplastic fibroma,
aneurysmal bone cyst, and
giant cell tumor.
• Some non neo-plastic processes can produce soft-tissue
masses, as well (osteomyelitis)- BUT the mass lacks sharp
definition and the fatty tissue layers appear obliterated.
• Masses related to malignancy look quite different; they
usually are well defined and extend through the damaged
cortex, with tissue planes remaining intact
74. • (A) Ill-defined soft-tissue mass in a patient with osteomyelitis of the proximal phalanx of the
great toe. (B) Well-defined soft-tissue mass in a patient with osteosarcoma of the clavicle.
75. whether the mass is an extension of a primary bone
tumor or is it a primary soft-tissue tumor invading
bone?
• if the bone lesion is small in relation to the soft-tissue mass, the
bone lesion likely represents secondary bone involvement.
• However, in a small number of primary malignancies—Ewing
sarcoma—the bone lesion may be smaller than the accompanying
soft-tissue mass.
• The periosteal response yields another clue. Primary malignant
bone tumors usually elicit a periosteal response when they break
through the cortex and invade neighboring soft tissues;
• conversely, primary soft-tissue tumors impinging on bone
generally elicit no such response as they destroy the adjacent
periosteum
76.
77. • Age: 2nd decade
• Site: Distal femur > proximal tibia
> proximal humerus
• Tumor location: Metaphyseal
• Direction of growth: Away from joint
• Stalk: Pedunculated or sessile
• Margin of tumor: Well defined
• Corticomedullary delineation: Intact
• Cortical part of tumor: It is continuous with cortex of parent bone
• Medullary cavity of tumor: It is continuous with medullary cavity of
parent bone
• Periosteal reaction: Absent
• Soft tissue extension: Absent
78. Radiological sign of malignant
transformation in exostosis:
chondrosarcoma.
• Š
Š
Stippled calcification in cartilage
cap
• Š
Š
Margin of tumor becomes ill
defined
• Soft tissue extension
• Š
Š
Cartilaginous cap size more than 2 cm in CT or MRI
(normally thickness of cartilage cap is more in children,i.e.
up to 2 cm than adult, i.e. in few millimeter.
79. GROSS FEATURES:
• Grey white tumour
• Broad or narrow base
• Mushroom shaped
• Section shows cortical bone
and bone marrow enclosed
within cartilagenous cap
HISTOPATHOLOGY:
• Hamartomatous lesion with
outer mature cartilage
resembling epiphyseal
cartilage
• Inner mature lamellar bone
and bone marrow
81. • Age: 2nd to 3rd decade (5–25 yr)
• Site: femur > tibia > spinous process
Description of a tumor radiographs:
• Tumor location: Diaphyseal/metaphyseal
(cortical or cancellous)
• Destruction pattern: Lytic, radiolucent
nidus < 1.5 cm.
• Margin of tumor: Well defined
• Corticomedullary delineation: Intact
• Status of cortex: Intact (thickened and
sclerosed)
• Matrix: Homogeneous
• Zone of transition: Narrow
82. • Periosteal reaction: Present
(continuous solid periosteal reaction)
• Soft tissue extension: Absent
• If size of nidus is more than 1.5 cm,
lesion is most likely osteoblastoma
• CT scanning is diagnostic tool for
osteoid osteoma.
CT SCAN - Lytic nidus surrounded by
sclerotic bone
Centre of nidus may be calcified
Double density sign on bone scan –
increased uptake in nidus and
decreased uptake in reactive sclerotic
zone (also seen in Brodie’s abcess)
83. GROSS DESCRIPTION
• Small circumscribed nidus with
surrounding sclerosis (intact specimen)
• Most often received as red, gritty
fragments post curettage
85. • Age - 10-25 years
• Site – spine (posterior elements)
> long bones
• Tumor location: Diaphyseal/
metaphyseal (cortical or
cancellous)
•Tumors with secondary ABC changes (aneurysmal
bone cyst) are expansile
•Spinal tumors originate in dorsal elements, may
secondarily involve vertebral body
•Up to 25% of radiographs are suspicious for
malignancy
86. • Destruction pattern: geographic,
radiolucent, nidus >1.5 cm.
• Margin of tumor: Well circumscribed with
thin shell of reactive bone
• Corticomedullary delineation: Intact
• Status of cortex: Intact (thickened and
sclerosed)
• Matrix: Homogeneous with variable
amounts of central ossification
• Zone of transition: Narrow
• Periosteal reaction: Present (continuous
solid periosteal reaction)
• Soft tissue extension: present in posterior
spine lesions
87. GROSS
DESCRIPTION
• Mostly curetted gritty, red
fragments of osteoblastoma
• Intact tumors well demarcated with
scalloped edges
• Often hemorrhagic
• One or more nidi
DIFFERENTIAL DIAGNOSIS:
• Osteoid osteoma
• Osteosarcoma
• Giant cell tumour
• ABC
• Chondromyxoid fibroma
88. • Age: 1st to 2nd decade
• Site: Proximal humerus > proximal femur > proximal tibia
• When tumor lies nearer to physis, it is called active tumor and
it migrates towards diaphysis it becomes inactive tumor.
Description of a tumor radiographs:
• Tumor location: Metaphyseal/
diaphyseal, centrally placed
• Destruction pattern: Lytic
• Margin of tumor: Well defined
• Corticomedullary delineation: Lost
• Status of cortex: Thinned out
89. • Matrix: Homogeneous
• Zone of transition: Narrow
• Periosteal reaction: Absent (present only with pathological
fracture)
• Soft tissue extension: Absent
• Note: Fallen fragment sign in X-ray is pathognomonic feature
for simple bone cyst with fracture.
• presence of a gas bubble in most nondependent area of
simple bone cyst called rising bubble sign
90. GROSS
• If an intact cyst is removed
– Straw or clear fluid filled large
intramedullary cavity
– Usually unilocular but may be
multilocular
– Thin and smooth cyst
membrane
• In curettage specimens
– Multiple thin greyish or
reddish membranes admixed
with blood clots and bony
fragments
91. MICROSCOPY:
• blood-filled cystic spaces lined by a single layer of flat
undifferentiated cells, separated by fibrous septa
• Fibrous septa are composed of uniform plump fibroblasts,
multinucleated osteoclast-like giant cells, (sometimes they
look like “jumping into swimming pool” of cystic spaces), and
reactive woven bone
DIFFERENTIAL DIAGNOSIS:
• Aneurysmal bone cyst
• Giant cell tumour
• Fibrous dysplasia
• Enchondroma
92. • A vasocystic tumor formed following arteriovenous malformation in
metaphysis (most accepted theory)
• Age: 1st to 2nd decade
• Site: Proximal humerus > proximal femur >proximal tibia > spinous
process
• ABC of spinous process closely resembles osteoblastoma.
93. Description of a tumor
radiographs:
• Tumor location:
Metaphyseal/diaphyseal, eccentric
• Destruction pattern: Lytic, expansile.
• Margin of tumor: Well defined
• Corticomedullary delineation: Lost
• Status of cortex: Thinned out or egg shell
• Matrix: Homogeneous
• Zone of transition: Narrow
• Periosteal reaction: Present (solid-soap
bubble septation)
• Soft tissue extension: Absent
• Finger in the balloon sign possible
• Does not extend to the joint (unlike GCT)
94. • CT scan:
– Well delineated lytic
lesion, usually with thin
rim of reactive bone
– Fluid-fluid levels
occasionally visible
• MRI:
– Multiloculated cyst with
characteristic fluid-fluid
levels
• Isotope scan:
– Peripheral uptake with
central photopenia
imparts a donut-like
appearances
95. Gross description
• Spongy, multiloculated, hemorrhagic
lesion
• Variable size
• Irregular, sharply demarcated
borders with thin shell of reactive
bone
• Variable amount of solid component
96. HISTOPATHOLOGY
• Multiloculated cystic lesion
• Blood filled cystic spaces
separated by cellular septa
containing fibroblasts, giant cells
and woven bone
• Calcified, basophilic material
(blue reticulated chondroid-like
material)
• Necrosis not common but
mitotic activity is easily
identified
• No cytologic atypia
98. • A tumor due to overproliferation of osteoclast (osteoclastoma)
• Age: 20–40 years (a tumor of mature skeleton)
• Site: Distal femur > proximal tibia > distal Radius
• The aneurysmal bone cyst is one of the tumor of giant cell group
that may exist with osteoclastoma.
99. Description of a tumor radiographs:
• Tumor location: Epiphyseal,
metaphyseal in skeletally immature
(less common)
• Destruction pattern: Lytic, eccentric
and abutting to joint cartilage
• Margin of tumor: Well defined
• Corticomedullary delineation: Lost
• Status of cortex: Intact or may
breached at some places
• Matrix: Homogeneous
• Zone of transition: Narrow
• Periosteal reaction: Minimal or
absent
• Soft tissue extension: Absent/present
100. • Three radiographic "grades" of giant cell tumor of bone called
Campanacci grades
• Campanacci grade I lesions ("quiescent lesions"): well defined
border limited to the medullary cavity; no cortical involvement
• Campanacci grade II lesions ("active lesions"): well defined
border; cortex is thinned and expanded
• Campanacci grade III lesions ("aggressive lesions"): ill defined
margins with cortical destruction and soft tissue extension
101. GROSS DESCRIPTION
• Greyish white well circumscribed
tumour
• Cut surface may have yellow
(xanthomatous), white (fibrous) or
hemorrhagic / cystic areas and
honey comb appearance
• Malignant transformation (if
present) is often a large, fleshy area
with soft tissue invasion
102. Microscopic
description
• Multinucleated giant cells
• Spindle and round mononuclear cells
• Highly vascular stroma with fibrosis or
reactive woven bone (common)
• necrosis (in large tumors) or secondary
aneurysmal bone cyst (ABC)-like changes
(10% of cases) may be present
103. GIANT CELL VARIANTS
mnemonic - FOGMACHINES
• F - Fibrous dysplasia
• O - Osteoblastoma
• G - Giant cell reparative granuloma
• M - Metastasis and multiple myeloma
• A - Aneurysmal bone cyst
• C - Chondroblastoma and CMF
• H - Histiocytosis and hyperparathyroidism
• I - Infection
• N - Non ossifying fibroma
• E - Enchondroma
• S - Solitary bone cyst
104. FIBROUS CORTICAL DEFECT
(NON-OSSIFYING FIBROMA)
• A hamartomatous fibrous tissue forming
tumor that disappears after skeletal
maturity.
• Age: 1st to 2nd decade
• Site: Long bones
Common association:
• Š
Š
Multiple nonossifying fibroma (NOF)
with café-au-lait-spots is called Jaffe
Campanacci syndrome.
• Š
A ossifying fibroma of long bone is called
osteofibrous dysplasia. (Campanacci
disease)
• Š
Š
NOF closely resembles chondromyxoid
fibroma a locally malignant tumor
105. Description of a tumor radiographs:
• Tumor location: Metaphyseal, eccentric
• Destruction pattern: lytic (geographical)
• Margin of tumor: Well defined
• Cortico-medullary delineation: Lost
• Status of cortex: Intact (thickened and
sclerosed)
• Matrix: Homogenous/multiloculated
• Zone of transition: Narrow
• Periosteal reaction: Present
(solidcontinuous periosteal reaction)
• Soft tissue extension: Absent
• Note: If the size of lesion is more than 3
cm, tumor is called non-ossifying fibroma
(NOF).
107. • Failure of normal lamellar bone formation and
abundance of fibrous tissue with flecks of
immature bone. May be mono or polyostotic.
• Age: 1st to 3rd decade
• Site: Proximal femur > proximal tibia
Common association:
• Š
Š
McCune Albright syndrome— polyostotic
fibrous dysplasia with precocious puberty.
• Š
Š
Mazabraud’s syndrome—fibrous dysplasia
with myxoma
• Š
Š
Cherubism (leontiasis ossea)—fibrous
dysplasia of jaw.
• Single or multiple well circumscribed
intramedullary lesions with a sclerotic rim
108. Description of a tumor radiographs:
• Tumor location: Epiphysis/metaphyseal/
diaphyseal
• Destruction pattern: Lytic
• Margin of tumor: Well defined
• Corticomedullary delineation: Lost
• Status of cortex: Some places thinned and
some places sclerosed
• Matrix: Ground glass appearance
• Zone of transition: Narrow
• Periosteal reaction: Present (continuous
solid periosteal reaction)
• Soft tissue extension: Absent
• A peculiar deformity involving proximal
femur is called Shepherd crook deformity.
109. MICROSCOPY
osteoid component comprised of irregular curvilinear
trabeculae or woven bone termed chinese letter like
pattern
DIFFERENTIAL DIAGNOSIS
• Hyperparathyroidism
• Osteogenesis imperfecta
• Neurofibromatosis
110. • A intramedullary cartilage forming
tumor sometime arises from
periosteum also.
• Age: Adults (3rd decade)
• Site: Hand > proximal humerus >
distal femur > proximal tibia
• Risk of malignant transformation is
less than 1% but it may extends up
to 25–30% in Ollier’ disease and
Mauffici syndrome.
111. Description of a tumor radiographs:
• Tumor location: Metaphyseal
• Destruction pattern: Lytic
(geographical)
• Margin of tumor: Well defined
• Corticomedullary delineation: Lost
• Status of cortex: Thinned or expanded
in small bone thickened and
sclerosed in others. Scalloped erosions on endosteal surface
• Matrix: Heterogeneous/central calcification from punctate to ring
type
• Zone of transition: Narrow
• Periosteal reaction: Absent in small bone present in other
(continuous-solid type)
• Soft tissue extension: Absent
112. GROSS DESCRIPTION
• Lobulated and bluish white
translucent in appearance
• May contain white areas of
calcification
MICROSCOPY:
• Hypocellular and avascular
hyaline cartilage with varying
degrees of mineralisation
113. DIFFERENTIAL DIAGNOSIS
• Low grade chondrosarcoma
• Simple bone cyst
• Non ossifying fibroma
• Fibrous dysplasia
114. Age: 2nd and 3rd decade
Metaphysis of long bones (m/c – tibia >
femur, fibula)
Rounded or oval eccentrically placed,
geographical lesion with narrow zone of
transition
May cross the growth plate
Sharp outline and sclerotic rim
Appear as Scalloped bite like destruction
with cortex thinning and mild expansion or
break in cortex with extraosseous soft
tissue component
115. GROSS DESCRIPTION
• In long bone lesion is eccentric
• In small tubular bone, it occupies entire width
• Producing fusiform swelling
• Cut surface – solid tumour mass of greyish white or bluish grey
colour with firm consistency
DD:
• Myxoid chondrosarcoma
• Chondroblastoma
• Chondroblastic osteosarcoma
• Fibrous dysplasia
• Giant cell tumour
• ABC
116. Epiphysis or apophysis
Well defined area of rarefaction
eccentrically placed in the epiphysis or
across the growth plate
Thin marginated sclerotic margin
50% show central calcification, 50%
show linear periosteal reaction
Bone scan increased uptake at margins
117. GROSS
• Dark red or tan coloured,
hemorrhagic and friable mass
• Scattered small yellow zones of
calcification within the mass
• MICROSCOPY:
• Large sheets of compact round
or polygonal cells
• Scatered osteoclast like giant
cells present
• Characteristic pericellular type
of calcifictaion (chicken wire
calcification)
119. m/c – sacrococcygeal region >
base of skull > vertebral body
Large osteolytic lesion in the
midline
May contain flecks of
calcification
Marked bone destruction
MRI – investigation of choice
120. GROSS
• Large, round, smooth,soft, bluish
white, glistening and lobulated
swelling with fibrous septa
• Bone is destroyed and replaced by
tumour
• MICROSCOPY:
• Physaliferous cells(abundant clear
cytoplasm)
• Cells arranged in cords/ sheets
121. Age – 25-35 years
Site – anterior metadiaphyseal region,
Eccentrically placed
well defined osteolytic, multiloculated
Expansile lesion( soap bubble / honey
comb appearance)
Marginal sclerosis and intralesional
septations and opacities
Cortical destruction
Extension into medullary canal and soft
tissue
122. GROSS
• Well defined, yellowish grey
lobulated, firm to hard
• Multiloculated with normal appearing
cortex in between
• Cystic spaces filled with straw
coloured or blood like fluid
MICROSCOPY:
• Epithelial and osteofibrous
components with four major patterns
of differentiation – basaloid, tubular,
spindle cell and squamous
124. 🞂
• Mottled lytic defect usually no sclerotic
rim
•May destroy cortex
•Usually endosteal or periosteal reaction
•Lesions in flat bones and ribs appear
punched out
•May appear loculated
•Spinal lesions- collapse (vertebra plana)
125. • A tumor of neuroectodermal
origin
• Age: 1st to 3rd decade (10–20
yr)
• Site: Flat bones > long bones
• These tumor can be mistaken
for acute osteomyelitis.
126. Description of a tumor radiographs:
• Tumor location: Metaphyseal/diaphyseal
• Destruction pattern: Permeative
• Margin of tumor: Ill defined
• Corticomedullary delineation: Lost
• Status of cortex: Breached
• Matrix: Heterogeneous
• Zone of transition: Wide
• Periosteal reaction: Present (continuous
lamellated periosteal reaction or onion peel
appearance, spiculated type— sun-burst
appearance and hair on end appearance)
• Codman triangle also present sometimes
• Soft tissue extension: Present (massive soft
tissue)
127. GROSS
• Grey white, fleshy with extensive
involvement of medulla and
cortex with periosteal elevation
• Soft friable necrotic area
resemble pus
• Specimens are usually excised
after therapy, and show fibrosis,
hemorrhage and necrosis
128. MICROSCOPY:
• Sheets of monomorphic small round, blue cells with pale and
indistinct cytoplasmic borders and small hyperchromatic
nuclei
• Rossette formation seen
Tumours containing round blue cell ( Mneumonic - PEARL
DOMS)
• Primitive neuroectodermal tumour
• Ewing sarcoma
• Acute leukemia
• Rhadbomyosarcoma
• Lymphoma
• Desmoplastic round cell tumour
• Osteosarcoma
• Mesenchymal chondrosarcoma
• Small cell mesothelioma
130. Description of a tumor radiographs:
• Tumor location: Metaphyseal, usually
eccentric
• Destruction pattern: Permeative
• Margin of tumor: Ill defined
• Corticomedullary delineation: Lost
• Status of cortex: Breached
• Matrix: Heterogeneous
• Zone of transition: Wide
• Periosteal reaction: Interrupted type
(Codman triangle) and spiculated type
(sun burst appearance)
• Soft tissue extension: Present
Joint space rarely involved
131. GROSS
• Conventional (high grade intramedullary)
osteosarcoma:
– Intramedullary mass with cortical
permeation and a soft tissue
component that raises the periosteum
– Size (mean): 5 - 10 cm
– Cut surface: gritty and mineralized
(hard) - may have cartilaginous areas ,
hemorrhage, necrosis and cystic
change
• Parosteal osteosarcoma:
– Hard lobulated mass: attached to
cortex with variable nodules of
cartilage partially capping tumor
surface and soft fleshy areas
132. GROSS
• Low grade central osteosarcoma:
– Firm, gritty cut surface
– May demonstrate cortical
destruction, soft tissue invasion
• High grade surface osteosarcoma:
– Tumor arises from the cortical
surface and erodes / invades the
cortex
– Cut surface may be osteoblastic,
chondroblastic or fibroblastic; areas
of necrosis present
133. • Periosteal osteosarcoma:
– Broad based (sessile) tumor arising from the
cortical surface (may circumferentially involve
bone)
– Cortex is thickened with heavily ossified base
– External aspect of tumour is cartilaginous
– Calcified spicules may extend perpendicularly
from the cortex within the mass
MICROSCOPY:
135. • Malignant chondroid forming
tumor.
• Age: Primary—5th to 7th
decade, Secondary—younger to
elderly
• Site: Pelvic girdle > proximal
femur > proximal humerus
• Clear cell chondrosarcoma
closely mimics chondroblastoma.
Characteristic of clear cell sarcoma:
• Š
Š
Common in male
• Š
Š
Common site—epiphysis of
femoral head
• Š
Š
Low-grade
136. Description of a tumor radiographs:
• Tumor location: Metaphyseal
• Destruction pattern: Moth eaten /
permeative
• Margin of tumor: Ill defined
• Corticomedullary delineation: Lost
• Status of cortex: Thin and breached,
endosteal scalloping and cortical
expansion;
• Matrix: Heterogeneous (punctate,ring
and arc/ popcorn calcification)- 60-78%
• Zone of transition: Wide
• Periosteal reaction: Present (continuous
solid periosteal reaction)
• Soft tissue extension: Present
137. CT- as many as 90% of
cases, tumors appear as
lucent areas containing
chondroid matrix
calcification.
• Endosteal scalloping and
cortical destruction are
frequently easier to
appreciate on CT scans than
on radiographs.
138. GROSS
• Neoplastic hyaline cartilage has a
lobular, gray-tan cut surface
• Cystic changes with myxoid or mucoid
material
• Mineralization appears as chalky calcium
deposits
• Cortical erosion and soft tissue
extension can be seen
• Thick cartilage cap (1.5 - 2 cm) with
cystic cavities in secondary peripheral
chondrosarcoma
• Periosteal chondrosarcoma appears as a
large, lobular mass attached to the
surface of bone
139. MICROSCOPY
• Abundant cartilaginous matrix with
chondrocytes embedded in lacunae
• Varying degrees of increased cellularity,
nuclear atypia and mitotic activity
– Grade I: minimally increased cellularity,
nodular growth and occasional binucleate
nuclei
– Grade II: moderate cellularity and diffuse
growth
– Grade III: high cellularity, marked atypical
cells, pleomorphic appearance and easily
identifiable mitotic figures
• Myxoid changes, chondroid matrix
liquefaction and necrosis can be seen
141. Highly destructive with a wide zone of
transition and often expansile.
Periosteal reaction is uncommon.
mottled or moth eaten with extension
into soft tissue
Osteolytic lesion may be surrounded by
reactive bone formation
MRI
best modality overall for examining soft-
tissue masses and for detecting the
intraosseous and extraosseous extent of
many bony sarcomas
FIBROSARCOMA
142. SYNOVIAL SARCOMA
• Site – around ankle and knee joint >
hip, shoulder
• Age- less than 30 yr
• MRI – investigation of choice
GROSS :
• well circumscribed, firm,
greyish pink
• Focal calcifications may be
frequent and visible in
radiograph
143. MICROSCOPY:
• Biphasic tumour composed of
sharply segregated epithelial and
sarcomatous components
• Epithelial – gland like spaces lined
by epi cells
• Sarcomatous- fibroblast like spindle
cells
DIFFERENTIAL DIAGNOSIS
• Fibrosarcoma
• Small round cell tumour
• mesothelioma
144. • A proliferative disorder of
plasma cell.
• Age: 6th to 7th decade
• Site: Spine >proximal femur >
proximal Humerus
• Secondary metastasis in the
spine mimic multiple
myeloma.
• In bone scan multiple
myeloma are almost cold
contrary to other metastasis.
MULTIPLE
MYELOMA
145. Description of a tumor radiographs:
• Tumor location: Metaphyseal
• Destruction pattern: Lytic (multiple)
• Margin of tumor: Well defined
(punched out)
• Corticomedullary delineation: Lost
• Status of cortex: Breached at some
places
• Matrix: Heterogeneous
• Zone of transition: Wide
• Periosteal reaction: Absent
• Soft tissue extension: May present
Spine- biconcave vertebral bodies
vertebral collapse
disappearing vertebra
146. GROSS FEATURES:
• Reddish grey tumour
• Section shows soft reddish material
in the body with intact disc and
normal vertebral height
HISTOPATHOLOGY:
• Sheets of plasma cells
• Abundant cytoplasm with
perinuclear halo
DIFFERENTIAL DIAGNOSIS:
• Metastasis
• Malignant lymphoma
• Monoclonal gammopathies
147. Osteolytic commonest - cortical destruction with little or no
periosteal reaction; Lungs, Kidney, Adrenal, Thyroid, Uterus
Osteoblastic deposits – Prostate, Bladder, Testis, Breast and
Bowel secondaries. Also carcinoid lung tumors, lymphoma
Mixed- Breast, Lung, Ovary, Cervix
Lymphoma deposits may resemble prostatic deposits,
i.e. sclerotic secondaries
Lytic, expansile, with soft tissue mass- RCC, thyroid
X-Ray- at least 50% loss of bone to produce lysis on X-ray,
Loss of single pedicle produces a “winking owl sign”.
151. SUMMARY OF CLASSIFICATION OF
TUMOURS
• Origin- Primary, Secondary
• Nature - Benign/ Malignant
• Enneking staging- Latent, Active, Aggressive
• TNM staging
• WHO Classification:
Chondrogenic tumors
Osteogenic tumors
Fibrogenic tumors
Vascular tumors of bone
Osteoclastic giant cell-rich tumors
Notochordal tumors
Other mesenchymal tumors of bone
Hematopoietic neoplasms of bone
152. MALIGNANT
⚫ Poorlydefined marginswith
wide zoneof transition
⚫ Moth-eatenorpermeative
• patternof bonedestruction
⚫ An interrupted periosteal
reaction of the sunburstor
onion skin type
⚫ Adjacentsoft tissue mass
BENIGN
⚫ Well defined sclerotic
borders
⚫ Geographic patternof bone
destruction
⚫ Continoussolid periosteal
reaction
⚫ No soft tissue extension
153. SUMMARY of RADIOGRAPHY
• Age
RADIOGRAPHY:
• Site of the Lesion
• Location of lesion
Longitudinal plane Transverse plane
Epiphysis central
Metaphysis eccentric
Diaphysis cortical
perisoteal
154. • Borders of the lesion - well/ ill defined
• Type of bone destruction – Geographical,Moth eaten,
Permeative
• Status of cortex: intact, breached, expansion
• Periosteal reaction
• Matrix of the lesion – homogenous / heterogenous
chondroid- stippled , flocculent, ring and arc
osteoid – solid, cloud like, ivory like
• Zone of transition – narrow, wide, lost
• Nature and extent of soft tissue involvement-absent/present
• Multiplicity – solitary, multiple lesions
155. SUMMARY OF PATHOLOGY
• GCT – honey comb appearance with
multinucleated giant cells –
campanacci grading
• Ewing sarcoma- multiple new layers of
bone lie parallel with shaft and small
round blue cells
• Osteosarcoma – cut surface is gritty
with variable consistency. Dense, pink,
amorphous filgree like osteoid material
• Fibrous dysplasia- chinese letter like
osseous component
• Chordoma- physaliferous cells
• Multiple myeloma – pleomorphic
plasma cells with nuclear chromatin
having spoke wheel pattern without
nucleoli
• Osteochondroma- cortical bone and
bone marrow enclosed within
cartilagenous cap
• Osteoid osteoma and osteoblastoma
– nidus
• ABC and UBC – blood filled cystic
spaces with fibro osseous septa, egg
shell thin bone in UBC
• Chondroblastoma- chicken wire
calcification and cobble stone
appearance
• Chondrosarcoma- cystic and myxoid
change with chalky white areas of
calcification.
