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Benign cysts of bone (orthopaedic pg).pptx
- 1. Benign cysts ofbone Shahnawaz khan Moderator: Dr. Vikas Bachhal
- 2. Types • Solitary bonecyst • Aneurysmal bone cyst • Intraosseous ganglion cyst • Epidermoid cyst
- 3.
- 4. Introduction • Unicameral bonecysts • In growing bones • 3% of all cysts • M:F=2:1 • Metaphyseal(>95%) • Most common sites: proximal humerus and proximal femur • Juxtaphyseal cyst (<0.5 cm from the physis) is considered active* • No progression after skeletal maturity** *Neer CS, Francis KC, Johnston AD, et al: Current concepts on the treatment of solitary unicameral bone cyst, ClinOrthop Relat Res 97:40, 1973. ** Jaffe H: Tumors and tumorous conditions of the bones and joints, Philadelphia, 1958, Lea & Febiger.
- 5. Etiology • Intraosseous synovialcyst in which a small amount of synovial tissue became entrapped in intraosseous position during early infant development or secondary to trauma at birth1 . • Current literature suggests disturbance in or occlusion of the intramedullary venous circulation2,3,4,5 . 1.Mirra JM: Bone tumors: diagnosis and treatment, Philadelphia, 1980, Lippincott. 2. Chigira M, Maehara S, Arita S, et al: The aetiology and treatmentof simple bone cysts, J Bone Joint Surg Br 65:633, 1983. 3. Gebhart M, Blaimont P: Contribution to the vascular origin of the unicameral bone cyst, Acta Orthop Belg 62:137, 1996. 4. Komiya S, Minamitani K, Sasaguri Y, et al: Simple bone cyst: treatment by trepanation and studies on bone resorptive factors in cyst fluid with a theory of its pathogenesis, Clin Orthop Relat Res 287:204, 1993. 5.Watanabe H, Arita S, Chigira M: Aetiology of a simple bone cyst: a case report, Int Orthop 18:16, 1994.
- 6. Pathology • Erode thecortex • Straw yellow colored or serosanguinous fluid • Thin lining of epithelium • May also possess osteoclasts, cholesterol cells, adipocytes • Hemosiderin, fibrin may be seen
- 8. Clinical features • Asymptomatic •Mild pain • Growth arrest* *Willis RB, Blokker C, Stoll TM, et al: Long-term follow-up of anterior tibial eminence fractures, J Pediatr Orthop 13:361, 1993.
- 9.
- 10. Radiographic findings • Metaphyseal •Expansile • Radiolucent • Fallen fragment sign
- 13. Treatment • Treat assoon as the pathologic fracture heals • Thick cortex and located in the upper extremity: periodic observation • Weight-bearing bones of the lower extremities: aggressive treatment
- 14. Treatment modalities • Opensurgery • Percutaneous procedures
- 15. Open surgery • Subtotalresection± bone grafting
- 16. Percutaneous procedures • Injectionof corticosteroids • Injection of autologous bone marrow • Calcium phosphate paste (alpha-BSM) injection • Multiple drilling and drainage of the cavity
- 17. Corticosteroid injection • Methylprednisolone:40to 120 mg (1 to 3 mL) • Fluoroscopy assisted • 14 gauge needle used • Repeat every 2-3 months • Evidence of healing : • diminution in the size of the cyst • cortical thickening • remodelling of the surrounding bone, and increased internal density • Disadvantage: Cushing’s syndrome
- 18. Complications • Pathological fractures •Growth arrest • Deformities
- 19.
- 20. Definition • WHO definesABC as“ an expanding osteolytic lesion consisting of blood-filled spaces of variable size separated by connective tissue septa containing trabeculae or osteoid tissue and osteoclast giant cells”* *Schajowicz F. Aneurysmal bone cyst. Histologic Typing of Bone Tumours. Berlin: Springer-Verlag; 1992. 37
- 21. Introduction • Annual incidence=0.1 per 109 individuals* • Age group=5 to 20 years* • No sex predilection* • Solitary • Expansile(locally aggressive) • Metaphyseal • Cross physis *Leithner A, Windhager R, Lang S, et al: Aneurysmal bone cyst:a population based epidemiologic study and literature review, Clin Orthop Relat Res 363:176, 1999
- 22. Location • Tibia –17.5% • Femur – 15.9% • Vertebra – 11.2% • Pelvis – 11.6% • Humerus – 9.1% • Fibula – 7.3% • Foot – 6.3% • Hand – 4.7% • Ulna – 3.8% • Radius – 3.1% • Other – 9.2% Schreuder HW, Veth RP, Pruszczynski M, et al. Aneurysmal bone cysts treated by curettage, cryotherapy and bone grafting. J Bone Joint Surg Br. 1997 Jan. 79(1):20-5.
- 23. Etiology • Primary (65%) •Genetic abnormalities - chromosome segments 7q, 16p, and 17p11-13 specifically to USP6 oncogene and CDH11 promoter rearrangements • Insulin-like growth factor-I • TRE17/USP6 oncogene • Secondary (35%) • Associated with nonossifying fibromas, fibromyxomas, fibrous dysplasia, chondroblastomas, giant cell tumors, simple bone cysts, telangiectatic osteosarcomas, chondrosarcomas, and metastatic disease.
- 24. Pathology (Gross) • Encapsulatedmass • Soft • Friable • Reddish-brown tissue • Thin subperiosteal shell of new bone. • May have serous or serosanguineous fluid or blood clots.
- 26. Pathology (Microscopy) • Vascularspaces • Wall lined by fibroblastic cells with collagen, giant cells, hemosiderin, and osteoid
- 28. Clinical features • Localizedpain • Swelling • Deformity • Disrupt physis • Neurologic deficit • Increased warmth
- 29. Investigations • Alkaline Phosphatase •Radiography • CT Scan • MRI • Angiography • Bone scan
- 30. Radiographic findings • Periosteal“blowout” or ballooned-out lesion • Outlined by a thin shell of subperiosteal new bone formation*. • Eccentric in its location • Spine: involves posterior elements • Short bones: central and extend into the diaphysis and subarticular region *Jaffe H: Aneurysmal bone cyst, Bull Hosp Jt Dis 11:3, 1950.
- 32. Radiographic Phases • Incipientphase • Mid phase • Healing or stabilization phase
- 33. Incipient phase • Smalleccentric lucent lesion • Pure lifting off of the periosteum from the host bone • No evidence of an intramedullary lesion • Cortex preserved • No periosteal reaction
- 34. Mid phase • Rapidand destructive growth • Extreme lysis of the bone • Focal cortical destruction • Codman triangle • Classic blowout appearance
- 35. Late healing orStabilization phase • Growth of cyst slows • Smooth appearance of walls • Soap bubble or trabecular appearance • Surrounding sclerosis
- 36. CT scan • Calcifiedrim • Fluid levels
- 37. MRI • Indications: • Spinalcord compression • Edges of the rapidly expanding cyst cannot be defined with CT • Gadolinium enhancement • Features: • Multicystic appearance • Hypointense rim • Contrast-enhancing cyst walls • Double-density fluid levels • Adjacent soft tissue edema
- 39. Stages • Stage 1-latent • Stage 2- active • Stage 3- aggressive
- 40. Stage 1 • Asymptomatic •Intracompartmental • Radiography- well marginated • Bone scan- no uptake
- 41. Stage 2 • Mildsymptoms • Steady growth • Encapsulated • Radiography- well defined, irregular margins, septated, bulging • CT- homogenous density
- 42. Stage 3 • Behavelike low grade malignancy • Inflammed appearance • Symptomatic • Destroy surrounding bone • Radigraphy- ragged appearance, cortex destroyed, codman triangles • Bone scan-increased uptake beyond radiological limits • CT- non homogenous, mottled, extra-compartmental • Histology- benign features
- 43. Treatment • Although spontaneoushealing of aneurysmal bone cysts has been reported, it is uncommon* • Intralesional injection • Curettage and Adjunctive Therapy • En-bloc excision: ribs and fibula • Wide resection • Radiation Therapy and adjunctive therapy *Malghem J, Maldague B, Esselinckx W, et al: Spontaneous healing of aneurysmal bone cysts: a report of three cases, J Bone Joint Surg Br 71:645, 1989
- 44. Adjunctive Therapy • Cementation-PMMA •Cryotherapy • Embolization- In spinal and pelvic ABC • Bone graft
- 45. Intralesional injection • Methylprednisolone •ETHIBLOC • Mixture of zein, oleum papaveris, and propylene glycol • Fibrosing agent • NCCT guided • Side effects: thrombosis, pulmonary embolism, osteocutaneous fistula • Calcium sulphate • Doxycycline • Matrix metalloproteinase (MMP) and angiogenesis inhibition • Osteoclast inhibition and apoptosis • Enhanced osteoblastic bone healing
- 46. Radiation therapy • Recurrentcases • Difficult to access areas • Failed embolization • Disadvantage: radiation induced sarcoma* *Campanacci M: Bone and soft tissue tumors, Vienna, 1990, Springer.
- 47. Surgery • Stage 1-Intralesional curettage • Stage 2- Intralesional excision • Stage 3- Wide excision
- 48. Summary • A UBCis also known as a simple bone cyst and is usually found in patients younger than 20 years, most commonly in the proximal humerus and femur. • A UBC is a central lytic lesion in the metaphysis and typically resolves with skeletal maturity. However, close follow-up is necessary while the patient is growing due to risk of fracture and growth disturbance. • The ABCs are also found in patients younger than 20 years, most commonly in the metaphysis of long bones. • An ABC is more expansive than a UBC and may be wider than the width of the physis. On radiographs, ABCs are also eccentric and lytic, with bony septae or a “bubbly” appearance.
- 49.
- 50. Intra osseous ganglioncyst • Intra osseous extension of soft tissue ganglia • Mucoid viscous material • In 4th and 5th decade of life • Treatment: Excision and curettage
- 51.
- 52. Epidermoid cyst ofbone • Keratin filled • Lined by squamous epithelium • In skull and phalanges • Pathogenesis unknown • Treatment: Excision
- 53.
Editor's Notes
- #4 Unicameral- one chamber Simple cysts are often categorized as “active” or “latent” based on their proximity to the growth plate. Active cyst: can grow Latent: far from physis- don’t grow
- #6 Colour diff from abc
- #8 Incidentally discovered Mild pain if pathological fracture Pathologic fracture heal with closure of physis Growth arrest
- #9 Mri- not done routinely- septations, fluid levels-non specific. May resemble abc
- #10 Don’t cross physis Fallen fragment sign-fractured cortex that has settled at the dependent part
- #15 Two third to 4/5 hs of cyst removed with surrounding periosteum
- #16 Drilling done by k wires
- #17 2 to 5 injections are sufficient ground-glass ossification
- #18 If physis crossed
- #24 Clots present if blood circulation is stopped Dark red-slow but continuous circulation
- #28 If abc involves spinal cord-urgent intervention
- #29 ALP raised. But no benefit Bone scan increased uptake
- #30 Short bones- bones of the feet
- #33 Misdiagnosis of NOF or lytic osteosarcoma
- #34 Mistaken as malignancy
- #35 Smooth appearance due to new bone
- #43 Curettage-30% recurrence>radiation Wide resection- 0%recurrence
- #44 Bone graft done 4-6 months following curettage or PMMA application
- #46 3000 to 5000 cGy
- #52 Metaplasia vs implantation of ectoderm in periosteum due to trauma