4/6/2022

Test Taking –
Bone and Stem and Answers
Soft Tissue Tumors

Approach of an orthopedic tumor px

Fahd I. Aljuaid • Hx

• STEM

• Exam

4/6/202

• DDx

– AGE

• Investigation to rule out diseases (systemic and local staging)

• Biopsy (CT or US guided or open biopsy) for histopathology

• Management

– PAIN

X- ‫ في تومرز ممكن نشخصها من شي معني في الهيستوري او من شي مميز في االكزام او شي مميز في‬:‫نوت‬

– LABS

‫ على حسب يعني‬،ray

• ANSWERS

Diaphyseal tumor location
• In local staging, we’ll ask for x-ray of the whole bone, CT & MRI

• In systemic staging, (we wanna check if there’s distal metastasis, or to search for the

– TREATMENT
origin (1ry) source of the lesion) —> ask for chest x-ray, CT chest abdomen & pelvis

• Adamantanoma

• Sarcoma usu. gives metastasis only to the lung

• Usually if px > 40 YO —> bone tumors • are
Eosinophilic
d/t metastasisgranuloma
from thyroid, lung, kidney,

• Infection
breast or prostate

• Osteoid osteoma/osteoblastoma

• Uings – Ewing’s

3 • Y ‐ fibrous dYsplasia/ lYmphoma/ mYeloma

Most tumors will occur in the metaphysis

1089

Bone lesions by Age
Bone Lesions by Age

Diaphyseal location

AGE <5 <30 >30 air

it • Adamantanoma

MALIGNANT LCH (Letter‐Siwe)
LCH (Hand‐Schüller‐
Ewing’s Sarcoma
Osteosarcoma
Chondrosarcoma
Metastases

• Eosinophilic granuloma Diaphyseal location

Christian) • Infection

Metastatic  Lymphoma

• Adamantanoma
Rhabdomyosarcoma • osteoid osteoma/Osteoblastoma

Metastatic  Myeloma
• Eosinophilic granuloma
• Ewing’s
Neuroblastoma

Chordoma

• Infection

• fibrous dysplasia

Adamantinoma

• Osteoid osteoma/Osteoblastoma
BENIGN Osteomyelitis Osteoid Osteoma Giant Cell Tumor

Osteofibrous Dysplasia Osteoblastoma Pagets disease

• Uings – Ewing’s

Chondroblastoma

Aneurysmal Bone Cyst
• Y ‐ fibrous dYsplasia

LCH

OSteofibrous dysplasia

Non‐ossifying fibroma

ANY AGE infection, fibrous dysplasia, simple bone cyst sissies ci

ANY AGE – infection, fibrous dysplasia, simple bone cyst swans

anyone
1090
2 3

54

2
 KEY TEST ITEM !
• Epiphyseal lesions

KEY TEST ITEM !
Skeletally Immature ‐ Chondroblastoma

• Epiphyseal lesions
• Skeletally Mature – GCT, clear cell 

Epiphyseal lesions
Presentation
• Skeletally Immature

‐ Chondroblastoma

chondrosarcoma

(femoral head)

• Skeletally Mature – GCT, clear cell 
cinema

• Skeletally Immature ‐ Chondroblastoma
• Pain

chondrosarcoma

(femoral head)
• Skeletally Mature – GCT, clear cell chondrosarcoma (femoral head)
giant two aan us.es

• Swelling

• Pathological fracture

lesion
epiphyses
• Asymptomatic mostofthe
time

distalfan

‫ و‬epiphysis ‫ موجود في ال‬lesion‫ال‬

‫ فيصير‬metaphysis

Metaphysio-epephysio lesion

GCTGCT

Clear Cell Chondrosarcoma
Clear Cell Chondrosarcoma

chondroblastoma

chondroblastoma

492 4 5

246

246

Pain D/t mass effect on other tissues causing pain, or d/t release of cytokines, or d/t patho. fx

im

• Not associated with trauma

Osteoid Osteoma
• Path fracture


Tumorthelesion

• Malignant tumor

• Osteoid Osteoma

• Diurnal/ night

• Relieved with ASA/ NSAID

• Soft tissue sarcomas are deceptively painless

 4/6/2022

4/6/2

Osteoid Osteoma

4/6/2022

Osteoid Osteoma Bone producing tumor

Osteoid Osteoma

‫تومر يكون عظم‬

• Spine

• Young patients (<30)

Osteoid Osteoma

– Secondary scoliosis
• Spine
Senario: 15 YO px complaining of thigh pain for 3 Another Senario: px with painful scoliosis

Osteoid Osteoma

on at

– Paraspinal pain
• Characteristic diurnal pain pattern months at night improved by NSAIDS • Secondary scoliosis

relieved with NSAIDS • Spine • Paraspinal pain dit spinalme sont

anti
• Metaphyseal lesions

para on

• PROSTAGLANDIN E2
– Secondary scoliosis
camethenigutpanemencees
tumor Osteoid Osteoma

• Misdiagnosed as stress Fx
– Paraspinal pain

– Do not have same 
• Spine
• Spine
periosteal reaction
• CT shows lesion best
• Metaphyseal lesions – Secondary scoliosis

• SELF LIMITED GROWTH

– Secondary scoliosis
– DO HAVE disproportionate 

– Do not have same 

edema
– Paraspinal pain

– Paraspinal pain
periosteal reaction

• Metaphyseal lesions

• Metaphyseal lesions

– DO HAVE disproportionate 

– Do not have same 
edemaperiosteal reaction

– Do not have same 

periosteal reaction
– DO HAVE disproportionate  405

edema 8

– DO HAVE disproportionate  9

edema 4/6/2022

405

405

Osteoid Osteoma
405

Osteoid Osteoma

Osteoid Osteoma • Radiographs

Osteoid Osteoma – CT SCAN
Osteoid Osteoma CT SCAN

Osteoid Osteoma

– Large bone reaction

• Radiographs Best • Radiographs

modaityi.me
Stress fx is undisplaced fx
occurs from repetitive trauma

– Nidus <2cm
was • Radiographs •• marathon

‫ممكن يقول في الهستوري‬

Osteoid Osteoma

• Large bone reaction – Large bone reaction military recruits

runner
normal

– Large bone reaction

• Nidus <2cm it 2 – Nidus <2cm

• CT of proximal femur

– Nidus <2cm tanning

• Osteoid osteoma

y stresses

annatto

• Radiographs

– Large bone reaction

– Nidus <2cm

Qian

surrounded
by
sclerosis

stresses

406

406

406 10

11

407

203 203
203

406
 409

407
407

Osteoid Osteoma

Osteoid Osteoma
Osteoid Osteoma

Osteoid Osteoma

Osteoid Osteoma

• Histology • Histology we
• Treatment

–• Demarcation between nidus 
Histology

– Demarcation between nidus 
• Demarcation between nidus and bone
and bone • NSAIDS (diurnal prostaglandins)fopainted

and bone
– Woven bone with rimming 
• Woven bone with rimming osteoblasts

• Excise • Treatment
– Woven bone with rimming 
osteoblasts

osteoblasts
• En bloc or curettage– NSAIDS (diurnal 
• if

prostaglandins)
a
pannotimprovedwithnsains
Radiofrequency ablation (except spine or

near nv intima
bundle) b ofneuralligament
– Excise
resections

• 90°C, 6 min

• En bloc or curettage

– Radiofrequency 

ablation (except spine or 
near nv bundle)

– 90°C, 6 min

408 408

12 13

204
204

410

Osteoblastoma

Osteoblastoma

• Rare
• Age <30 Samehistology Boneforming

• NOT self‐limiting zcminsize

intermittentpain

• Pain NOT relieved with NSAIDS

14 15

 4/6/2022

413

4/6/2022

Osteoblastoma

• Radiographs

– Mixed lytic/blastic

Osteoblastoma – > 2.0 cm

Osteoblastoma
Osteoblastoma

Osteoblastoma

• Radiographs
• Histology


osteoma
osteoid
•
Radiographs
• Mixed lytic/blastic biopsy • Similar to O.O. • Histology

– Mixed lytic/blastic
• > 2.0 cm 0 ran

– Similar to
• Woven bone with nonmalignant rimmingO.O.
osteoblasts

– > 2.0 cm
– Woven bone with non‐
• Vascularized bone merges with normal

trabecular bone
malignant rimming 


osteoblasts


• Treatment
– Vascularized bone merges 

413

• with normal trabecular bone
Intralesional resection/ curettage

• Treatment


– Intralesional resection/ 


curettage

Osteoblastoma

• Histology 16 414 17
413

– Similar to O.O.

– Woven bone with non‐

malignant rimming 

osteoblasts 207
– Vascularized bone merges 
with normal trabecular bone

Osteoblastoma • Treatment
– Intralesional resection/ 

4/6/2022

4/6/2022

curettage

•
Histology

– Similar to O.O.

– Woven bone with non‐

414

malignant rimming 

osteoblasts OO 
as

– Vascularized bone merges  vs 

207
with normal trabecular bone OB ?

•
Treatment

– Intralesional resection/ 

curettage

C C Left: lesion 

< 1cm; 
414
Right lesion 

> 2 cm

207
Osteoid osteoma is best seen on CT scan

415

417
18 19

OO vs OB – SIZE MATTERS!
Osteoblastoma


OO vs Osteoblastoma

4/6/2022

• Histology OO vs OB

Enchondroma
• same

Cartilageforming

• Treatment OO vs OB

• RFA (O.O.) vs

• Intralesional resection/ curettage (O.B.)

Enchondroma

• SIZE and Symptoms

• <2cm (OO) and diurnal pain

• Cartilage rest in 

• >2cm (OB) and intermittent pain

metaphysis

• Calcified arc rings or 

punctate calcification

• No symptoms in most 

cases

• 1% of all people

20

4/6/2022

459

Enchondroma Enchondroma

Histology nosignsofmalignancy
Signs of malignancy/features of atypia

• mitosis

• inc nuclear to cytoplasm ratio

• Binucleus

Histology

‫ما تكون موجود هنا‬

• Cartilage rest in 
• Cartilage rest in metaphysis

• Acellular, lots of matrix

•
metaphysis
Calcified arc rings or punctate

• Acellular, lots of matrix
• Some clumps of cellularity
calcification matrix
• Well defined

• More cellular in hands and feet Yggenous
• Calcified arc rings or 
• Central

yeomanappear
• Some clumps of 
• Arc ring or punctate

• No symptoms in most cases

nun
a winsingle
G
calcification or popcorn
calcification

• 1% of all people
punctate calcification

cellularity

• No symptoms in most 

• More cellular in hands 

cases
and feet

• 1% of all people

460
22 23

459
230
 4/6/2022
4/6/2022

Most common tumor in hands/feet

Most common tumor in hands/feet
Tumor‐like Conditions of Bone
Most •common
Occasional pathological 
tumor in hands/feet

fracture

T •
with • Bone graft
Occasional •pathological
Occasional pathological 
fracture
Aneurysmal Bone Cyst

• • Aneurysmal Bone Cyst
• Bone Generally, enchondromas 
graft fracture

• elsewhere are not operated 
• Simple Bone Cyst
• Bone graft elsewhere are
Generally, enchondromas

on
not operated on
• Generally, enchondromas 

• • • Paget’s Disease
Distinguish elsewhere are not operated 
source of pain
Distinguish source of pain

on
Histology in hands/feet appears
• • Infection
•

malignant, Histology in hands/feet 
but is not

• Distinguish source of pain
appears malignant, but is 

• Histology in hands/feet 
not
Mostly incedental finding

‫يعني واحد طاح وملا تكشف عليه تالقي عنده تومر‬

appears malignant, but is 

not

4/

461

461
24

669

Ollier’s Disease
Ollier’s Disease

Aneurysmal Bone Cyst

Aneurysmal
Aneurysmal bone cyst
bone cyst Aneurysmal Bone Cyst

• bad
Multiple 
• fined
Multiple 

enchondromatosis
enchondromatosis

• Age <20
•
‫اللي في الجدول مكتوب انها تجي فوق عمر الثالثني نحفظها‬

Inborn error of 

• •Location
Location vertebralxray

•Age <20
Inborn error of 
‫واي شي غيرها يعتبر تحت عمر الثالثني‬

• aggressive
• Cystic, appearing at

• 25% Vertebrae
enchondral ossification  –• 25% Vertebrae
expantion

• Primary or enchondral ossification  20% Long bones metaphysis

• Cystic, aggressive 

secondary

results in mono‐ostotic 

results in mono‐ostotic 

–• 20% Long bones ‐
• 12% Hands/feet

or mono‐melic 
appearing

or mono‐melic  Remainder can be in any bone

deformity

metaphysis

• Primary or secondary
deformity
• Higher chance of 

• Higher chance of 
malignancy expanded o

– 12% Hands/feet
malignancy – Remainder can be in any 

• Can arise in pre‐

bone

existing GCT, CBMA, 

CMF, FD
462

462 26 27

231

670

671 231

335
 4/6/

671

4/6/2022
Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

• Present with pain and swelling

• MRI shows multiple•fluid
MRI shows multiple 
spaces fundkidlevel

• Present with pain and 
• Radiographically eccentric, lytic,

fluid spaces 
• Multiple fluid‐fluid lines (from settled

expansile swelling
hemosiderin)

• Multiple fluid‐fluid lines 
• Radiographically 

Aneurysmal Bone Cyst
eccentric, lytic, 

(from settled 

expansile
hemosiderin)
D/t precipitation of the blood

• hemosiderin and cells go to the bottom of the

• MRI shows multiple 
– ALSO SEEN IN GCT, 
tube, while the fluid goes up is

fluid spaces 

CBMA, OBMA, 

• Multiple fluid‐fluid lines 
Aneurysmal bone cyst is located eccentric

telangiectatic OSA!!!

(from settled 
While simple bone cyst is centric

hemosiderin)

– ALSO SEEN IN GCT, 

CBMA, OBMA, 

672
telangiectatic OSA!!!

673
28 29

336

673

Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

• Pathology

Aneurysmal Bone Cyst

– Blood filled cystic spaces

• Pathology
Simple bone cyst
– Giant cells

• spaces
• Blood filled cystic Pathology

• Giant cells – Blood filled cystic spaces

– Reactive woven bone

• Reactive woven bone – Giant cells

– Fibrous septa

• Fibrous septa – Reactive woven bone

– USP6 (17p13) gene 

– Fibrous septa
so •t USP6 (17p13) gene rearrangement
rearrangement

forimmunohistopathology

– USP6 (17p13) gene 

rearrangement

• Treatment

• Treatment
• Treatment – Aggressive, OPEN, 

• Aggressive, OPEN, currettage and bone currettage and bone grafting

grafting – Aggressive, OPEN, 

currettage and bone grafting

674

674

30 31

337

 4/6/2022 675

Simple bone cyst

Simple bone cyst
finalwithmucoidfund

Simple Bone Cyst Simple Bone Cyst

• Age 3‐14 • ‘active’ cyst abuts 

• Postulated physeal 
• Postulated physeal disturbance

physis• Age 3‐14 disturbance

• Cystic lesion • ? Resorptive erosion from increased

• • Cystic lesion  
Metaphysis of long bones

hydrostatic pressure
– ? Resorptive erosion from 

• ‘latent’ cyst has 
common
increased hydrostatic 
pressure
• Metaphysis of long 
• Present with path fracture and pain

normal intervening 
• XRAY
• XRAY

bones
• Central lucency

bone

• Thinned cortex –path

Central lucency

• Present with path 
Etiology: most likely growth disturbance

‫وتنتج هذي التومر‬

ex is
– Thinned cortex
• Width of bone no greater than width of

fracture and pain
physis – Width of bone no greater 

• ‘fallen leaf sign’ than width of physis

– ‘fallen leaf sign’

32 33

675

676
677

4/6/2022

Simple Bone Cyst

Simple Bone Cyst

• Postulated physeal 

Simple Bone Cyst

disturbance

Simple Bone Cyst

• MRI scan •shows large fluid–filled

MRI scan shows  ? Resorptive erosion from 
cavity
u • Histology

increased hydrostatic 
• Histology
large fluid filled pressure
• Dark T1, bright T2 • Thin fibrous lining

– Thin fibrous lining

• No fluid‐fluid levels • XRAY

• Fibrous tissue

cavity – Central lucency
• Giant cells
– Fibrous tissue
– Giant cells

– Thinned cortex

• Dark T1, bright T2
• Hemosiderin

– Hemosiderin
– Width of bone no greater 

than width of physis
• Treatment

• No fluid‐fluid 
– ‘fallen leaf sign’

• Treatment
– Observe
levels 

• Observe bpathexwinheat
– normally
Aspirate/inject

• Aspirate/inject – Currettage for lesions 

• Currettage for lesions at at risk for path Fx
risk for path Fx

676

34

679 35

678
338

339 KEY TEST ITEM!
ABC vs Simple Bone Cyst
 4/6/2022

KEY TEST ITEM!

ABC vs Simple Bone Cyst

ABC vs Simple Bone Cyst

Aneurysmal Bone Cyst vs Unicameral Bone Cyst

Aneurysmal Bone Cyst Unicameral Bone Cyst
Aneurysmal Bone Cyst Unicameral Bone Cyst
x
Occurs with other lesions, ‘collision lesion’ Does NOT occur with other lesions


NO fallen leaf sign Fallen leaf sign

Occurs with other lesions, ‘collision lesion’ Does NOT occur with other lesions 4/6/2022

imorany
XRAY – eccentric XRAY – central
‐ Width of the tumor is greater that the width of the physis ‐ Width of the tumor is NOT greater that the width of the 


physis
NO fallen leaf sign Fallen leaf sign


Initial TREATMENT is OPEN curettage  Initial TREATMENT aspiration/ injection

XRAY – eccentric XRAY – central

‐ Width of the tumor is greater that the width of the  ‐ Width of the tumor is NOT greater that the width of the 

physis physis

Aneurysmal Bone Cyst vs Unicameral Bone Cyst

Aneurysmal Bone Cyst Unicameral Bone Cyst

Occurs with other lesions, ‘collision lesion’ Does NOT occur with other lesions

Histology/ IHC NO fallen leaf sign Histology/ IHC
Fallen leaf sign

‐ USP6 (17p13 gene rearrangement)
XRAY – eccentric
‐ Width of the tumor is NOT greater that the width of the 
none
XRAY – central

‐ Width of the tumor is greater that the width of the physis ‐

physis

Initial TREATMENT is OPEN curettage  Initial TREATMENT aspiration/ injection

Initial TREATMENT is OPEN curettage  Initial TREATMENT aspiration/ injection

atthetune toavowhealing

681
36 37

680 Aneurysmal Bone Cyst vs Unicameral Bone Cyst

Aneurysmal Bone Cyst Unicameral Bone Cyst
Occurs with other lesions, ‘collision lesion’ Does NOT occur with other lesions

681

NO fallen leaf sign Fallen leaf sign

XRAY – eccentric XRAY – central

‐ Width of the tumor is greater that the width of the physis ‐ Width of the tumor is NOT greater that the width of the 


physis

Initial TREATMENT is OPEN curettage  Initial TREATMENT aspiration/ injection

340

Aneurysmal Bone Cyst vs Unicameral Bone Cyst

Aneurysmal Bone Cyst
Occurs with other lesions, ‘collision lesion’
Unicameral Bone Cyst
Does NOT occur with other lesions
x

Ewing’s Sarcoma
NO fallen leaf sign Fallen leaf sign

XRAY – eccentric XRAY – central

‐ Width of the tumor is greater that the width of the physis ‐ Width of the tumor is NOT greater that the width of the 

physis

Initial TREATMENT is OPEN curettage  Initial TREATMENT aspiration/ injection

682

341

682

38

341

 reaction
595 – MRI shows large soft 
tissue mass
4/6/2022 4/6/2022

4/6/2022

597

Ewing’s Sarcoma
Ewing’s Sarcoma Ewing’s Sarcoma

Bone forming tumor

4/6/2022

• Age < 30
• Radiographs

• Age < 30
• Present with soft tissue mass

Ewing’s Sarcoma
• Permeative, aggressive lesions Ewing’s Sarcoma 4/6/2022

orhairrise periosteal

• Fever •andPresent with soft tissue 
weight loss frequent
• ‘onion skinning’ or ‘sunburst’
• Radiographs
reaction • Radiographs

• Elevated mass
ESR/CRP
– Permeative, aggressive 
– Permeative, aggressive 

• MRI shows large soft tissue mass
lesions
Frequently confused with infection!!!! Ewing’s Sarcoma
lesions
• Fever and weight loss 
•

– ‘onion skinning’ or 
‘sunburst’  periosteal  – ‘onion skinning’ or 

• Radiographs

frequent
Px has presentation of an infection

So we differentiate between them by pathology

reaction
lesions
‘sunburst’  periosteal 
– Permeative, aggressive 
reaction
The cause of this –appearance
MRI shows large soft 
is

• Elevated ESR/CRP

– ‘onion skinning’ or 
– MRI shows large soft 
tissue mass
Tumor starts in the bony part and then in the
‘sunburst’  periosteal 

tissue mass

e
soft tissue
reaction
‫ بالبدايه‬aggressive ‫يقاوم التومر النها تكون‬
– ‫يحاول‬ ‫البون‬

• Frequently confused 

MRI shows large soft 
‫ويك ّون عظم جديد ويطلع الشكل هذا‬tissue mass

with infection!!!!

hsofttissue component oftumor

i ta bright

598
in ti baa
599

597
40 41

299

596
Ewing’s sarcoma
601 601 Diaphyseal/ 
• Location
Ewing’s Sarcoma
flat bones

• Tumor Aggressive, large 
soft tissue mass

• Bone triangle  Onion skin/ Codman’s 

298 601 • Radiographs
• Matrix Small round blue cells

– Permeative, aggressive 
• Skeletally
lesions

immature
– ‘onion skinning’ or 

Ewing’s sarcoma
Ewing’s sarcoma
Ewing’s sarcoma
‘sunburst’  periosteal 

Ewing’s sarcoma

reaction

600
– MRI shows large soft 

Ewing’s sarcoma
• Location : diaphyseal/flat bones appearance
Radiographic tissue mass

Radiographic
Soft appearance
tissue mass Codman’s triangle
• Tumor : aggressive, large soft tissue mass 300

Radiographic appearance

• Bone : Onion skin/ Codman’s triangle

• Matrix : Small round blue cells

• Skeletally immature
598

Esv

299

Soft tissue mass – stage IIB Codman’s triangle

Soft tissue mass – stage IIB Codman’s triangle

42

Soft tissue mass – stage IIB Codman’s triangle 43

602

602

602

301
301
301
 4/6/2022

603

Ewing’s histology

Ewing’s histology
Round blue cells

4/6/2022

• Small blue cell tumor To differentiate it from osteosarcoma

• Pseudorosettes
• Small blue cell tumor

• CD99 +
• Pseudorosettes

• CD99 +

• 11:22 reciprocal translocation

CD99• 11:22 reciprocal 

• EWS‐FLI‐1 translocation

translocation

• EWS‐FLI‐1 translocation

603
Ewing sarcoma/PNET

44 604 45

• RNA‐PCR + for type 1 EWSR1‐FLI1 

fusion

302

605

a b

Ewing’s Sarcoma

Key Items

Ewing’s Sarcoma

• Treatment • EWINGS SARCOMA

• Treatment
• Neoadjuvant chemotherapy • CD 99 IHC

• Surgerywide
• 11:22 translocation
– Neoadjuvant chemotherapy
excisionon
reconstruction

• Chemotherapy knew
• EWS‐FLI 1

– Surgery

• Prognosis • Treatment chemotherapy and limb

• Overall 60‐80%
– Chemotherapy
salvage/ wide excision

• <40% for pelvis • Prognosis

– Overall
• <20% when presents with mets 60‐80%

604 – <40% for pelvis

– <20% when presents with mets

302

606

46 47

303

 493

Chondrosarcoma
Chondrosarcoma
Aggressive

Chondrosarcoma
• Malignant cartilage tumor Mostly in

• Malignant cartilage tumor  Chondrosarcoma
• flat bones

so • Proximal femur

• Age greater than 50 • Proximal humerous

•
• Age greater than 50
2/3 develop in a previously normal bone-
primary • 2/3 develop in a 

• 1/3 develop in a pre‐existingpreviously normal bone‐
cartilage
• Location Metaphys

lesion-secondary primary • Tumor Slowly expand

• Enchondroma • 1/3 develop in a pre‐

• Osteochondroma existing cartilage lesion‐
• Bone Slowly expands
endosteal scallo

secondary • Matrix Cartilage

– Enchondroma There is calcification in X-ray bc
it’s cartilaginous

– Osteochondroma
• Skeletally

mature

494 49

4/6/2022 495 2

Chondrosarcoma
Chondrosarcoma‐location

Chondrosarcoma

Chondrosarcoma‐location

• Proximal and distal femur

• Location Metaphyseal

• Proximal humerus • Proximal and dista

• Tumor Slowly expanding
• FLAT BONES femur

• Proximal humerus
• Scapula

• Bone Slowly expands/ 
endosteal scalloping

Senario: px older than 30 years old with flat bone

lesion with soft tissue component

• Pelvis ‫ علطول‬chondrosarcoma ‫املفروض يروح بالك‬

• Matrix Cartilage

• FLAT BONES
aggressivennineineatoma

cantiagenasmatixwinancing
scanning.me
tendosted

– Scapula

• Skeletally
– Pelvis

O mature

495

50 51

496

Chondrosarcoma‐location
 4/6/2022
4/6/2022

Chondrosarcoma
Chondrosarcoma
Chondrosarcoma on MRI
on MRI on MRI 4/6/2022

Chondrosarcoma tumor‐bone interaction

Eva

• Radiographic appearance is

• Matrix

• Punctate calcifications/arcs and rings

• Cortex

Chondrosarcoma ‐ MRI
• Endosteal scalloping

• Cortical expansion

• Cortical disruption

52 53

497

497

499 4/6/2022

Chondrosarcoma – tumor‐bone interaction 
Chondrosarcoma – tumor‐bone interaction 

Chondrosarcoma‐location
Chondrosarcoma scapula

• Radiographic  Chondrosarcoma‐location
• Radiographic  in see

Chondrosarcoma scapula

appearance
appearance

• Proximal and distal femur

– Matrix

– •Matrix
• Proximal humerusProximal and distal femur

• Punctate 

• Scapula • •Proximal humerus
Punctate 
calcifications/arcs and 

calcifications/arcs and 
rings • Scapula

• Pelvis

rings

– Cortex

– •Cortex
Pelvis

• Endosteal scalloping

• Endosteal scalloping

• Cortical expansion
G
• Cortical expansion a.ee saw

• Cortical disruption

• Cortical disruption

501

498

498 500

54 55

249
250
Chondrosarcoma pelvis

249
 501 4/6/2022

Chondrosarcoma pelvis
Chondrosarcoma pelvis Chondrosarcoma

Chondrosarcoma

wing 4/6/2022 • Histology

• Chondroid matrix• Histology

• Increased cellularity – Chondroid matrix

– Increased cellularity

CT
• Binucleate cells

• – Binucleate
Degree of cellularity, mitoses and cells

– Degree of cellularity, 
cytologic atypia determines grade

• aness
Low grade CSA
aroma
vs. mitoses and cytologic

• enchondroma atypia determines grade

– Low grade CSA vs. 

enchondroma

502

56
505 57

251

511

Chondrosarcoma

• Systemic staging

Histopathology shows signs of atypia compared

to Echondroma

Chondrosarcoma
– Chest – CT or CXR

• Surgery/ wide 

• Systemic staging
excision is treatment
• Chest CT or CXR

• Surgery/ wide excision is treatment

Nochemoneeded

aemo tisslowgrowingsixes

506

253

512

58 59

256

4/6/2022

Key Items

• Chondrosarcoma

Osteosarcoma
• XRAY slow and expansile medullary/conventional ‫اهم نوع رح نعرفه هوا‬

• MATRIX punctate calcifications

OO vs Osteoblastoma

• COMMON in pelvis/ scapula/ flat bones

• Treatment surgery only

• Systemic staging

• Histology OO vs OB

• Chest CT or CXR

– same

• Treatment OO vs OB

– RFA (O.O.) vs

– Intralesional resection/ curettage 

(O.B.)

• SIZE and Symptoms

– <2cm (OO) and diurnal pain

– >2cm (OB) and intermittent 
60
4/6/2022
61

pain

419

Osteosarcoma Bone producing tumor

Osteosarcoma
Osteosarcoma
• Age < 30 years
• Age < 30 years  sunburst
• Most commonim
1°bone sarcoma
• Most common 1°
Conventional / bone 
medullary

O
• Multiple types variable sarcoma
prognosis Paraosteal

Periosteal

telangiectatic

tape
• Most common • Multiple types –
conventional
intramedullary
mostcommonsite
variable prognosis
• 50% around the knee
• Most common –
• Prox humerus secondconventional 
intramedullary
– 50% around the knee
– Prox humerus second

420
62 63

210

421
 4/6/2022

421

4/6/2022
Osteosarcoma
Osteosarcoma
• Central (90‐95%) x 4/6/2022 x 4/6/2022
• Conventional
Osteosarcoma • Location Metaphyseal
• Telangiectatic
• Osteosarcoma • Tumor Aggressive soft 
tissue mass
• Low grade – Central (90‐95%)
Osteosarcoma
4/6/2022
• Small cell
•Conventional • Bone Codman’s triangle 
•Telangiectatic
• Secondary in abnormal bone •
•
Low grade
Small cell
• Matrix Bone
• Secondary degeneration
• Location
•
•
Osteosarcoma
Secondary in abnormal bone
Metaphyseal
Secondary degeneration Osteosarcoma
• Non‐osteogenic
• Tumor
•Non‐osteogenic
– Surface (5‐10%)
Aggressive soft 
tissue mass • Skeletally
• Surface (5‐10%)
• Location Metaphyseal
• Parosteal
• Parosteal
• Bone
• Periosteal Codman’s triangle  immature
Osteosarcoma
– Extraosseous • Tumor Aggressive soft  • Location Metaphyseal
• Periosteal • Matrix Bone tissue mass

• Extraosseous • Bone Codman’s triangle  • Tumor Aggressive soft 

Usually with soft tissue extension –
stage IIB
tissue mass

• Matrix Bone • • Bone Codman’s triangle 

Location Metaphyseal
422
• Skeletally 423 • Tumor Aggressive soft 
tissue mass• Matrix Bone

• Bone Codman’s triangle 
immature 64

• Matrix Bone
65

• Skeletally • Skeletally
Usually with soft tissue extension – immature 211
• Skeletally
immature
stage IIB
immature Usually with soft tissue extension –
Usually with soft tissue extension – stage IIB
423 stage IIB Usually with soft tissue extension –
4/6/2022
Osteosarcoma stage IIB

423
427
• Plain Xray
427

• ‘hair on end’
Osteosarcoma
Osteosarcoma • ‘Sunburst’ see

• Plain Xray Osteosarcoma

Osteosarcoma
• Plain Xray

O
• ‘hair on end’
d
• ‘hair on end’ • Plain Xray • Plain Xray
misany

f
• ‘Sunburst’
• ‘hair on end’
• ‘Sunburst’ • ‘hair on end’
codmontrinsle
answer

O
camo
• ‘Sunburst’ • ‘Sunburst’ trans

424

212

424
428
424 66 67

425
428
212 214
212

214

Example:
 429

Osteosarcoma Osteosarcoma
Osteosarcoma
• Treatment
• Histology • Chemo and Surgery

– Osteoid (immature  • NO GENETIC TRANSLOCATION

bone) with  • vs Ewing’s 11:22

• Associated with GENETIC ALTERATIONS

IN THE RETINOBLASTOMA GENE (Rb)/
wi
– malignant rimming  z
p53 TUMOR SUPRESSOR GENE
osteoblasts

430 68 69

215