Bone 2nd Edition G.

Petur Nielsen
Visit to download the full and correct content document:
https://ebookmass.com/product/bone-2nd-edition-g-petur-nielsen/
 SECOND EDITION

NIELSEN | ROSENBERG
DESHPANDE • HORNICEK • KATTAPURAM • ROSENTHAL
ii
 SECOND EDITION

G. Petur Nielsen, MD
Pathologist, Department of Pathology
Director of Electron Microscopy
Director of Bone & Soft Tissue Pathology
Massachusetts General Hospital
Professor of Pathology
Harvard Medical School
Boston, Massachusetts

Andrew E. Rosenberg, MD
Professor and Vice Chair
Director of Bone & Soft Tissue Pathology
Department of Pathology
Miller School of Medicine
University of Miami
Miami, Florida

Vikram Deshpande, MD Susan V. Kattapuram, MD

Associate Pathologist Associate Radiologist
Department of Pathology Massachusetts General Hospital
Massachusetts General Hospital Associate Professor of Radiology
Associate Professor of Pathology Harvard Medical School
Harvard Medical School Boston, Massachusetts
Boston, Massachusetts
Daniel I. Rosenthal, MD
Francis J. Hornicek, MD, PhD Associate Radiologist-in-Chief
Chief, Orthopaedic Oncology Service Massachusetts General Hospital
Co-Director, Center for Sarcoma and Professor of Radiology
Connective Tissue Oncology Harvard Medical School
Massachusetts General Hospital Boston, Massachusetts
Director, Stephan L. Harris Chordoma Center
The Henry J. Mankin, MD, Endowed Scholar
Professor
Harvard Medical School
Co-Leader, Dana Farber/Harvard Cancer
Center Sarcoma Program
Boston, Massachusetts

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC PATHOLOGY: BONE, SECOND EDITION ISBN: 978-0-323-47777-2

Copyright © 2017 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Publisher Cataloging-in-Publication Data

Names: Nielsen, G. Petur (Gunnlaugur Petur) | Rosenberg, Andrew, 1953-

Title: Diagnostic pathology. Bone / [edited by] G. Petur Nielsen and Andrew E. Rosenberg.
Other titles: Bone.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2017] | Includes
bibliographical references and index.
Identifiers: ISBN 978-0-323-47777-2
Subjects: LCSH: Bones--Tumors--Handbooks, manuals, etc. | MESH: Bone Neoplasms--pathology--Atlases. |
Bone Neoplasms--diagnosis--Atlases.
Classification: LCC RC280.B6 N54 2017 | NLM WZ 17 | DDC 616.8’4--dc23

International Standard Book Number: 978-0-323-47777-2

Cover Designer: Tom M. Olson, BA
Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To my wife and family.
GPN

To my daughters, Olivia and Miranda, who are my lifelong joy; my parents,

Philip and Evelyn, who did their best; my siblings, David, Stuart, and Elaine,
who have been supportive; my friend and colleague, Al, who always has my
back; my teachers who have helped show me the way; my colleagues with
whom I have had the honor to be in the trenches; and the patients who
have given me their trust.
AER

To my father, Dhirendra, and mother, Shashi.

VD

v
vi
 Preface
The pathology of the skeleton is complex and is the morphologic expression of a broad spectrum of
diseases, including those caused by genetic (sporadic and inherited), malformative, inflammatory, metabolic,
circulatory, traumatic, iatrogenic, and neoplastic disorders. Bone tumors, including both neoplasms
and various conditions that may simulate them, are the focus of our book. This topic is one of the most
challenging areas in surgical pathology for several reasons: Bone tumors are uncommon, making it difficult
to acquire the necessary experience with their histological variants and mimics; the correct diagnosis usually
requires the careful integration of radiological imaging studies and clinical findings; the implications of a
diagnosis on a patient can be life changing; and medical schools and pathology training programs often have
insufficient expertise to provide medical students and young pathologists with the skills needed to diagnose
these lesions accurately and precisely.

This book reflects the philosophy and high standards practiced by the truly multidisciplinary team of
physicians at the Massachusetts General Hospital and University of Miami, who have diagnosed and surgically
treated tens of thousands of patients with bone tumors for many decades. Also important to acknowledge
are the contributions of the many fellows and residents who participated in the efforts of patient care.

The authors are subspecialized physicians who have dedicated their professional lives to the diagnosis and
surgical management of bone tumors. As a result, the figures include beautiful and classic examples and
unusual variants of many of the diseases discussed and are the product of painstaking correlations between
the clinical, imaging, macroscopic, histological, immunohistochemical, and molecular characteristics of bone
tumors. The text synthesizes the literature and our combined extensive experience, and the images have
been selectively culled from the patient files of the Massachusetts General Hospital, the University of Miami
Miller School of Medicine, and the private consultations of the authors. The book is constructed in a thematic
format with sections representing groups of related diseases and the chapters discussing individual entities
and their differential diagnosis.

Accordingly, this textbook serves as an excellent resource for medical students, residents, fellows, and
practicing physicians in the disciplines of pathology, radiology, and orthopedics. Medical and radiation
oncologists who treat bone tumors will also find it valuable. Our opportunity to participate in the care
of patients with bone tumors has been our call and honor, and we hope to do it justice by sharing our
experience with the medical community—our goal is to enhance diagnostic accuracy and to provide the
biological basis for optimal treatment.

G. Petur Nielsen, MD
Pathologist, Department of Pathology
Director of Electron Microscopy
Director of Bone & Soft Tissue Pathology
Massachusetts General Hospital
Professor of Pathology
Harvard Medical School
Boston, Massachusetts

Andrew E. Rosenberg, MD
Professor and Vice Chair
Director of Bone & Soft Tissue Pathology
Department of Pathology
Miller School of Medicine
University of Miami Hospital
Miami, Florida

vii
viii
Acknowledgments
Text Editors
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Lisa A. Gervais, BS
Karen E. Concannon, MA, PhD
Matt W. Hoecherl, BS
Megg Morin, BA

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Laura C. Sesto, MA
Richard Coombs, MS
Lane R. Bennion, MS

Art Direction and Design

Tom M. Olson, BA
Laura C. Sesto, MA

Lead Editor
Terry W. Ferrell, MS

Production Coordinators
Angela M. G. Terry, BA
Rebecca L. Bluth, BA
Emily C. Fassett, BA

ix
x
 Sections
SECTION 1: Benign Bone-Forming Tumors

SECTION 2: Malignant Bone-Forming Tumors

SECTION 3: Benign Cartilage Tumors

SECTION 4: Malignant Cartilage Tumors

SECTION 5: Fibrous and Fibrohistiocytic Tumors

SECTION 6: Fibroosseous Tumors

SECTION 7: Malignant Small Round Cell Tumors

SECTION 8: Notochordal Tumors

SECTION 9: Giant Cell-Rich Tumors

SECTION 10: Cystic Lesions of Bone

SECTION 11: Vascular Tumors

SECTION 12: Hematopoietic Tumors

SECTION 13: Miscellaneous Mesenchymal Tumors

SECTION 14: Metastatic Tumors

SECTION 15: Bone Tumor Mimics

xi
 TABLE OF CONTENTS

SECTION 1: BENIGN BONE-FORMING SECTION 4: MALIGNANT CARTILAGE

TUMORS TUMORS
4 Bone Island/Osteopoikilosis 138 Conventional Chondrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
10 Osteoma 150 Dedifferentiated Chondrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
16 Osteoid Osteoma 156 Clear Cell Chondrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
22 Osteoblastoma 162 Mesenchymal Chondrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD

SECTION 2: MALIGNANT BONE-FORMING SECTION 5: FIBROUS AND

TUMORS FIBROHISTIOCYTIC TUMORS
32 Conventional Osteosarcoma 172 Fibrous Cortical Defect/Nonossifying Fibroma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
52 Well-Differentiated Intramedullary Osteosarcoma 178 Desmoplastic Fibroma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
58 Parosteal Osteosarcoma 184 Myofibroma and Myofibromatosis
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
68 Periosteal Osteosarcoma 188 Fibrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
72 High-Grade Surface Osteosarcoma 194 Benign Fibrous Histiocytoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
76 Secondary Osteosarcoma 196 Solitary Fibrous Tumor/Hemangiopericytoma
Vikram Deshpande, MD, G. Petur Nielsen, MD, and G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
Andrew E. Rosenberg, MD
SECTION 6: FIBROOSSEOUS TUMORS
SECTION 3: BENIGN CARTILAGE TUMORS 200 Fibrous Dysplasia
82 Vascular Cartilaginous Hamartoma of Chest Wall G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 212 Liposclerosing Myxofibrous Tumor
84 Osteochondroma G. Petur Nielsen, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD
94 Multiple Hereditary Osteochondromatosis
Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and SECTION 7: MALIGNANT SMALL ROUND
G. Petur Nielsen, MD CELL TUMORS
98 Enchondroma 218 Ewing Sarcoma and Related Tumors
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
110 Enchondromatosis 230 Melanotic Neuroectodermal Tumor
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
116 Periosteal Chondroma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD SECTION 8: NOTOCHORDAL TUMORS
120 Chondroblastoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 234 Ecchordosis
128 Chondromyxoid Fibroma Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD
236 Benign Notochordal Cell Tumor
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
242 Chordoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD

xii
 TABLE OF CONTENTS
400 Leiomyosarcoma
SECTION 9: GIANT CELL-RICH TUMORS G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
256 Giant Cell Tumor 404 Myoepithelioma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
270 Brown Tumor 410 Schwannoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
274 Giant Cell Reparative Granuloma 414 Myxopapillary Ependymoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD, G. Petur Nielsen, MD, and
Andrew E. Rosenberg, MD
SECTION 10: CYSTIC LESIONS OF BONE 416 Phosphaturic Mesenchymal Tumor
282 Intraosseous Ganglion G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
286 Unicameral Bone Cyst SECTION 14: METASTATIC TUMORS
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 420 Metastatic Tumors
294 Aneurysmal Bone Cyst Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD
306 Epidermoid Inclusion Cyst
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD SECTION 15: BONE TUMOR MIMICS
428 Bizarre Parosteal Osteochondromatous
SECTION 11: VASCULAR TUMORS
Proliferation and Related Lesions
310 Conventional Hemangioma G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 434 Melorheostosis
318 Lymphangioma/Lymphangiomatosis G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 438 Amyloidoma
320 Epithelioid Hemangioma G. Petur Nielsen, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD
328 Pseudomyogenic Hemangioendothelioma 440 Gaucher Disease
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
334 Epithelioid Hemangioendothelioma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
340 Angiosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD

SECTION 12: HEMATOPOIETIC TUMORS

346 Langerhans Cell Histiocytosis (Eosinophilic
Granuloma)
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
352 Primary Lymphoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
360 Plasma Cell Myeloma
Vikram Deshpande, MD, G. Petur Nielsen, MD, and
Andrew E. Rosenberg, MD
368 Mast Cell Disease
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
370 Erdheim-Chester Disease
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
376 Rosai-Dorfman Disease
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD

SECTION 13: MISCELLANEOUS

MESENCHYMAL TUMORS
382 Osteofibrous Dysplasia
Vikram Deshpande, MD, G. Petur Nielsen, MD, and
Andrew E. Rosenberg, MD
386 Adamantinoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
392 Adipocytic Tumors
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD

xiii
This page intentionally left blank
 SECOND EDITION

NIELSEN | ROSENBERG
DESHPANDE • HORNICEK • KATTAPURAM • ROSENTHAL
This page intentionally left blank
 SECTION 1

Benign Bone-Forming Tumors

Bone Island/Osteopoikilosis 4
Osteoma 10
Osteoid Osteoma 16
Osteoblastoma 22
 Bone Island/Osteopoikilosis

KEY FACTS
Benign Bone-Forming Tumors

TERMINOLOGY • Homogeneously radiodense lesions with spiculated

• Enostosis margins, which merge with surrounding cancellous bone

CLINICAL ISSUES MACROSCOPIC

• Incidental radiographic finding • Hard, solid, tan-white
• Large bone islands in children may be concerning for • Periphery blends with surrounding cancellous bone
osteosarcoma MICROSCOPIC
• Rarely need to be biopsied • Consist of cortical-type bone containing haversian-like
• Multiple bone islands represent osteopoikilosis canals
• Observation for small solitary characteristic lesions, but • Predominately lamellar but may be focally woven
those that are large or have unusual features may require • Osteopoikilosis bone island tumors are identical to
biopsy sporadic, solitary bone islands
IMAGING TOP DIFFERENTIAL DIAGNOSES
• Most frequent sites include pelvis, proximal femur, and ribs • Well-differentiated osteosarcoma
• In osteopoikilosis, usually involve epiphyses of short tubular • Sclerotic metastases
bones
• Generally not much larger than 1 cm in diameter

Specimen Radiograph of Bone Island Gross Photograph of Bone Island

(Left) Specimen radiograph
shows excised femoral head
containing a bone island. The
bone island is oval and
radiodense. The periphery has
a stellate margin merging with
the neighboring cancellous
bone. (Right) Gross
photograph of femoral head
shows bone island beneath the
articular surface. The bone
island is dense, tan-white, and
has a spiculated border as it
merges with the adjacent bony
trabeculae.

Bone Island Involving Pelvis CT Scan of Pelvic Bone Island

(Left) Radiograph of the pelvis
demonstrates a uniformly
dense bone island ﬈. The
spiculated margins represent
extensions from the lesion,
which merge with the
surrounding cancellous bone.
(Right) CT of a bone island ﬈
demonstrates that it is of the
same density as cortical bone.
The absence of a lytic
component can be difficult to
confirm without additional
cross-sectional imaging, an
important feature to
distinguish bone island from
other, more sinister bone-
forming lesions.

4
 Bone Island/Osteopoikilosis

Benign Bone-Forming Tumors

TERMINOLOGY Radiographic Findings
• Small
Synonyms • Oval
• Enostosis ○ Long axis of oval is usually parallel to mechanical stresses
• Spotted bone disease on bone, representing adaptation to Wolff law
Definitions • Single or multiple
• Larger variants may abut or be based on endosteal surface
• Benign bone-forming tumor composed of cortical-type
bone that develops within medullary cavity ○ Do not involve cortex and do not elicit periosteal
reaction
• Osteopoikilosis
• Homogeneously radiodense lesions with spiculated
○ Syndrome characterized by presence of multiple (usually
margins that merge with surrounding cancellous bone
many) bone islands
○ Can be associated with Buschke-Ollendorff syndrome MR Findings
and melorheostosis-like lesions • Dark on T1WI and T2WI, similar to normal cortical bone

ETIOLOGY/PATHOGENESIS CT Findings
• Small stellate medullary lesion with characteristics of
Neoplasm
cortical-type bone
• Cause of bone island is unknown
• Osteopoikilosis may be inherited in autosomal dominant Bone Scan
fashion • Can show some uptake of radionuclide
○ Associated with mutations and loss of function in LEMD3
located on 12q14 MACROSCOPIC
General Features
CLINICAL ISSUES
• Hard, solid, and tan-white; periphery blends into
Presentation surrounding trabeculae, which accounts for irregular
• Incidental radiographic finding and asymptomatic spiculated margins
○ Large bone islands may be painful
• Uncommon in children MICROSCOPIC
• Lesions in osteopoikilosis may undergo slow, progressive Histologic Features
enlargement or involution
• Consist of cortical-type bone containing haversian-like
Treatment canals
• Observation for small solitary lesions with classic • Predominately lamellar but may be focally woven
radiographic features • Osteoblasts lining surfaces are flat and quiescent
• Larger variants or cases in adolescents may require biopsy • Osteocytes are small and cytologically banal
to exclude more aggressive lesions, such as well- • Bone islands in osteopoikilosis are identical to sporadic,
differentiated osteosarcoma and sclerotic metastases in solitary bone islands
adults
DIFFERENTIAL DIAGNOSIS
Prognosis
• Excellent Well-Differentiated Osteosarcoma
• Malignant transformation does not occur • Infiltrative, composed of proliferating mildly atypical
spindle cells and woven bone
IMAGING Sclerotic Metastases
General Features • Usually in adults and contain histologically malignant cells
• Location
○ Most frequent sites are pelvis, ribs, and proximal femur DIAGNOSTIC CHECKLIST
○ In adults, incidence in pelvic bones (1.0%) and ribs (0.5%) Clinically Relevant Pathologic Features
○ Epiphyseal in tubular bones • Multiple lesions raise differential diagnosis of blastic
○ Osteopoikilosis is bilateral and symmetrical in metastases; multiple bone islands seen in osteopoikilosis
distribution and in metaphyseal and epiphyseal regions
of tubular bones Pathologic Interpretation Pearls
– Any bone may be affected, including tarsal and carpal • Lesion is intramedullary, cortical in type, and predominately
bones lamellar in architecture
• Size
○ Usually < 1 cm in diameter SELECTED REFERENCES
○ Infrequently, "giant" bone islands several cm in diameter 1. Korkmaz MF et al: Osteopoikilosis: report of a familial case and review of the
occur literature. Rheumatol Int. ePub, 2014

5
 Bone Island/Osteopoikilosis
Benign Bone-Forming Tumors

CT Scan of Bone Island MR of Bone Island

(Left) CT scan of the shoulder
demonstrates a very large
bone island ſt of the scapula
at the base of the coracoid
process. The lesion is
uniformly and completely
dense and abuts the cortex
but does not invade or
transgress it. (Right) MR of a
round bone island ſt shows
that it is uniformly
hypointense and abuts the
cortex but does not invade or
transgress it. The marrow
adjacent to the ossified lesion
is completely normal.

Bone Island of Spine Bone Island of Spine

(Left) A bone island of the
central portion of the
vertebral body shows
characteristic features:
Uniform density and
spiculated margins ſt. The
lesion is surrounded by
unremarkable cancellous
bone, and the cortex is
uninvolved. (Right) A giant
bone island of the vertebra is
shown ſt almost filling the
entire vertebral body. Such
large lesions can show uptake
on isotope bone scans due to
their size. In other respects,
the features are similar to
conventional bone islands.

Bone Island Involving Pedicle Bone Island of Pedicle

(Left) Sagittal CT scan shows a
large bone island involving the
pedicle and facet joint of T12
ſt. The lesion fills a
significant portion of the
medullary cavity and merges
with the overlying cortex. The
intramedullary margin is
undulating and focally
spiculated. Smaller lesions are
seen in the adjacent vertebra.
(Right) Axial CT of a large
bone island involves the
pedicle and facet joint of T12
ſt. The tumor has the same
density as the cortex, which is
unremarkable.

6
 Bone Island/Osteopoikilosis
Large Bone Island of Femur
CT of Bone Island of Femur
Large Bone Island of Proximal Humerus
Benign Bone-Forming Tumors
Large Bone Island of Femur
(Left) AP radiograph of the
distal femur demonstrates a
large bone island involving the
metaphysis ﬈. Note the
spiculated margin proximally.
In this particular lesion, the
elongated shape of the lesion
is apparent, representing
adaptation to mechanical
stresses. (Right) Lateral
radiograph of the distal femur
demonstrates a large bone
island of the posterior portion
of the bone ſt. The lesion
appears to be based on the
endosteal surface and extends
into the medullary cavity.
Bone Scan
(Left) Axial CT shows a giant
bone island of the distal femur
ſt with uniform density of
compact bone and spiculated
margins. The broad base of
the tumor is attached to the
endosteal surface of the
posterior cortex. (Right)
Isotope bone scan shows a
small amount of uptake ſt in
the lateral aspect of the right
proximal humerus. A small
amount of uptake can be
present in bone islands
because they are actively bone
forming. It should not be
considered a marker of
malignancy.
MR of Bone Island of Humerus
(Left) CT scan demonstrates a
large bone island of the
proximal humerus ſt. The
lesion is eccentric, abuts the
endosteal surface of the
cortex, and extends in the
medullary cavity in an
irregular fashion. (Right)
Coronal T1-weighted MR of
the bone island of the
humerus demonstrates the
homogeneous low signal
intensity of the lesion ﬈. The
bone island is based on the
inner surface of the cortex and
has irregular margins. The
adjacent marrow is
unremarkable.
7
 Bone Island/Osteopoikilosis
Benign Bone-Forming Tumors

Osteopoikilosis Osteopoikilosis
(Left) AP radiograph
demonstrates osteopoikilosis
with multiple bone islands
involving the ends of the short
tubular bones. The small
lesions cluster at the ends of
the bones. (Right) AP
radiograph of the knees shows
the typical features of
osteopoikilosis. A large
number of small bone islands
are symmetrically distributed
in a primarily juxtaarticular
and metaphyseal distribution.
Despite their multiplicity, each
lesion individually has the
features typical of a bone
island.

Osteopoikilosis MR of Osteopoikilosis
(Left) Reformatted coronal CT
scan of the hip shows multiple
small bone islands that are
juxtaarticular and
metaphyseal in distribution.
Each lesion is individually
indistinguishable from a
solitary bone island. (Right)
T1-weighted MR of the knee in
a patient with osteopoikilosis
demonstrates that the bone
islands are small, rather
uniform in size, oval in shape,
and uniformly dense. Each
lesion is individually
indistinguishable from a
solitary bone island.

Bone Island of Mandible Gross Photo of Bone Island Arising in Rib

(Left) Coronal CT
demonstrates an
intramedullary bone island
involving the right mandible
ſt. The lesion is sclerotic with
the same density as the
surrounding cortex. (Right)
Gross photograph shows rib
and adjacent costal cartilage.
An elongate, dense, and tan-
white bone island fills the
involved segment of the
medullary cavity ſt. The
adjacent cortex and costal
cartilage are unremarkable.

8
 Bone Island/Osteopoikilosis

Benign Bone-Forming Tumors

Gross Photograph Whole-Mount Section
(Left) Gross photograph shows
an excised femoral head with
an incidental bone island ﬈.
The tumor is located beneath
the articular cartilage and
merges with the surrounding
trabecular bone. The
neighboring marrow is fatty
and unremarkable. (Right)
Low-power view shows a bone
island involving the medullary
cavity of the proximal femur
﬈. The lesion is composed of
cortical-type bone that blends
imperceptively with the
surrounding trabecular bone.

Light Microscopy Light Microscopy

(Left) Histologic section of a
solitary bone island is shown.
The bone island is composed
of cortical-type bone with
haversian-like canals and
transitions into the adjacent
cancellous bone. The
surrounding marrow is
predominately fatty with
scattered islands of
hematopoietic cells. (Right)
Bone island with numerous
haversian-like systems
scattered throughout the
lesion is shown. The bone of
the tumor is sharply
demarcated from the adjacent
marrow.

Periphery of Bone Island Osteopoikilosis

(Left) Close view of the
transition between the
periphery of the bone island is
shown as it merges with an
adjacent bone trabeculum.
The bone is woven and
lamellar and has a sharp
border with the surrounding
fatty and hematopoietic
marrow. (Right) Resected
femoral head from a patient
with osteopoikilosis shows
that numerous bone islands
are present within the
medullary cavity. The lesions
are round to oval and vary in
size. The margins are irregular
and spiculated.

9
 Osteoma
KEY FACTS
Benign Bone-Forming Tumors
TERMINOLOGY
• Benign surface bone-forming tumor, usually composed of
cortical-type bone
CLINICAL ISSUES
• Usually small and solitary
• Commonly asymptomatic and incidental finding
• Most frequently develop in craniofacial skeleton
• Appendicular tumors are very uncommon
• Multiple lesions raise possibility of Gardner syndrome
• Asymptomatic lesions can be observed
• Symptomatic lesions can be conservatively excised
IMAGING
• Small and uniformly radiodense
• Sharply marginated with well-formed periosteal reaction
• Oval to dome-shaped with broad attachment to cortical
surface
• Underlying cortex is not involved
Osteoma of Fibula
Radiograph of proximal lower leg shows a dense, well-
defined ossific mass on the surface of the proximal fibula.
There is thick, periosteal bone apposition proximal to the
mass that is triangular in shape.
10
MACROSCOPIC
• Generally < 2 cm in diameter; round, tan-white, and hard
• Resembles cortical bone with which it merges
MICROSCOPIC
• Consists mainly of lamellar bone admixed with some woven
bone
• Bone has cortical-type architecture
• Minority of osteomas composed of trabecular bone
• Lesional osteoblasts and osteocytes usually inconspicuous
DIAGNOSTIC CHECKLIST
• Well-formed cortical bone and banal cytology distinguishes
osteoma from osteosarcoma
• Intact cortex and absence of cartilage excludes
osteochondroma
• Hypocellularity of lesion is evidence against myositis
ossificans
• Melorheostosis and osteoma are histologically similar
Osteoma of Long Bone Resection Specimen
Osteoma is composed of hard, dense, compact bone with a
broad attachment to the underlying cortex. A triangular-
shaped zone of subperiosteal bone is present proximal and
distal to the osteoma.
 Osteoma

Benign Bone-Forming Tumors

TERMINOLOGY CT Findings
• Well-delineated surface mass with cortical density
Abbreviations
• Osteoma (OS) Bone Scan
• May show increased or no radiotracer uptake
Synonyms
• Torus palatinus (palate) and mandibularis (mandible) MACROSCOPIC
Definitions General Features
• Benign surface tumor composed of cortical-type bone • Generally < 2 cm in diameter
○ Minority composed of trabecular bone (trabecular • Oval, round, or hemispheric
osteoma) • Hard
• Tan to white
CLINICAL ISSUES • Resembles cortical bone with which it merges
Epidemiology • Well-formed, triangular-shaped subperiosteal reactive bone
• Incidence may surround attachment site to cortex
○ Paranasal sinus osteoma: 3-4%
○ Cranial osteoma at autopsy: 4-5%
MICROSCOPIC
○ Accounts for 0.03% of biopsied primary bone tumors Histologic Features
• Age • Admixture of lamellar and woven bone with haversian-like
○ Most common in 4th to 6th decades of life systems
• Sex • Infrequently composed of trabecular bone
○ No predilection • Growing lesion may have fibrous component mimicking
fibroosseous tumor
Site
• Osteoblasts rimming bone are inconspicuous and elongate
• Craniofacial skeleton most common ○ Growing lesions lined by plump metabolically active
○ Often located in frontal and ethmoid sinuses (75%) osteoblasts
○ Sphenoid sinus, cranium, jaw – Abundant eosinophilic cytoplasm and nuclei polarized
• Appendicular skeleton rare away from bone-forming surface
○ Long tubular bones • Inactive osteoblasts and osteocytes have small round dark
– Femur and tibia most common nuclei and no nucleoli
Presentation
DIFFERENTIAL DIAGNOSIS
• Slow-growing small lesions; usually incidental finding
• Large lesions: Symptoms related to anatomic location Bone-Forming Lesions
○ Sinus tumors: Obstruction and mucocele • Parosteal osteosarcoma
○ Orbital tumors: Exophthalmos and vision disturbances ○ Contains prominent spindle cell component
○ Oral tumors: Interfere with dentures and mastication • Juxtacortical myositis ossificans
○ Appendicular tumors: Palpable hard mass ○ Composed of hypercellular cancellous bone
• Usually solitary • Melorheostosis
○ Multiple tumors may be seen in Gardner syndrome ○ Dripping candle wax configuration
• Osteochondroma
Treatment
○ Has cartilage cap
• Observation
• Simple excision DIAGNOSTIC CHECKLIST
Prognosis Pathologic Interpretation Pearls
• Excellent, no recurrence • Well-formed cortical bone and banal cytology distinguishes
osteoma from osteosarcoma
IMAGING • Intact cortex and absence of cartilage excludes
General Features osteochondroma
• Uniformly radiodense surface lesion well demarcated from • Hypocellularity is evidence against myositis ossificans
soft tissue • Melorheostosis and osteoma are histologically similar
• Ovoid with broad base of attachment to cortex
• Dense periosteal reaction along margin of attachment may
SELECTED REFERENCES
be present 1. Halawi AM et al: Craniofacial osteoma: clinical presentation and patterns of
growth. Am J Rhinol Allergy. 27(2):128-33, 2013
MR Findings 2. Greenspan A. Benign bone-forming lesions: osteoma et al: clinical, imaging,
pathologic, and differential considerations. Skeletal Radiol. 22(7):485-500,
• Low signal intensity on T1- and T2-weighted images 1993
○ Lesion does not enhance with contrast 3. O'Connell JX et al: Solitary osteoma of a long bone. A case report. J Bone
Joint Surg Am. 75(12):1830-4, 1993

11
 Osteoma
Benign Bone-Forming Tumors

Osteoma of Femur Large Osteoma of Femur

(Left) Anteroposterior view
of the left thigh shows a
dense, well-defined ossific
mass on the surface of the
medial femur. There is
periosteal bone apposition
proximal and distal to the
attachment site ſt. (Right)
CT shows a well-defined,
homogeneously sclerotic
mass ﬈ contiguous with the
outer cortex of the femur
and extending into the soft
tissues. The underlying
cortex contains cylindrical
lucencies ﬉, which contain
feeding blood vessels that
branch into the tumor.

Osteoma Resembling Cortical Bone Osteomas in Gardner Syndrome

(Left) Gross photograph
shows osteoma of femur cut
in a sagittal plane. The mass
merges imperceptibly with
the underlying cortex. Notice
how the proximal and distal
portions of the cortex
adjacent to the mass are
thickened by reactive, well-
formed bone both proximally
and distally ſt. (Right) AP
radiograph of femur in a
patient with Gardner
syndrome shows 2 elongated
sessile osteomas. The masses
protrude from the medial
and lateral surfaces of the
cortex ſt and merge with
the underlying bone.

12

Osteoma Displacing Eye
Osteoma of Sinus Producing Mucocele
Osteoma of Palate
Osteoma
Benign Bone-Forming Tumors
Marble-Like Mass
(Left) CT shows a well-defined,
oval, homogeneously sclerotic
osteoma. The tumor is
contiguous with the outer
cortex of the orbital roof,
extends into the periorbital
soft tissues, and displaces the
globe inferiorly. The
underlying cortex is intact.
(Right) Gross photograph of
resected osteoma shows a
marble-like mass that
protrudes from the cortex. The
tumor is covered by a
translucent layer of
periosteum and is tan-white,
hard, and well circumscribed.
MR of Mucocele Caused by Osteoma
(Left) Axial CT shows a
homogeneously dense
osteoma projecting into the
frontal lobe from the inner
table of the skull. Note the
low-density area representing
a mucocele ſt surrounding
the lesion adjacent to the
frontal lobe of the brain.
(Right) T2-weighted MR shows
a heterogeneous, mostly
hypointense mass projecting
from the inner table of the
skull. There is a lobulated,
hyperintense mucocele ſt
adjacent to the lesion. The
mucocele distorts the adjacent
brain parenchyma.
Osteomas in Gardner Syndrome
(Left) In this clinical
photograph of torus palatinus,
the mass appears as a midline,
oval, tan-white lesion ﬈
beneath the oral mucosa
lining. The mucosa is intact
and translucent. (Courtesy T.
Dodson, MD.) (Right) AP
radiograph shows gnathic
bones in a patient with
confirmed Gardner syndrome.
Multiple large, lobulated
osteomas arise from the
surface of the mandible
bilaterally st. The radiodense
masses are well circumscribed
from the surrounding soft
tissues.
13
 Osteoma
Benign Bone-Forming Tumors

Osteoma at Surgery Osteoma Having Cortical-Like Features

(Left) Surgical exposure of an
osteoma of the forehead
shows that the small round
lesion is pearly white. The
tumor easily separates and is
sharply demarcated from the
neighboring soft tissues. The
vascularized periosteum ﬈
can be seen covering a portion
of the periphery of the lesion.
(Right) Hematoxylin & eosin
section of osteoma shows that
the tumor has cortical-like
architecture. The bone is
composed of an admixture of
woven and lamellar bone ſt.
Note the haversian-like canals
that are scattered throughout
the mass st.

Woven and Lamellar Bone Osteoma With Haversian-Like Canals

(Left) Hematoxylin & eosin
section of osteoma shows that
the bone is both woven ſt
and lamellar st in pattern.
The osteoblasts lining the
surface of the haversian-like
canal are not well seen ﬈,
and the osteocytes in the
matrix are small and randomly
distributed. (Right)
Hematoxylin & eosin of
osteoma shows haversian-like
canals ſt that are prominent
and vary in size and shape. The
lining osteoblasts are small
and osteocytes are numerous.
Some of the spaces are filled
with fatty marrow.

Multinodular Mass on Calvarium Trabecular Osteoma

(Left) Gross photograph shows
cancellous osteoma arising
from the inner table of the
skull. The bilobed tumor ſt
has a spongy appearance with
the intertrabecular spaces
filled with marrow. (Right)
Cancellous osteoma of the
skull merges with the
underlying inner table. The
surface of the lesion is
composed of a thin plate of
cortical-type bone, and the
central component consists of
interconnecting trabeculae of
mainly lamellar bone.

14

Mixture of Cortical and Cancellous Bone
Trabeculae Surrounded by Marrow
Myositis Ossificans
Osteoma
Benign Bone-Forming Tumors
Osteoma Composed of Trabecular Bone
(Left) Hematoxylin & eosin
section shows osteoma with
cortical ſt and cancellous ﬉
patterns. The intertrabecular
spaces are filled with loose
connective tissue, which
contains dilated feeder blood
vessels. (Right) Hematoxylin &
eosin section of cancellous
osteoma shows that the
interconnecting trabeculae
are covered by prominent
osteoblasts ﬈. The bone is
surrounded by loose
connective tissue.
Cap of Osteochondroma
(Left) Interconnecting
trabeculae in osteoma are
composed of collagen fibers
that are arranged in a lamellar
pattern. The surface
osteoblasts are inconspicuous.
The osteocytes ſt are small.
The marrow spaces are filled
with hematopoietic elements.
(Right) Osteochondroma has a
cap of hyaline cartilage that
resembles disorganized
growth plate cartilage. This
feature and the continuity of
the center of the tumor with
the underlying medullary
cavity of the originating bone
distinguishes osteochondroma
from osteoma.
Parosteal Osteosarcoma
(Left) Myositis ossificans is
hypercellular with primitive-
appearing trabecular woven
bone that merges with more
mature-appearing bone
peripherally. The appearance
of the bone and
hypercellularity helps
distinguish it from osteoma.
(Right) Parosteal
osteosarcoma is composed of
long trabeculae of woven
bone surrounded by fascicles
of spindle cells. The
architecture of the bone and
spindle cells distinguish the
tumor from osteoma.
15
 Osteoid Osteoma

KEY FACTS
Benign Bone-Forming Tumors

TERMINOLOGY • Excellent prognosis as lesion is not locally aggressive and

• Benign bone-forming tumor characterized by its small size, does not metastasize
limited growth potential, classic pattern of pain, and IMAGING
composition of woven bone trabeculae rimmed by
• Does not exceed 1-2 cm in diameter
osteoblasts
• Lesion has well-defined margins and is round, lucent, and
CLINICAL ISSUES often contains variable amount of patchy central
• Accounts for ~ 13% of all primary benign bone tumors and mineralization
3% of all other primary bone tumors • Nidus is surrounded by zone of subperiosteal or medullary
• Peak incidence: 5-25 years (76%) sclerosis
• Located in long tubular bones, especially lower extremity, • Increased uptake on bone scan
followed by posterior elements of spine and tubular bones ANCILLARY TESTS
of hands and feet
• S100 and neurofilament show nerve fibers within and
• Presents as severe localized pain that is often worse at
adjacent to tumor
night, which is relieved by aspirin or related medications
• Induces joint pain that may mimic primary articular disorder TOP DIFFERENTIAL DIAGNOSES
• Most common cause of painful scoliosis • Osteoblastoma
• Treatment of choice is radiofrequency ablation with • Intraosseous abscess (Brodie abscess)
surgical removal in select patients • Stress fracture

Oval Radiolucency Red-White Tumor

AP plain radiograph of the distal femur shows an osteoid
osteoma on the surface of the medial metaphyseal cortex.
The oval tumor (nidus) manifests a small lucency with
subtle central mineralization surrounded by a very thick
16 layer of periosteal new bone formation.
Osteoid osteoma appears as a well-circumscribed, oval,
hemorrhagic, red, solid mass. The tumor is surrounded by a
thick rind of reactive bone.
 Osteoid Osteoma

Benign Bone-Forming Tumors

TERMINOLOGY
Abbreviations
• Osteoid osteoma (OO)
Definitions
• Benign bone-forming tumor characterized by small size,
limited growth potential, classic pattern of pain, and
composition of woven bone trabeculae rimmed by
osteoblasts
CLINICAL ISSUES
Epidemiology
• Incidence
○ Accounts for 13% of benign bone tumors
• Age
○ Usually develops in adolescents and young adults
– Peak incidence: 5-25 years (76%)
• Sex
○ M:F = 2-3:1
Site
• Long tubular bones (75% of cases)
○ Proximal femur is most common location
○ Diaphysis and metaphysis (65-80%), infrequently
epiphysis
○ Subperiosteal and intracortical (70-80%), intramedullary
(25%); intraarticular is uncommon
• Vertebral column (10-14% of cases)
○ Posterior elements (90%), body (10%)
• Short tubular bones of hands and feet (8-10%)
Presentation
• Severe localized pain worse at night, relieved by aspirin or
nonsteroidal antiinflammatory medications
○ High levels of prostaglandin E2 and prostacyclins
○ COX-2 overexpression by osteoblasts
• Joint pain and effusion can mimic articular disorder
• Swelling can simulate infection with tumors in phalanges
• Painful scoliosis due to spasm of paravertebral muscles
○ Most common cause of painful scoliosis
• Overgrowth of bone when located near growth plate
• Limp and limitation of range of motion
• Usually solitary and rarely multifocal
Radiographic Findings
• Round, radiolucent with central mineralization
• Peripheral sclerosis frequent and may be extensive
MR Findings
• Isodense to skeletal muscle on T1-weighted images
• Lucent components and surrounding edema have
increased signal intensity on T2-weighted images
CT Findings
• Well-demarcated, small, round with central mineralization,
bordered by reactive bone
Bone Scan
• Marked uptake of radionuclide
MACROSCOPIC
General Features
• Round, well demarcated, gritty, dark red with central tan-
white speckles and < 2 cm
• Surrounded by dense sclerotic bone
MICROSCOPIC
Histologic Features
• Haphazard, interanastomosing trabeculae of woven bone
rimmed by osteoblasts
○ Neoplastic bone may be sheet-like or solid
○ Some osteoblasts may be epithelioid
○ Cartilaginous foci are rare
• Scattered osteoclasts often on surfaces of trabeculae
• Vascular stroma containing loose connective tissue
ANCILLARY TESTS
Immunohistochemistry
• S100 and neurofilament show nerve fibers involving tumor
Genetic Testing
• Monosomies and chromosome 22q abnormalities
Hormone Production
• Produces osteocalcin, which can raise blood glucose

Treatment DIFFERENTIAL DIAGNOSIS

• Radiofrequency ablation
○ No removal of normal tissue and outpatient procedure
• Curettage, burring, cryoablation, ultrasound therapy,
resection
• Medical therapy and observation in select patients
Prognosis
• Excellent; local recurrence rate 0-10%
IMAGING
General Features
• Lytic tumor (nidus) is 1-2 cm in diameter
• Well-defined margins and central patchy mineralization
• Surrounded by reactive sclerosis and edema
○ Extensive reactive changes simulate aggressive
neoplasm, obscures lesion
Osteoblastoma
• > 2 cm; morphologic overlap
Intraosseous Abscess (Brodie Abscess)
• Rich in inflammatory cells and granulation tissue
Stress Fracture
• Reactive woven bone network well oriented (not
haphazard) around fractured trabeculae
SELECTED REFERENCES
1. Abboud S et al: Long-term clinical outcomes of dual-cycle radiofrequency
ablation technique for treatment of osteoid osteoma. Skeletal Radiol.
45(5):599-606, 2016
2. Boscainos PJ et al: Osteoid osteoma. Orthopedics. 36(10):792-800, 2013
3. Trotta B et al: Benign osteoid-producing bone lesions: update on imaging
and treatment. Semin Musculoskelet Radiol. 17(2):116-22, 2013

17
 Osteoid Osteoma
Benign Bone-Forming Tumors

Cortical Thickening Marked Edema

(Left) A child presents with leg
pain that is worse at night,
and a radiograph shows a
region of cortical thickening
﬈. Within the area of
sclerosis is a subtle oval
lucency that represents an
osteoid osteoma ﬉. (Right)
Coronal T2-weighted MR of
the right hip shows an osteoid
osteoma ﬉ on the surface of
the bone. The tumor is
partially obscured by extensive
intramedullary, periosteal, and
soft tissue edema ﬈ (bright
white areas).

Oval Lucency With Surrounding Sclerosis Round Intracortical Tumor

(Left) Osteoid osteoma is oval,
radiolucent, and often has a
mineralized central portion
﬈. This tumor involves the
cortex and has elicited
abundant subperiosteal well-
formed reactive bone that is
sclerotic ſt. (Right) In this
axial CT, the osteoid osteoma
is intracortical and has elicited
reactive new bone within the
medullary cavity beneath the
periosteum. The tumor is
round and lytic with a small
central mineralized region.

Eccentric Tumor Intracortical Tumor

(Left) This radiograph shows
an osteoid osteoma of the
distal ulnar metaphysis. The
oval, well-demarcated, lytic
tumor ſt eccentrically
involves the cortex and is
surrounded by reactive new
bone ﬈. (Right) This axial CT
exhibits the features
characteristic of osteoid
osteoma. The tumor is small,
round, and lytic ſt with
central mineralization and is
surrounded by abundant
subperiosteal reactive bone
﬈.

18
 Osteoid Osteoma
Osteoid Osteoma of Posterior Elements
Tumor in Base of Pedicle
Round Tumor in Posterior Elements
Benign Bone-Forming Tumors
Intense Uptake
(Left) AP radiograph of the
cervical spine demonstrates a
round osteoid osteoma ſt of
the left posterior elements of
C7. The lesion is mostly lytic,
although a small amount of
central hazy mineralization is
visible. (Right) Radionuclide
bone scan (posterior view)
shows a small focus of intense
uptake st in the left posterior
elements of C7, representing
the osteoid osteoma. A larger,
but much less intense, "halo"
of uptake surrounds the lesion
representing reactive tissue
changes.
Surrounding Edema
(Left) Osteoid osteoma often
develops in the posterior
elements of the spine. In this
case, the oblong lytic tumor is
well circumscribed ſt and
involves the base of the
pedicle. (Right) Osteoid
osteoma often produces
edema of the surrounding
tissues. In this axial T2-
weighted fat-saturated image
a rim of bright intensity ſt
edematous tissue encircles the
tumor st.
Osteoid Osteoma of Vertebral Body
(Left) Sagittal reformation of
a CT scan demonstrates an
osteoid osteoma of the
posterior elements of T12. The
lesion is 1 cm in diameter ﬈,
contains ring-like internal
mineralization, and is
surrounded by dense sclerosis
﬉ of the pedicle and articular
facets. (Right) It is uncommon
for osteoid osteoma to be
centered in the vertebral body.
In this axial reformatted CT,
the eccentric lytic tumor ﬈ is
surrounded by a rim of
sclerosis ﬉.
19
 Osteoid Osteoma
Benign Bone-Forming Tumors

Marked Sclerosis Intramedullary Tumor

(Left) Axial CT of the ilium
shows an osteoid osteoma
within the cancellous bone ﬉.
It is surrounded by very dense
sclerosis ﬈, which merges
with the endosteum of the
cortex. Little or no periosteal
reaction is present. (Right)
Axial CT of the distal femur
shows a purely intramedullary
lytic osteoid osteoma ﬈. This
location is relatively
uncommon, and when it
occurs, periosteal reaction
may be minimal. Note the
irregular rim of surrounding
sclerosis.

Arthroscopic View of Tumor Red-White, Well-Demarcated Mass

(Left) Arthroscopic view of
osteoid osteoma shows the
round, bulging, red tumor. The
white tissue surrounding the
mass is smooth articular
cartilage. (Right) Gross
photograph of a resected
osteoid osteoma of the fibula
shows that the oval, red,
intramedullary tumor has a
central tan-white mineralized
region. The adjacent cortex on
one side of the mass is
thickened by subperiosteal
reactive new bone. The
periosteum is intact.

Specimen Radiograph of Osteoid Osteoma Round Tumor Straddling Cortex

(Left) Specimen radiograph of
intracortical osteoid osteoma
reveals the small, round,
lucent tumor has a central
area of mineralization ſt and
is sharply demarcated from
the surrounding reactive bone
﬈. The involved portion of
cortex has been trabecularized
st. (Right) Cross section of
intracortical osteoid osteoma
of long bone reveals the
round, red-white nidus. The
lesion has scattered white
areas and is sharply
demarcated from the
peripheral reactive bone ﬈. A
portion of the cortex is
uninvolved st.

20

Osteoid Osteoma With Sharp Margins
Osteoblastic Rimming
Plump Osteoblasts
Osteoid Osteoma
Benign Bone-Forming Tumors
Haphazardly Interconnecting Trabeculae
(Left) Low-power image of a
resected osteoid osteoma
shows a small, round nidus st
located adjacent to the
surface of the cortex ﬈. The
lesion is surrounded
peripherally by abundant
reactive bone. (Right)
Trabeculae of osteoid
osteoma are randomly
arranged and interconnect
haphazardly. Large
osteoblasts rim the woven
bone surfaces, and
intertrabecular spaces contain
loose fibrovascular tissue.
Osteoid Osteoma With Sheet-Like Bone
(Left) Large osteoblasts ﬈ rim
the surface of the bone in
osteoid osteoma. The
intertrabecular spaces are
filled with very vascular loose
connective tissue. (Right)
Osteoid osteoma composed of
sheet-like bone matrix entraps
bone-forming cells. The matrix
varies in color from pink to
purple, depending on its state
of mineralization. The
neoplastic matrix does not
encase preexisting bony
trabeculae.
Cartilage in Osteoid Osteoma
(Left) Plumb osteoblasts ſt
rim the woven bone st in this
osteoid osteoma. Some of the
osteoblasts have a perinuclear
huff that represents a
prominent Golgi apparatus ﬈.
(Right) Some osteoid osteomas
rarely have cartilage as a part
of the matrix. In this example
the basophilic cartilage ſt is
focally mineralized and is
adjacent to the eosinophilic
woven bone of the tumor st.
21
 Osteoblastoma

KEY FACTS
Benign Bone-Forming Tumors

CLINICAL ISSUES MICROSCOPIC

• Benign bone-forming neoplasm > 2 cm in dimension
• Diagnosed in young adults with male predominance of 2:1
• Commonly arises in tubular bones and posterior elements
of spinal column
• Presents with pain and swelling with neurologic symptoms
in some spinal lesions
• Treated by curettage or en bloc excision
• Excellent prognosis with local recurrence rate of 20%
IMAGING
• Expansile, well-defined mixed lytic and blastic mass with
sclerotic margins
MACROSCOPIC
• Well-circumscribed, gritty, tan-white, dark red mass
• Usually 2-5 cm in size
• Sharply demarcated from adjacent preexisting and reactive
bone
• Composed of haphazardly interconnecting trabeculae or
sheet-like aggregates of woven bone rimmed prominently
by metabolically active osteoblasts
• Intertrabecular tissue consists of loose, richly vascular
connective tissue
• Variants contain cartilage, epithelioid osteoblasts,
degenerative nuclear changes, and aneurysmal bone cyst-
like changes
TOP DIFFERENTIAL DIAGNOSES
• Osteoid osteoma
• Aneurysmal bone cyst
• Osteoblastoma-like osteosarcoma

Radiograph of Osteoblastoma Gross Photograph of Osteoblastoma

Radiograph of the humerus shows a lytic osteoblastoma of
the mid shaft surrounded by solid periosteal new bone. It
extends into periosseous soft tissues where cloud-like
neoplastic ossification is noted.
22
A long bone with an osteoblastoma involves the cortex
and surface of bone. The well-circumscribed tumor is oval
and red with speckled tan-white foci, which correspond to
areas rich in neoplastic bone.
 Osteoblastoma
TERMINOLOGY
Abbreviations
• Osteoblastoma (OB)
Synonyms
• Giant osteoid osteoma
Definitions
• Benign bone-forming neoplasm > 2 cm composed of
woven bone trabeculae lined by osteoblasts
ETIOLOGY/PATHOGENESIS
Etiology
• Neoplasm: Some have deletion of portion of chromosome
22q12; does not upregulate miRNA-210
CLINICAL ISSUES
Epidemiology
• Incidence
○ Uncommon; accounts for 1% of primary bone tumors
• Age
○ Adolescents and young adults (2nd-4th decades)
– 75% younger than 25 years old at diagnosis
• Sex
○ Males affected more frequently than females (2:1)
Site
• Most commonly arise in tubular bones
○ ~ 60% develop in appendicular skeleton
– Metadiaphyseal region of tubular bones
– Cortical: 65%; medullary cavity: 35% of cases
– Femur: 12%; tibia: 10%; bones of foot and ankle: 9%
• Axial skeleton frequently affected
○ 30% arise in spinal column
– Posterior elements: Lamina, pedicles; vertebral body
occurs secondarily
– Cervical > lumbar > thoracic > sacral
• Craniofacial bones: 10% of cases; mandible most common
Presentation
• Pain, swelling, decreased range of motion
• Spine tumors: Paresthesias, paraparesis, paraplegia
• Rarely associated with systemic "toxic" symptoms
Treatment
• Curettage or selective en bloc resection
Prognosis
• Curettage: Local recurrence in 20% of cases
• Aggressive variant behaves similar to conventional type
• Malignant transformation is exceptionally rare
IMAGING
Radiographic Findings
• Expansile, well-defined, oval mixed lytic and blastic mass
○ Peripheral lucent halo and central mineralization
○ Poorly defined margins in small minority
• Periosteal reactive bone; solid, laminated or spiculated
Benign Bone-Forming Tumors
MR Findings
• Well-delineated mass low to intermediate signal intensity
on T1 and intermediate to high signal intensity on T2
○ Mineralized areas manifest as signal void (dark)
○ Tumor and edema enhance with contrast
CT Findings
• Expansile lytic and sclerotic mass with circumscribed
margins and surrounding reactive bone
Bone Scan
• Intense uptake on scintigraphy
MACROSCOPIC
General Features
• Solitary, well circumscribed, tan-white, dark red, gritty
○ Rarely multifocal/multicentric
• Cystic changes prominent in 10% of cases
• Periosteal shell of reactive bone
Size
• Range: 2-20 cm; most measure between 3-5 cm
MICROSCOPIC
Microscopic Features
• Sharply demarcated
• Trabeculae in haphazard, interconnecting, sheet-like
patterns
○ Woven bone rimmed by plump osteoblasts and
scattered osteoclasts
• Vascular connective tissue fills intertrabecular space
• Scattered mitoses with no atypical forms
• Necrosis usually absent or focal
• Occasional cystic change mimicking aneurysmal bone cyst
• 75% epithelioid osteoblasts: Aggressive OB
○ Large, polyhedral, abundant eosinophilic cytoplasm,
vesicular nucleus, and prominent nucleolus
• Cartilaginous variant (5%) contains hyaline cartilage
• Pseudomalignant: Degenerative large, hyperchromatic,
vacuolated nuclei
DIFFERENTIAL DIAGNOSIS
Osteoid Osteoma
• < 2 cm; characteristic clinical symptoms
Aneurysmal Bone Cyst
• No haphazardly joining trabeculae of woven bone
Osteoblastoma-Like Osteosarcoma
• Grows with infiltrative pattern
DIAGNOSTIC CHECKLIST
Pathologic Interpretation Pearls
• Well demarcated: Neoplastic bone rimmed by osteoblasts
SELECTED REFERENCES
1. Lucas DR et al: Osteoblastoma: clinicopathologic study of 306 cases. Hum
Pathol. 25(2):117-34, 1994
23
 Osteoblastoma
Benign Bone-Forming Tumors

Avid Uptake on Bone Scan Osteoblastoma Expanding Bone

(Left) AP bone scan shows a
small oval focus of intense
isotope uptake on the left of
T2 ſt. (Right) CT scan through
osteoblastoma of pedicle and
lamina of the vertebra
demonstrates a well-
circumscribed, expansile, oval
mass, which contains
substantial internal fine
ossification ﬈. The tumor
impinges upon the spinal
canal. Thick periosteal
reaction is present along the
surface of the lamina and the
base of the spinous process
ſt.

Subtle Tumor in Wing of Sacrum Large Osteoblastoma of Sacrum

(Left) The sacral wing contains
a large osteoblastoma ſt that
is difficult to appreciate on the
plan film. The tumor is mixed
lytic and blastic and has a
well-defined margin. (Right)
This is the axial CT that
corresponds to the
accompanying plain film. The
round tumor ﬈ is mixed lytic
and blastic with a fine pattern
of mineralization.

Osteoblastoma Expanding Mandible Osteoblastoma of Mandible

(Left) Axial CT of a mandibular
osteoblastoma shows a well-
demarcated lytic lesion arising
in the anterior symphyseal
portion of the mandible. The
tumor has faint internal
ossifications and is surrounded
by a shell of periosteal new
bone formation ſt. (Right) A
3D reformation of a CT scan of
an osteoblastoma of the
mandible demonstrates a lytic
lesion involving the inferior
margin of the body, causing
irregular elevation of the
periosteum ſt. Several teeth
were previously removed.

24
 t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss

Benign Bone-Forming Tumors

o k e
k e Subperiosteal Osteoblastoma
o ke
ke
Subperiosteal Osteoblastoma

o
eebb o o e bboo o e b o o
(Left) Radiograph of the

b
m ee/ /e m ee/ / e
humerus shows a lytic
osteoblastoma ﬈ of the mid

: / /
/ t
/ .t.m : / /
/ t
/ .t.m shaft surrounded by solid
periosteal new bone ſt. It

t t p
t ss:
p t t p
t ss:
p
extends into periosseous soft
tissues where cloud-like

hht hht neoplastic ossification is

noted. (Right) Coronal T2-
weighted MR demonstrates
osteoblastoma ſt of the outer
surface of diaphyseal cortex

k eers
rs k e r
erss
surrounded by periosteal
bone. No mineralization is

o o
o ok oooo k detected.

oo
eebb e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
Osteoblastoma With Rim Reactive Bone

hht t t
Red Oval Osteoblastoma

hht t (Left) Specimen radiograph

demonstrates an oval lytic
osteoblastoma arising in the
cortex. Superior spatial
resolution is possible because

keerrss k eers
r s
of the absence of overlying
soft tissues. The tumor is well

b ooook b o ook
o
demarcated, contains faint

oo
mineralization ſt, and is
b
eeb ee/ e
/ e b e / e
/e b
surrounded by well-formed
reactive bone st. (Right) A
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
surface osteoblastoma is
shown. The red-gray, sharply

t p ss
p : / t p ss
p : / demarcated, solid tumor is

t
hht t t
hht t
surrounded by a thick rim of
reactive periosteal new bone
st. The medullary cavity is
filled with yellow fat.

k eers
rs
Abundant Reactive Woven Bone
k e rrss
Osteoblastoma Extending Through Cortex
e
b ooook b o ook
o
(Left) Osteoblastoma is

b oo
eccentrically located in the

eeb ee/ e
/ e b ee/ e
/e b
distal femur ﬈. The tumor is
oval, lytic, and well

: / / t
/ m
.t.m : / / t
/ m
.t.m demarcated. There is

t ppss : / t ppss : / abundant reactive bone that

forms a zone of sclerosis

t
hhtt t
hhtt
around the tumor st. (Right)
Axial CT scan accompanying
the radiograph shows a lytic
tumor that contains a small
area of central mineralization
ſt. The well-demarcated

rrss rrss
tumor is surrounded by a zone

o k e
k e o ke
k e
of sclerosis of varying
radiodensity ﬉.

o
eebb o o e bboo o e b o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 25
 t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss
Benign Bone-Forming Tumors

o k e
k e o ke
ke
Large Osteoblastoma of Humerus Osteoblastoma Eroding Cortex

o
eebb o o (Left) AP radiograph

e bboo o e b o
b o
demonstrates an unusually
large and invasive

m ee/ /e m ee/ / e
osteoblastoma of the proximal

:
humerus. The tumor is lytic
/ /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
with faint mineralization,

p
involves the metadiaphysis,
t t p
t ss:
p
hht
and extends into the
surrounding soft tissues ſt.
(Right) T2-weighted MR shows
hht
a large osteoblastoma arising
in the proximal humerus and

k eers
rs
extending into the adjacent
soft tissue. The soft tissue

k e r
erss
o o
o ok mass engulfs a portion of the
cortex ﬈. Low signal intensity
oooo k oo
eebb areas correspond to foci of
ossification.
e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
(Left) A large osteoblastoma
spans the distal epiphysis,
t
Osteoblastoma With Sharp Margins

hht t Heterogeneous Osteoblastoma

metaphysis, and diaphysis of

the distal femur. The oval
tumor ſt is lytic with fine

keerrss
trabeculations. The tumor is
well demarcated and has a

k eers
r s
b ooook sclerotic margin ﬈. The
differential diagnosis includes
b o ook
o b oo
eeb giant cell tumor of bone.
(Right) Coronal T2 fat-
ee/ e
/ e b ee/ e
/e b
saturated weighted MR shows

/
a large oval osteoblastoma ﬈

: / t
/ .
t m
. m : / / t
/ .
t m
. m
ss : /
of the distal femur. The tumor

t p p t p ss
p : /
t
has a nodular architecture and

hht t
is heterogeneous in intensity.
The tumor is well
circumscribed with mild
t
hht t
surrounding edema st.

k eers
rs k e rrss
Osteoblastoma Expanding Metatarsal
e
Multifocal Osteoblastoma

b ooook (Left) Plain radiograph of the

foot demonstrates a large
b o ook
o b oo
eeb intramedullary, expansile
osteoblastoma arising within
ee/ e
/ e b ee/ e
/e b
the 4th metatarsal. The lesion

: / / t
/ m
.t.m : / / t
/ m
.t.m
exhibits faint ground-glass

s
opacity of the sort more

t pp s : / t ppss : /
t
hhtt
characteristic of fibrous
dysplasia, indicating
microscopic internal
t
hhtt
ossification. (Right) Sagittal
T1-weighted MR through the
lower leg and foot shows a

rrss rrss
rare example of multicentric

o k e
k e
osteoblastoma. Individual low
and mixed signal intensity oval
o ke
k e
o
eebb o o lesions are present in the
anterior distal tibia ſt and
e bboo o e b o
b o
talus ﬈.

m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
26
hht hht
 t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss

Benign Bone-Forming Tumors

o k e
k e Large Cystic Osteoblastoma
o ke
ke
Large Osteoblastoma With Hemorrhage

o
eebb o o e bboo o e b o o
(Left) Large round

b
m ee/ /e m ee/ / e
osteoblastoma from the spine
is shown. The hemorrhagic

: / /
/ t
/ .t.m : / /
/ t
/ .t.m
tumor has undergone
extensive cystic change

t t p
t ss:
p t t p
t ss:
p
causing it to mimic an
aneurysmal bone cyst. Some of

hht hht the cystic spaces are filled

with clotted blood. (Right) A
large, solid and cystic
osteoblastoma arises in the
proximal fibula in a growing

k eers
rs k e r
erss
child; note the growth plate
st. The tumor involves the

o o
o ok oooo k medullary cavity and extends

o
through the cortex and into

o
eebb e/
e e
/ b
e b e / e
/ b
eb
the soft tissues where it is
covered by reactive bone ſt.

e
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
Osteoblastoma With Abundant Bone

hht t t
Osteoblastoma Expanding Bone

hht t (Left) An osteoblastoma of the

scapula is shown. The oval,
well-delineated tumor is solid
tan-red and contains abundant
neoplastic bone ﬈. The

keerrss k eers
r s
adjacent cortex is thickened by
reactive bone ſt. (Right) A

b ooook b o ook
o
resected osteoblastoma is

oo
shown involving the distal
b
eeb ee/ e
/ e b e / e
/e b
sacrum. The tan hemorrhagic
tumor involves 2 consecutive
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
vertebral bodies crossing the
intervertebral disc and

t p ss
p : / t p ss
p : / protruding into the anterior

t
hht t t
hht t
soft tissues where it is
surrounded by reactive bone
﬈. The spinal canal is visible
﬉.

k eers
rs
Expansile Osteoblastoma of Rib
k e rrss
Subperiosteal Tumor
e
b ooook b o ook
o
(Left) Expansile

b oo
osteoblastoma of the rib has

eeb ee/ e
/ e b ee/ e
/e b
well-circumscribed margins.
The tumor is red-tan and the

: / / t
/ m
.t.m : / / t
/ m
.t.m
tan areas correspond to

t ppss : / t ppss : / mineralized matrix. (Right)

This osteoblastoma arises on

t
hhtt t
hhtt
the surface of a long bone.
The tumor is tan-white, gritty,
and contains scattered
hemorrhagic cysts that are
peripheral in location. The
tumor is well defined from the

rrss rrss
adjacent cortex ﬈ and is

o k e
k e o ke
k e
covered by periosteum ſt.

o
eebb o o e bboo o e b o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 27
 t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss
Benign Bone-Forming Tumors

o k e
k e o ke
ke
Sharply Demarcated Osteoblastoma Sharp Margin

o
eebb o o (Left) Low-power view shows

e bboo o e b o
b o
margin of an osteoblastoma.
The tumor contains abundant

m ee/ /e m ee/ / e
haphazardly interconnecting
trabeculae of woven bone,
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t
﬈ from the surrounding ss:
which is sharply demarcated

p t t p
t ss:
p
hht
uninvolved cancellous and
cortical bone. (Right) A sharp
margin of an osteoblastoma is
hht
shown with adjacent
cancellous bone. The cellular

k eers
rs
tumor contains many small
neoplastic bony trabeculae ﬉

k e r
erss
o o
o ok with intervening loose
fibrovascular tissue. The
oooo k oo
eebb uninvolved bony trabeculae
are large and well formed.
e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
(Left) An osteoblastoma is
composed of irregular
t
Woven Bone Trabeculae of Osteoblastoma

hht t Interconnecting Trabeculae of Bone

trabeculae of woven bone.

The surfaces of the bone are
rimmed by prominent

keerrss
osteoblasts. The
intertrabecular space is filled

k eers
r s
b ooook with loose fibrovascular tissue.
Many blood vessels are
b o ook
o b oo
eeb congested with red blood cells.
(Right) Plump osteoblasts ﬈
ee/ e
/ e b ee/ e
/e b
line the surfaces of the
neoplastic bone. Scattered

: / / t
/ .
t m
. m : / / t
/ .
t m
. m
ss :
osteoclasts ſt are also found

t p p / t p ss
p : /
t
on the surfaces of the woven

hht t
bone. Many dilated, blood-
filled capillaries course
amongst the bony trabeculae.
t
hht t

k eers
rs k e rrss
Osteoblastoma With Epithelioid Cells
e
Epithelioid Osteoblasts

b ooook (Left) A cellular

osteoblastoma is shown with
b o ook
o b oo
eeb irregular trabeculae of woven
bone. Scattered large
ee/ e
/ e b ee/ e
/e b
epithelioid osteoblasts ﬈ are

: / / t
/ m
.t.m : / / t
/ m
.t.m
present. Some of the

ss : /
neoplastic bone is mineralized

t pp t ppss : /
t
hhtt
and dark magenta in color ſt.
(Right) In an aggressive
osteoblastoma composed of
t
hhtt
epithelioid osteoblasts, tumor
cells are large, polyhedral, and
contain abundant eosinophilic

rrss rrss
cytoplasm and vesicular nuclei

o k e
k e
with prominent nucleoli. The
neoplastic bone is coarse and
o ke
k e
o
eebb o o lace-like in appearance.

e bboo o e b o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
28
hht hht
 t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss

Benign Bone-Forming Tumors

o k e
k e
Prominent Osteoblastic Rimming
o ke
ke
Large Osteoblasts of Osteoblastoma

o
eebb o o e bboo o e b o o
(Left) Interconnecting

b
m ee/ /e m ee/ / e
trabeculae of bone are
characteristic of

: / /
/ t
/ .t.m : / /
/ t
/ .t.m
osteoblastoma. The pink-
purple bone is covered by a

t t p
t ss:
p t t p
t ss:
p
layer of osteoblasts. The
nuclei of the osteoblasts tend

hht hht to be polarized away from the

bone-forming surfaces. (Right)
High-power H&E shows
neoplastic osteoblasts in an
osteoblastoma. The

k eers
rs k e r
erss
polyhedral cells have
abundant purple cytoplasm,

o o
o ok oooo k which contain a prominent

o
perinuclear Golgi apparatus

o
eebb e/
e e
/ b
e b e / e
/ b
eb
﬈ and eccentric nuclei. The
pink tumor bone is woven in

e
: // t
/ .
t m
. m : / /t/.tm. m
architecture.

t p ss
p : / tp pss : /
t
Cystic Change

hht t t
Hemorrhagic Cystic Change

hht t (Left) Low-power view shows

a cystic osteoblastoma. The
cystic spaces are small and
contain red blood cells. The
solid portion consists of

keerrss k eers
r s
interconnecting trabeculae of
woven bone. Cystic spaces can

b ooook b o ook
o
cause confusion with

oo
aneurysmal bone cyst. (Right)
b
eeb ee/ e
/ e b e / e
/e b
A cystic osteoblastoma is
shown with a large cystic
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
space filled with red blood
cells and fibrin. Areas

t p ss
p : / t p ss
p : / diagnostic of osteoblastoma

t
hht t t
hht t
are visible in the cyst wall
consisting of haphazardly
interconnecting trabeculae of
woven bone lined by
osteoblasts.

k eers
rs
Osteoblastoma With Cartilage
k e rrss
Pseudomalignant Change
e
b ooook b o ook
o
(Left) An osteoblastoma with

b oo
a nodular cartilaginous

eeb ee/ e
/ e b ee/ e
/e b
component is shown. The
neoplastic blue cartilage is

: / / t
/ m
.t.m : / / t
/ m
.t.m
hyaline in type, moderately

t ppss : / t ppss : / cellular, and adjacent to the

bone-forming component of

t
hhtt t
hhtt
the tumor. The neoplastic
bone has a trabecular pattern
and is lined by osteoblasts.
(Right) An osteoblastoma is
seen with pseudomalignant
change. Pseudomalignant

rrss rrss
features manifest as enlarged

o k e
k e o ke
k e
nuclei that are dark and
hyperchromatic. Surrounding

o
eebb o o e bboo o e b o
the bone is collagenous tissue

b o
with small blood vessels.

m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 29
 t t ppss : t t ps
ps :
hhtt hhtt
This page intentionally left blank

k e rrss
e keerrss
o o
o o k oooo k o o
eebb ee/e/ebb ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t

k eers
rs k e r
erss
o o
o ok oooo k oo
eebb e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t

keerrss k eers
r s
b ooook b o ook
o b oo
eeb ee/ e
/ e b ee/ e
/e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t

k eers
rs k eerrss
b ooook b o ook
o b oo
eeb ee/ e
/ e b ee/ e
/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : /
t
hhtt t
hhtt

k e rrss
e ke rrss
e
o o
o o k oooo k o o
eebb ee/e/ b
eb ee/ e
/ b
e b
: / /t/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
Another random document with
no related content on Scribd:
The doctor took a small bottle out of his pocket, saying, "I must, I
suppose. I would rather have waited for Dr. Haddon."

He mixed a few drops with water, and gave the glass to Mrs. Eyre.

"Flo, you must drink this," Mrs. Eyre said softly. And Flo, having
learned long ago to obey that gentle voice, checked her wild outcry
and swallowed the medicine at once.

"Oh, mamma! is that you?"

"Yes, darling. Lie still; I want you to go to sleep."

"But—the big black dog."

"There is no dog here. Close your eyes, Flo; try to sleep."

Flo obeyed, and slept uneasily for about half an hour. During this
sleep, Mrs. Eyre whispered to the nurse, "Mrs. Dooner, I must just
run down and see what has become of the other children."

Mrs. Dooner did not know that they had gone away, and the doctor
did not hear what was said. Mrs. Eyre left the room.

Poor Hetty, half stupefied with grief and terror, heard her step, and
knew it. The child had ceased to cry. What had happened? She
could not face her kind mistress. She could not bear to hear her say
"Go," as her master had done. She could not bear to hear that the
child was dead. She started up, crept out of the room, and ran out of
the house.

She went to the railway station, and was told that there would not be
another train until seven o'clock—a slow train, the ticket clerk told
her, but she could not understand him, she was so dazed. There was
a seat close by, and she crawled over to it, and sat there until the
train ran in. Then she took her ticket, and got into a third-class
carriage.
The door was opened just as the train was starting, and a woman
got in. At the same moment something white made its appearance.
Zelica sprang into Hetty's lap.

"Is the cat yours?" inquired the porter.

"Oh, Zelica, Zelica!" cried Hetty. "You don't know what we've done."

The man looked at the woman who had just got in, and said, "I hope
the girl's in her right mind."

The woman half rose, but sat down again, saying, "I'm only going to
the next station, and she's but a slip of a girl." And as Hetty sat quite
quiet, she was soon satisfied that there was no danger.

It was a long, weary journey. The train stopped at every station, and
sometimes where there was no station at all. Hetty felt as if she was
dreaming, and could not wake. She did not even cry, and whether
the noise she heard were the whistle of the engine or Flo's screams,
she did not know. But at last they reached B—, and she left the train.
She had a long way to walk, but she did not think of that; she went
slowly along with the cat in her arms. At last she reached the
straggling street of Little Hayes, and then she found herself at her
mother's door.

It was shut, of course, for it was nearly midnight. Hetty tapped with
her hand, and when no notice was taken of this, she tried to call out,
and could not. Then she picked up a little stone and hammered at
the door. She heard the door of the inner room open and her
mother's voice, crying, "Dan! Ned! Get up and come down. The
house must be on fire, the police are knocking at the door."

Dan, however, was so sound asleep that he never heard her, and
Ned only said, "Yes, ma'am, directly," and relapsed into sleep.

Mrs. Hardy and Matty, in their night-gowns, opened the door; and
instead of the policeman they expected to see, there stood Hetty.
The light from Mrs. Hardy's candle fell upon her white face as she
stumbled in, letting the cat fall. Zelica walked over to the fireplace
with an air of dignity, and selected the warmest spot to lie down in.

"Oh, you unfortunate child what's wrong with you now?" said Mrs.
Hardy.

"I have killed Miss Flo!" Hetty answered, in a hoarse whisper. "She's
dead, or dying; the master told me to go home, for he couldn't bear
the sight of me. Mother," holding out her trembling hands, "don't you
hate me, for oh, I'm just dead myself."

Mrs. Hardy made no answer in words. She just took the poor girl in
her arms and kissed her. Hetty clung to her, but neither cried nor
tried to explain; and Mrs. Hardy was very much frightened.

"Matty, get a chair; help me to put her in it. There. Now tell me, Hetty,
my poor child, tell me what happened. I'm very sure you never hurt
Miss Flo a'purpose. Maybe things aren't as bad as you think."

"Yes, I'll tell you all. Where shall I begin? Oh, it was a girl gave me
some shrimps—that was the beginning."

"Well?—go on. Did you give the child the shrimps to eat?"

"No—oh, no! It was—Zelica. She—mother, I can't remember. I'm

worn out. Matty, don't look at me like that—you've no call to be afraid
of me. I'll go away if you like, but take care of Zelica—Miss Flo's pet."

"The girl isn't herself," said Mrs. Hardy. "Help me to get her to bed,
Matty; maybe she'll come to when she has slept."

They made her a cup of tea, and then got her to bed. She fell asleep
at once; and in the morning her mind was somewhat clearer. But she
was not a bit like Hetty. She told her story, but she never once cried
over it. If she had wept and bemoaned herself as usual, her mother
would have had plenty to say to her, but this trembling, silent girl
frightened the good woman out of her wits.
It was on Friday night that Hetty came home, and on Saturday she
was too ill to get up; but Mrs. Hardy made inquiries, and found out
that the child was certainly alive. On Sunday Hetty dressed herself,
and said, "I'll go up to Adelaide Terrace. Maybe Mrs. Goodenough
may know something."

"I'll go with you," said Matty. "I'll be back in time for church, mother."

The two sisters walked together, almost in silence. The door was
opened by Mrs. Goodenough. This worthy creature had questioned
Lina, and had a general idea as to what had happened.

"Well!" said she, "I think, in your place, Hetty Hardy, I'd have had the
decency to stay away."

"Have you heard how Miss Flo is?"

"Just alive—that's all. There's that boy crying again! Master John, if
you don't stop, I'll spank you! The master brought the three home,
and said I must stay here and take care of them."

"Troublesome they are, too—but of course I couldn't refuse."

"They're all crying," said Hetty miserably. "Mrs. Goodenough, let me

come in and mind them."

"Let you come in! The master says to me, says he, 'Mrs.
Goodenough, I look to you—I've turned Hetty Hardy out for bad
conduct, and if she comes here, send her about her business;
character she'll get none,' says he, 'and I'll send a policeman after
her if the child dies, for it's manslaughter, if not murder!' So good-
bye, Hetty; don't be coming here any more. It's my turn to shut the
door with you on the wrong side of it now."

She shut the door accordingly.

"Hetty dear, the half of that is not true. Mr. Eyre never spoke like that.
You never meant to hurt the child, and—"
"No, I did not. But it's all my fault. Nothing's too bad for me!" And she
turned wearily to walk home again.

On the way they met Fred Smith, who you may remember was
employed in the Little Hayes post office.

"Why, Hetty!" he cried. "Whatever ails you?"

Hetty shook her head and walked on, but Matty lingered to tell Fred
what was wrong.

"Poor Hetty!" he said; "and she is so fond of the child! I'll tell you
what, Matty: I'll go this very moment, and find out about the trains,
and I'll go to R—, and bring Hetty word how the child is."

"But, Fred, it is Sunday!"

"Yes, and my Sunday out, or I could not go. Oh, never you mind,
Matty; I'm sure I am not doing wrong in trying to comfort poor Hetty
when she's in such trouble. I owe her a good turn, for she made me
downright ashamed of myself once."

It was late in the evening when he came to the Hardy's.

"Is that you, Fred Smith?" Mrs. Hardy said. "Dan's out."

"I've brought Hetty good news, ma'am. The little girl is much better,
they think. Mr. Eyre is coming home to-morrow, but Mrs. Eyre is to
stay till the child can be moved."

"Oh, Fred, thank you!" said Hetty. "It's very kind of you to come and
tell me."

"He did more than that for you," Matty said. "He went to R— to
inquire."

"Oh, I like to get a sight of the sea," Fred remarked hurriedly. "Good-
night, ma'am. I must get home."
"It was very kind, all the same," said Hetty again. "Oh, if Miss Flo
gets well, what a load will be off my heart! They can never forgive
me, I know; but I do love Miss Flo."

CHAPTER X.
FORGIVEN.

IT was a very, very sad time for Hetty. She did not know, when she
used to cry and bewail herself over her misfortunes, that she could
be as unhappy as she was now. She longed for news of little Flo,
and many a time did she steal up to Adelaide Terrace to question
Mrs. Goodenough, at times when she knew that Mr. Eyre was out.

Worthy Mrs. Goodenough gave her scant information, and less

comfort. If she might be believed, Mr. Eyre spent a good deal of his
scanty leisure in telling her that he thought Hetty very little better
than a murderer, and that she should never so much as see Miss Flo
again.

Hetty was so dejected that she believed all this, and even thought
that Mr. Eyre did not say a word too much; but Matty stoutly declared
that Mrs. Goodenough invented these speeches for Hetty's benefit.

Mrs. Hardy had no reason to complain of Hetty now, for she worked
hard all day, and never cared to go out, except for her melancholy
pilgrimage to Adelaide Terrace, or to go to church.
Meantime, little Flo was really very ill, and suffering greatly both in
mind and body. Her terror about the big black dog was such that the
doctor said that no questions must be asked about her part in the
day's misadventures, nor must she be in any way reminded of them.

Mrs. Eyre, however, did not forget poor Hetty, and she took some
trouble to find out that the story she had told her master was the true
one. The shrimp-girl, and a lad who had met the poor girl in the lane,
and put her into the right road, confirmed Hetty's story. Not many
women, with little Flo before their eyes, would have taken so much
trouble about poor, heedless Hetty, who certainly was fortunate in
her mistress.

After about a month Flo got better. The pain decreased, and she
became calmer and more like her little self. Of course, Mrs. Eyre was
anxious to get home, for the three children there were both unhappy
and troublesome under Mrs. Goodenough's care. So as soon as it
was at all safe Mr. Eyre came to R—, and Flo was carefully
conveyed home.

Up to this time the child had not spoken of Hetty since her mother
had silenced her constant cry for her. But as she grew stronger, and
returned to her familiar home and her familiar habits, Mrs. Eyre
became aware that there was something weighing on little Flo's
heart,—some question that was often on her lips, though she
seemed afraid to ask it. A little questioning soon made the child
speak out.

"Mamma, you bid me speak no more of Hetty. I know the big dog
must have killed Zelica, but did he kill my dear Hetty too?"

"Oh no, my dear child. Hetty is quite well, and safe in her mother's
house."

"Then why might I not speak of her?"

"You misunderstood me, dear; you kept calling, calling, and I only
meant to quiet you."
"But if Hetty was not hurt, why did she not stay with me and nurse
me, mamma?"

"Well; dear, Hetty was to blame about that day—she had left the hut
while you were asleep, to search for Zelica, I believe; but, indeed, I
do not know exactly what happened. Papa sent Hetty away."

Flo was too well taught to question papa's doings; but that very
evening she began begging him to bring Hetty back.

"I want her so much. I do love Hetty. Just tell her that 'Miss Flo'
wants her, and I know she will come at once. She loves me so."

"My dear, I sent her away because it was through her carelessness
that this accident happened to you. When mamma has time, she will
look about for a nice, kind girl to carry you; and now we'll say no
more about Hetty."

To this hint Flo declined to attend. She was very weak, and mamma
had others to attend to now, and could not devote herself to Flo as
she did while at R—, and Flo cried for Hetty far too often for her own
good, and began to look as bad as ever.

Hetty, no longer daring to come to the house, used now to waylay

Mrs. Goodenough on her way home, to ask about Miss Flo. One day
the old woman did not appear at her usual time; it was quite evening
before she came, but Hetty waited all the time.

"Well, Hetty, here you are, to bother me about that child, that's the
worrit of the whole house! The crossest, complainingest little worry
that ever I did see! Morning, noon, and night, the cry is—"

Here Mrs. Goodenough paused. She had very nearly said the word
"'Hetty,'" but that, she thought, would rejoice the poor girl, so she
substituted "'Zelica.'"

"'Zelica! I want Zelica!' That's always on her lips; little peevish brat! I
wonder how her mother keeps her hands off her!"
"I declare," cried Hetty, "I never thought of that. I suppose they think
Zelica is lost."

"Lost she surely is, and a good thing too. But that redic'lous child
thinks some dog ate her! She was in such a state this morning,
declaring I hurt her lifting her up, that we could get nothing done.
That's why I'm late. Mrs. Eyre's going to get a girl in your place,
otherwise I'd have to quit; but I suppose I shan't be turned out this
time, as you're not there to carry tales."

All this did Mrs. Goodenough say, with the amiable wish to make
Hetty miserable; but this time she failed, for Hetty did not know what
she was saying. She was thinking about Zelica, and Zelica's little
mistress, and now with a hasty "good-evening" she turned away and
went quickly home. Mrs. Goodenough immediately made a kind of
general proclamation that "Hetty Hardy was getting to be a greater
fool every day."

Hetty went home, and procured a sheet of notepaper and Matty's

pen and ink. She then sat down to write. It took her a long time, but
at last, with a deep sigh, she folded up her paper, caught up Zelica
from her comfortable nook by the fire, and ran out into the now
almost dark evening.

The Eyres were at supper, or tea, as they called it. Flo was on her
sofa, looking smaller than ever; presently Lina and Edgar ran off to
play, and Mr. Eyre drew a chair over and sat down near Flo.

"Come, my little girl, you haven't eaten any of the nice bread and jam
I cut for you. Try to eat a little bit, Flo. Why are you crying? You make
poor mamma and me very sad."

"I can't help it, papa. I am so sorry for poor dear Hetty. I do want
Hetty—I love her."

"What is that?" cried Mrs. Eyre, as a slight noise was heard.

"It was the window. I suppose the sash has closed a bit. I must see
to it to-morrow, or it may catch somebody's fingers."

But the sash had not closed—quite the contrary. Some one outside
had pushed it up a tiny bit more, and behold!—in walked, fat, snow-
white, and beautiful as ever, Mrs. Zelica! Purring loudly, she marched
over to the sofa, sprang up, curled herself up in her own particular
place, and looked at the astonished assembly with a condescending
and self-satisfied air. What a fuss a little dog would have been in!
What waggings of the tail, and ecstatic wriggles, mingled with small
strangled squeals of joy at seeing his dear mistress again! But
Zelica, being but a cat, just blinked at them all, and felt important.

"Why! Oh, my Zelica! Is this you? Then he didn't eat you? Where
have you been? Who brought you? Oh, mamma! 'Twas Hetty—my
dear, dear Hetty! Oh, run, call her to me! I do love Hetty!"

Mr. Eyre sprang up and went to the door; but Hetty was gone.

Flo did not know how to make enough of Zelica. But the loving little
heart was not satisfied. Mrs. Eyre, who had gone to the window
when her husband ran to the door, had found poor Hetty's letter, but
she slipped it into her pocket, and said nothing about it until the
children were in bed. Then she said,—

"John, there was a letter left on the window-sill. I have it here. I did
not want to excite poor Flo. Here it is, dear; read it to me."

For she had baby in her arms.

"'My dear mistress,'" began John, in a stern tone of voice, which,

however, softened as he read on,—

"'I hope I may be forgiven for writing to you. Mrs.

Goodenough told me to-night that Miss Flo still cries
after Zelica. I did not know that she was well enough to
care for her yet. I found her at the station that day; she
 must have followed me there.'"

"'Dear mistress, try to forgive me. I am too sorry to

know how to say it. I do not feel as if I could ever be
happy any more. After all your kindness, and the
master's, such a return to make and, loving Miss Flo
with all my heart, to be so wicked about her. I know
master was right to send me off, and he never could
trust me any more. I am glad Miss Flo has forgotten
me. I pray continually that she may grow strong and
well, and I hope your new girl will be fond of her, and
patient with her.'"

"'If you could say you forgive me, maybe I could be

more at rest. Sometimes I get stupid, thinking of Miss
Flo; for indeed, ma'am, though you may well not
believe it, I do love both of you, and I think I shall never
forget what I felt when I got back to the hut, and could
not find her.'"

"'I remain, ma'am,'"

"'Your poor, bad servant,'"

"'HESTER
HARDY.'"

"Poor girl," said John Eyre to himself, as he folded up the letter.

"That old Goodenough! Why, Flo thought Zelica was dead; and as to
forgetting Hetty, I wish she had!"

"It would be very ungrateful of her if she had, for Hetty was very
good to her."

"Poor girl!" said the master again.

"John, dear, I must have a girl; and, to be frank with you, I would
rather have Hetty than a stranger. She is so gentle and patient, and
so perfectly truthful. She is a really good girl, and it is not so easy to
find a really good girl. Besides, Flo is too ill to be reasonable, and
she will not like any stranger, because she is longing for Hetty."

"Well, dear, I know I told the girl never to let me see her face again,
but—I suppose we had better make our poor little Flora as happy as
we can while we have her with us. But I tell you fairly, I think we
ought never to lose sight of the girl when she has the cart of Flo. She
is so terribly heedless, though, as you say, a good girl for all that."

"Then I may see her to-morrow?"

"Yes; but don't tell Flo till you are sure of her."

So it came about that once again Mrs. Eyre tapped on the half-
closed door of Mrs. Hardy's house, and was told to "come in."

"Why, if it isn't Mrs. Eyre!" cried Matty joyfully.

"Mrs. Eyre! Matty, you're a—But it is, for all that. Ma'am, I'm nearly
ashamed to face you."

"You have no cause to be, Mrs. Hardy. Hetty is a good girl, and, if
she was heedless, we must remember that she is very young. It was
a great misfortune; but, you know, if the dog had not awakened my
poor little girl, no harm would have been done. Where is Hetty?"

"I sent her into town for some things we wanted, but she must soon
be home. A dog, did you say? I've heard nothing of a dog. Indeed,
Hetty does not rightly know yet what happened to Miss Flora."

"Well, Hetty went, as you, I am sure, know, to look for the little cat.
Zelica led her a regular chase, and when she got back the child was
gone."
"Yes," said Matty, "and the shawls on the path, and the cat's basket
all torn, and some shrimps a girl gave her all mashed up. Oh,
ma'am! she dreams of it often—you never saw the like."

"What had really happened was this. Flo woke up to find the dog—a
big, rough-haired creature-tearing at the cat's basket; and, I confess,
I think it was well for Zelica that she was not in it; but the dog would
not have hurt Flo on any account; in fact, he did not touch her. She
screamed for Hetty, the dog got at the shrimps and tried to eat them,
and while he was at that work my poor little girl got up and tried to
run away. She actually dragged herself some way down the steep
path, when the dog came after her, and she fell. Mr. Eyre thinks that
the creature saved her from falling over the edge, for he was sitting
between her and it, in great distress. He belongs to the
stationmaster, and is a most good-natured dog, very fond of
children."

Matty had seen her sister come in, but Mrs. Eyre did not, her back
being turned to the door. Hetty stood, listening and trembling, and
now seemed about to steal out again; but Matty stopped her.

"Now, Hetty," said she, "you know what really happened."

Mrs. Eyre turned round, and Hetty covered her face with her hands.
Mrs. Eyre fully expected a burst of tears, and "Oh, I'm so sorry,
ma'am!" but there were neither tears nor words.

"My poor girl! My poor Hetty! Have you never a word to say to me?"

"No, not one." Mrs. Hardy spoke for her. "There's something come to
the girl, ma'am, for dear knows her tears and her tongue used to be
ready enough. I used to be tired hearing, 'Oh I'm so sorry, mother!'"

"Oh, I used to say that," said Hetty; "but I was only sorry because
things were broken, or because you were angry. I was not sorry for
my own fault, because I did not think it a fault—only a misfortune.
Though Matty warned me, and made me promise to pray against it, I
never did—I forgot. I thought how unlucky I was to be so
thoughtless; but since I've been at home I've been thinking, and I
see now that it's a sin. Oh, ma'am, if you could only forgive me, I'd
take heart and try to do better. I'll take Matty's way now, for I'm sure
it's the right one."

"You are quite right, Hetty. We are all of us more given to one fault
than to others, and only God can cure us of them. He gives us time,
and grace, and many lessons; some, sad ones. This has been a sad
one to you, but you see it has opened your eyes to your sin. As to
forgiving you, I do indeed, Hetty, and so does Mr. Eyre."

"And Miss Flo? Oh! Does she forget me altogether?"

"Forget you? No, indeed—she is never done crying for you. And she
is so ill and so weak that you must come back to her, Hetty."

Hetty opened both mouth and eyes as wide as ever she could, and
uttered the most extraordinary shout; the poor girl really did not know
what she was doing.

"Hetty! Behave, do! To yell like that in a lady's very ears! Eh! Here
come the tears! I've got my poor Hetty back again. I didn't know that
one with a silent tongue and dry eyes. You're a lucky girl, Hetty, to
have such people to do with as your master and mistress; and
indeed, ma'am, the girl's been breaking her heart after you."

Matty took her sister away into the other room, where she kissed her,
and coaxed her, and cried with her, and altogether contrived to quiet
her so that she was in a fit state to set out at once with her mistress.

"Dan shall bring your things up in the evening, Hetty," said her
mother. "And now, my dearie dear, remember this time as long as
you live, and don't fall back into idle ways. Remember what Matty
said to you: you'll find it's true. These thoughtless doings are real
sins, and it's only God can change your heart. God bless you, Hetty!
I'm glad for you, child."
On the way to Adelaide Terrace Hetty asked many questions about
Flo's state.

"I don't see how you can bear the sight of me, ma'am, nor Miss Flo
either."

"You'll soon know what she thinks about it, Hetty. And you know, if
you had got back and found her still asleep, so that no harm was
done, your fault would have been exactly the same, yet you would
have expected me to forgive you. It seems to me, therefore, that we
ought to forgive you now. You must learn not to measure a fault by
its consequences; you were wrong to leave the child, and it would
have been just as wrong if poor Black Rover had not visited the hut
while you were absent. Do you understand, Hetty?"

"I think I do, ma'am. Oh, I must try very hard."

"Ah! Hetty, trying hard won't do, not by itself. I will talk to you about
this some day soon. But now, here we are at home," Mrs. Eyre said,
as she knocked at the door.

Mrs. Goodenough opened it; her face was really worth seeing when
she recognised Hetty.

"You see, Mrs. Goodenough, I've brought Hetty Hardy back, and you
will be pleased, I hope, to hear that it is partly your doing. She wrote
to me after hearing from you that Miss Flo was still fretting after the
cat. Stay here for a moment, Hetty; I will just say a word to the child
and then call you."

But it was Flo's weak little voice that called—

"Hetty! Oh Hetty! My own good Hetty! Come to me quick!"

It was not for a few days that Mrs. Eyre found time for the talk with
Hetty which she had promised her. But one morning, Flo being
asleep, and the others out, Mrs. Eyre said: "Hetty, you know you and
I were to have a serious talk; for I did not say what I wished to say to
you that evening."

"I remember, ma'am. You were saying that trying hard won't do, by
itself. Ma'am, if you'll believe me, Matty told me that when I was
coming here, that first time, and I never minded. I didn't really
understand. But I do now. I see plain enough that it is not in my own
strength that I can cure my heedlessness. And I know now that it is a
sin, and not just a misfortune, as I used to call it. But indeed, ma'am,
I do not think I could ever forget this lesson."

"Perhaps not. But, Hetty, try to think of what I am going to say to you.
You are an affectionate girl, and so, to please those you love, you
would do nearly anything. When you ran off to search for Zelica, I
know well it was because the loss of the little cat would have grieved
Miss Flo so much. But you see what came of it, and you know now
that you did wrong. Now, had you asked yourself, not what would
please Miss Flo, but what it was your duty to do—then you would
have stayed at your post, and the child would have been safe."

"So it always is, Hetty. The moment our motive is less than the
highest; the moment we act to please this person or that, without
remembering that we have to please God, that moment we go
wrong. I want you to pray, as Matty said to you; but, dear Hetty, pray
that God will give you such a love for Him, your Father, who sent His
Son to save you from your sins, that to please him may become the
first thought of your heart. Will you do this, Hetty? Do you
understand me?"

"I do, ma'am. You've said the like to me before, and so has Matty, but
I didn't heed; I seemed not to understand. But all the time I was so
unhappy about Miss Flo, those thoughts seemed to come back to
me. And I will pray, as you tell me, ma'am. Indeed, I do love Him
even now, though not as I ought; for He has been very merciful to
me. Oh, ma'am!—when I think that she might have been killed! How
could I have borne it, when it was my doing?"

"Indeed, Hetty, we all have much to be thankful for."

Well, if Hetty was not entirely cured of her heedlessness, she was
certainly cured of treating it as a mere misfortune, for which she was
to be pitied. And the best proof of her improvement was that in no
long time Mr. Eyre quite laid aside his distrust of her, and ceased to
be uneasy if she was left in charge of Flo.

Flo was very ill for a long time, and often they thought that a few
weeks more would see the close of her suffering and her life. But
she at last began to improve; and, to the great joy of all who loved
her, she continued to get steadily better, until at last she could walk
about nearly as well as Lina. She grew a great deal, too, and health
brought back her pretty pink colour, and the unchildlike gravity
vanished from her face.

Indeed, if the truth must be told, Miss Flora was rather a troublesome
lassie for a time; for it seemed as if all the fun and frolic she had
missed had to be got through somehow. But she sobered down
again, and is a very good girl, and a great comfort to her parents.
Lina is married, and Flo is the home daughter, helping her mother,
and caring for the younger children.

As to Hetty, after ten years of faithful service, she left her dear
mistress, and still dearer Miss Flo, to become the wife of Fred Smith,
who is now postmaster in the very office where she was once too
late for the London post, thanks to the attractions of Punch and Judy.
And as Fred is a good, steady, God-fearing man, we may hope that
she will be as happy as she deserves to be, I think; even though she
once earned the name of Heedless Hetty.

Butler & Tanner, The Selwood Printing Works, Frome, and London.
 *** END OF THE PROJECT GUTENBERG EBOOK HEEDLESS
HETTY ***

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright in
these works, so the Foundation (and you!) can copy and distribute it
in the United States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part of
this license, apply to copying and distributing Project Gutenberg™
electronic works to protect the PROJECT GUTENBERG™ concept
and trademark. Project Gutenberg is a registered trademark, and
may not be used if you charge for an eBook, except by following the
terms of the trademark license, including paying royalties for use of
the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as
creation of derivative works, reports, performances and research.
Project Gutenberg eBooks may be modified and printed and given
away—you may do practically ANYTHING in the United States with
eBooks not protected by U.S. copyright law. Redistribution is subject
to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE