Bone & Joint

Tumors
 Periostal reactions
Response to RAPIDLY growing lesions

1. Spiculated "hair-on-end"
2. Onion-skinning
 Codman's triangle
 Periostal reactions
Response to SLOW growing lesions

focal cortical thickening

I. Cartilaginous Tumors
 Osteochondroma

 Solitary
Enchondroma
 Chondrosarcoma
 Osteochondroma
 Osteocartilaginous exostosis
 Most common benign tumors or tumorlike lesions
of bone,
 In almost any bone preformed in cartilage,
particularly long tubular bones,
 Presents as a solitary cartilage-capped bony
outgrowth protruding from the bone surface near
the metaphysis.
 The most common location of an
osteochondroma is in the region of the
knee,
 particularly the lower metaphysis of the
femur or the upper metaphysis of the tibia.
 occasionally in a flat bone
 such as a rib, clavicle, ilium, or vertebra.
 Pathology
A sessile or stalked, cartilage-capped,
bony protusion which extends from
the metaphysial region
 Microscopically
 bony protusion
 a cap of mature cartilage
- bony protusion
- a cap of mature cartilage
 Solitary Enchondroma

 Central Chondroma
 Composed of mature hyaline cartilage
 Develops in the medullary cavity of a single
bone
 Third to sixth decades of life
 average age : between 30 and 40 years.
 The most common location is in the
bones of the hand:
 About one-third of all cases occur in the
phalanges.
 Sometimes:
 the bones of the foot
 long tubular bone (the humerus or femur)

 pelvic bones

 shoulder girdles.
 Radiology:
 A central, or slightly eccentric, well-
circumscribed or "bubbly" radiolucent
lesion,
 finely or densely stippled with calcification.
 Pathology:
 Microscopically, small neoplastic cartilage
cells with single small nuclei
 May form lobules or facets

 May be partially calcified

- lobules or facets
- partially calcified
Enchondromatosis
(Ollier’s Disease)
 Chondrosarcoma
 A malignant cartilaginous tumor
 The third to sixth decades of life (average age of
45 years)
 Slightly more common in males than females
 Chondrosarcoma may originate in the
medullary cavity (central chondrosarcoma)
 about 75% of cases or by malignant transformation
of a preexisting enchondroma particularly in
patients with enchondromatosis,
 May originate in a juxtacortical location
(peripheral chondrosarcoma) by sarcomatous
change in the cartilage cap of an
osteochondroma.
 Location:
 flatbones of the pelvis
 the large limb bones
 femur 25%
 humerus

 the ribs
 Radiology:
 Radiolucencies (irregular or circular or
bubbly)
 Calcification (granular or lobular
radiopaque areas)
 Destruction of the inner cortex,

 Enlargement of bone contours,

 Focal periosteal reaction,

 Penetration of the cortex.

Chondrosarcoma
Chondrosarcoma
Chondrosarcoma
 Microscopy
 a lobular cartilaginous architecture,
 highly cellular,

 more than one nucleated cell per lacuna,

 occasionally reveals tumor giant cells or

clear cells,
 with increasing grades of malignancy, has
marked variation in nuclear and cellular
size and shape.
Chondrosarcoma
II. Bone-Forming Tumors
- Osteoid Osteoma
- Osteoblastoma
- Osteogenic Sarcoma
 Osteoid Osteoma

 A distinctive, small (<2 cm), solitary, benign,

tumorlike lesion of bone
 It is composed of osteoid tissue intermixed with
woven bone and surrounded by reactive bony
sclerosis.
 Osteoid osteoma most often occurs in children
and young adults.
 A frequent presenting symptom of this condition
is night pain, often relieved by aspirin, with
localized tenderness in the painful area.
 Osteoid osteoma is commonly located in
a femur or tibia,
 Radiology:
 A representative x-ray picture
 An osteoid osteoma shows a well
circumscribed, small, round or oval,
radioluscent or radiodense lesion (the
nidus)
 May be located in or near the cortex and
surrounded by densely sclerotic bone.
Osteoid Osteoma
 Microscopy
 The nidus:
 narrow trabeculae of osteoid or newly formed
bone produced by osteoblasts + vascularized
stroma
 surrounded by a sclerotic mature bone.
Osteoid Osteoma
 Osteoblastoma
 Osteoblastomas are larger (> 2 cm) than osteoid
osteomas
 Mainly osteolytic
 do not evoke reactive bone sclerosis
 Higher recurrence rate (~10%)
 Characterised by immature osteoid production
 Commonly in the cancellous bone of the spine
(posterior elements) and skull
 Osteogenic Sarcoma
 Osteosarcoma: a malignant tumor of bone
 Most common primary bone tumor after
myeloma
 In young people under 20 years of age
 Male / Female : 2/1

 Peak beyond 40 years of age:

 Secondary to preexisting disease
 Paget's disease (Paget's sarcoma)
 Previous radiation (irradiation sarcoma)

 Other conditions
 Osteosarcoma may occur in any bone
 The most frequent location is near the knee
(~50-60% of cases)
 most commonly in the distal end of the femur
 the upper end of the tibia,
 upper end of the humerus,
 pelvis,
 upper end of the femur.
 Bone-forming cells produce alkaline
phosphatase
 The serum alkaline phosphatase is markedly elevated
in many patients with osteosarcoma.
 Radiology of a long bone usually show a large,
ill-defined tumor.
 The bone-producing (osteoblastic) lesion is
located in the medulla near the metaphysis
 Lifts up the periosteum (periostal reaction)
 often producing "Codman's triangle", an angle
between the outer cortex and the elevated
periosteum,
 Sun-rays pattern
 Less common :
 destructive (osteolytic) lesions with a "moth eaten"
appearance of the cortex.
Osteosarcoma
Osteosarcoma Osteosarcoma
Osteosarcoma
Osteosarcoma: Lung mets
Microscopy
 Proliferating malignant spindle- cell
stroma
 Osteoid or immature bone
Osteosarcoma
Osteosarcoma
 III. Tumors of Other or
Unknown Histogenesis
 Ewing’s sarcoma
 Giant Cell Tumor
 Ewing's Sarcoma

 A malignant, small, round-cell tumor of

bone
 Composed of uniform, densely packed,
tumor cells with round nuclei and indistinct
cellular borders
 The histogenesis of Ewing's sarcoma
remains controversial
 Mainly in children
 second decade of life
 average age of 13-14 years

 Male/Female : 2/1
 The most common presenting symptom
of Ewing's sarcoma is bone pain,
 swelling, tenderness, and heat in the
affected part, slight fever, and elevated
erythrocyte sedimentation rate, which all
together may mimic osteomyelitis.
 Ewing's sarcoma may occur in any bone
but most frequently involves long bones.
 Femur (27%), pelvic bones (18%), tibia and
fibula (17%), humerus (10%), scapula (6%).
 Radiology:
 A mottled "moth eaten" destructive lesion
in the diaphysis
 periosteal reactive new bone
 sometimes formed in concentric layers and
producing an "onion skin" appearance, and
often accompanied by a soft-tissue mass.
Ewing's sarcoma
 Microscopically,
 uniform, densely packed, tumor cells with a
single, round or oval nucleus, indistinct cellular
borders, and a size and appearance somewhat
resembling lymphocytes (small round blue
cells).
 The tumor cell cytoplasm characteristically
contains PAS-positive glycogen granules.
 The tumor cells grow in sheets, sometimes
with central necrosis, but without pattern, such
as the rosettes typically formed by metastatic
neuroblastoma.
 Giant Cell Tumor

 An aggressive benign tumor

 Composed of :
 well vascularized stroma
 plump, spindly, and oval tumor cells

 multinucleated tumor giant cells

 Over the age of 20:

 most commonly in the third decade of life
 slight female preponderance
 The skeletal location:
 50% of cases occur near the knee
 most commonly in the distal end of the femur or
the upper end of the tibia.
 The x-ray picture :
 Large, eccentric, oval,
 Radioluscent destructive lesion centered in the
epiphysis,
 Cortical erosion and thinning,

 Expanding the bone contours without a

border.
Giant Cell Tumor
Giant Cell Tumor
 Microscopy:
1. plump, spindly, and oval stromal cells
2. multinucleated tumor giant cells which
are formed by fusion of the stromal cells
 Differential diagnosis:
 reparative granulomas
 brown tumors of hyperparathyroidism

 the lytic phase of Paget's disease

 aneurysmal bone cyst

 IV. Miscellaneous Tumors and
Tumor-like Lesions of Bone
 Multiple Myeloma
 Chordoma
 Myositis Ossificans
 Multiple Myeloma
 Multiple myeloma is a malignant tumor of
plasma cells
 Characterized by
 multiple lytic destructive lesions of bone,
 immunoglobulin abnormalities (monoclonal
gammopathy),
 bone marrow failure,
 recurrent infections,
 hypercalcemia,
 amyloid deposits,
 renal insufficiency.
 Over 40 years of age and with an average age of
60 years.
 Multiple myeloma most often involves the
vertebral column, ribs, and skull although
virtually any, or all, bones can be affected.
 The most common symptom is bone pain,
 Other symptoms
 bone marrow failure (anemia, bleeding),
 recurrent infections,
 serum hyperviscosity,
 hypercalcemia,
 renal failure of multifactorial pathogenesis (myeloma
nephropathy, associated amyloidosis,
nephrocalcinosis).
 Radiology:
 Skull, ribs, or other affected bones
 Multiple lytic "punched out" lesions.

 Osteopenia/Osteoporosis
Multiple Myeloma
 Microscopy:
 Bone marrow.
 Plasma cell tumor:
 an eccentric, round, hyperchromatic nucleus
sometimes with a "cartwheel" distribution of
chromatin
 frequent double or triple nuclei,

 abundance of cytoplasm with a purple

(basophilic) color and an occasional perinuclear
"halo",
 distinct cell borders.
Multiple Myeloma
 Chordoma

 A malignant tumor of the notochord

 Arises towards either end of the vertebral
column, most often in the sacrococcygeal
region but also in the spheno-occipital
region.
 Fifth to eighth decades of life,
 average age : 50 years
 slight female preponderance.
 Clinical x-rays :
 large soft tissue mass
 lytic destruction of the sacrococcygeal
bone.
 Pathology
 Grossly,
 large, soft, lobulated, gelatinous tumor
 extends from the sacrum and expanding into the
pelvic cavity.
 Microscopically,
 large and vacuolated, so-called physaliferous
(bubbly/drop-like) cells.
Chordoma
 Myositis Ossificans
 A nonneoplastic tumor-like lesion
 Trauma to skeletal muscle  hemorrhage
 distrophic calcification  heterotropic
ossification
 It must be distinguished from extraosseous
osteogenic sarcoma.
 Clinical x-rays:
 peripherally calcifying (ossifying) lesion
located in the soft tissues or next to bone.
 Microscopically,
 newly formed bone
 matures toward the periphery of the lesion,

 whereas the center or interior of the lesion

is cellular and poorly differentiated.
 The presence of peripheral maturity and central
immaturity of the lesion is called "zoning
phenomenon" and is characteristic of myositis
ossificans but lacking in osteogenic sarcoma.
Myositis Ossificans
 Joint Tumors
Synovial tumors
 Benign tumors
 Tenosynovial giant cell tumor
 Localized tenosynovial giant cell tumor
 Diffuse tenosynovial giant cell tumor (extraarticular pigmented
villonodular synovitis, florid tenosynovitis)
 Malignant tumors
 Synovial sarcoma
 Biphasic (fibrous and epithelial) synovial sarcoma
 Monophasic (fibrous or epithelial) synovial sarcoma
 Malignant giant cell tumor of tendon sheath
 8-10% of all sarcomas
 All ages
 Location:
 extremities
 especially the lower extremities around the
knees
 Misdiagnose  benign tumor
 small size, slow growth, and well-defined
appearance
Synovial sarcoma in the anterior left upper thigh and/or inguinal region