BY : DR.ASHWIN CHAIRPERSON: PROF.B.S.

NAZEER

INTRODUCTION
y A team comprising an orthopaedic surgeon,

radiologist, pathologist, radiation oncologist, and medical oncologist is necessary to treat the spectrum of musculoskeletal tumors. y Other surgical specialists frequently are required, such as a vascular surgeon, thoracic surgeon, or plastic surgeon. y The orthopaedic surgeon must be well versed in the principles of oncological surgery, and the radiologist and pathologist should have a special interest in bone and soft-tissue tumors.

GENERAL APPROACH TO MUSCULOSKELETAL TUMOURS
y An adequate history and physical examination

are the first and most important steps in evaluating a patient with a musculoskeletal tumor. y Patients may present with pain, a mass, or an abnormal radiographic finding detected during the evaluation of an unrelated problem y Patients with bone tumors most frequently present with pain.

y Family history occasionally can be helpful. this is rarely of diagnostic significance.. but more often complain of a mass.g. female predominance with giant cell tumors).y Patients with soft-tissue tumors rarely complain of pain. y Although some tumors show a sex predilection (e. . as in cases of multiple hereditary exostosis and neurofibromatosis.

consistency. local temperature. shape. y Atrophy of the surrounding musculature recorded. and change with position should be noted. tenderness. mobility. y A mass should be measured. as should neurological deficits and adequacy of circulation.y The physical examination include 1) evaluation of the patient's general health 2) a careful examination of the part in question. and its location. . y Café au lait spots or cutaneous hemangiomas also may provide diagnostic clues.

y BENIGN 1. Latent 2. Aggressive . Active 3.STAGING OF TUMOURS y Benign and malignant tumors of bone and soft tissue can be staged according to the Enneking staging system .

Enneking Staging (malignant) STAGE IA GRADE LOW SITE INTRACOMPARTMENTAL METASTASES NONE IB LOW EXTRACOMPARTMENTAL NONE IIA HIGH INTRACOMPARTMENTAL NONE IIB HIGH EXTRACOMPARTMENTAL NONE III ANY ANY REGIONAL OR DISTANT METASTASES .

AJCC System for staging soft tissue sarcomas Stage I Grade Low Size Any Depth Any Metastases None II Low 5 cm Any None High >5 cm Superficial None III High >5 cm Deep None IV Any Any Any Regional or distant .

AJCC System for staging bone sarcomas Stage I-A I-B II-A II-B III IV-A IV-B Grade Low Low High High Any Any Any Size 8 cm >8 cm 8 cm >8 cm Any Any Any Metastases None None None None Skip metastasis Pulmonary metastases Nonpulmonary metastases .

y Radiographic features include a well-defined margin with a thick rim of reactive bone. .BENINGN TUMOURS STAGE 1 ( LATENT ) y lesions are intracapsular. and frequently incidental findings. y These lesions do not require treatment because they do not compromise the strength of the bone and usually resolve spontaneously. y usually asymptomatic. There is no cortical destruction or expansion.

y Treatment usually consists of extented curettage . . y Usually they have only a thin rim of reactive bone. y are actively growing and can cause symptoms or lead to pathological fracture.STAGE 2( ACTIVE ) y lesions also are intracapsular. y They have well-defined margins on radiographs but may expand and thin the cortex.

and local recurrences are common. y Their aggressive nature is apparent clinically and radiographically. and metastases may be present in 5% of patients with these lesions. They usually have broken through the reactive bone and possibly the cortex. y MRI may show a soft-tissue mass. y Treatment consists of extended curettage and marginal or even wide resection.STAGE 3( AGGRESSIVE ) y lesions are extracapsular. .

y If a tourniquet is used.y A biopsy should be planned as carefully as the BIOPSY definitive procedure. y provide more information leading to a more accurate pathological diagnosis. y Placement of the biopsy incision is a crucial decision because the biopsy track needs to be excised en bloc with the tumor. the limb may be elevated before inflation but should not be exsanguinated by compression. and radiographic examinations are complete. Biopsy should be done only after clinical. and avoids artifacts on imaging studies. laboratory. .

because a hematoma would be contaminated with tumor cells. should be round or oval to minimize stress concentration and prevent a subsequent fracture. if possible. hole made in the bone. core needle biopsy. The periphery of a lesion usually contains the most viable tissue and is the best tissue on which to base a diagnosis. If a tourniquet has been used.y Transverse incisions should be avoided . or an open incisional procedure . y Soft-tissue extension of a bone lesion should be y y y y sampled. A biopsy can be done by fine needle aspiration. it should be deflated and meticulous hemostasis ensured before closure.

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ADJUVANT THERAPY y In includes : y 1) RADIATION THERAPY y 2) CHEMOTHERAPY RADIATION THERAPY Radiation causes cell death by inducing the formation of intracellular free radicals that subsequently cause DNA damage. The goal of radiation treatment is to deliver the highest possible dose of radiation to the tumor cells. . while minimizing toxicity to normal tissues.

y Most primary bone malignancies are relatively radioresistant. y Exceptions are the marrow cell tumors. which are each exquisitely sensitive. lymphoma.y After a single treatment of 200 cGy. all cells in the most sensitive phase of the cell cycle are killed. . y Radiation therapy is associated with significant acute and long-term complications. and Ewing sarcoma. including multiple myeloma.

meaning close ). Currently using this technique more frequently with good results . hollow catheters are implanted in the tumor bed at the time of resection. Postoperative radiographic evaluation and computer calculations determine the optimal loading of the catheters with radioisotopes. These catheters exit through the skin. By this method.BRACHYTHERAPY y Radiation can be delivered by brachytherapy y y y y (from the Greek. brachys. This technique allows for high doses to be delivered to the target tissues.

Brachytherapy catheters .

or micrometastases. the current 5-year survival rate for osteosarcoma is approximately 70%. y Neoadjuvant chemotherapy refers to chemotherapy administered before surgical resection of the primary tumor. on presentation. With the use of modern chemotherapy protocols.CHEMOTHERAPY y 80% of patients with apparently localized osteosarcoma actually have undetectable metastases. . y Adjuvant chemotherapy refers to chemotherapy administered postoperatively to treat presumed micrometastases.

y Alkylating Agents Mustards : Ifosfamide Cyclophoshamide Platinum Compounds : Cisplatin Carboplatin Antimetabolites: Methotrexate Topoisomerase .

Interactive Agents y Antitumor Antibiotics :Doxorubicin Dactinomycin y Epipodophyllotoxins :Etoposide Antimicrotubule Agents Vinca Alkaloids (Vincristine) .

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BENIGN BONE TUMOURS 1) BONE FORMING TUMOURS Osteoma Osteoid osteoma Bone island 2) CARTILAGE LESIONS Chondroma Osteochondroma 3) FIBROUS LESIONS Nonossifying fibroma Cortical desmoid Fibrous histiocytoma Fibrous dysplasia Osteofibrous dysplasia Desmoplastic fibroma .

3) CYSTIC LESIONS Unicameral bone cyst Aneurysmal bone cyst Intraosseous ganglion cyst Epidermoid cyst 4) FATTY TUMOURS Lipoma 5) VASCULAR TUMOURS Hemangioma 6) NON NEOPLASTIC CONDITIONS Paget disease Brown tumor of hyperparathyroidism .

OSTEOID OSTEOMA y Osteoid osteoma is a benign neoplasm most often seen in young men. y Multicentric lesions have been reported. y Found in the second or third decades of life. y No malignant change has ever been documented. y The typical patient with an osteoid osteoma has pain that is worse at night . with half the cases involving the femur or tibia. y predilection for the lower extremity. y The tumor may be found in cortical or cancellous bone.

y Plain radiographs often are sufficient to make the diagnosis.5 cm) central nidus with surrounding bony sclerosis. y The lesion usually is surrounded by a sclerotic rim. . y CT is the best study to identify the nidus and confirm the diagnosis. y The microscopic appearance consists of fibrovascular tissue with immature bony trabeculae that are rimmed by prominent osteoblasts.y Imaging studies usually are diagnostic. y The lesion consists of a small (<1.

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. percutaneous radiofrequency ablation. (enbloc excision & burr down technique ) 2) lesions of the pelvis or long bones of the extremities can be treated with percutaneous radiofrequency ablation y Differential diagnosis: Brodie s abscess. eosinophilic granuloma.y Treatment options 1) are medical treatment. and open surgical procedures. chronic osteomyelitis.

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A radiofrequency ablation probe under CT guidance .

also called enostoses. y Almost any bone can be involved. are benign lesions of cancellous bone. y They usually are asymptomatic and are discovered incidentally. It is unclear whether they represent a developmental abnormality or neoplastic process. y Osteopoikilosis is a rare condition consisting of multiple small bone islands throughout the skeleton. y Autosomal dominant and sporadic forms of the syndrome have been identified. .BONE ISLANDS( Enostoses) y Bone islands.

y Diagnosed by plain radiographs. y If a patient experiences pain. y Most patients with bone islands can be treated with observation with serial plain radiographs. or sclerotic myeloma. biopsy is indicated to rule out more aggressive lesions. . blastic metastasis. such as a sclerosing osteosarcoma. y Radiating spicules on the periphery of the bone islands merge with the native bone creating a brushlike border. y They typically are small. round or oval areas of homogeneous increased density within the cancellous bone . or if the lesion grows.

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they arise on the surface of the bone. y The phalanges of the hand are the most common location. y All age groups are affected. y Chondromas usually are asymptomatic. y Rarely. where they are referred to as enchondromas. where they are referred to as periosteal chondromas or juxtacortical chondromas. . They are the most common tumor of the small bones of the hands and feet. y arise in the medullary canal.CARTILAGE LESIONS CHONDROMA y Benign lesions of hyaline cartilage.

and bowing of the long bones. is a y y y y rare condition in which many cartilaginous tumors appear in the large and small tubular bones and in the flat bones. Tumors are located in the epiphysis and the adjacent parts of the metaphysis and shaft.(Ollier disease).y Multiple enchondromatosis. . It is caused by failure of normal endochondral ossification. Associated with hemangiomas of the overlying soft tissues. Deformities include shortening caused by lack of epiphyseal growth. broadening of the metaphyses. the disease is known as Maffucci syndrome.

y In more proximal locations. deep endosteal erosion (two thirds of the thickness of the cortex) frequently indicates a chondrosarcoma. enchondromas are benign- appearing tumors with intralesional calcification. y An associated soft-tissue mass is never present with an enchondroma and always indicates a chondrosarcoma. y Plain radiographs are usually sufficient to diagnose a chondroma. or popcorn.y Radiographically. punctate. y The calcification is irregular and has been described as stippled. .

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Enchondroma with pathological fracture .

Enchondroma with calcification .

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Multiple enchondromatosis (Ollier s disease )

y The microscopic appearance of a chondroma

is that of mature hyaline cartilage Treatment of patients with solitary enchondromas usually consists of observation with serial radiographs. y If the lesion remains radiographically stable and asymptomatic, no further intervention is indicated. y If a lesion grows, or if it becomes symptomatic, extended curettage usually is curative. y Recurrence rates are low.

OSTEOCHONDROMA
y Osteochondromas are common benign bone

tumors. y They probably are developmental malformations rather than true neoplasms . y Thought to originate within the periosteum as small cartilaginous nodules. y The lesions consist of a bony mass, often in the form of a stalk, produced by progressive endochondral ossification of a growing cartilaginous cap. y Their growth usually parallels that of the patient and usually ceases when skeletal maturity is reached. y Female : male ratio is 1.4 : 1

y Cause no symptoms and are discovered incidentally. the proximal tibia. and the proximal humerus. Pedunculated tumors are more common . Some cause pain by irritating the surrounding structures.y Seen most often on the distal femur. y The physical finding usually is a palpable mass. y Osteochondromas are of two types: 1)pedunculated 2) broad-based or sessile. y Multiple hereditary exostoses constitute an autosomal dominant condition.

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y Incidence of malignant degeneration to be approximately 1% for patients with a solitary osteochondroma and 5% for patients with multiple hereditary exostoses. y Occasionally.y The projecting part of the lesion has cortical and cancellous components. calcification within the cap may be seen. . both of which are continuous with corresponding components of the parent bone. y The lesion is covered by a cartilaginous cap that often is irregular and usually cannot be seen on radiographs.

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Pathogenesis of osteochondroma .

y Patients with multiple hereditary exostoses may require osteotomies to correct deformity. or when imaging features suggest malignancy.y Surgery (en bloc resection) is indicated when the lesion is large enough to be unsightly or produce symptoms from pressure on surrounding structures. may develop on a distal phalanx. y Excision is indicated when elevation of the nail produces pain. y A similar lesion. . especially of the great toe. subungual exostosis. y Often there is a definite history of trauma.

y Also known as metaphyseal fibrous defects. y Approximately 40% are found in the distal femur. fibrous cortical defects. y Lesions occur in the metaphyseal region of long bones in individuals 2 to 20 years old.FIBROUS LESIONS NON OSSIFYING FIBROMA y Common developmental abnormalities and are believed to occur in 35% of children. y On X-RAY appears as a well-defined lobulated lesion located eccentrically in the metaphysis. . 40% in the tibia. and fibroxanthomas. and 10% in the fibula.

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y Treatment for lesions that are larger than50% of the diameter of the bone . the defect is filled with spindleshaped cells distributed in a whorled or storiform pattern.y Multilocular appearance or ridges in the bony wall. sclerotic scalloped borders. y Most nonossifying fibromas are asymptomatic and regress spontaneously in adulthood. y There is no periosteal reaction in the absence of a pathological fracture. y Histologically. and erosion of the cortex are frequent findings.

y Exist in a monostotic or polyostotic form. woven spicules of bone. cutaneous pigmentation. y Mazabraud syndrome is polyostotic fibrous dysplasia with intramuscular myxomas.FIBROUS DYSPLASIA y Fibrous dysplasia is a developmental anomaly of bone formation . or diaphysis. . and endocrine abnormalities. metaphysis. y The hallmark is replacement of normal bone and marrow by fibrous tissue and small. y occur in the epiphysis. y McCune-Albright syndrome refers to polyostotic fibrous dysplasia.

. y Surgical treatment is indicated when significant deformity or pathological fracture occurs or when significant pain exists. y The X-ray appearance is characteristic. with the lucent area having a granular.y Malignant change has been reported occasionally with and without prior radiotherapy. groundglass appearance. y Recurrence rates are high after curettage and bone grafting. cortical bone preferred over cancellous grafts (or bone graft substitutes) because of their slower resorption.

FIBROUS DYSPLASIA .

y The tibia is enlarged and often bowed anterolaterally. y Usually affecting the tibia and fibula. it may encroach on the metaphysis.OSTEOFIBROUS DYSPLASIA y Ossifying fibroma of long bones. y Also known as Campanacci disease. . y Patients usually are in the first two decades of life. y The middle third of the tibia is the most frequently affected location. and although the lesion usually is diaphyseal.

y Histological studies reveal zonal architecture with loose fibrous tissue in the center of the lesion and a band of bony trabeculae rimmed by active osteoblasts at the periphery. . unless pathological fracture has occurred. y The lesion must be distinguished from adamantinoma and monostotic fibrous dysplasia. y X-rays show eccentric intracortical osteolysis with expansion of the cortex.y Pain usually is absent.

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UNICAMERAL BONE CYST y Common lesions of childhood. y The lesions are most active during skeletal growth and usually heal spontaneously at maturity. . y 85 % occur in the first 2 decades with a 2 : 1 male predominance. the ilium and calcaneus are more common locations. y Developmental or reactive lesion than a true tumor. y In adults. y Unicameral bone cysts are most common in the proximal humerus and femur.

y Two thirds of patients present with fractures. 3) Prominent osseous ridges on the inner cortical wall may give it a multiloculated appearance.y Unicameral bone cysts often are asymptomatic. purely lytic lesion with a well. unless a pathological fracture has occurred. 2)The cyst may expand concentrically. but never penetrates the cortex. y Plain radiographs shows 1)centrally located. which can stimulate the cyst to heal. marginated outline (diagnostic for a unicameral bone cyst. unless there has been a fracture. 4)No periosteal reaction is present. .

MRI showing dark signal on T1 & T2 images .

y Occasionally (20%). y Unicameral bone cysts start as metaphyseal lesions that abut the physis in growing children. . a thinned cortical fragment fractures and falls into the base of the lesion confirming its empty cystic nature. y Unicameral bone cysts are classified 1)active when they are within 1 cm of the physis 2)latent when they are closer to the diaphysis. This fallen fragment sign is pathognomonic of a unicameral bone cyst with a fracture.

. lines the cyst wall. serous fluid. rather than endothelial cells. 2) This leads to increased pressure. Unicameral bone cysts are filled with a clear yellow. which leads to focal bone necrosis and accumulation of fluid. A fibrous membrane.Pathogenesis : 1) focal defect in metaphyseal remodeling blocks interstitial fluid drainage. usually less than 1 mm thick. The lining of a unicameral bone cyst is composed of fibroblasts. unless a pathological fracture has caused bleeding into the cavity.

asymptomatic lesions in the upper extremities can be treated with observation with serial plain radiographs. or other materials). symptomatic lesions. y Larger lesions (lesions at risk for pathological fracture).y Small. demineralized bone matrix. bone marrow aspirate. and lesions in the lower extremities usually are treated with: 1)curratage (with or without bone grafting or internal fixation) or 2)aspiration and injection (often using steroids. .

. y Works either by an antiprostaglandin effect or by decreasing the pressure of the cyst. y Steroid injection was described as an effective new treatment option that was inexpensive and involved less morbidity. y Generally. and the age of the patient. the size of the lesion.Fractures through unicameral bone cysts in the proximal femur should be treated with curettage. bone grafting. y Reduces the recurrence rate. and internal fixation( Flexible intramedullary nailing). 80 to 200 mg of methylprednisolone is used. depending on the size of the patient.

and cancellous allograft. y 2)high-porosity hydroxyapatite. calcium sulfate.Other materials used for percutaneous treatment of unicameral bone cysts include : y 1)autogenous bone marrow mixed with allograft demineralized bone matrix. .

accounting for 15% to 20% of these entities. proximal tibia.ANEURYSMAL BONE CYST y Aneurysmal bone cysts are locally destructive. and spine. blood-filled reactive lesions of bone and are not considered to be true neoplasms. are located in the posterior elements y occur in patients younger than 20 years old. y Vertebral lesions. . y there is a slight female predominance. distal femur. y Commonly involves proximal humerus. y Most patients complain of mild to moderate pain present for weeks to several months.

y MRI shows the multiloculated cavities and fluid levels. y When differentiating between a unicameral and aneurysmal bone cyst using MRI.y Rapid growth can occur and clinically may mimic a malignancy. . the presence of a double-density fluid level and intralesional septations usually indicates an aneurysmal bone cyst. y Radiographs reveal an expansile lytic lesion that elevates the periosteum. but remains contained by a thin shell of cortical bone.

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y TREATMENT : * Most cysts are treated with extended curettage and grafting with a bone graft substitute.y Aneurysmal bone cysts result from local circulatory disturbance leading to increased venous pressure and production of local hemorrhage. ananeurysmal bone cyst is a cavitary lesion with blood-filled septate spaces. y Grossly. * Marginal resection sometimes is indicated for lesions in expendable bones. * Lesions in the spine or pelvis can be treated with preoperative embolization to minimize surgical blood loss. .

y Low-dose irradiation has been reported to be an effective method of treatment.y Arterial embolization has been used as definitive treatment of aneurysmal bone cysts in locations where curettage would be extremely difficult. often associated with rapid ossification. y The recurrence rate after curettage of an aneurysmal bone cyst is approximately 10% to 20%. .

GIANT CELL TUMOUR y Giant cell tumors represent 5% of bone neoplasms. followed by the proximal tibia. . y In the distal radius (the third most common location). y The most common location for this tumor is the distal femur . y Slight female predominance. these tumors frequently are more aggressive. y Pain is the presenting complaint with a mass from few weeks to several months. y Occur in patients 20 to 40 years old.

suggesting a rapid and permeative growth . GRADE 2 : has relatively well defined margins but no radioopaque rim.STAGING (RADIOLOGICAL) GRADE 1 : well marginated border of thin rim of mature bone & cortex is intact. tumour bulged into the soft tissues . GRADE 3 : tumour with fuzzy borders . The combined cortex and rim of reactive bone is rather thin and moderately expanded.

1% to 2% may be synchronously or metachronously multicentric. that lead to death even when tumors remained histologically benign. however. y Some pateints have progressive pulmonary lesions. y Some patients with pulmonary metastases have spontaneous regression or remain asymptomatic for many years.y usually are solitary lesions. however. y typically are benign but pulmonary metastases occur in approximately 3% of patients. . y mortality rate with pulmonary metastases is approximately 15%.

. 2) Secondary malignant giant cell tumors are sarcomas that occur at the sites of giant cell tumors that have been treated.y Malignant giant cell tumors repersent < 5% y Are classified as primary or secondary. 1) Primary malignant giant cell tumors are extremely rare and are defined as sarcomas that occur within lesions that otherwise are typical of benign giant cell tumors. usually with radiation.

In less aggressive tumors.y The lesions are eccentrically located in the epiphyses of long bone. a partial rim of reactive bone may be present y On MRI. y The zone of transition can be poorly defined on plain radiographs. . giant cell tumors rarely arise in the metaphysis. y Radiographically. the lesion usually is dark on T1weighted images and bright on T2-weighted images. y In skeletally immature patients. the lesions are purely lytic.

y The nuclei of the mononuclear cells are identical to the nuclei of the giant cells. giant cell tumors are composed of many multinucleated giant cells (typically 40 to 60 nuclei per cell) in a sea of mononuclear stromal cells. a feature that helps to distinguish giant cell tumors from other tumors that may contain many giant cells. which occurs in 20% of patients Microscopically. . y Giant cell tumors frequently are locally aggressive.MRI also may reveal fluid-fluid levels typical of a secondary aneurysmal bone cyst. Most manifest as stage 2 or stage 3 lesions.

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4) To fill the defect after curettage. an artificial bone graft substitute. 2) use of a power burr to enlarge the cavity 1 to 2 cm in all directions is now considered standard. such as liquid nitrogen. phenol. or an argon beam coagulator. the surgeon has several options. allograft bone. . electrocautery. 3) The use of adjuvants. bone cement.y TREATMENT : 1) Treatment consisted of simple curettage. or methylmethacrylate bone cement. theoretically help to kill any remaining tumor cells. including autograft bone.

y Bone cement is used to fill the cavity because of its ease of application. extended curettage followed by argon beam coagulation. a hemicondylar osteoarticular allograft reconstruction or a rotating hinge endoprosthesis may be necessary. . y Around the knee. and primary resection may be required after biopsy. y Curettage may not be effective in some stage 3 tumors.y Presently most giant cell tumors with aggressive.

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primary resection without reconstruction may be indicated.g. the distal ulna or proximal fibula). radiation or embolization (or both) may be used . resection should be attempted. y For lesions in the spine or pelvis.. primary resection and reconstruction with a proximal fibular autograft (either as an arthroplasty or as an arthrodesis) may be indicated .y For aggressive lesions of the distal radius. . y For lesions in expendable bones (e. y In patients with pulmonary metastases.

After biopsy shows that the tumor is still benign. . patients should have radiographs of the primary tumor site and the chest at 3. at 6-month intervals for the following year. y Treatment of recurrent lesions is the same as for primary lesions.to 4-month intervals for 2 years.y Most local recurrences and pulmonary metastases occur within 3 years but have been reported to occur 20 years later. and annually thereafter. repeat curettage or resection should be performed. y At minimum.

y The distal femur. y In older patients. y Most patients complain of progressive pain that may mimic a chronic synovitis or other intraarticular pathological conditions. chondroblastoma has a tendency to occur in flat bones. and proximal tibia are the most common sites of occurrence. proximal humerus. y Occurs in patients 10 to 25 years old. y 2 : 1 male predominance .CHONDROBLASTOMA y Represents 1% of all bone tumors. y Also referred as CODMAN S TUMOUR .

4) In children. Soft-tissue extension is extremely rare. 2) Also located in an apophysis. . and 30% to 50% exhibit calcification on plain radiographs.y Radiographic findings 1) Well-circumscribed lesion usually centered in an epiphysis of a long bone. 3) Has a surrounding rim of reactive bone. such as the greater trochanter or the greater tuberosity. a well-circumscribed epiphyseal lesion that crosses an open growth plate is virtually diagnostic of chondroblastoma.

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y Differential diagnoses include

1) giant cell tumor and 2) clear cell chondrosarcoma. In contrast to chondroblastomas, however, giant cell tumors usually do not have a rim of sclerotic bone or intralesional calcification and may have a soft-tissue component. y MICROSCOPY 1) Sheets of chondroblasts usually with a background of chondroid matrix. 2) The cells are polygonal with distinct cytoplasmic outlines.

3) Calcification is present and may surround individual cells, giving the classic chicken wire appearance. 4) Multinucleated giant cells are abundant.

TREATMENT:
y Extended curettage and bone grafting or

placement of bone cement. y Recurrence occurs in 10% to 20% of patients and can be treated similar to a primary lesion. y Benign pulmonary metastases occur in approximately 1% of patients and should be treated by resection.

Microscopy showing chicken wire calcification

y Patients typically complain of pain. .5% of all bone tumors. y Occur in patients 10 to 30 years old . y if the tumor is located in the hands or feet. y This has both myxoid and fibrous elements. a painless mass or swelling may be the chief complaint.CHONDROMYXOID FIBROMA y Represents less than 0. y Proximal tibia is the most common location. y bubbly appearance(lobulated) with bite like cortical destruction. y Radiographic appearance is well-circumscribed lesion with a rim of sclerosis in the metaphysis.

y Microscopically: 1) Chondromyxoid fibroma has zonal architectute appears lobulated.y Radiographic evidence of intralesional calcification usually is absent. although distinct areas of hyaline cartilage are rare. . and the periphery contains a more cellular fibrous tissue. 3) The background often appears chondroid. 2) The center of the lobules contains loose myxoid tissue. 3) Microscopic calcification may be present.

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y Sarcomatous change is rare. . y Local recurrence occurs in about 20% of patients and is treated with repeat surgery.y TREATMENT : Resection or extended curettage with bone grafting .

. which is the most common symptom. may be similar to that produced by an osteoid osteoma y i. y Male predominance of 3 : 1.e. y Pain. y 40% to 50% of the lesions are located in the spine. worse at night and relieved by nonsteroidal antiinflammatory drugs. .OSTEOBLASTOMA y bone-forming neoplasm. represents less than 1% of bone tumors. y Occurs in patients 10 to 30 years old.

. y In the lumbar spine. 2) The nidus of an osteoid osteoma is less than 1. y RADIOGRAPHY : 1) The classic appearance of a calcified central nidus with a surrounding radiolucent halo in the posterior elements of spine . cord compression is more common. y In the thoracic spine. painful scoliosis or neurological deficit may be present.y In the spine. signs and symptoms of nerve root compression may be evident.5 cm.

sclerotic. y Microscopically: 1) The lesion resembles an osteoid osteoma. 2) It contains a fibrovascular stroma with production of osteoid and primitive woven bone. or mixed. Lesions may be diaphyseal or metaphyseal .3) The lesion may be radiolucent. 3) Bony trabeculae are lined by a single layer of osteoblasts. which may be important in differentiating osteoblastoma from osteosarcoma . 4) may be primarily cortical or intramedullary.

4) Other features favoring an osteoblastoma include sharp circumscription and a loose arrangement of the tissue. . instrumented fusion may be necessary if resection causes instability. ** Some authors recommend adjuvant radiation for spinal lesions. ** In the spine. ** Bone grafting of the defect may be necessary. y Treatment : ** consists of extended curettage or resection.

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