an atlas of musculoskeletal oncology: volume 1
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Contents for Volume 1
Osteoid osteoma--------------------------------Case 1-50 Osteoblastoma----------------------------------Case 51-94Osteofibrous dysplasia-------------------------Case 95-101Ossifying fibroma of jawbone----------------Case 102-107
Osteoid Osteoid OsteomaOsteoma
Osteoid Osteoma
The osteoid osteoma is the most common osteoid-forming tumorseen in the skeletal system, accounting for 10% of all benignbone tumors. It is more common in males than females with the peak incidence in the second decade of life. The lesions producesymptoms of dull, aching pain that is more severe at night. Thepain is relieved with anti-inflammatory medication such as aspirin or non-steroidal anti-inflammatory drugs (NSAID)that inhibit the high concentration of prostaglandins found in the nidus of the osteoid osteoma. The lesions occur typically inthe cortical structures of long bones such as the femur or tibia but can also be found in the small bones of the ankle, wrist or vertebral column. The lesion is characteristic for its dense,sclerotic response in the cortical bone resulting in a fusiform enlargement on the surface of the cortex as a response to thesmall inflammatory nidus or granuloma (measuring up to one
centimeter in diameter) in the central area of the scleroticresponse. If the lesion is located in a central medullary area,such as the metaphysis or on the very superficial surface of abone, the sclerotic response is less severe. If the nidus is located close to or within a joint structure, as in the femoralneck area, there will be a significant inflammatory synovitisin the adjacent joint that gives the clinical appearance of apyarthrosis. In the spine, the lesions are usually located in theposterior elements of the spine such as the laminae or pedicles.The lumbar spine is the most common location followed secondby the dorsal spine. Atypical secondary painful scoliosis willdevelop with the convexity seen on the side opposite the inflammatory lesion. The two most significant diagnostic imaging studies are a CTscan through the nidus area to identify its anatomic location and a bone isotope scan which is invariably positive, especially in asymptomatic lesion. It is the current feeling that the osteoid.
osteoma is a true benign neoplasm of bone in which a com-bination of osteoclastic and osteoblastic activity are seen. There are no inflammatory cells such as lymphocytes orplasma cells as would be seen in a Brodie’s abscess. Non-steroidal anti-inflammatory medications such as prostaglandininhibitors can be very effective in controlling the disablingsymptoms and helping the patient get thru a period of one ortwo years during which time the lesion will typically involuteinto a painless lesion that does not require surgery. However,if the patient is unable to live with the pain during this time,a surgical approach is indicated. Following exposure of the lesion, a high speed burr is used to burr into the inflammatorybone that is characterized by a pinkish hyperemia. When the nidus is found, a small curette is used to core the inflammatorynidus for pathological diagnosis and the cavity of the nidusis burred an additional 2 or 3 mm which usually results in a verydramatic relief of symptoms and a permanent cure from the
disease process. It is not necessary to remove the large dense sclerotic bone surrounding the nidus; doing so couldresult in a pathologic fracture following surgery. In the spine, a simple laminectomy is frequently carried out. If the lesion islocated in the pedicle a simple burring into the pedicle will relieve the patient of the inflammatory pain. More recently, relatively non-invasive techniques have beentried to remove the nidus of the osteoid osteoma by means of a CT guided burr placed through a protective trocar or by place-ment of a heat-producing radio frequency probe that, when properly positioned, can destroy the nidus through thermal coagulation. These techniques are particularly valuable for deep-seated lesions located in the acetabulum. For lesions located inthe pedicle of a vertebra one must be careful not to damage anadjacent spinal root or spinal cord.
19 yr old femaleOsteoid osteomafemur
painfulnidus
CLASSICCase #1
Bone scan
CT scan
nidus
Macro section of nidus
Photomic of nidus
29 year maleosteoid osteomafemur
nidus
Case #2
nidus
CT scan
11 yr maleosteoid osteomafemur
Case #3
Bonescan
CT scan
nidus
Photomic
5 yr male osteoid osteoma femur
nidus
Case #4
12 yr maleosteoid osteoma femur
Case #5
nidus
10 yr maleosteoid osteomafemur
nidus
Case #6
nidus
CT scan
nidus
30 yr femaleosteoid osteomafemur
nidus
Case #7
Coronal T-1 MRI
nidus
Axial PD MRI
edema
nidus
Macrosection
nidus
Case #8
23 yr femaleosteoid osteomafemur
nidus
Bone Scan
CT Scan
Nidus
Case #9
12 yr maleosteoid osteomafemur nidus
Macro section nidus
Photomic
Case #10
10 yr female with osteoid osteoma femoral neck
nidus
Photomic
One yr after curettement
Case #11
25 yr male with osteoid osteoma femoral neck
nidus
CT scan
nidus
Case #12
6 yr male osteoid osteoma acetabulum
nidus
nidus
Bone scan
Case #13
11 yr maleosteoid osteomadistal femur
nidus
Bone scan
Case #14
16 yr maleosteoid osteomadistal femur
nidus
Case #15
6 yr maleosteoid osteomatibia
nidus
Bone scan
Excessivebone blockresection
nidus
Macro section of nidus
nidus
Photomic
Post op x-ray
Resultant fractureone year later
Case # 16
10 yr maleosteoid osteomatibia
Shaving down with osteotome
Further shaving to find nidus
Burred out nidus defect
Case # 17
15 yr maleosteoid osteomatibia
Lateral view
nidus
Bone scan
Coronal T-2 MRI
nidus
Coronal Gad contrast MRI
nidus
edema
T-1 axial MRI
nidus
Photomic
Photomic
Case #17.1
52 year old male with ankle pain for 3 mos.
Osteoid osteoma
Sag T-1 T-2 Gad
Axial T-1 T-2
Gad
Case #18
17 yr maleosteoid osteomafemur
nidus
Grossspecimen
nidus
Photomic
Case #19
18 yr maleOsteoid osteoma tibia
Case #20
18 yr femaleosteoid osteomatibia
nidus
Case #21
12 yr male with parosteal osteoid osteoma tibia
nidus
Case #22
17 yr maleosteoid osteomafibula
nidus
Lateral view
Case #23
26 year female with epiphyseal osteoidosteoma prox radius
nidus
Case #24
16 yr femaleosteoid osteomaulna
nidus
Bone scan
Case #25
16 yr maleosteoid osteomahumerus
nidus
Case # 26
14 yr maleosteoid osteomaL-4
nidus
Bone scan
Photomic
Case # 27
15 yr maleosteoid osteomaL-3
nidus
Case #28
46 yr maleosteoid osteomadorsal spine
nidus
Bone scan
Case #29
18 yr male with osteoid osteoma C-3
nidus
Laminogram
nidus
Bone scan
Case #30
12 yr male with osteoid osteoma C-3 spine
nidus
Case #31
25 yr maleosteoid osteomaC-5
nidus
Case # 32
27 yr female with osteoid osteoma S-1
nidus
Case #33
22 yr male with osteoid osteoma sacrum
nidus
Case #34
18 yr maleosteoid osteomafinger
nidus
X-ray
nidus
AP x-ray
nidus
Case #35
24 yr male with osteoid osteoma thumb
nidus
Bone scan
Case #36
19 yr female with osteoid osteoma finger
nidus
Case #37
20 yr male with osteoid osteoma thumb
nidus
Case #37.1
17 year female with dull aching pain index finger 1 yr
nidus
Case #38
23 yr male with osteoid osteoma capitate
nidus
Case #39
25 yr male with osteoid osteoma narvicular
nidus
Case # 40
34 yr female with osteoid osteoma 2nd metatarsal
nidus
CT scan
nidusdouble
Axial T-2 MRI
edema
Case #41
24 yr female with osteoid osteoma big toe
nidus
Gross Specimen
nidus
Photomic
Photomic
Case #42
Osteoid osteoma talus
nidus
Photomic
Case #43
Osteoid osteomapseudotumor
Brodie’s abscess13 yr femaletibia
nidus
Gopher’s sign
tunnel
Case # 44
Osteoid osteomapseudotumor
Brodie’s abscesstibia38 yr male
nidus
Axial T-2 MRI
nidus
Case #45
Osteoid osteoma pseudotumorstress fracture femoral neck 38 yr male
fractureline
pseudo-nidus
Bone scan
Case #46
Osteoid osteoma pseudotumor 33 year female
e
Early stressfracture femoralneck with pain for 3 mos
Bone scan
One month later
Case #47
Osteoid osteoma pseudotumorstress fracture femoral neck 50 yr female
pseudonidus
Axial T-2 MRI
pseudonidus
Coronal T-2 MRI
fracture line
Case #48
20 year old male with pre-tibial pain for 3 months
Stress fractureOO pseudotumor
Sag T-1 PD Gad
Case #49
Pseudo osteoid osteoma femur
Chronic stressperiostitis from adductor pull14 yr male
CT scan
pseudonidus
Bone scan
Case #50
Pseudo osteoid osteoma femur
Bone island
38 yr male
Bone scan
CoronalT-1 MRI
pseudonidus
OsteoblastoOsteoblastomama
Osteoblastoma The so-called osteoblastoma is considered by most to be a largeor giant form of the similar clinical entity known as the osteoidosteoma. As with the osteoid osteoma, it is found in children andyoung adults, more often in males than females. It is less commonthan the osteoid osteoma, representing approximately 1% of allbone tumors. It is found mostly in metaphyseal areas of long boneand in the posterolateral elements of the axial skeleton wherenearly 50% of the lesions are identified. Radiographically these lesions are more osteolytic than the osteoid osteoma and have acentral nidus that measures more than 1.5 cm in diameter with less reactive sclerosis seen at the periphery than an osteoid osteoma. It is not unusual for an aneurysmal component to beassociated with the osteoblastoma, similar to the reaction seenadjacent to chondroblastomas and giant cell tumors. The micro-scopic appearance of the nidus material is almost identical to
that of the osteoid osteoma and under higher power cannot bedifferentiated by even the most competent pathologists. The major concern is a microscopic appearance similar to an osteo-sarcoma and, for this reason, multiple samples must be evaluatedin order to establish the correct diagnosis in cases where these lesions arise from the metaphyseal areas of long bone. In the spinal area, the osteoblastoma is typically located in theposterolateral elements where it can cause problems with spinal cord or nerve root compression that may require aggressive surgical decompression and even spinal stabilization. On occasionan osteoblastoma will spontaneously convert into an osteo-sacoma, especially if it has been treated with radiation therapy. The primary treatment for the osteoblastoma is a surgical one witha fairly aggressive curettement of the lesion. There is no particularreason to take wide margins because the recurrence rate is quite low and in some cases the lesions resolve spontaneously with out any surgery at all, similar to what occurs with osteoid osteomas.
A variant of the osteoblastoma, the so-called aggressive or“malignant” osteoblastoma, is a clinical entity halfway between theclassic benign osteoblastoma and a full blown malignant osteo-sarcoma. This “malignant” osteoblastoma appears and behaves clinically at the local site like an osteosarcoma but has no potential to metastasize to distant parts. In this situation, local treatment must be more aggressive and probably would require a wide localresection to avoid a local recurrence because radiation therapy or even systemic chemotherapy is not effective for this aggressive but benign entity.
CLASSICCase #51
26 yr maleosteoblastoma L-4
Lateral view
Bone scan
CT scan
Sagittal T-2 MRI
Photomic
Photomic
5 yrs post op with spontaneous fusion
AP x-ray 5 yrs post op
Sagittal gad contrast MRI 5 yrs post op
Axial gad contrast MRI 5 yrs post op
Case #52
23 yr male with osteoid osteoma L-5
nidus
CT scan
nidus
Photomic
Photomic
Recurrence 8 mos post op laminectomy
Recurrence
CT
Recurrence as an osteoblastoma
ABC
Secondary ABCbehind osteoblastoma
osteoblastoma
Sagittal T-2 MRI
Axial T-2 MRI
fluid-fluidlevel
ABC histology
ABC histology
Osteoblastoma histology
Osteoblastoma histology
Post op posteriorresection and fusion
AP x-raypost op fusion
CT scan later shows anterior recurrence
Post op anteriorresection and bonecement reconstruction
Lateral x-ray showinganterior reconstructionwith cement
cement
Post op CT scan showing cement reconstruction
cement
CD rods
bone graft
Post op CT
cement
graft
Case #53
26 yr male with osteoblastoma L-4 following a laminectomy curettement three years previous for an osteoid osteoma
surgical towel clip
Appearance 4 months later with a 1.5 cm nidus
CT scan
A curettement at this time revealed an osteoblastoma
Myelogram 4 yrslater
CT scan at same time and no pain
burned-outlesion
Another CT cut
Sagittal T-1 MRI at same time
Burnt outlesion
Sagittal T-2 MRI same time
T-2 MRI with residual ABC in inactive lesion
Axial T-1 MRI same time
Axial T-2 MRI with residual ABC component
Case #54
7 yr femaleosteoblastoma L-2
Bone scan
T-2 MRI showshigh signal ABCposterior to low signalosteoblastoma
osteoblastoma
ABC
SagittalT-2 MRI
osteoblastoma
ABC
Osteoblastoma Photomic
AP x-raypost op posteriorspinal fusion
Lateral X-raypost op
Case #55
14 yr femaleosteoblastoma L-5
Oblique X-ray
Bone scan
CT scan
CT scan
Case #56
24 yr male with osteoblastoma L-3
Lateral view
Oblique view
Opposite oblique
Case #57
22 year male with osteoblastoma L-1 vertebra
Oblique view
Case #58
23yr male with burned out obteoblastoma L-4
Case #59
14 yr maleosteoblastoma C-3
Oblique view
Opposite oblique
post op posteriorfusion and recurrenttumor anterior
One year
Anterior viewwith recurrence
Post op anteriordebriedment andfusion
Case #60
18 yr maleosteoblastomaC-7
Oblique view
Lateral view2 mo later
AP view 1 mo later
Resected nidus
Photomic
Photomic
Case #61
CT scan
55 yr female with osteoblastoma C-6
Bone scan
Sagittal T-1 MRI
Sagittal T-2 MRI
Axial T-2 MRI
Case #62
25 yr female with osteoblastoma C-6
AP x-ray
10 yrs later
Lateral view 10 yrs later
Photomic
Photomic
Case #63
CT scan
40 yr male with osteoblastoma C 5-6
CT scan
Sagittal T-2 MRI
T-2 MRI showing bulge in floor ofvertebral canal
Sagittal
Case #64
13 yr female with osteoblastoma C-6
Lateral view
Post op X-rayAfter anteriorinterbody fusion
Case #65
14 yr female with osteoblastoma C-7
AP X-ray
AP myelogram
Arteriogram showingpressure on vertebralartery
Post op debriedment
Case #66
CT scan
43 yr female with osteoblastoma T-8
Axial T-2 MRI
Sagittal T-1 MRI
Post op posteriorspine fusion
28 yr male with osteoblastoma thoracic spine
Case #67
CT scan
Post op resection
CT scan post op resection
Case #68
21 yr male osteoblastoma S-1
2 years later
5 years later
Lateral view 5 years later
Photomic
Photomic
Case #69
8 yr male with ostoblastoma sacrum
Case #70
26 yr female with osteoblastoma acetabulum
Close up AP
Photomic
Photomic
X-ray 3 mosfollowing THA
Case #71
19 yr male with aggressive osteoblastoma acetabulum
Bone scan
Gross specimen from curettement
Photomic
Photomic
Post op internalhemipelvectomy
Recurrence 4 months later
Ablative hemipelvectomy specimen
tumor
Hemipelvectomy specimen
tumor
Several years later with recurrent tumor on sacrum
Lateral view of recurrence
Case #72
38 yr male osteoblastomapelvis
Frog lateral
Post op x-ray following curettage and cementation
Case #73
33 yr female with osteoblastoma acetabulum
Axial T-1 MRI
Coronal T-2 MRI
Case #74
26 yr male with osteoblastoma acetabulum
Frog lateral
Case #75
24 yr male with osteoblastoma pelvis
18 mos later
Case #76
22 yr male with osteoblastoma ischium
X-ray of resected specimen
nidus
Case #77
26 yr male with osteoblastoma ilium
CT scan
Post op x-ray appearance after resection and cementation
Case #78
23 yr maleosteoblastomafemur
CT scan
T-2 MRI
Sagittal T-2 MRI
Photomic
Case #78.1
19 year male with tibial pain for 6 mos
Axial
T-1 T-2
Gad +
Coronal T-1 T-2 Gad
X-ray 3 months post op
Case #79
15 yr maleosteoblastomafemur
Bone scan
CT scan
Axial T-2 MRI
Coronal T-1MRI
X-ray at time ofsurgery with markerin tumor defect
Photomic of nidus
Case #79.1
14 yr male with dull aching thigh pain for 1 year
CT scan Sclerosing osteomyelitis of Garre
Coronal T-1 Coronal T-2
Sagittal T-2 Axial T-2
Case #80
13 yr male with osteoblastoma femoral neckfrog lateral view
AP view
Bone scan
Case #81
22 yr male with osteoblastoma talus
Sagittal T-1 MRI
Coronal T-2 MRI
Coronal T-2 MRI
Photomic
Case #82
25 yr maleosteoblastomatalus
Lateral view
Close up lateral
Photomic
Case #83
18 yr female with osteoblastoma talus
Mortise view
X-ray 1 yr after curettage
Case #84
23 yr male with osteoblastoma talus
Case #85
25 yr female with osteoblastoma os calcis
Os calcis view
X-ray several months with progression of disease
Case #86
29 yr male with osteoblastoma os calcis
Case #87
53 yr male with osteoblastoma distal humerus
X-ray 3 years later
tumor
edema
Axial T-2 MRI
Coronal T-2 MRI
nidusedema
Post op x-rayfollowing distalhumeral resectionand allograft reconstruction
Case #88
9 yr femaleosteoblastomadistal humerus
Coronal T-1 MRI
edema
Axial T-2 MRI
tumor
edema
Case #88.1
11 yr male with ABC response to osteoblastoma humerus
nidus
Sag T-1
Sag T-2
Axial T-2 MRI shows the multiloculated aneurysmal cysts
Case #89
21 yr male with osteoblastoma ring finger
AP and Lateral radiographs
Gross specimen
Photomic
Case #90
18 yr male with osteoblastoma finger
Case #91
21 yr male with osteoblastoma thumb
Case #92
10 yr female with osteoblastoma finger tip
AP X-ray
Case #93
9 yr femaleosteoblastoma tibia
AP x-ray
Case #94
24 yr male with osteoblastoma fibula
Lateral view
Osteofibrous Osteofibrous DysplasiaDysplasia
Osteofibrous Dysplasia
Osteofibrous dysplasia is a rare condition occurring in children less than 10 years of age. This benign lesion has radiographic and microscopic features similar to fibrousdysplasia of the tibia, the main difference being the presenceof more heavily ossified tissue at the periphery of the lesiongiving it a soap-bubbly appearance on x-ray. Microscopicallyit has a similar “alphabet-soup” metablastic bone appearance in a benign fibrous tissue stroma but with the additional featureof heavy osteoblastic rimming of the trabeculae not seen in fibrous dysplasia. It typically arises from the anterior cortex of the tibia at mid shaft and causes a progressive anterior bowing of the tibia over time, creating a cosmetic deformity associated with pain of a dull, aching nature. The radiographic appearanceIs very similar to and impossible to separate from that of theMalignant adamantinoma that also affects the tibia in children
and, for this reason, a biopsy must be performed to rule out themalignant possibility. Occasionally osteofibrous dysplasia of thetibia can progress gradually into a well-differentiated formof the adamantinoma, which will have the microscopic features of both osteofibrous dysplasia and adamantinomain the same lesion. As far as treatment is concerned, early surgical debriedment and bone grafting before age 15 years results in a high local recurrence rate and thus should be discouraged until the child reaches full bone maturity at which time a definitive debriedment and bone grafting procedurecan be performed without significant risk of recurrence. Thislesion occurs bilaterally in a very small percentage of cases and can also involve the fibula on the same side. This processin newborns appears to be more osteolytic and destructive in nature.
CLASSICCase #95
9 yr male osteofibrous dysplasiatibia
AP and lateral x-ray
Photomic
Case #96
6 year femaleosteofibrous dysplasiatibia
Same case
Case #97
16 year femaleosteofibrous dysplasiatibia
Case #98
8 yr maleosteofibrous dysplasiatibia
X-ray appearance3 yrs later
8 yrs later with spontaneous healing
Case #98.1
61 year old male with incidental finding in tibia for years
Burnt out osteofibrous dysplasia
Bone scan
Sag T-1 PD FS Gad
Cor STIR Gad
Axial T-1 T-2 FS
Gad
Case #99
15 yr femaleosteofibrous dysplasiatibia
AP x-ray
Lateral x-ray
Case #100
Newborn with osteofibrous dysplasia tibia
T-2 axial MRI
edema
Photomic
Photomic
X-ray 1 yr later
Case #101
Another newbornosteofibrous dysplasiatibia
Another view
Ossifying Ossifying Fibroma of Fibroma of
JawboneJawbone
Ossifying Fibroma of Jawbone
Ossifying fibroma of jawbone is a benign condition similar toosteofibrous dysplasia of the tibia in that histologically they arealmost identical. It is also a condition that is related to fibrous dysplasia, which can have a very similar radiographic appearance,but in the case of fibrous dysplasia of jawbone osteoblastic rimming of the trabecular bone is not seen under microscopicevaluation. As with fibrous dysplasia, this condition is found in children and is almost always an asymptomatic process resulting in cosmetic deformation of the maxilla or mandible, usually on one side but can be bilateral. The condition can result in significant malocclusion of the teeth because of deformationof the subadjacent alveolar ridge or maxillary structures. It alsocan create problems with normal drainage from the air sinuses in the maxilla that can lead to infection requiring surgical drainage.Most of the surgical treatment for this condition is for cosmeticdeformity.
Case #102
5 yr female ossifying fibromamaxilla
Maxillary view
tumor
Tomogram cut
tumor
CT scan
tumor
Another cut
tumor
Another cut
Photomic
Case #103
18 yr female with ossifying fibroma mandible
Oblique view
Photomic
Closeup of alphabet-soup metaplastic bone
Case #104
12 yr female with ossifying fibroma mandible
tumor
Opposite ramus
Case #105
14 yr female with ossifying fibroma mandible
Case #106
Young adultosteoma skull
tumor
Occipital view
tumor
Lateral view
Case #107
Cementoma mandible
Oblique view
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