1. BONE TUMORS Dr.ZEENAT NASEERUDDIN m.d pathology

2. LECTURE 48 BONE FORMING TUMORS
OBJECTIVES
a.Enlist and classify common types of bone tumors.
b.Discuss their epidemiology.
c.Describe their morphology and location.
d.Describe their clinical features and course.

3. Bone tumors Bone tumors are classified into:
Primary bone tumors
Secondary bone tumors ( Metastasis)
Most are classified according to the normal cell of origin and apparent pattern of differentiation

4. Bone tumors Bone-forming tumors Cartilage-forming tumors
Miscellaneous tumors
Hematopoietic tumors
Fibrous tumors

5. Primary Bone Tumors Bone-Forming tumors Osteoma
Osteoid osteoma and Osteoblastoma
Osteosarcoma
Cartilage-Forming tumors
Chondroma (Enchondroma)
Osteochondroma
Chondrosarcoma
Miscellaneous tumors
Ewing’s sarcoma
Giant cell tumor of bone

6. Bone tumors: Etiology ???
Although the cause of most bone tumors is unknown.
Genetic alterations e.g. bone sarcomas in the Li-Fraumeni and hereditary retinoblastoma which are linked to mutations in p53 and Rb genes.
Bone infarcts
Chronic osteomyelitis
Paget’s disease
Radiation and
Metal prostheses are also associated with increased incidence of bone neoplasia.

7. Diagnosis of Bone Tumors:
1. Age of patient
2. Location of tumor
3. Radiological appearance
4. Histological features

8. Bone-Forming Tumors

9. Osteoma
Osteoma are benign lesions of bone that in many cases represent developmental aberrations or reactive growths rather than true neoplasms.
Site;
Age;
Gross:
Histology:

10. Osteoma Small bosselated benign tumor.
Usually solitary and detected in the middle age.
Multiple in the setting of Gardner syndrome.
Do not transform into osteosarcoma.

13. Osteoid Osteoma Signs/Symptoms: Age: Sex: Anatomic Distribution:
Pain, characteristically more intense at night, relieved by NSAID (PG-E) and eliminated by excision
Vertebral lesions may cause scoliosis
Age:
10-30 years
Sex:
M > F (2:1)
Anatomic Distribution:
Nearly every location, most frequent in femur, tibia, humerus, bones of hands and feet, vertebrae and fibula
Over 50% of cases in femur or tibia
Metaphysis of long bones
By definition less than 2 cm in diameter.

14. Central radiolucent nidus with or without a radiodense center; surrounded by thickened sclerotic bone

16. Central hemorrhagic nidus surrounded by dense rim of sclerotic bone

17. Nidus contains interlacing network of osteoid and bony trabeculae with variable amount of mineralization, lying in vascular fibrous tissue

19. Osteoid Osteoma Ancillary Testing: Prognosis/Treatment: N/A
Surgical excision is treatment of choice
Recurrence unlikely with complete excision

20. Osteoblastoma (Giant Osteoid Osteoma)
Signs/Symptoms:
Pain
Gait disturbances
Age:
80% of patients < 30 years
Sex:
M >> F (3:1)
Anatomic Distribution:
Predilection for vertebral column
Metaphysis of long bones

22. Osteoblastoma (Giant Osteoid Osteoma)
Radiographic Findings:
Similar to osteoid osteoma, though much larger (up to 11.0 cm)
Gross and Microscopic Findings:
Similar to osteoid osteoma, though much larger nidus
Ancillary Testing:
N/A
Prognosis/Treatment:
Curettage followed by bone grafting
If incompletely removed, tumor may recur
Malignant change to osteosarcoma has been rarely reported

23. Osteosarcoma
Osteosarcoma is a bone-producing malignant mesenchymal tumor .

24. Osteosarcoma
Incidence:
Age:
Sex:
Site :

25. Osteogenic Sarcoma (Osteosarcoma)
Most frequent primary malignant bone tumor
Malignant cells must produce osteoid
Most tumors arise de novo (primary), though others arise in the setting of:
Paget’s disease
Previous RT
Previous chemo (especially alkylating agents)
Fibrous dysplasia
Osteochondromatosis
Chondromatosis
Chronic osteomyelitis

26. Osteogenic Sarcoma (Osteosarcoma)
Signs/Symptoms:
Pain and swelling
Pathologic fracture is uncommon
Age:
Bi-modal age group
Peak in 2nd decade with gradual decrease thereafter.
Sex:
M > F
Anatomic Distribution:
50% arise around the knee
Metaphysis of long bones

27. Osteosarcoma Distribution

28. Osteosarcoma Radiograph

31. Osteogenic Sarcoma Morphology:
Most commonly involves metaphysis of long bones.
Gross features: Big bulky tumors, grey white often containing areas of hemorrhage and cystic degeneration.
Micro: Pleomorphic tumor cells with large hyper chromatic nuclei ,mitotic figures. Formation of pink homogenous bone is the most characteristic feature of osteogenic sarcoma

32. Osteosarcoma Gross features

35. Bone-Forming tumors; Tumor Type Locations Age Morphology BENIGN
Osteoma
Facial bones, skull
40-50
Exophytic growths attached to bone surface; histologically resemble normal bon
Osteoid osteoma
Metaphysis of femur and tibia
10-20
Cortical tumors, characterized by pain; histologically interlacing trabeculae of woven bone
Osteoblastoma
Vertebral column
vertebral processes; histologically similar to osteoid osteoma
MALIGNANT
Primary osteosarcoma
Metaphysis of distal femur, proximal tibia, and humerus
Grow outward, lifting periosteum, and inward to the medullary cavity; microscopically malignant cells form osteoid.
Secondary osteosarcoma
Femur, humerus, pelvis
>40
Complications of polyostotic Paget disease; histologically similar to primary osteosarcoma

36. An 11-year-old male was seen in consultation for an increasingly painful distal femoral lesion associated with a soft tissue mass.
Plain radiograph shows an ill-defined destructive tumor in the distal femur. Fluffy radio-dense infiltrates represent malignant tumor osteoid.
Biopsy material shows two major components of this neoplasm: highly pleomorphic cells and haphazard deposits of osteoid. Note that the malignant cells fill the spaces between osteoid deposits. Lace-like osteoid deposition is very characteristic of this neoplasm.

37. A 16-year-old boy was seen in consultation for increasing pain in the mid upper arm. Characteristically, the pain intensified at night and subsided with aspirin.
Plain film shows a small, intracortical, radiolucent focus (nidus), surrounded by dense reactive periosteal bone. The lesion is located in the mid portion of the humeral shaft.
If the nidus is removed intact, it appears as a circumscribed portion of red, trabecular bone, usually less than 1cm in size.
Low-power view shows the lesional tissue ("nidus"), well demarcated from the surrounding sclerotic bone.
The lesion is composed of thin, often interconnected spicules of osteoid and woven bone rimmed by osteoblasts. Osteoclast-like giant cells can be seen. Intervening fibrous stroma shows prominent vascularity.

38. METASTATIC BONE TUMORS
Metastatic tumors are the most common malignant tumor of bone.
Pathways of spread:
Origin:
The radiologic appearance of metastases

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