Diagnosis of Bone Tumours

1.

Age of patient

2.

Location of tumour

3.

Radiological appearance

4.

Histological features

Age group

0-20

21-40

>40

Most common benign lesions

Most common malignant tumors

non-ossifying fibroma
fibrous dysplasia
simple bone cyst
aneurysmal bone cyst
osteochondroma (exostosis)
osteoid osteoma
osteoblastoma
chondroblastoma
chondromyxoid fibroma
eosinophilic granuloma

Ewing's sarcoma
leukemic involvement
metastatic neuroblastoma
osteosarcoma,
Ewing's sarcoma

enchondroma
giant cell tumor

chondrosarcoma

osteoma

metastatic tumors
myeloma
leukemic involvement
chondrosarcoma
osteosarcoma (Paget's associated)
MFH
chordoma

SITE OF LONG BONE INVOLVEMENT

(most primary bone tumors have favored sites within long bones; this may provide a clue to
diagnosis).

Diaphyseal lesions centered in

the cortex:
Osteoid osteoma

Metaphyseal intramedullary lesions:

Osteosarcoma is usually centered in the
metaphysis. Chondrosarcoma and
fibrosarcoma often present as metaphyseal
lesions. Osteoblastoma, enchondroma,
fibrous dysplasia, simple bone cyst, and
aneurysmal bone cyst are common in this
location.

Metaphyseal exostosis:
Osteochondroma

Diaphyseal intramedullary lesions:

Ewing's sarcoma, lymphoma, myeloma.
Common for fibrous dysplasia and
enchondroma

Metaphyseal lesions centered in the

cortex:
Classic location for a non-ossifying
fibroma (NOF). Also, a common site for
osteoid osteoma.
Epiphyseal lesions:
Chondroblastoma (Ch) and Giant
Cell Tumor (GCT) are almost
invariably centered in the epiphysis.
Chondroblastoma is a rare tumor
seen in children and adolescents with
open growth plates. GCT is the most
common tumor of epiphyses in
skeletally mature individuals with
closed growth plates. GCT often
shows metaphyseal extension.

Radiological Features

PRIMARY TUMORS OF BONE

Bone-producing tumors
Osteoma, osteoid osteoma, osteoblastoma
Osteosarcoma*
Cartilage-producing tumors
Osteochondroma, chondroma (enchondroma)
chondromyxoid fibroma
chondroblastoma
Chondrosarcoma*
Miscellaneous tumors
Ewings sarcoma*
Giant cell tumor of bone

Tumour-like conditions of bone

Bone cysts
Simple bone cyst
Aneurysmal bone cyst

Fibrous-osseous lesions
Fibrous dysplasia

Eosinophilic granuloma (Langerhans

histiocytosis)

Benign Tumours
Osteochondroma
Also known as an exostosis, is a cartilage capped
out growth.
Men are affected three times more often
than women
Develop in bones of endochondral origin and arise from
the metaphysis near the growth plate of long bones
especially about the knee

Development over time of an osteochondroma

beginning with an outgrowth from the epiphyseal
cartilage

Osteochondroma
Clinically present as slow growing masses
Can be painful if they impinge on a nerve
or if stalk is fractured.
In many cases, they are detected as an
incidental finding.

Rarely they give rise to chondrosarcoma

Osteochondroma
of femur

The white arrows point to a mushroom-shaped, peduculated

bony excresence arising from the anteromedial aspect of the
distal femoral metaphysis, attached to the parent bone and
pointing away from the metaphyisis

Osteochondroma

Chondroma
Benign tumours of hyaline cartilage
May arise within the medullary cavity-enchondroma
May arise on the surface of bone subperiosteal chondroma

Enchondromas are the most common

Located in the metaphyseal region of tubular bones
Most enchondromas are asymptomatic and detected
as incidental finding

Enchondroma of the phalanx with

a
pathological fracture

Enchondroma with a nodule of hyaline cartilage encased

by a thin layer of reactive bone.

Olliers Disease: Multiple

enchondroma.

Chondroblastoma
Rare benign tumor
Most common primary epiphyseal tumor in
children
Signs/Symptoms:
Local pain and swelling; tumors 1.0 to 7.0 cm

Age:
2nd decade of life

Sex:
M>F

Anatomic Distribution:
Epiphysis of long bones
40% in distal femur or proximal tibia

Chondroblastoma

Lytic lesion of epiphysis with

thin sclerotic rim; thinning
without destruction of cortex

Cellular lesion with

polyhedral chondroblasts;
giant cells and areas of
calcification may be seen;
mitoses common

Osteoid osteoma and Osteoblastoma

Have identical histology

Osteoblastoma larger than osteoid
osteoma

Osteoid osteoma
< 2 cm in greatest dimension
Affects teenagers and adolescents
75 % of patients < 25 years
Affects cortex of femur or tibia
Painful lesion
Relieved by salicylate

Osteoid osteoma of
Femoral neck

Osteoid osteoma

OSTEOBLASTOMA

Clinically similar to osteoid osteoma (large)

Also known as giant osteoid osteoma.
Common location -- vertebral column
Histology similar but rare nidus.
Can be locally aggressive
Therapy - curettage/resection with bone graft.

Osteosarcoma (OS)
Most common primary malignant
tumor of the bone
Mesenchymal tumor
Cancerous cells produce bone matrix
75 % occur in patients younger than 20
years of age

Osteosarcoma (OS)
Primary osteosarcoma arise in the
metaphysis of long bones of the
extremities
Secondary osteosarcomas occur in older
patients with Pagets disease
More common in men than women
Common sites are distal end of femur
or proximal tibia

Osteosarcoma (OS)
Patients with Mutation of Rb gene are
predisposed to osteosarcoma
Concurrent trauma to bones and joints
In the elderly OS often arises from pre
existing bone diseases eg: Pagets
disease of bone

Osteosarcoma (OS)
Clinical Presentation
Painful and progressively enlarging
masses
Spread through blood stream
The tumour breaks through the cortex
and lifts the periosteum
Often metastasizes to the lungs

Osteosarcoma
on distal end of
femur

Cortex is
destroyed

Neoplastic osteoblasts forming osteoid

Chondrosarcoma
Frequency is about half of
osteosarcoma
Second most common malignant matrix
producing tumor
Mean age for chondrosarcoma is 43
years
Men are affected more than women

Chondrosarcomas
Commonly arise in the central
portions of the skeleton
including Pelvis, proximal femur, ribs,
sternum and shoulder girdle

Chondrosarcoma
Present as painful progressively
enlarging masses
Prognosis depends on size of tumor
Spreads to lungs and skeleton

Chondrosarcoma

Chondrosarcoma
Tumor has developed in the proximal
femur
Not destroyed the cortex
Has a bluish, glassy appearance ,
reminiscent of cartilage

Malignant neoplastic cells produce a chondroid matrix

The aggressiveness of chondrosarcomas can be predicted by their histologic grade. Grading system is based on three parameters: cellularity,
degree of nuclear atypia and mitotic activity.

Grade 1 (low-grade)
Very similar to enchondroma. However, the cellularity is
higher, and there is mild cellular pleomorphism. The nuclei are
small but often show open chromatin pattern and small
nucleoli. Binucleated cells are frequent. Mitoses are very rare.
Grade 1 chondrosarcomas are locally aggressive and prone to
recurrences, but usually do not metastasize.

Grade 2 (low-grade)
The cellularity is higher than in Grade 1 tumors. Characteristic
findings are moderate cellular pleomorphism, plump nuclei,
frequent bi-nucleated cells, and occasional bizarre cells. Mitoses
are rare. Foci of myxoid change may be seen. Unlike Grade 1
tumors, about 10% to 15% of Grade 2 chondrosarcomas
produce metastases.

Grade 3 (high-grade)
Characteristic findings are high cellularity,
marked cellular pleomorphism, high N/C
ratio, many bizarre cells and frequent
mitoses (more than 1 per hpf). These are
high grade tumors with significant
metastatic potential.

OSTEOSARCOMA

10-25 years of age

affects long bones
sensitive to
chemotherapy

CHRONDROSARCOMA

>40 years of age

affects axial skeleton
not sensitive to
chemotherapy

Giant cell tumour of bone (GCT)

Contains a profusion of multinucleated
osteoclast type giant cells
Relatively uncommon benign
But locally aggressive
Usually arises during 5th decade
Slight female predominance

Giant cell tumour of bone (GCT)

Involve both epiphysis and metaphysis

In adolescents limited to metaphysis
Common sites are distal femur and
proximal tibia

Ewing sarcoma(ES)
Primary malignant small round cell tumour
Ewing sarcoma has the youngest
average age at presentations (10-15 years)
Boys slightly more often affected than girls

Ewing sarcoma(ES)

Pelvis is the most common site

usually arises in the diaphysis of
long bones especially femur
followed by tibia and humerus

Ewing sarcoma
of tibia from a
child

The following studies are required to support the diagnosis of ES and PNET:
Demonstration of t(11;22) or EWS-FLI-1 fusion transcript (present in both ES and PNET)
Immunostains(both ES and PNET are positive for CD99/O13. In addition, PNET shows positive staining
with neural markers)
EM (ES cells are undifferentiated and show prominent glycogen deposits; PNET shows neural
differentiation)

Ewing sarcoma(ES)
The pathways of spread include
Direct extension
Lymphatic or vascular dissemination

Intraspinal seeding

Secondary tumours of bone

Metastatic cancer to bone is
more common than primary
cancer of bone

75% of bone metastasis originate from

Cancers of prostate
breast
kidney
lung
thyroid
Metastatic lesions are multifocal
Produce a lytic and or blastic reaction

Bone metastasis

Bone metastasis

Prostatic carcinoma metastatic to bone