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Bone Tumours

Osteoma
I. Compact osteoma (Ivory osteoma).

⁕ Pathology:

▪ Origin : Osteoblast.

▪ Site: Bones develops from membranes especially the skull.

▪ Gross picture: Usually single but may be multiple , rounded, sessile

hard & well-defined.

▪ Never turn malignant.

⁕ Clinical picture : According to site:

▪ Outer table → cosmetic

▪ Inner table →increase intracranial pressur .

▪ Orbit → proptosis .

▪ Auditory meatus → deafness.

⁕ Treatment:

1- Small: Excision in a trephine hole.

1- Large: Excision of a piece of skull bone carrying the tumour by multiple

burr holes and Gigli saw.
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II. Osteochondroma

1- Single osteochondroma:

⁕ Incidence & Pathology:

▪ It is the commonest benign bone tumour .

▪ It is autosomal dominant disease .

▪ Usually starts in teen agers .

▪ Site: Usually affect the metaphyses especially around the knee and
upper humerus .
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▪ Origin:
 Chondroblast.
 Possibly arise from a part of epiphyseal cartilage that herniates
through the cortex under the periosteum
 Recently it is considered as a skeletal hamartoma in which parts
of the epiphyseal cartilage are detached and lie in the metaphysis.
▪ Gross picture:
 It arises from the surface of the bone and continues with the
medullary cavity .
 Smooth, sessile or usually pedunculated swelling of spongy bone
covered by a cap of cartilage ,which form the bony mass by
endochondral ossification , but at the age of epiphyseal fusion, it
ossifies and the swelling stop to grow.
 The cap of cartilage has the same histological structure as that of
the epiphyseal cartilage .
 A bursa may be present overlying the cartilaginous cap .
 It grows oblique away from the epiphyseal cartilage.
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⁕ Complications :

1- It may turn malignant in 1% of cases → chondrosarcoma → the

swelling becomes painful, rapidly growing & recurrent after excision.

2- Compression of neurovascular bundle or tendons

3- Block of movements of near by joint.

4- Adventitious bursa and bursitis.

5- Fracture of the pedicle

⁕ Clinical pictures :

1- Characteristic incidence .

2- Usually symptomless .

3- Painless swelling metaphyseal swelling in th characteristic site .

Pain usually occur due to complications.

4- Manifestations of complications .

⁕ Investigations :

▪ Plain x ray : Sessile or pedunculated well-defined metaphyseal

bony swelling on the bone surface .

▪ MRI shows the cartilaginous cap.

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⁕ Treatment:
▪ Observation for symptomless tumour.

▪ If complications or symptoms occur: Excision of the tumour from its

base after the age of epiphyseal fusion .

▪ Wide surgical excision if malignant transformation occurs.

2) Multiple exostosis :

▪ Definition : A heridetary autosomal dominant disease , more in

males , characterised by the following clinical features :

1- Multiple osteochondromata .

2- Broadening of metaphysis of long bones with many sessile tumours.

3- Skeletal deformity ( usually in thigh , leg and forearm ).

4-Short stature ( short femur and tibia ).

5- Malignant transformation to chondrosarcoma in 10% of cases

.Malignancy is suspected if there is recent rapid increase in size and
appearance of pain .
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⁕ Investigations : Plain x ray and MRI

⁕ Treatment: Excision of complicated tumours only.

III. Osteoid osteoma

⁕ It is a rare , benign bone forming neoplasm .

⁕ Incidence : More in males below 20 years .

⁕ Pathology :

▪ Site:

 In one side of the cortex of diaphysis of long bone

 The commonest site below lesser trochanter .

 Femur & tibia are the commonest site .

▪ It has a small nidus of neoplastic tissues surrounded by reactive mature

bone formation .

⁕ Clinical picture :

▪ It is a painful condition worsen by night and relieved by NSAID .

⁕ D.D : Brodie’s abscess and osteosrcoma .

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⁕ Investigations :

1- Plain x ray show rounded or oval lytic well demarcated nidus in one
side of cortex surrounded by sclerotic area .

2- CT scan & MRI .

⁕ Treatment :

I) Conservative :

▪ It is the main treatment as the lesion usually becomes asymptomatic

and spontaneously heals .

▪ Method : Observation & anti-infilammatory medications .

II) CT guided radiofrequency ablation if conservative treatment fails.

CHONDROMA

⁕ Chondroma is a benign tumor arising from the chondroblasts

characterized by cartilage formation .
⁕ Incidence : A relatively common tumor and the commonest tumor of
hand & feet .
⁕ Pathology :
▪ Typically the tumor involves the short long bones of the hand
& feet or the metabphysis of long bones ( especially femur & tibia ).
▪ It may be situated centrally in the medulla causing bone expansion
(enchondromo) ,or eccentrically situated appear on the surface (
ecchondromo).
▪ It may occur as a single or multiple tumours.
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⁕ Complications : Pathological fracture and malignant transformation into

chondrosarcoma may occur.
⁕ Clinical picture :
1- Enchondroma in long bones usually seen as incidental
finding in plain
x-ray finding or it may present by complications.
2- Ecchondroma uaually appears as firm well defined slowly
growing swelling .
⁕ Investigations :
▪ Plain x-ray shows well defined radiotranslucent lesion with bone
expansion and areas of calcification.
▪ No infilteration of surrounding structures .

▪ The cortex is intact or endosteal scalloping affecting less than 2/3 of

cortical thickness .

⁕ Treatment:
▪ No symptoms → no treatment and follow up by x-ray .
▪ Presence of smptoms or complications →Curettage and bone graft.

⁕ N.B :
❖Olier’s disease :
 It is multiple enchondromatosis , present from birth, due to error in
endochondral ossification .
 The patients have short bowed limb with high incidence of
malignancy .
❖ Maffucci syndrome :
 It is multiple enchondromatosis & hemangiomas .
 The patients have high risk of angiosrcoma .
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Malignant Bone Tumours

( General )

⁕ Staging: TNM classification

⁕ Complications :
1- Spread :
a- Direct : Longitudinal through the medulla and transversely to
cortex then to the surrounding structures .
b-Lymphatic : rarely, to the regional lymph nodes , only common
in Ewing’s sarcoma .
c- Mainly blood spread to the lungs or other bones .
2- Pathological fracture in advanced tumors .
3- Anaemia , cachexia and death.
⁕ Clinical picture :
1. Characteristic incidence (Mention)
2. Swelling , pain (as usual) & tenderness
3. Manifestations of complications.
4. Sympathetic effusion in the near by joint.
⁕ Investigations:
1. Plain X-ray is the first investigation.
2. C.T scan & MRI : are best investigations for accurate staging of the
tumor
3. Radioactive isotopic bone scan.
4. Open biopsy during operation while a tourniquet is applied. The edge is
the ideal part.
5.Angiography show irregular vascularity of the tumor .
6.Investigations to detect metastases (mention)
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7. ESR & alkaline phosphatase are raised.

Chondrosarcoma
⁕ It is a malignant tumor arising from the chondroblasts .
⁕ Incidence : It is the 3rd. common primary malignant bone tumor ( after
multiple myeloma & osteosarcoma ) and usually occur between 40-60 year

⁕ Pathology :

▪ Site : Usually pelvis , scapula or less commonly in the epiphysis of

femur , tibia and upper humerus .

▪ Whitish irregular ill-defined tissue infilterate the surrounding structures .

▪ The tumor may be de novo or on top of chondroma or osteochondrma .

⁕ Complications :

▪ Pathological fracture .

▪ Spread :

1- Direct : to the surrounding structures .

2- Blood spread is late to the lung .

3- Lymphatic spread is very rare .

⁕ Clinical picture :
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▪ There may be history of chondroma or osteochondroma .

▪ Large rapidly growing, painful , hard ,fixed swelling in the characteristic site .

⁕ Investigations : ( As all malignant bone tumors ) +

1- Plain x-ray :

▪ Chondrosarcoma appear as a lytic lesion with intra-lesional

calcification (rings , arcs & popcorn calcification = fluffy cotton
appearance ).

▪ Endosteal scalloping affecting more than 2/3 of cortical thickness .

Intra-lesional calcification

Endosteal scalloping

⁕ Treatment :
▪ The tumor is resistant to chemotherapy and radiotherapy .
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▪ The usual treatment is similar to osteosarcoma .

Osteoclastoma Osteosarcoma
(Giant cell tumour) (Osteogenic Sarcoma)
* Incidence  A common 1ry. bone tumor which  The 2nd common 1ry
may be benign, locally malignant malignant bone tumour after
or frankly malignant. multiple myeloma.
 Age :  20 - 40 years (after epiphyseal  Usually 10-20 years or above
union). 50 years if on top of Paget's
disease
 Sex :
 More in males .  More in males .
*Predisposing  Trauma ( usually call the  Trauma, osteoclastoma,
factors : attension of the patient to the irradiation & Paget's disease.
already present disease ).

⁕ Pathology:
 Origin  Uncertain.  Osteoblasts (bone forming
 Site : cells).
 Eccentric in epiphyses of long  The rule of 80: 80% of
bones especially around knee, osteosarcoma in teen ages,
upper part of humerus, lower 80% in the lower limb, 80%
part of radius & mandible. around the knee, 80% in the
lower end of femur & 80%
metaphyseal.
 Gross picture  The tumour causing bone  The tumour destrory &
expansion & finally thinning of invades the medulla &
the cortex → egg shell crackling cortex → fusiform swelling.
sensation.  Thus the tumour is formed
 The tumour is separated from of 2 parts:
the medulla by an operculum or 1- Intramedullary part
medullary plug. 2-Subperiosteal part: It
 Usually does not invade the raises the periosteum →
articular cartilage or adjacent stretch of subperiosteal
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joint . vessels→ reactive new

bone formation in 2 sites:
a. Codman's triangle: at
the angle between raised
periosteum & shaft.
b. Along the subperiosteal
vessels → sun ray appearance.
 It respects the articular &
epiphyseal cartilage → rare
& late invasion of the joint or
epiphysis .
 Cut section:  A localized soft, friable well-  Irregular , ill-efined,vascular,
defined growth with no bone of fleshy or grayish white mass
cartilage . infiltrating the surrounding
 Fibrous or bone trabeculae structures with wide areas of
dividing the tumour in hemorrhage, necrosis &
compartments variable in size degeneration.
 The cut surface has a redish
brown fleshy appearance with
areas of hemorrhage &
degeneration.
 Microscopic  The tumour composed of 2  Pleomorphic cells (spindle,
picture: elements : round, polyhydral & giant
 Mononuclear small spindle cells).
shaped neoplastic cells.  Pleomorphic stroma show
 Large number of reactive osteoid tissue, fibrous,
multinucleated giant cells cartilagenous, myxomatous
similar to osteoclasts . or osseous tissues.
 Well formed blood vessels  Numerous thin walled
which are not invaded by any malformed blood vessels
cells. which are invaded by
malignant cells.
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 Pathological  It is a tumor present with 1.Intra-medullary type

Types: 2. Intra-cortical type
different grades of aggression ,
3. Juxta-cortical types( on
from totally benign to frankly
the surface of the bone )
malignant .
which may be :
 Agression depends on the  Parosteal type : arises
percentage of the spindle cells from the outer layer of
periosteum .
showing atypical morphology
 Periosteal type : arises
and mitotic figures.
from the inner layer of
 1ry. malignant giant cell tumor
periosteum .
behaves like osteosarcoma with
4- Telangectatic type
abundant giant cells . It gives
5- Secondary osteosarcoma
metastases in 5% of cases .
on top of Paget’s disease or
 2nd. malignant giant cell tumor
after radiotherapy .
follows recurrence after surgery or
6.Osteolytic type.
radiotherapy .
7. Osteosclerotic type.
Radiosensitivity:  Sensitive  Insensitive
⁕ Complications

1. Spread:  Direct spread only in low grade  Direct spread (to the
type but may spread to lungs in surrounding),
malignant type .
 Blood spread (early &
mainly to lungs)
 Very rarely lymphatic
spread.
2.Pathological  Occurs in advanced cases.  Very rare as severe pain
fracture : prevents the patient to use
the limb & he is bed ridden.
3.Malignancy  May turn to 1ry or 2nd
malignant giant cell tumor
4.Anaemia ,  Not occur .  Very common
cachexia & death:
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5. Recurrence after incomplete excision

* C/P:
1. Swelling:  Main & earliest presentation  It is not the earliest syptom.
 It occurs before pain.  It occurs after pain
 The swelling is well defined,  The swelling is tender,
slowly growing, in the fusiform, ill-defined, rapidly
epiphysis of long bone. growing, metaphyseal
 Early it is hard in consistency  Hard or heterogenous.
but later on it has an eggshell  The skin is warm & shows
crackling sensation. dilated veins.
 If the tumour is highly
vascular → pulsation, thrill &
bruit.
2. Pain:  It is a late symptom.(Mention  Is the main & earliest
its features) symptom and it occurs
months before the swelling .
 Pain is severe, sawing,
increased by night → prevent
sleep.
3. Near by joint  May show sympathetic effusion
4. Picture of  Pathological fracture or  In advanced cases, there are
complications recurrence after incomplete low grade fever, anaemia,
excision. cachexia & features of lung
metastasis.
⁕ Investigations:  Characteristic site & age.  Characteristic site & age.
1- Plain X-ray:  Osteolytic lesion.  Osteolytic osteosclerotic
 Bone expansion without soft lesion.
tissue shadow outside the bone.  Bone destruction & new bone
 Soap bubble appearance formation → sun ray
 Medullary plug ( abscent in appearance & Codman's
malignant transformation) triangle.
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 Eroded cortex (bone ghost)

 Large soft tissue shadow
outside the cortex .
2. Other investigations (as before in any bone tumour).
* D.D.:  Hyperparathyroidism  Osteoclastoma
 Aneurysmal bone cyst  Other malignant bone
 Osteosarcoma tumours
 Metastases
 Chronic non-specific
osteomgelitis.
* Treatment: A) Surgical : ( main treatment) I) Early cases: (No lung metasuses)

I) Unimportant bone (e.g. a. Pre-operative ( neo-

upper fibula or lower ulna ) → adjuvant) chemotherapy .
excision with wide safety b. Surgery :Local control of
margin. the tumour by one of the
II) Important bone: followings:
a.Early small low grade tumour: 1) Limb salvage surgery :
▪ Aggressive curettage with  Method: Wide local
adjuvant ( phenol or resection with replacement
cryotherapy ) to decrease local of the defect by prosthesis.
recurrence .  Indication : If the tumor
▪ The defect is closed by bone can be removed with
graft or sement . adequate safety margin
▪ Disadvantage :High and the resulting limb has
incidence of recurrence . satisfactory function .
b.Wide excision with safety 2)Amputation : Proximal to
margin & reconstruction by the joint above the tumor .
prothesis or arthrodesis .  Indication : reverse of
▪ Indications : number 1
➢ Large or aggressive tumour c.Post-operative adjuvant
➢ Extension to subchondral chemotherapy
bone or soft tissues . II) Advanced cases: (With
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➢ Recurrence lung metastases):

c. Amputation : 1. Palliative amputation.
▪ Indications :Recurrence with
2. Palliative radiotherapy &
evidence of malignancy
chemotherapy,
A) Radiotherapy : ( inferior to
3. Solitary lung metastasis is
surgery ) ,for inaccessable
treated by lobectomy.
tumors e.g. vertebrae .
B) Medical treatment:
a.Bisphosphonates + vit. D
inhibit bone resorbtion &
encourage new bone formation
b.Denosumab is a human
monoclonal antibody for
unresectable tumor +
indications of wide excision
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Microscopic picture of

Giant cell tumor

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Ewing’s Sarcoma

⁕ Incidence: Rare , more in males ,10-20 years.

⁕ Pathology:

• Origin : from the vascular endothelium of bone marrow.

• Site: In the center of the diaphysis of a long bone especially tibia,

fibula, femur.

• Gross picture: The tumour arises in the medulla as a greyish white

mass which spread longitudinally and transversely → raising the
periosteum → subperiosteal new bone formation in successive layers.

• Cut section: Ill-defined greyish white mass with areas of haemorrhage

and necrosis.

• Microscopic picture: Small rounded cells arranged in rosette around

the blood vessels.
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⁕ Complications: (As any malignant bone tumor ) +

• Lymphatic (common) →regional L.Ns.

⁕ Clinical picture:

1- Fever , headache , anorexia and malaise

2- Pain and tenderness.

3- Swelling: Fusiform, ill-defined, diaphyseal, soft, the overlying skin is

warm and shows dilated veins.

⁕ Investigations: (As any malignant bone tumour)+

1- Pain X-ray: Diaphyseal bone destruction + Onion peel appearance is

diagnostic .

2- Leucocytosis & high ESR.

⁕ D.D.: Acute osteomyelitis, reticulum cell sarcoma & secondaries from

neuroblastoma.

⁕ Treatment: Complete surgical resection + radiotherapy & chemotherapy.