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Similar to Radiological and pathological correlation of bone tumours Dr.Argha Baruah
Radiological and pathological correlation of bone tumours Dr.Argha Baruah
- 1. RADIOLOGICAL APPEARANCES INDICATING PATHOLOGICAL CHANGESIN BONE TUMORS DR.ARGHA BARUAH
- 2. If the clinician, radiologist & pathologist share information, an accurate diagnosis is possible in at least 95 % of cases of bone tumors. Pathologist who attempts to diagnose a neoplasm of bone without knowledge of clinical features & radiographic findings is AT A DISTINCT DISADVANTAGE.
- 3. There are variousindividual aspects to be taken into account so that question of diagnosis & treatment can only be solved by closest interdisciplinary co operation Strategy for Diagnosis of Bone Neoplasms Proved by experience – as the best way to avoid clinical disasters.
- 6. Clinical aspects ofdiagnosis • Symptoms of bone tumors are non specific Pain , Swelling, Pathological fracture Generally, benign non-growing lesions tend to be asymptomatic and represent incidental findings.
- 7. Following clinical symptomsare worth remembering since they may help in the differential diagnosis: Osteoid osteoma Small lesion, but highly irritative to adjacent tissues and typically causes intense night pain relieved by non-steroidal anti inflammatory drugs. .
- 8. Enchondroma vs. chondrosarcoma,grade 1 • Histologically, the distinction between a grade 1 chondrosarcoma and an enchondroma is extremely difficult, • Histologic features overlap considerably. • Low-grade chondrosarcoma is a growing tumor and, therefore, presents with pain. • Enchondromas tend to be asymptomatic, unless associated with a pathologic fracture.
- 9. Metastatic cancers –remember! Byfar more common than primary bone tumors characterized by the following features • Predominant occurrence : adults > 40 years of age • Children in the first decade of life. • Multi focality and predilection for the hematopoietic marrow • Sites in the axial skeleton and proximal long bones. Metastases to long bones distal to the elbows and knees are unusual.
- 10. Radiographic appearance ofthe metastatic tumors can be - Purely lytic (kidney, lung, colon, and melanoma) - Purely blastic (prostate and breast carcinoma) - Mixed lytic and blastic (most common appearance)
- 13. Primary bone tumorsare characterized by: • Predominant occurrence in the first 3 decades of life, during the ages of the greatest skeletal growth activity • The commonest sites for many primary tumors, both benign and malignant, are in the distal femur and proximal tibia, the bones with the highest growth rate.
- 14. Radiological aspects ofdiagnosis PLAIN RADIOGRAPH is usually the first imaging technique for a suspected bone lesion • Inexpensive • Easily obtainable • Best for assessment of general radiological features of the tumor.
- 15. COMPUTER TOMOGRAPHY isa method of choice when plain film assessment is: - Difficult owing to the nature of the lesion (eg., permeative pattern of destruction) or anatomic site (eg., sacrum). - CT is the best technique in - Assessment of matrix mineralization, - Cortical detail, and - Detection of the cystic and fatty lesions. CT remains a standard imaging procedure for use in well-selected clinical situations. Perhaps the best indication for CT is for smaller lesions that involve cortical structures of bone or spine .
- 16. MRI is amethod of choice for local staging. It is superior to CT in the definition of Medullary and Extracortical spread and of the relationship of the tumour to critical neurovascular structures. Remember that the MRI appearances of the majority of bone tumors are totally non-specific. You need to examine plain films or CT films to define a neoplasm.
- 17. BONE SCINTIGRAPHY isa highly sensitive but relatively non-specific technique. Main role is in detection of suspected metastases in the whole skeleton. It may also be helpful in the detection of osteoid osteomas ("double density sign" is present in about 50% of cases and is highly suggestive of this tumor).
- 20. Osteolytic lesion ofbone:
- 21. A L T- M C P S • Age • Location • Transitional zone • Matrix • Cortex • Periosteal reaction • Soft tissue swelling
- 22. According to theage:
- 24. SITE OF LONGBONE INVOLVEMENT
- 25. DIAPHYSEAL • Ewing sarcoma •Fibrous dysplasia • Adamantinoma • Langerhans cell histiocytosis • Lymphoma • Osteoid osteoma METAPHYSEAL • Osteosarcoma • Nonossifying fibroma • Osteochondroma • Aneurysmal bone cyst • Osteomyelitis • Central Enchondroma • Chondrosarcoma • Solitary bone cyst • Osteomyelitis EPIPHYSEAL • Giant cell tumor • Chondroblastoma • Osteomyelitis • Degenerative cyst • Pigmented villo nodular synovitis
- 26.
- 29. Location: Centric in longbone: SBC, eosinophilic granuloma, fibrous dysplasia, ABC and enchondroma are lesions that are located centrally within long bones. Eccentric in long bone: Osteosarcoma, NOF, chondroblastoma,, GCT and osteoblastoma are located eccentrically in long bones.
- 30. Zone of transition: Inorder to classify osteolytic lesions as well-defined or ill- defined, we need to look at the zone of transition between the lesion and the adjacent normal bone. Wide zone of transition: An ill-defined border with a broad zone of transition is a sign of aggressive growth Small zone of transition:A small zone of transition results in a sharp, well-defined border and is a sign of slow growth.
- 37. PATTERNS OF MATRIXMINERALIZATION Mineralization patterns (calcification or ossification) are helpful in identification of bone producing and cartilage producing tumors.
- 39. Matrix “Cloud” like Ossificdensities in Bone = Osteosarcoma
- 40. Chondroid: Radiologically, it isusually easier to recognize cartilage as opposed to osteoid by the presence of focal stippled or flocculent densities, or in lobulated areas as rings or arcs of calcifications. They are best demonstrated by CT.
- 41. Wide Zone of Transitionand Broken Cortex could be signs of Aggressiveness / Malignancy Cortex: Intact or Broken
- 42. TYPES OF PERIOSTEALREACTION The periosteum responds to traumatic stimuli or pressure from an underlying growing tumor by depositing new bone. The radiographic appearances of this response reflect the degree of aggressiveness of the tumor.
- 47. Soft Tissue Enormous softtissue seen in Ewing’s Sarcoma
- 49. WHO CLASSIFICATION OFBONE TUMORS CARTILAGE TUMOURS Osteochondroma Chondroma Enchondroma Periosteal chondroma Multiple chondromatosis Chondroblastoma Chondromyxoid fibroma Chondrosarcoma Central, primary, and secondary Peripheral Dedifferentiated Mesenchymal Clear cell OSTEOGENIC TUMOURS Osteoid osteoma Osteoblastoma Osteosarcoma Conventional - chondroblastic - fibroblastic - osteoblastic Telangiectatic Small cell Low grade central Secondary Parosteal Periosteal High grade surface
- 50. FIBROGENIC TUMOURS Desmoplasticfibroma Fibrosarcoma FIBROHISTIOCYTIC TUMOURS Benign fibrous histiocytoma Malignant fibrous histiocytoma EWING SARCOMA/ PNET Ewing sarcoma HAEMATOPOIETIC TUMOURS Plasma cell myeloma Malignant lymphoma, NOS GIANT CELL TUMOUR Giant cell tumour Malignancy in giant cell tumour NOTOCHORDAL TUMOURS Chordoma VASCULAR TUMOURS Haemangioma Angiosarcoma NEURAL TUMOURS Neurilemmoma SMOOTH MUSCLE TUMOURS • Leiomyoma • Leiomyosarcoma LIPOGENIC TUMOURS • Lipoma • Liposarcoma MISCELLANEOUS TUMOURS • Adamantinoma • Metastatic malignancy MISCELLANEOUS LESIONS • Aneurysmal bone cyst • Simple cyst • Fibrous dysplasia • Osteofibrous dysplasia • Langerhans cell histiocytosis • Erdheim-Chester disease • Chest wall hamartoma JOINT LESIONS • Synovial chondromatosis
- 51. TNM staging Primary tumour(T) TX: primary tumour cannot be assessed T0: no evidence of primary tumour T1: tumour </= 8 cm in greatest dimension T2: tumour > 8 cm in greatest dimension T3: discontinuous tumours in the primary bone site Regional lymph nodes (N) NX: regional lymph nodes cannot be assessed N0: no regional lymph node metastasis N1: regional lymph node metastasis Distant metastasis (M) MX: distant metastasis cannot be assessed M0: no distant metastasis M1: distant metastasis M1a: lung M1b: other distant sites
- 52. The characteristic featureis a projection of the cortex in continuity with the underlying bone. Irregular calcification is often seen. Excessive cartilage type flocculent calcification should raise the suspicion of malignant transformation.
- 54. Chondromyxoid fibroma • Oval,eccentric, lytic metaphyseal lesion with long axis parellel to bone. • Sharply defined, sclerotic, scalloped borders. • May extend to diaphyseal region.
- 55. Gross • Firm, graywhite lobulated mass, sharply demarcated & eccentrically located. • Periosteum is intact. • Semi solid myxoid areas may be seen. • Chondroid foci usually not seen grossly.
- 57.
- 60. Gross • Soft, gelatinous,red tan tumor with flecks of chalky calcification. • Hemorrhage and cystic change can be present.
- 63. Chondrosarcoma: This case, whichlikely arose from an osteochondroma, shows the charactristic ' rings and arcs" pattern of calcification.
- 64. Have translucent, blue-grey/whitecolour corresponding to presence of hyaline cartilage. lobular growth pattern is a consistent finding. Zones of myxoid/ mucoid material & cystic areas +/-.
- 67. Osteoid Osteoma: • Welldemarcated lytic lesion (nidus) surrounded by a distinct zone of sclerosis. • A zone of central opacity that represents more sclerotic portion of the nidus surrounded by a lucent halo may be present within the nidus.
- 68. Gross • Nidus tissue-Distinct oval or round, reddish area that can be easily separated from its bed. Vary in consistency from soft friable to densely sclerotic. • Nidus is usually surrounded by large zone of dense sclerotic bone.
- 69. Small cortical based,red, gritty/ granular round, sharply circumscribed lesion surrounded by ivory white sclerotic bone Nidus < 1.5 cm (any larger size arbitrarily considered to be an osteoblastoma)
- 71.
- 72. OSTEOBLASTOMA • Rare benigntumor with nidus > 1.5cms in diameter & differs from osteoid osteoma by 1) Has a higher growth potential (>2cms.). 2) Lacks nocturnal pain. 3) Pain is not relieved by aspirin. 4) Peripheral sclerosis may be minimal or absent.
- 73. GROSS: Size: 2-15 cm Extremelyvascular red-brown color with gritty/ sandpaper consistency Has pushing borders
- 78. OSTEOSARCOMA Is a primaryintramedullary high grade malignant tumour in which the neoplastic cells produce osteoid Involve metaphysis(91%), diaphysis(9%) C/F: pain, palpable mass+/-, reduced range of motion, warmth, edema, telenectasias & bruit on ascultation LAB: raised S. Alk.phos & LDH
- 79.
- 81. MICROSCOPY Frequently referred toas a "spindle cell“ tumour Tends to be highly anaplastic & pleomorphic Tumour cells may be: epithelioid, plasmacytoid, fusiform, ovoid, small round cells, clear cells, mono- or multinucleated giant cells, or, spindle cells. Usually show complex mixtures of two or more of cell types. ACCURATE IDENTIFICATION OF OSTEOID
- 82. OSTEOID Dense, pink, amorphous,intercellular material, somewhat refractile Based on thickness: 1. Thinnest – filigree osteoid 2. Osseous matrix with predisposition for appositional deposit on pre- existing bone trabeculae – scaffolding 3. Grow in angiocentric fashion basket-weave/ cording pattern to tumor 4. Thin tubular anastomosing microtrabeculae which may be basophilic & vaguely reminiscent of appearance of fungal hyphae/ laid in fish-net appearance
- 83. 1. unmineralized osteiod2. filigree 3. flat 4. basket-weave 5. scaffolding 6. fungal hyphae
- 86.
- 88. Periosteal Osteosarcoma: Upper shaftof tibia shows a well demarcated tumour arising from cortical surface of the bone. Fluffy calcifications are present. Proximal Femur-broad based, mushroom-like, large surface tumour with a thickened ossified area blending in with cortex. Covering this, is a large soft tissue component with 2 layers of tissue: One is whitish-cartilaginous and the other is tan-yellow.
- 89. Cartilagenous component predominates. Matrixmay be myxoid. Bony spicule shows elongated vascular cores surrounded by calcified/ ossoeus/ chondro- osseous matrix which is further surrounded by a non- calcified cartilagenous growth Periphery of tumor shows fascicles of spindly cells
- 91. ‘Soap bubble appearance’- dueto marked trabeculation and marginal sclerosis.
- 92. Gross • Soft ,friable, fleshy and red brown. • Well demarcated and usually extends to the articular cartilage, but it is unlikely to be invaded • Eccentrically placed
- 94.
- 101. Gross • Cystic cavityfilled with a clear or yellowish fluid. • Wall- composed of paper thin tan yellow fibrous tissue with multiple bony ridges. • Focal hemosiderin deposition is seen.
- 102. Microscopic examination showed blandfibrous tissue with sparse inflammatory infiltrate, hemosiderin-laden macrofages, and occasional osteoclast-like multinucleated giant cells.
- 104. Gross • Spongy, multilocularcystic lesion filled with blood ( size varies from 1 mm- several cms.). • Small amount of spongy red brown soft tissue or thin membranous septa. • Borders- Irregular, lobulated, sharply demarcated.
- 116. TO CONCLUDE….. • Thediagnostic triangle recommended by Jaffe – surgeon ,radiologist, & pathologist sharing their points of view on a bone lesion to arrive at a rational diagnosis is still valid. • The advent of newer molecular techniques has expanded this diagnostic triangle into a diagnostic quadrangle. DIAGNOSIS CLINICAL PRESENTATION RADIOLOGIC FEATURES MOLECULAR DATA MICROSCOPIC FEATURES
- 117. References: 1. WHO Classificationof Tumors- Pathology & Genetics of Tumors of Soft Tissue & Bone, 2013. 2. Rosai & Ackerman’s Surgical Pathology 11TH EDITION 3. Radiopaedia.org
Editor's Notes
- #62 Sheets of uniform-appearing chondroblasts, numerous randomly-distributed osteoclast type g.c. Individual chondroblasts-round to polygonal with sharply defined cytoplasmic borders, round to ovoid/ histiocyte-like nuclei, occasional small nucleoli. Nuclear grooves frequently +. Fine network of pericellular calcification i.e. chicken-wire calcification / form obvious deposits
- #63 Cellular smears with mononucl CB admixed with scatered m.n.g.c. CB show well def deeply eosino & oval cytop, central/ eccen o-r nucl, nucl grooves & dispersed chromatin.
- #65 Have translucent, blue-grey/white colour corresponding to presence of hyaline cartilage. lobular growth pattern is a consistent finding. Zones of myxoid/ mucoid material & cystic areas +/-. Yellow-white, chalky areas of calcium deposit usually +. Proximal femur & shaft with bulging in proximal shaft. Side by side: bisected tumour and X-ray of surgical specimen. lesion has thickened the cortex or irregularly eroded it
- #70 Small cortical based, red, gritty/ granular round, sharply circum lesion surr by ivory white sclerotic bone
- #74 well-demarcated fleshy tumour.
- #80 large, metaphyseally centred, fleshy/ hard tumor confined to bone/ with s.t. extension. Skip mets.
- #84 Osteoid is unmineralized bone matrix- is eosinophilic, dense, homogeneous & curvilinear & becomes bone as a result of mineralization (blue areas). Filigree osteoid:thin, randomly arborizing lines of osteoid interweaving b/w neoplastic cells. Osteoid: flat & thick. Angiocentric pattern of gr.basket-weave appearance while combined with abundant osteoid production. Appositional osteoid/bone deposition i.e scaffolding
- #87 Purely lytic lesion in metaphysis of distal femur, no surrounding bony sclerosis+ cortical bone destruction with periosteal reaction (Codman's triangle) & massive extension of tumour into s.t. Dominant cystic architecture, incompletely filled with blood clots ("a bag of blood")
- #89 upper shaft of tibia shows a well demarcated tumour arising from cortical surface of the bone. Fluffy calcifications are present. Proximal Femur-broad based, mushroom-like, large surface tumour with a thickened ossified area blending in with cortex. Covering this, is a large soft tissue component with 2 layers of tissue: One is whitish-cartilaginous and the other is tan-yellow.
- #90 cross section of tibial tumour shows an ossified mass blending with & thickening the cortex & covered by an uncalcified component. Chondroblastic grade 3 os showing lobules of malignant-appearing cartilage with bone formation in the centre of the lobules. Has better prog than conventional os.