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Contents for Volume 1


Osteoid osteoma--------------------------------Case 1-50
Osteoblastoma----------------------------------Case 51-94
Osteofibrous dysplasia-------------------------Case 95-101
Ossifying fibroma of jawbone----------------Case 102-107
Osteoid
Osteoma
Osteoid Osteoma
   The osteoid osteoma is the most common osteoid-forming tumor
seen in the skeletal system, accounting for 10% of all benign
bone tumors. It is more common in males than females with the
peak incidence in the second decade of life. The lesions produce
symptoms of dull, aching pain that is more severe at night. The
pain 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 in
the 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 the
small inflammatory nidus or granuloma (measuring up to one
centimeter in diameter) in the central area of the sclerotic
response. If the lesion is located in a central medullary area,
such as the metaphysis or on the very superficial surface of a
bone, the sclerotic response is less severe. If the nidus is
located close to or within a joint structure, as in the femoral
neck area, there will be a significant inflammatory synovitis
in the adjacent joint that gives the clinical appearance of a
pyarthrosis. In the spine, the lesions are usually located in the
posterior elements of the spine such as the laminae or pedicles.
The lumbar spine is the most common location followed second
by the dorsal spine. Atypical secondary painful scoliosis will
develop with the convexity seen on the side opposite the
inflammatory lesion.
    The two most significant diagnostic imaging studies are a CT
scan through the nidus area to identify its anatomic location and a
bone isotope scan which is invariably positive, especially in a
symptomatic 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 or
plasma cells as would be seen in a Brodie’s abscess. Non-
steroidal anti-inflammatory medications such as prostaglandin
inhibitors can be very effective in controlling the disabling
symptoms and helping the patient get thru a period of one or
two years during which time the lesion will typically involute
into 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 inflammatory
bone that is characterized by a pinkish hyperemia. When the
nidus is found, a small curette is used to core the inflammatory
nidus for pathological diagnosis and the cavity of the nidus
is burred an additional 2 or 3 mm which usually results in a very
dramatic 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 could
result in a pathologic fracture following surgery. In the spine,
a simple laminectomy is frequently carried out. If the lesion is
located in the pedicle a simple burring into the pedicle will
relieve the patient of the inflammatory pain.
    More recently, relatively non-invasive techniques have been
tried 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 in
the pedicle of a vertebra one must be careful not to damage an
adjacent spinal root or spinal cord.
CLASSIC
Case #1




19 yr old female   painful
Osteoid osteoma    nidus
femur
CT scan




          nidus
Macro section of nidus
Photomic of nidus
Case #2




29 year male
osteoid osteoma
femur
                  nidus
CT scan




          nidus
Case #3




  11 yr male
  osteoid osteoma
  femur
Bone
scan
CT scan



          nidus
Photomic
Case #4




                  nidus




          5 yr male osteoid osteoma femur
Case #5



12 yr male
osteoid osteoma
femur




                  nidus
Case #6




10 yr male
osteoid osteoma
femur

                  nidus
nidus
nidus




CT scan
Case #7




30 yr female
osteoid osteoma
femur

                  nidus
nidus




Coronal T-1 MRI
nidus



               edema




Axial PD MRI
nidus




Macrosection
Case #8




23 yr female
osteoid osteoma
femur


                  nidus
Bone Scan
Nidus




        CT Scan
Case #9




12 yr male
osteoid osteoma
femur             nidus
Macro section nidus
Photomic
Case #10




                                       nidus



     10 yr female with osteoid osteoma femoral neck
Photomic
One yr after curettement
Case #11




                                   nidus




     25 yr male with osteoid osteoma femoral neck
nidus




CT scan
Case #12




                             nidus




           6 yr male osteoid osteoma acetabulum
nidus
Bone scan
Case #13




                  nidus

11 yr male
osteoid osteoma
distal femur
Bone scan
Case #14
                  nidus




16 yr male
osteoid osteoma
distal femur
Case #15




6 yr male
osteoid osteoma
tibia

                  nidus
Bone scan
Excessive
bone block
resection




             nidus
nidus




Macro section of nidus
Photomic
Post op x-ray
Resultant fracture
one year later
Case # 16




10 yr male
osteoid osteoma
tibia
Shaving down with osteotome
Further shaving to find nidus
Burred out nidus defect
Case # 17




15 yr male
osteoid osteoma
tibia
Lateral view




               nidus
Bone scan
Coronal T-2 MRI




                  nidus
Coronal Gad
contrast MRI           edema


               nidus
nidus




  T-1 axial MRI
Photomic
Photomic
Case #17.1                             Osteoid osteoma




             52 year old male with ankle pain for 3 mos.
Sag T-1   T-2   Gad
Axial T-1   T-2




Gad
Case #18




                  nidus
17 yr male
osteoid osteoma
femur
Gross
specimen
           nidus
Photomic
Case #19




               18 yr male
           Osteoid osteoma tibia
Case #20




18 yr female
osteoid osteoma   nidus
tibia
Case #21




                                                  nidus




      12 yr male with parosteal osteoid osteoma tibia
Case #22




                  nidus

17 yr male
osteoid osteoma
fibula
Lateral view
Case #23




                      nidus
26 year female with
epiphyseal osteoid
osteoma prox radius
Case #24




16 yr female
osteoid osteoma
ulna
                  nidus
Bone scan
Case #25




16 yr male
osteoid osteoma
humerus
                  nidus
Case # 26



                  nidus
14 yr male
osteoid osteoma
L-4
Bone scan
Photomic
Case # 27




                  nidus
15 yr male
osteoid osteoma
L-3
Case #28

                  nidus



46 yr male
osteoid osteoma
dorsal spine
Bone scan
Case #29


     nidus




           18 yr male with osteoid osteoma C-3
nidus




Laminogram
Bone scan
Case #30




   nidus




     12 yr male with osteoid osteoma C-3 spine
Case #31




                  nidus

25 yr male
osteoid osteoma
C-5
Case # 32




                                   nidus




            27 yr female with osteoid osteoma S-1
Case #33




     nidus




           22 yr male with osteoid osteoma sacrum
Case #34



                  nidus

18 yr male
osteoid osteoma
finger
nidus



X-ray
nidus



AP x-ray
Case #35




                     nidus



           24 yr male with osteoid osteoma thumb
Bone scan
Case #36




                                 nidus




       19 yr female with osteoid osteoma finger
Case #37

                    nidus




           20 yr male with osteoid osteoma thumb
Case #37.1




                              nidus




 17 year female with dull aching pain index finger 1 yr
Case #38




                                    nidus




       23 yr male with osteoid osteoma capitate
Case #39




  nidus




    25 yr male with osteoid osteoma narvicular
Case # 40




                                       nidus




     34 yr female with osteoid osteoma 2nd metatarsal
double
 nidus




CT scan
edema




Axial T-2 MRI
Case #41




nidus




        24 yr female with osteoid osteoma big toe
nidus




Gross Specimen
Photomic
Photomic
Case #42




           nidus




           Osteoid osteoma talus
Photomic
Case #43


Osteoid osteoma
pseudotumor



 Brodie’s abscess
13 yr female
tibia

                    nidus
tunnel




Gopher’s sign
Case # 44


Osteoid osteoma
pseudotumor


Brodie’s abscess   nidus
tibia
38 yr male
nidus




        Axial T-2 MRI
Case #45




     pseudo-nidus            fracture
                             line



            Osteoid osteoma pseudotumor
       stress fracture femoral neck 38 yr male
Bone scan
Case #46


Osteoid osteoma
pseudotumor
33 year female

Early stress
fracture femoral
neck with pain
for 3 mos
Bone scan
One month later
Case #47




                              pseudonidus




                Osteoid osteoma pseudotumor
           stress fracture femoral neck 50 yr female
pseudonidus


Axial T-2 MRI
fracture line



Coronal T-2 MRI
Case #48                OO pseudotumor                Stress fracture




           20 year old male with pre-tibial pain for 3 months
Sag T-1   PD   Gad
Case #49




Pseudo osteoid
osteoma femur


Chronic stress
periostitis from
adductor pull
14 yr male
pseudonidus




              CT scan
Bone scan
Case #50




Pseudo osteoid
osteoma femur
38 yr male


Bone island
Bone scan
Coronal
T-1 MRI

          pseudonidus
Osteoblastoma
Osteoblastoma
    The so-called osteoblastoma is considered by most to be a large
or giant form of the similar clinical entity known as the osteoid
osteoma. As with the osteoid osteoma, it is found in children and
young adults, more often in males than females. It is less common
than the osteoid osteoma, representing approximately 1% of all
bone tumors. It is found mostly in metaphyseal areas of long bone
and in the posterolateral elements of the axial skeleton where
nearly 50% of the lesions are identified. Radiographically these
lesions are more osteolytic than the osteoid osteoma and have a
central 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 be
associated with the osteoblastoma, similar to the reaction seen
adjacent 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 be
differentiated 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 evaluated
in 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 the
posterolateral elements where it can cause problems with spinal
cord or nerve root compression that may require aggressive
surgical decompression and even spinal stabilization. On occasion
an 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 with
a fairly aggressive curettement of the lesion. There is no particular
reason 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 the
classic 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 local
resection to avoid a local recurrence because radiation therapy or
even systemic chemotherapy is not effective for this aggressive but
benign entity.
CLASSIC
Case #51



26 yr male
osteoblastoma 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




                        nidus




           23 yr male with osteoid osteoma L-5
nidus




CT scan
Photomic
Photomic
Recurrence




Recurrence 8 mos post op laminectomy
CT




     Recurrence as an osteoblastoma
Secondary ABC
behind osteoblastoma



 Sagittal T-2 MRI

                       ABC

       osteoblastoma
fluid-fluid
            level




Axial T-2 MRI
ABC histology
ABC histology
Osteoblastoma histology
Osteoblastoma histology
Post op posterior
resection and fusion
AP x-ray
post op fusion
CT scan later shows anterior recurrence
Post op anterior
resection and bone
cement reconstruction
Lateral x-ray showing
anterior reconstruction
with cement

                          cement
cement
bone
graft


                        CD rods



Post op CT scan showing cement reconstruction
cement




graft



        Post op CT
Case #53




                                         surgical
                                         towel clip



26 yr male with osteoblastoma L-4 following a laminectomy
 curettement three years previous for an osteoid osteoma
CT scan




Appearance 4 months later with a 1.5 cm nidus
A curettement at this time revealed an osteoblastoma
Myelogram 4 yrs
later
burned-out
                         lesion


CT scan at same time and no pain
Another CT cut
Burnt out
                 lesion



Sagittal T-1 MRI at same time
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 female
osteoblastoma L-2
Bone scan
T-2 MRI shows
high signal ABC
posterior to low signal
osteoblastoma
                          osteoblastoma




                                          ABC
osteoblastoma

Sagittal                   ABC
T-2 MRI
Osteoblastoma Photomic
AP x-ray
post op posterior
spinal fusion
Lateral X-ray
post op
Case #55




14 yr female
osteoblastoma 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 male
osteoblastoma C-3
Oblique view
Opposite oblique
One year
post op posterior
fusion and recurrent
tumor anterior
Anterior view
with recurrence
Post op anterior
debriedment and
fusion
Case #60




18 yr male
osteoblastoma
C-7
Oblique view
Lateral view
2 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
Sagittal
T-2 MRI showing
bulge in floor of
vertebral canal
Case #64




           13 yr female with osteoblastoma C-6
Lateral view
Post op X-ray
After anterior
interbody fusion
Case #65




AP X-ray




           14 yr female with osteoblastoma C-7
AP myelogram
Arteriogram showing
pressure on vertebral
artery
Post op debriedment
Case #66




CT scan




           43 yr female with osteoblastoma T-8
Axial T-2 MRI
Sagittal T-1 MRI
Post op posterior
spine fusion
Case #67




       28 yr male with osteoblastoma thoracic spine
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 mos
following THA
Case #71




  19 yr male with aggressive osteoblastoma acetabulum
Bone scan
Gross specimen from curettement
Photomic
Photomic
Post op internal
hemipelvectomy
Recurrence 4 months later
tumor




Ablative hemipelvectomy specimen
tumor




    Hemipelvectomy specimen
Several years later with recurrent tumor on sacrum
Lateral view of recurrence
Case #72




38 yr male
osteoblastoma
pelvis
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
nidus




X-ray of resected specimen
Case #77




           26 yr male with osteoblastoma ilium
CT scan
Post op x-ray appearance after resection and cementation
Case #78




 23 yr male
 osteoblastoma
 femur
CT scan
T-2 MRI
Sagittal T-2 MRI
Photomic
Case #78.1




19 year male with
tibial pain for 6 mos
T-1             T-2




        Gad +
Axial
Coronal T-1   T-2   Gad
X-ray 3 months post op
Case #79




15 yr male
osteoblastoma
femur
Bone scan
CT scan
Axial T-2 MRI
Coronal T-1
MRI
X-ray at time of
surgery with marker
in tumor defect
Photomic of nidus
Case #79.1            CT scan           Sclerosing
                                        osteomyelitis
                                        of Garre




   14 yr male with dull aching thigh pain for 1 year
Coronal T-1   Coronal T-2
Sagittal T-2   Axial T-2
Case #80




       13 yr male with osteoblastoma femoral neck
                  frog 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 male
osteoblastoma
talus
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
edema   nidus




Coronal T-2 MRI
Post op x-ray
following distal
humeral resection
and allograft
reconstruction
Case #88




9 yr female
osteoblastoma
distal humerus
Coronal T-1 MRI

                  edema
tumor




edema




        Axial T-2 MRI
Case #88.1




                                 nidus




11 yr male with ABC response to osteoblastoma humerus
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 female
osteoblastoma tibia
AP x-ray
Case #94




           24 yr male with osteoblastoma fibula
Lateral view
Osteofibrous
 Dysplasia
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 fibrous
dysplasia of the tibia, the main difference being the presence
of more heavily ossified tissue at the periphery of the lesion
giving it a soap-bubbly appearance on x-ray. Microscopically
it has a similar “alphabet-soup” metablastic bone appearance
in a benign fibrous tissue stroma but with the additional feature
of 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 appearance
Is very similar to and impossible to separate from that of the
Malignant adamantinoma that also affects the tibia in children
and, for this reason, a biopsy must be performed to rule out the
malignant possibility. Occasionally osteofibrous dysplasia of the
tibia can progress gradually into a well-differentiated form
of the adamantinoma, which will have the microscopic
features of both osteofibrous dysplasia and adamantinoma
in 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 procedure
can be performed without significant risk of recurrence. This
lesion occurs bilaterally in a very small percentage of cases
and can also involve the fibula on the same side. This process
in newborns appears to be more osteolytic and destructive in
nature.
CLASSIC
Case #95




 9 yr male
 osteofibrous dysplasia
 tibia
AP and lateral x-ray
Photomic
Case #96




 6 year female
 osteofibrous dysplasia
 tibia
Same case
Case #97




 16 year female
 osteofibrous dysplasia
 tibia
Case #98




 8 yr male
 osteofibrous dysplasia
 tibia
X-ray appearance
3 yrs later
8 yrs later with
spontaneous healing
Case #98.1                     Burnt out osteofibrous dysplasia




      61 year old male with incidental finding in tibia for years
Bone scan
Sag T-1   PD FS   Gad
Cor STIR   Gad
Axial T-1     T-2 FS




        Gad
Case #99




 15 yr female
 osteofibrous dysplasia
 tibia


AP x-ray
Lateral x-ray
Case #100




            Newborn with osteofibrous dysplasia tibia
edema




T-2 axial MRI
Photomic
Photomic
X-ray 1 yr later
Case #101




Another newborn
osteofibrous dysplasia
tibia
Another view
Ossifying Fibroma
   of Jawbone
Ossifying Fibroma of Jawbone
    Ossifying fibroma of jawbone is a benign condition similar to
osteofibrous dysplasia of the tibia in that histologically they are
almost 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 microscopic
evaluation. 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 deformation
of the subadjacent alveolar ridge or maxillary structures. It also
can 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 cosmetic
deformity.
Case #102




 5 yr female
 ossifying fibroma
 maxilla
tumor




Maxillary view
tumor




Tomogram cut
tumor




CT scan
tumor




Another cut
Another cut
Photomic
Case #103




       18 yr female with ossifying fibroma mandible
Oblique view
Photomic
Closeup of alphabet-soup metaplastic bone
Case #104




                        tumor




      12 yr female with ossifying fibroma mandible
Opposite ramus
Case #105




      14 yr female with ossifying fibroma mandible
Case #106




 Young adult     tumor
 osteoma skull
tumor

Occipital view
Lateral view
Case #107




            Cementoma mandible
Oblique view

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Semelhante a Volume 1

An Atlas of Musculoskeletal Oncology: Volume 1
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Volume 7
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Volume 11
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Vol 21 congenital 2
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Vol 20 congenital 1
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Volume 1