Review of Benign Bone TUMORS

1. Review of Benign Bone TUMORS Scott Shelton, DPM R1

2. Common Benign Tumors/Lesions • Enchondroma, osteochondroma, non-ossifying fibroma, chondroblastoma, osteoid osteoma, osteoblastoma, periosteal chondroma, giant cell tumor, and chondromyxoid fibroma. • Some conditions such as aneurysmal bone cyst, unicameral bone cyst, and fibrous dysplasia are sometimes grouped with benign bone tumors. They often require similar treatment, but are not truly tumors.

3. Diagnostic Indicators for Evaluating a Solitary Bone Lesion To get the most accurate diagnosis it is important to think of various factors: Radiographic • 1-Destructive Pattern • 2-Size and Shape • 3-Cortical Involvement • 4-Periosteal reaction • 5-Anatomic position (transverse and longitudinal planes) • 6-Skeletal location • 7-Trabeculation • 8-Matrix production Non-radiologic 1-Clinical course 2-Age of patient

4. Age Ranges Benign Bone Tumors Osteoma 15 to 45 Osteoid osteoma 10 to 23 Benign osteoblastoma 10 to 30 Osteochondroma 10 to 30 Central Chondroma 10 to 40 Chondroblastoma 10 to 20 Chondromyxoid fibroma 10 to 30 Eosinophilic granuloma 5 to 10 Nonosteogenic granuloma 10 to 20 Desmoplastic fibroma 10 to 30 Intraosseous lipoma 30 to 50 Neurilemoma 10 to 30 Hemangioma 40 to 50 Giant Cell Tumor 25 to 40 Simple bone cyst 5 to 20 Aneurysmal bone cyst 10 to 30 Enchondroma 30’s

5. Fibrous Tumors/Lesions • Benign: Fibrous Cortical Defect, Non-Ossifying Fibroma, Fibroma of Bone. • Benign Aggressive: Fibromatosis(desmoid), Ossifying Fibroma of bone, Fibrous Dysplasia. • Malignant: Malignant Fibrous Histiocytoma of bone, Fibrosarcoma.

6. Chondroid Lesions • Benign: Enchondroma, Peri-osteal Chondroma, Osteochondroma. • Benign Aggressive: Chondromyxoid Fibroma, Chondroblastoma. • Malignant: Chondrosarcoma.

7. Other Lesions • Benign: Bone Cyst, Ganglion, Hemangioma. • Benign Aggressive: Giant Cell Tumor, Aneurysmal Bone Cyst, EOG. • Malignant: Adamantinoma, Chordoma, Ewings Sarcoma.

8. What are its borders? • Geographic • Moth Eaten • Permeative

9. Destructive Pattern • Geographic - lesion has a recognizable form; it is well defined • Moth-eaten & Permeative - have no definitive form or shape. Moth-eaten refers to cancellous bone and permeative to cortical bone.

10. Pattern of Destruction: Geographic

11. Lytic vs. Blastic Lesions Lytic Blastic

12. Zone of Transition Wide Narrow

13. Anatomic Location

14. Osteoma • Clinical features 40-50 yr. old, M:F = 2:1 Slow growing, multiple lesions • No malignant potential • Radiographic features Sharply circumscribed radiopaque mass protruding from the bone surface.

15. Osteoid Osteoma • Osteoblastic lesion with central area of new bone formation, known as a nidus • Known to cause pain, especially at night. Pain relieved by aspirin. • 7.5% seen in the foot • Age 5-25 • Male 2:1

16. Osteochondroma • Most common benign lesion • Protruding, mushroom-shaped exostosis with cartilage cap • Points away from joint • Male 2:1 • Typically originates from the metaphysis

17. Chondroblastoma • Clinical features 5-25 yrs old. Epiphysis, knee and proximal humerus • Radiographic features Well-defined epiphyseal radiolucency with spotty calcification

18. Fibrous Cortical Defect • Asymptomatic incidental finding, usually self-healing may regress spontaneously. • Age 4-8, rare after 14. Fairly common, may be present in 30% of the population. • Round to oval radiolucent intracortical lesion that typically erodes the outer cortical surface

19. Fibrous Dysplasia • Etiology Localized developmental arrest • Sites Monostotic: ribs, femur, tibia Polyostotic: femur, skull, tibia Clinical signs Early adolescence, three types Monostotic (70%): minimal Sx to fracture • Polyostotic w/o (27%) or w/ endocrinopathies (McCune-Albright's syndrome) (3%): fractures and deformities - "shepherd crook" proximal femur; rare malignant transformation to sarcomas • Radiographic Features Well-defined intramedullary lesion Ground glass appearance

20. Giant Cell Tumor of Bone • Clinical features 20-45 yrs old Female > male: the only bone tumor with female prevalence. • Rapidly expansile radiolucent lesion. Epiphyseal and metaphyseal in adults; metaphyseal in adolescents • Phalanges and metatarsals most commonly affected also seen in the talus and posterior calcaneus

21. Enostosis (Bone Island) • Discrete intramedullary sclerotic zone comprised of compact bone • Asymptomatic, and are usually incidental findings on xray • Posterior calcaneus, lesser metatarsal heads, talar neck, and distal tibia are most frequent in foot and ankle.

22. NonossifyingFibroma • Usually asymptomatic, incidental findings. • Fairly uncommon • May regress spontaneously • Age 4-40, median age 13 • Round to oval geographic lesion, eccentric medullary location, multiloculated

23. Chondromyxoid Fibroma • Markedly eccentric, oval geographic lesion of the metaphysis • Lobules of myxoid and/or chondroid tissue separated by fibrous septa • Male 2:1 • Most commonly seen in first 2 decades • Knees and proximal tibia most commonly affected • In the feet the talus and plantar mid-calcanues are most frequent pedal locations

24. Enchondroma • Most common tumor of the phalanges (hand 6:1) • Age 10-35 • Male = Female • Usually painless except with pathologic fracture • Central intramedullary oval geographic lesion with sharp margination and a thin rim of reactive sclerosis

25. Ollier’s Disease • Multiple enchondromatosis, especially involving the hands and feet. • One extremity is affected more than the other

26. Maffucci’s Syndrome • Multiple enchondromatosis with soft tissue hemangiomas

27. Simple Bone Cyst(Unicameral or Solitary Bone Cyst) • Fluid filled intramedullay cavity • Fluid may be serous, serosanguineous, or frank blood. • Peak incidence in first two decades of life • Asymptomatic unless pathologic fracture occurs • Common in calcaneus neutral triangle

28. Aneurysmal Bone Cyst(ABC) • Is a reactive process • Rapidly expansile lesion with multiple blood filled cystic cavities. • Age 5-20 • Rapid onset of pain

29. Tumors of the foot and ankle : Analysis of 196 cases MUSTAFA OZDEMIR H.; YILDIZ Y.; YILMAZ C.; SAGLIK Y. • A retrospective assessment was performed on 196 tumors of the foot and ankle between March 1986 and March 1996 • Mean age was 28 years (range 3 to 75 years). • Of the 196 foot and ankle tumor cases, • 171 (87.2%) were benign • 25 (12.8%) were malignant. • One hundred ninety-four (98.9%) were primary tumors • 2(1.1%) were metastatic tumors. • One hundred thirty-six (69.4%) originated from bone • 60 (30.6%) originated from soft tissue. • The most frequent foot and ankle tumors were: • Osteosarcoma among malignant osseous tumors • Squamous cell carcinoma among malignant soft tissue lesions, • Solitary exostosis among benign osseous tumors, and xanthoma and giant cell tumor among benign soft tissue tumors. • Mean follow-up time was 21.3 months (12 to 90 months). • One hundred forty (71.4%) of the patients underwent various operations • 56 (28.6%) were treated conservatively. • Of the 140 surgical cases, 13 (9.3%) had a recurrence, 3 (2.1%) died, and 124 (88.6%) had a clinical cure. • For most of the patients who required surgery, nonaggressive procedures were sufficient while amputations were required for 14 patients. MUSTAFA OZDEMIR H.; YILDIZ Y.; YILMAZ C.; SAGLIK Y. Tumors of the foot and ankle : Analysis of 196 cases. The Journal of foot and ankle surgery. 1997, vol. 36, pp. 403-408

30. Common vs Rare Tumors

31. WHO Classification of Bone Tumors (1993)

32. References 1-grading of bone tumors. Joon, Choi MD @ pathology.yu.ac.kr/lecture/grading_of_bone_tumors.pdf. 2-Bone Tumors-Benign @Uptodate.com keyword bone tumors 3-Hershey Manual. Singer, Jonathan DPM. PPMA 2003. 4-Hetherington Manual. Dagnall, J. Coughlin 5-Bone Tumors @http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=278. 7/16/07. 6-MUSTAFA OZDEMIR H.; YILDIZ Y.; YILMAZ C.; SAGLIK Y. Tumors of the foot and ankle : Analysis of 196 cases. The Journal of foot and ankle surgery. 1997, vol. 36, pp. 403-408 7-Christman R.A. Foot and Ankle Radiology. Church Hill Livingstone. 2003