Difference between revisions of "Chondro-osseous tumours"

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'''Chondro-osseous tumours''' occasionally cross the desk of the pathologist.  They are grouped together as [[bone]] may develop from [[cartilage]].
[[Image:Osteosarcoma - very high mag.jpg|thumb|250px|right|A chondro-osseous tumour ([[osteosarcoma]]). [[H&E stain]].]]
'''Chondro-osseous tumours''' occasionally cross the desk of the pathologist.  They are grouped together as [[bone]] may develop from [[cartilage]].  


Primary bone tumours are rare; the most common bone tumour is [[metastases]].<ref name=Ref_WMSP632>{{Ref WMSP|632}}</ref>   
Primary bone tumours are rare; the most common bone tumour is [[metastases]].<ref name=Ref_WMSP632>{{Ref WMSP|632}}</ref>   
Line 61: Line 62:
| ?
| ?
| no stains / may be assoc. with [[FAP]]
| no stains / may be assoc. with [[FAP]]
| Image (???)
| [[Image:Osteoma -- intermed mag.jpg |thumb|center|150px| Osteoma. (WC)]]
|-
|-
| [[Osteoid osteoma]]
| [[Osteoid osteoma]]
| osteoblastic rimming
| osteoblastic rimming
| anastomosing bony trabeculae
| anastomosing bony trabeculae
| <= 1.5 cm, metaphysis
| must be <2 cm,<ref name=pmid25224389>{{Cite journal  | last1 = Yalcinkaya | first1 = U. | last2 = Doganavsargil | first2 = B. | last3 = Sezak | first3 = M. | last4 = Kececi | first4 = B. | last5 = Argin | first5 = M. | last6 = Basdemir | first6 = G. | last7 = Oztop | first7 = F. | title = Clinical and morphological characteristics of osteoid osteoma and osteoblastoma: a retrospective single-center analysis of 204 patients. | journal = Ann Diagn Pathol | volume = 18 | issue = 6 | pages = 319-25 | month = Dec | year = 2014 | doi = 10.1016/j.anndiagpath.2014.08.006 | PMID = 25224389 }}</ref> metaphysis
| painful, NSAIDs remove pain, young
| painful, NSAIDs remove pain, young
| IHC / other
| IHC / other
Line 74: Line 75:
| osteoblastic rimming
| osteoblastic rimming
| anastomosing bony trabeculae
| anastomosing bony trabeculae
| > 1.5 cm, metaphysis
| must be >1 cm,<ref name=pmid25224389/> often >=2 cm, metaphysis
| not painful
| not painful
| IHC / other
| IHC / other
Line 308: Line 309:
=Cartilage=
=Cartilage=
==Chondroma==
==Chondroma==
===General===
{{Main|Chondroma}}
*Benign thingy.
*Usual legs and feet.
*May be difficult to separate from [[chondrosarcoma]].
*Multiple chondromas = ''enchondromatosis''; three distinct syndromes:<ref name=emed_enchondroma>URL: [http://emedicine.medscape.com/article/389224-overview http://emedicine.medscape.com/article/389224-overview]. Accessed on: 25 December 2010.</ref>
**Ollier disease.
**Maffucci syndrome - with [[hemangioma]]s, increased risk of [[chondrosarcoma]].<ref name=omim166000>{{OMIM|166000}}</ref>
**Metachondromatosis - autosomal dominant.
*''Enchondroma'' = chondroma in the marrow space.
 
Clinical:<ref name=emed_enchondroma>URL: [http://emedicine.medscape.com/article/389224-overview http://emedicine.medscape.com/article/389224-overview]. Accessed on: 25 December 2010.</ref>
*Pain.
 
===Radiology===
Features:<ref name=emed_enchondroma>URL: [http://emedicine.medscape.com/article/389224-overview http://emedicine.medscape.com/article/389224-overview]. Accessed on: 25 December 2010.</ref>
*Lytic lesion.
*Usual close to a growth plate.
 
Important suspicious findings that favour malignant:<ref name=pmid23041161>{{Cite journal  | last1 = Choi | first1 = BB. | last2 = Jee | first2 = WH. | last3 = Sunwoo | first3 = HJ. | last4 = Cho | first4 = JH. | last5 = Kim | first5 = JY. | last6 = Chun | first6 = KA. | last7 = Hong | first7 = SJ. | last8 = Chung | first8 = HW. | last9 = Sung | first9 = MS. | title = MR differentiation of low-grade chondrosarcoma from enchondroma. | journal = Clin Imaging | volume = 37 | issue = 3 | pages = 542-7 | month =  | year =  | doi = 10.1016/j.clinimag.2012.08.006 | PMID = 23041161 }}</ref>
*Cortical destruction.
*Soft tissue component.
 
Note:
*High-grade chondroid lesions (high-grade chondrosarcoma) can usually be separated radiologically from low-grade ones.<ref name=pmid22696998>{{Cite journal  | last1 = Berber | first1 = O. | last2 = Datta | first2 = G. | last3 = Sabharwal | first3 = S. | last4 = Aston | first4 = W. | last5 = Saifuddin | first5 = A. | last6 = Briggs | first6 = T. | title = The safety of direct primary excision of low-grade chondral lesions based on radiological diagnosis alone. | journal = Acta Orthop Belg | volume = 78 | issue = 2 | pages = 254-62 | month = Apr | year = 2012 | doi =  | PMID = 22696998 }}</ref>
 
===Microscopic===
Features:
*Ctyologically benign cells is spaced nests.
 
DDx:
*Low-grade [[chondrosarcoma]] - should be considered, correlation with radiology essential.
 
====Images====
<gallery>
Image:Enchondroma_-_intermed_mag.jpg | Enchondroma - intermed mag. (WC)
Image:Enchondroma_-_very_high_mag.jpg | Enchondroma - very high mag. (WC)
</gallery>
 
===Sign out===
<pre>
TISSUE ("CHONDROMA"), LEFT COSTAL MARGIN, EXCISION:
- CHONDROMA.
</pre>
 
====Micro====
The sections show spaced small cells in a pale matrix with a light-blue tinge. No nuclear atypia is appreciated. No mitotic activity is apparent. Degenerative changes are seen focally.
 
A small focus of cholesterol clefts with giant cells is present. Benign bone, bone marrow and skeletal muscle are present.


==Chondroblastoma==
==Chondroblastoma==
===General===
{{Main|Chondroblastoma}}
*Growth plate lesion.
*Sclerotic margin.
*"Young" = growth plates open.
*Typically painful.<ref name=Ref_PCPBoD8_625>{{Ref PCPBoD8|625}}</ref>
 
===Gross===
*Well-defined lesion.
 
Image:
*[http://www.flickr.com/photos/35441329@N05/4052875138/in/set-72157622681280610 Chondroblastoma (flickr.com/humpath)].
 
===Microscopic===
Features:<ref name=Ref_WMSP_642>{{Ref WMSP|642}}</ref>
*Abundant extracellular material - pink on [[H&E stain]] - looks vaguely like cartilage.
*Chondroblasts:
**Nuclear morphology variable: ovoid, folded or grooved.
**Moderate-abundant eosinophilic cytoplasm.
*+/-Calcification surrounds the cell nests ("chickenwire" appearance) - '''classic feature'''.
**Cell nests have a thin pale blue rimming.
*+/-[[Giant cells]].
**May lead to confusion with ''[[giant cell tumour of bone]]''.
 
DDx:
*[[Giant cell tumour of bone]].
*[[Chondroma]].
*Well-differentiated [[chondrosarcoma]].
 
====Images====
<gallery>
Image:Chondroblastoma_-_intermed_mag.jpg | Chondroblastoma - intermed. mag. (WC)
Image:Chondroblastoma_-_very_high_mag.jpg | Chondroblastoma - very high mag. (WC)
</gallery>
www:
*[http://img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1254949-996.jpg Chondroblastoma (medscape.com)].<ref name=emed_chondroblastoma>URL: [http://emedicine.medscape.com/article/1254949-diagnosis http://emedicine.medscape.com/article/1254949-diagnosis]. Accessed on: 31 December 2010.</ref>
*[http://img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1254949-997.jpg Chondroblastoma with "chickenwire" appearance (medscape.com)].<ref name=emed_chondroblastoma>URL: [http://emedicine.medscape.com/article/1254949-diagnosis http://emedicine.medscape.com/article/1254949-diagnosis]. Accessed on: 31 December 2010.</ref>
*[http://path.upmc.edu/cases/case494/images/fig2a.jpg Chondroblastoma (upmc.edu)].<ref>URL: [http://path.upmc.edu/cases/case494.html http://path.upmc.edu/cases/case494.html]. Accessed on: 24 January 2012.</ref>
 
===IHC===
Features:<ref name=Ref_WMSP_642>{{Ref WMSP|642}}</ref>
*S100 +ve.
*Vimentin +ve.<ref name=emed_chondroblastoma>URL: [http://emedicine.medscape.com/article/1254949-diagnosis http://emedicine.medscape.com/article/1254949-diagnosis]. Accessed on: 31 December 2010.</ref>


==Chondromyxoid fibroma==
==Chondromyxoid fibroma==
===General===
{{Main|Chondromyxoid fibroma}}
*Benign.
*Teenagers or young adults.
 
===Gross===
*Metaphyseal lesion.
*Well-circumscribed.
 
===Microscopic===
Features:<ref name=Ref_WMSP642>{{Ref WMSP|642}}</ref>
*Spindle cells or stellate cells in a myxoid or chondroid stroma.
 
Images:
*[http://www.webpathology.com/image.asp?n=7&Case=331 Chondromyxoid fibroma - low mag. (webpathology.com)].
*[http://www.webpathology.com/image.asp?case=331&n=8 Chondromyxoid fibroma - high mag. (webpathology.com)].


==Chondrosarcoma==
==Chondrosarcoma==
Line 423: Line 322:
=Bone=
=Bone=
==Osteoma==
==Osteoma==
===General===
{{Main|Osteoma}}
*Benign.
*May be associated with [[familial adenomatous polyposis]].
*Normal bone - unusual location/outgrowth.
 
===Microscopic===
Features:
*Normal bone.


==Osteoid osteoma==
==Osteoid osteoma==
Line 449: Line 341:
=Other=
=Other=
This section collects stuff that doesn't neatly fit into the ''bone'' or ''cartilage'' category.
This section collects stuff that doesn't neatly fit into the ''bone'' or ''cartilage'' category.
==Osteochondroma==
===General===
*Benign.
*Very common.
*Abnormal outgrowth of bone and cartilage - associated with growth plate.
*Usually present before age 20.<ref name=pmid12873205>{{Cite journal  | last1 = Parkin | first1 = B. | last2 = Bennett | first2 = JC. | last3 = Zaher | first3 = A. | title = Pathologic quiz case: an iliac mass in a 25-year-old woman. Osteochondroma. | journal = Arch Pathol Lab Med | volume = 127 | issue = 8 | pages = e355-6 | month = Aug | year = 2003 | doi = 10.1043/1543-2165(2003)127e355:PQCAIM2.0.CO;2 | PMID = 12873205 | URL = http://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282003%29127%3Ce355:PQCAIM%3E2.0.CO;2}}</ref>


===Gross===
==Notochordal tumors==
Features:
Notochordal tumors arise from notochordal remnants and thus are seen in the clivus or sacrum.
*Metasphyseal lesions.<ref name=medpath>URL: [http://www.medpath.info/MainContent/Skeletal/Bone_07.html http://www.medpath.info/MainContent/Skeletal/Bone_07.html]. Accessed on: 18 September 2012.</ref>
{{Main|Chordoma}}
**Often distal femur, proximal humerus or proximal tibia.<ref name=pmid12873205/>
**Occasionally iliac mass.<ref name=pmid22217414>{{Cite journal  | last1 = Kokavec | first1 = M. | last2 = Gajdoš | first2 = M. | last3 = Džupa | first3 = V. | title = [Osteochondroma of the iliac crest: case report]. | journal = Acta Chir Orthop Traumatol Cech | volume = 78 | issue = 6 | pages = 583-5 | month =  | year = 2011 | doi =  | PMID = 22217414 }}
</ref>
*Mushroom-like shape - with broad or narrow base.


Note:
==Osteochondroma==
*Very unusual in craniofacial bones.<ref name=pmid12873205/>
{{Main|Osteochondroma}}
 
===Microscopic===
Features:<ref name=pmid12873205/>
*Bone - forms base of "mushroom".
*Cartilage - layer usu. thinner in older individuals.
**Lobular arrangement<ref name=upmc_case341>URL: [http://path.upmc.edu/cases/case341/dx.html http://path.upmc.edu/cases/case341/dx.html]. Accessed on: 19 September 2012.</ref> - clusters of 3-12 lacunae (separated by stroma).
**May have mild atypia.
**Nuclear enlargement - up to 5x normal.
*[[Perichondrium]] - covers the cartilage.
**Thin layer of cells - higher cellular density than cartilage.
***Bland spindle cells in a fibrous (eosinophilic) stroma.
 
Notes:
*Benign cartilage - one chondrocyte per lacuna, small and round nucleus, no binucleation.
 
DDx:
*[[Chondrosarcoma]] - esp. in older individuals.
 
Images:
*[http://path.upmc.edu/cases/case341.html Super rare intracranial mesenchymal osteochondroma - several images (upmc.edu)].<ref name=upmc_case341/>


==Diffuse tenosynovial giant-cell tumour==  
==Diffuse tenosynovial giant-cell tumour==  

Latest revision as of 01:46, 20 June 2016

A chondro-osseous tumour (osteosarcoma). H&E stain.

Chondro-osseous tumours occasionally cross the desk of the pathologist. They are grouped together as bone may develop from cartilage.

Primary bone tumours are rare; the most common bone tumour is metastases.[1]

Bone tumours occasionally are lumped with soft tissue tumours. Soft tissue tumours are dealt with in the soft tissue lesions article. An introduction to bone is found in the bone article. An introduction to cartilage is found in the cartilage article.

General

  • Diagnosis of a primary bone tumour should not be made without radiologic & clinical information!
  • Metastasis:primary bone tumours = >20:1.[1]

Common malignant

Epidemiology:[2]

  • Osteosarcoma -> 2nd decade.
  • Ewing's ->5-20 yrs.
  • Chondrosarcoma -> from enchondroma or osteochrondroma -- patients over 40 yrs.
  • Multiple myeloma -> most common primary bone tumour in adults.

Malignant bone tumours by age

Most common by age:[2]

Benign aggressive bone tumours

Ref.:[3][4]

Summary tables

Bone tumours

Entity Key feature Other features Radiology / gross Clinical Stains / other Image
Osteoma normal bone (???) other features (???) radiology / gross (???) ? no stains / may be assoc. with FAP
Osteoma. (WC)
Osteoid osteoma osteoblastic rimming anastomosing bony trabeculae must be <2 cm,[5] metaphysis painful, NSAIDs remove pain, young IHC / other
Osteoid osteoma. (WC)
Osteoblastoma osteoblastic rimming anastomosing bony trabeculae must be >1 cm,[5] often >=2 cm, metaphysis not painful IHC / other
Osteoblastoma. (WC)
Ewing sarcoma small round blue cell tumour cytoplasmic clearing (due to glycogen) usu. diaphysis pediatric, typically 1-10 years PAS+, PASD-, chromosomal translocations (usually t(11;22)(q24;q12))
Ewing sarcoma. PAS stain. (WC)
Osteosarcoma osteoid +/-hemorrhage, +/-cartilage distal femur, prox. tibia, prox. humerous typically 10-30 years, pain, swelling no stains; many subtypes
Osteosarcoma. (WC)
Giant cell tumour of bone abundant giant cells nuclei of surrounding cells similar to those in giant cells growth plate of long bones 20-45 years old, +/-joint pain, +/-immobility IHC / other
Giant cell tumour. (WC)

Cartilage tumours

Entity Key feature Other features Radiology / gross Clinical Stains / other Image
Chondroma ctyologically benign cells equally spaced nests usu. diaphysis benign / DDx: chondroma, well-diff. chondrosarcoma IHC / bone marrow cavity chondroma = enchondroma
Enchondroma. (WC)
Chondroblastoma abundant extracellular material, abundant eosinophilic cytoplasm calcifications surround cells nests ("chickenwire" appearance) - classic epiphysis DDx: giant cell tumour of bone S100+ve, vimentin +ve
Chondroblastoma. (WC)
Chondrosarcoma cartilaginous appearance +/- nuclear atypia lack osteoid, if present -> osteosarcoma usu. diaphysis, classically hip; almost never distal extremity >40 years old IHC / may be histologically benign looking
Chondrosarcoma. (WC)

Other

Entity Key feature Other features Radiology / gross Clinical Stains / other Image
Osteochondroma benign bone and cartilage Other features metaphyseal lesions Clinical IHC / other Image
Adamantinoma bisphasic - stroma & epithelium Other features tibia, fibula, intracortical, radiolucent Clinical IHC / other
Adamantinoma. (WC)
Diffuse tenosynovial giant-cell tumour (AKA PVNS) pigmented giant cells nodules Radiology / gross Clinical IHC / other
PVNS. (WC)
Brown tumour fibrosis, +/-giant cells unaffected bone incr. osteoblasts and osteoclasts Radiology / gross due to hypercalcemia; not a neoplasm IHC / other
Brown tumour. (WC)

Radiology

Radiologic features
Features Benign Malignant
Bone changes sclerotic rim tumour perforation
Circumscription pushing margins ill-defined/moth-eaten
Soft tissue involvement no common
Periosteal reaction no "hair-on-end" or "sunburst",
"onion skin", Codman's triangle
Location
Diagnosis Epiphysis Metaphysis Diaphysis Type of lesion
Aneurysmal bone cyst common most common rare bone
Chondroblastoma most common rare extremely rare cartilage
Chondrosarcoma uncommon common most common cartilage
Chondromyxoid fibroma rare most common common other
Enchondroma rare common common cartilage
Ewing sarcoma rare common most common bone
Giant cell tumour most common rare extremely rare bone
Metastatic carcinoma rare common most common other
Non-ossifying fibroma extremely rare most common common other
Osteoblastoma rare most common uncommon bone
Osteochondroma extremely rare[citation needed] most common common bone/cartilage
Osteoid osteoma uncommon common common[6] bone
Osteosarcoma rare most common uncommon bone

How to remember the primary bone lesions:

  1. Ewing sarcoma is the only malignant primary bone tumour of the diaphysis.
  2. Giant cell tumour of bone is the only primary bone lesion of the epiphysis.
  3. The rest of the primary bone lesions are metaphyseal.
    • Osteochondroma is bone first and cartilage second. It behaves like most primary bone lesions; it is usually metaphyseal.

How to remember the primary cartilaginous lesions:

  1. Chondroblastoma is epiphyseal. The chicken wire goes around the chicken coop.
  2. The others are diaphyseal.

Cartilage

Chondroma

Main article: Chondroma

Chondroblastoma

Main article: Chondroblastoma

Chondromyxoid fibroma

Main article: Chondromyxoid fibroma

Chondrosarcoma

Main article: Chondrosarcoma

Bone

Osteoma

Main article: Osteoma

Osteoid osteoma

Main article: Osteoid osteoma

Osteoblastoma

Main article: Osteoblastoma

Ewing sarcoma

Main article: Ewing sarcoma

Osteosarcoma

Main article: Osteosarcoma

Giant cell tumour of bone

Main article: Giant cell tumour of bone

Other

This section collects stuff that doesn't neatly fit into the bone or cartilage category.

Notochordal tumors

Notochordal tumors arise from notochordal remnants and thus are seen in the clivus or sacrum.

Main article: Chordoma

Osteochondroma

Main article: Osteochondroma

Diffuse tenosynovial giant-cell tumour

  • AKA tenosynovial giant-cell tumour, diffuse type.
  • Previously known as pigmented villonodular synovitis (PVNS).[7]
Main article: Diffuse tenosynovial giant-cell tumour

Giant cell tumour of tendon sheath

  • Abbreviated GCT of tendon sheath.
Main article: Giant cell tumour of tendon sheath

Adamantinoma

Main article: Adamantinoma

Brown tumour

General

  • Not a true neoplasm.[8]
    • If tumour is understood as a synonym for neoplasm, the name is a misnomer.
    • May (clinically) mimic a true neoplasm.
  • Due to hyperparathyroidism - usually parathyroid adenoma.
    • Usually secondary to chronic renal failure.

Hypercalcemia DDx

Mnemonic GRIMED:[9]

Microscopic

Features:

  • Fibrosis.
  • +/-Giant cells with round to oval nuclei and nucleoli.[10]
  • Bone unaffected by tumour - increased numbers of the following:
    • Multinucleated cells (osteoclasts).
    • Mononuclear cells around the bony trabeculae (osteoblasts).

DDx:

Images

  • Brown tumour - low mag. (WC)

  • Brown tumour - intermed. mag. (WC)

  • Brown tumour - high mag. (WC)

www:

See also

References

  1. ↑ 1.0 1.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 632. ISBN 978-0781765275.
  2. ↑ 2.0 2.1 Yeung, J.C.; Leonard, Blair J. N. (2005). The Toronto Notes 2005 - Review for the MCCQE and Comprehensive Medical Reference (2005 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. OR42. ISBN 978-0968592854.
  3. ↑ Yeung, J.C.; Leonard, Blair J. N. (2005). The Toronto Notes 2005 - Review for the MCCQE and Comprehensive Medical Reference (2005 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. OR41. ISBN 978-0968592854.
  4. ↑ URL: http://www.emedicine.com/RADIO/topic494.htm.
  5. ↑ 5.0 5.1 Yalcinkaya, U.; Doganavsargil, B.; Sezak, M.; Kececi, B.; Argin, M.; Basdemir, G.; Oztop, F. (Dec 2014). "Clinical and morphological characteristics of osteoid osteoma and osteoblastoma: a retrospective single-center analysis of 204 patients.". Ann Diagn Pathol 18 (6): 319-25. doi:10.1016/j.anndiagpath.2014.08.006. PMID 25224389.
  6. ↑ URL: http://www.wheelessonline.com/ortho/osteoid_osteoma. Accessed on: 7 May 2012
  7. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1247. ISBN 978-1416031215.
  8. ↑ Meydan N, Barutca S, Guney E, et al. (June 2006). "Brown tumors mimicking bone metastases". J Natl Med Assoc 98 (6): 950–3. PMC 2569361. PMID 16775919. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569361/?page=1.
  9. ↑ Shiau, Carolyn; Toren, Andrew (2006). Toronto Notes 2006: Comprehensive Medical Reference (Review for MCCQE 1 and USMLE Step 2) (22nd edition (2006) ed.). Toronto Notes for Medical Students, Inc.. pp. Emerg.. ISBN 978-0968592861.
  10. ↑ URL: http://path.upmc.edu/cases/case139/micro.html. Accessed on: 6 January 2012.

External links

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