Bone

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Bone is a scaffold it bears weight and occasionally gets infected.

Tumours often spread to bone and occasionally arise in bone. Bone tumours are dealt with in the bone tumours article.

Normal bone

Bone

Matrix

Two types (based on arrangement of collagen):

  1. Woven.
    • Always abnormal in adults.
    • Collagen arranged haphazardly - mechanically weak.
  2. Lamellar.
    • Collagen organized in layers (lamellae).

Woven vs. lamellar:

  • Easiest way to differentiate: polarize; lamellar bone has well-defined layers.

Images:

Cells

  • Osteocytes.
    • Sit in lacunae.
      • Empty lacunae = necrotic bone.
  • Osteoblasts.
    • Make bone.
  • Osteoclasts.
    • Destroy bone.
    • Multinucleated.

Memory device: 'b' before 'c'.

Bone marrow

Main article: Haematopoiesis
  • Fat content (%) ~= age (in years)[2]
    • e.g. 60 year old will have 60% fatty replacement.
  • One should see three cell lines:[3]
    1. Erythroid (red cells),
    2. Myeloid (white blood cells),
    3. Megakaryocytic (platelets).

Note: Lymphocytes are considered separately and typically spared in bone marrow failure.[4]

Identifying the lines:[5]

  1. Megakaryocytes:
    • Big cells ~ 3x the size of a RBC.
  2. Normoblasts (RBC precursors):
    • Hyperchromatic, i.e. blue, nucleus.
  3. Myeloid line:
    • Granules.
    • Reniform nucleus, i.e. kidney bean shaped nucleus.

Images:

Organization

  • Mature hematopoeitic cells at the centre (distant from bone).
  • Immature hematopoeitic cells adjacent to the bone.

Note:

Benign variants

Hyperostosis frontalis interna

  • Extra-thick frontal bone.[7]
  • No clinical significance -- just has to be recognized as a "nothing".

Infections

Osteomyelitis

General

  • Hematogenous - often in children.
  • Direct entry (skin defect) - adults with diabetes.

Microscopic

Chronic osteomyelitis

Microscopic

Features:

  • Plasma cells.
    • May be sterile, i.e. no organisms.
  • +/-Amyloid.
    • ~10% of patients in one series.[8]

Bone tumours

Main article: Bone tumours

This is a big topic. It is dealt with in a separate article.

The bone tumour article covers tumour mimics, e.g. brown cell tumour.

Fractures

Main article: Bone fractures

This is dealt with in the forensic pathology article.

Others

The following is a collection of stuff that doesn't really fit in another category or is just weird.

A general DDx for cystic bone lesions is found on radipedia.com.[9]

Osteoarthritis

Main article: Osteoarthritis

This keeps orthopaedic surgeons busy.

Aneurysmal bone cyst

  • Abbreviated ABC.

General

Features:[10]

  • Benign.
    • May grow rapidly.
  • Osteolysis -> cystic space -> filled with blood.
  • Relatively common; in children second only to osteosarcoma.[11]

Microscopic

Features:[10]

  • Bony trabeculae or osteoid tissue.
  • Osteoclast giant cells.
    • Multi-nucleated giant-cells with round randomly arranged nuclei.
  • Benign spindle cells (fibroblasts) - surround bone/adjacent to the giant cells.

DDx:

Images:

Myositis ossificans

  • AKA fibro-osseous pseudotumour of digits.[12]

General

Epidemiology:

  • Young people.
  • History of trauma - typically.
  • Extremities - digits (fingers, toes).

Notes:

  • Histologically "worrisome" (for malignancy) - due to high cellularity.[12]

Microscopic

Features:[12]

  • High cellularity.
  • Low mitotic activity.
  • No atypical mitoses.
  • No hyperchromasia.

Other features:[13]

  • Low power diagnosis:
    • Lesion is well-circumscribed.
    • Normal muscle is adjacent to the lesion - key feature.

Images:

Paget disease of the bone

General

Classically divided into three phases:[14][15]

  1. Lytic (predominantly osteoclasts).
  2. Mixed lytic (osteoclastic) and blastic (osteoblastic).
  3. Sclerotic (burned-out).

Clinical:

  • Elevated ALP.

Microscopic

Features:[14]

  • Bone matrix has jigsaw-puzzle like pattern.
    • Jigsaw-puzzle pieces each ~ 100-500 micrometres in size (largest dimension).
  • Increased osteoclast activity.
    • Osteoclast = macrophage that resorbs bone matrix.

Images:

Fibrous dysplasia

  • AKA osteitis fibrosa.

General

Classification:

  • Monostotic - one bone involved, ~80% of cases.
  • Polyostotic - several bones involved, ~20% of cases.

Microscopic

Features:[16]

  • Woven bone with odd irregular shapes - key feature.
    • Described as "chinese characters".[17]
  • Fibrous tissue around bone.

Notes:

  • No osteoblastic rimming.

DDx:

Images:

Desmoplastic fibroma

General

  • Rare.

Microscopic

Features:[18]

  • Lamellar bone.
  • Fibrotic marrow space with:
    • Collagen.
    • Low cellularity.
    • Spindle cells without significant atypia.

DDx:

  • Fibrous dysplasia - has woven bone.
  • Low grade fibrosarcoma.

Gaucher disease

Main article: Gaucher disease

General

  • May present as a fracture.

Microscopic

  • Macrophages in the marrow space with a "crumpled tissue paper" appearance.

Langerhans cell histiocytosis of bone

  • AKA eosinophilic granuloma of bone.
Main article: Langerhans cell histiocytosis

General

  • Rare.
  • Children.

Microscopic

Features:

  • Eosinophils.
  • Cerebriform and/or reniform macrophages.

Giant cell reparative granuloma

General

  • Lesion of the mandible and maxilla.[19]

Radiology

  • Lytic lesion.

Microscopic

Features:[19]

  • Giant cells.
  • Fibroblasts.
  • Osteoid.
  • Hemosiderin-laden macrophages.

See also

References

  1. ↑ Lin DD, Gailloud P, McCarthy EF, Comi AM (February 2006). "Oromaxillofacial osseous abnormality in Sturge-Weber syndrome: case report and review of the literature". AJNR Am J Neuroradiol 27 (2): 274–7. PMID 16484391.
  2. ↑ IAV. 26 Feb 2009.
  3. ↑ http://emedicine.medscape.com/article/199003-overview
  4. ↑ http://emedicine.medscape.com/article/199003-overview
  5. ↑ http://upload.wikimedia.org/wikipedia/commons/6/69/Hematopoiesis_%28human%29_diagram.png
  6. ↑ Iancu, D.; Hao, S.; Lin, P.; Anderson, SK.; Jorgensen, JL.; McLaughlin, P.; Medeiros, LJ. (Feb 2007). "Follicular lymphoma in staging bone marrow specimens: correlation of histologic findings with the results of flow cytometry immunophenotypic analysis.". Arch Pathol Lab Med 131 (2): 282-7. doi:10.1043/1543-2165(2007)131[282:FLISBM]2.0.CO;2. PMID 17284114.
  7. ↑ URL: http://radiopaedia.org/articles/hyperostosis_frontalis_interna. Accessed on: 29 September 2010.
  8. ↑ Alabi, ZO.; Ojo, OS.; Odesanmi, WO. (1991). "Secondary amyloidosis in chronic osteomyelitis.". Int Orthop 15 (1): 21-2. PMID 2071276.
  9. ↑ URL: http://radipedia.com/WikiMedia/index.php?title=Benign_cystic_bone_lesions. Accessed on: 15 March 2011.
  10. ↑ 10.0 10.1 URL: http://emedicine.medscape.com/article/1254784-overview. Accessed on: 4 February 2011.
  11. ↑ van den Berg H, Kroon HM, Slaar A, Hogendoorn P (2008). "Incidence of biopsy-proven bone tumors in children: a report based on the Dutch pathology registration "PALGA"". J Pediatr Orthop 28 (1): 29–35. doi:10.1097/BPO.0b013e3181558cb5. PMID 18157043.
  12. ↑ 12.0 12.1 12.2 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 607. ISBN 978-0781765275.
  13. ↑ IAV. 9 December 2010.
  14. ↑ 14.0 14.1 URL: http://emedicine.medscape.com/article/311688-overview. Accessed on: 25 December 2010.
  15. ↑ URL: http://radiopaedia.org/articles/paget-disease-of-bone-1. Accessed on: 25 December 2010.
  16. ↑ URL: http://www.pathologypics.com/pictview.aspx?id=104. Accessed on: 14 April 2011.
  17. ↑ URL: http://www.pathcases.com/bone_tumors_and_tumor.htm. Accessed on: 31 May 2011.
  18. ↑ URL: http://www.bonetumor.org/tumors-fibrous-tissue/desmoplastic-fibroma. Accessed on: 14 April 2011.
  19. ↑ 19.0 19.1 URL: http://www.ijri.org/text.asp?2006/16/4/677/32297. Accessed on: 4 February 2012.
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