Difference between revisions of "Chondro-osseous tumours"

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*Commonly abbreviated: ''PVNS''.
*Commonly abbreviated: ''PVNS''.
*Course: benign.
*Course: benign.
*''Giant cell tumor of the tendon sheath'' is considered to be soft-tissue counterpart of PVNS.<ref>URL: [http://emedicine.medscape.com/article/1253223-overview http://emedicine.medscape.com/article/1253223-overview]. Accessed on: 6 January 2011.</ref>
*''Giant cell tumor of the tendon sheath'' is considered to be the soft-tissue counterpart of PVNS.<ref>URL: [http://emedicine.medscape.com/article/1253223-overview http://emedicine.medscape.com/article/1253223-overview]. Accessed on: 6 January 2011.</ref>


===Microscopic===
===Microscopic===

Revision as of 16:23, 6 January 2011

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:[3]

  • <1 year old - neuroblastoma.
  • 1-10 years old - Ewing's of tubular bones.
  • 10-30 years old - osteosarcoma, Ewing's of flat bones.
  • 30-40 years old - reticulum cell sarcoma, fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumour, lymphoma.
  • >40 years old - mets, multiple myeloma, chondrosarcoma.

Benign aggressive bone tumours

  • Giant cell tumours.
  • Osteoblastoma.
    • Thought to be related to osteoid osteoma.
    • If in long bones often diaphyseal.

Ref.:[4][5]

Cartilage

Enchondroma

General

  • Benign thingy.
  • Usu. legs and feet.
  • May be difficult to separate from chondrosarcoma.
  • Multiple chondromas = enchondromatosis; three distinct syndromes.[6]

Radiology:[6]

  • Lytic lesion.
  • Usu. close to a growth plate.

Clinical:[6]

  • Pain.

Microscopic

Features:

  • Ctyologically benign cells is spaced nests.

Images:

Chondroblastoma

General

  • Growth plate lesion.
  • Sclerotic margin.
  • "Young" = growth plates open.

Microscopic

Features:[7]

  • Abundant extracellular material - pink on H&E stain - looks vaguely like cartilage.
  • Chondroblasts:
    • Nuclear morphology variable: ovoid, folded or grooved.
    • Moderate-abundant eosinophilic cytoplasm.
  • +/-Calcifications surround cells nests ("chickenwire" appearance) - classic feature.
  • +/-Giant cells.
    • May lead to confusion with giant cell tumour.

Images:

IHC

Features:[7]

  • S100 +ve.
  • Vimentin +ve.[8]

Chondrosarcoma

General

Clinical/epidemiologic features:[9]

  • Usually arise in a (benign) abnormality of cartilage (e.g. osteochondroma, enchondroma).
  • May be associated with a syndrome:
    • Olier disease (multiple enchondromatosis).
    • Maffucci syndrome (multiple enchondromas and hemangiomas).

Notes:

  • Review article (from oncology perspective): PMID 17545802.

Subtypes

Several subtypes exist:

  • Chondrosarcoma not otherwise specified (NOS).
  • Juxtacortical chondrosarcoma.
  • Myxoid chondrosarcoma.
  • Mesenchymal chondrosarcoma.
  • Clear cell chondrosarcoma.
  • Dedifferentiated chondrosarcoma chondrosarcoma.

Microscopic

Features:[10]

  • "Abnormal cartilage":
    • Nuclear atypia.
      • Nuclear clearing.
      • Nucleoli.

Images:

Mesenchymal chondrosarcoma

  • Arise in soft tissue; this is where the name comes from.[11]
  • Rare variant of chondrosarcoma.

Bone

Osteoid osteoma

General

  • Benign bone lesion.

Clinical:[12]

  • Extremely painful.
    • Relieved by NSAIDS.

Microscopic

Features:[12]

  • Anastomosing bony trabeculae with:
    • Variable mineralization.
      • Mineralization (calcium phosphate) = purple on H&E stain.
    • Osteoblasts rimming.
      • Cells line-up at edge of bone.

Images:

Notes:

  • Histomorphologically near identical/indistinguishable from osteoblastoma.[13]

Osteoblastoma

General

  • Benign bone tumour.

Microscopic

Features:[12]

  • Anastomosing bony trabeculae with:
    • Osteoblasts rimming.
      • Cells line-up at edge of bone.

Notes:

  • Histomorphologically near identical/indistinguishable from osteoid osteoma.[13]
  • Must be greater 1.5 cm by definition.[13]

Images:

Ewing sarcoma

General

  • AKA EWS/PNET:
    • EWS = Ewing sarcoma.
    • PNET = Primative neuroectodermal tumour.
  • EWS and PNET were once thought to be different tumours.

Clinical

  • Painful.
  • Usually younger than 20 years.

Radiology

Features:[14]

  • Long bones, diaphyses.
  • Destructive.
  • "Onion-skin" periosteal reaction.

Microscopic

Features:[15]

  • Scant clear cytoplasm (contain glycogen - PAS +ve, PAS-D -ve).
  • Lack nucleoli.
  • Round small nucleus.

Notes:

IHC

Features:[16]

  • CD99 +ve (plasma membrane staining).
  • CD45 -ve.
  • +/-Neural markers (NSE, synaptophysin, CD57 (??? CD56 ???), S100).
  • +/-Cytokeratins.
  • Caveolin-1.[17]
    • New kid on the block.

Notes:[18]

  • CD99 +ve (plasma membrane) tumours:
    • Lymphoblastic lymphoma/leukemia.
    • Angiomatoid fibrous histiocytoma.
    • Desmoplastic small round cell tumour.

Molecular diagnostics

Common features:

  • EWS/FLI-1 fusion gene formation due to translocation: t(11;22)(q24;q12).[19][20]
    • Often detected by RT-PCR (with EWS 5' and FLI-1 3' primers).

Notes:

  • The t(11;22)(q24;q12) is seen in ~90% of EWS/PNET... but also in:
    • Olfactory neuroblastoma.
    • Small cell osteogenic sarcoma.
    • Polyphenotypic tumours.
    • Rhbdomyosarcoma.
    • Neuroblastoma (possibly).
  • Several other translocations exist.

Osteosarcoma

General

  • Terry Fox was afflicited by this tumour.

Definition

  • Tumour that makes osteoid.
    • Osteoid = (extracellular) organic component of bone, normally produced by osteoblasts (cells which make bone matrix).

Microscopic

Features:

  • Cells with malignant features (e.g. nuclear membrane irregularities, marked nuclear size differences, mitoses) surrounded by delicate strands of osteoid.
    • Osteoid on H&E: pink, homogenous, "glassy".
    • Tumours typically very cellular - when compared to normal bone.
  • Large (multinucleated) osteoclast-like giant cells may be seen.[21]

Images:

Other

Pigmented villonodular synovitis

General

  • Commonly abbreviated: PVNS.
  • Course: benign.
  • Giant cell tumor of the tendon sheath is considered to be the soft-tissue counterpart of PVNS.[22]

Microscopic

Features:[23]

  • Subsynovial nodules composed of cells with:
    • Abundant cytoplasm.
    • Pale nuclei.
  • Multinucleated giant cells.
  • Hemosiderin-laden macrophages.
  • Foam cells.

Images:

Adamantinoma

General

Features:[14]

  • Rare: < 1% of bone tumours.
  • 25-35 years old.
  • Tibia, fibula.
  • Benign, may be locally aggressive.
  • Cousin of ameloblastoma. (???)

Radiology

  • Intracortical, radiolucent.

Microscopic

Features:

  • Biphasic tumour:
    1. Fibrous/spindle cell component.
    2. Epithelial component.

Images:

Brown cell tumour

Etiology

  • Due to hyperparathyroidism - usually parathyroid adenoma.

Microscopy

Features:

  • Fibrosis.

Hypercalcemia DDx

Mnemonic GRIMED:[25]

  • Granulomatous disease (tuberculosis, sarcoidosis).
  • Renal disease.
  • Immobility.
  • Malignancy (esp. squamous cell carcinoma, plasmacytoma).
  • Endocrine (primary hyperparathyroidism - leads to brown cell tumour).
  • Drugs (thiazides ... others).

Giant cell tumour

General

Features:[26]

  • Approximately 5% of primary bone tumours.
  • Typical age: 20-45 years.

Clinical

  • May present with joint pain, immobility.

Microscopic

Features:[27]

  • Giant cells.
  • Mononuclear cells, with nuclei similar to those in giant cells - key feature

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. ↑ TN05 OR42.
  3. ↑ TN05 OR42.
  4. ↑ TN05 OR41.
  5. ↑ URL: http://www.emedicine.com/RADIO/topic494.htm.
  6. ↑ 6.0 6.1 6.2 URL: http://emedicine.medscape.com/article/389224-overview. Accessed on: 25 December 2010.
  7. ↑ 7.0 7.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 642. ISBN 978-0781765275.
  8. ↑ 8.0 8.1 8.2 URL: http://emedicine.medscape.com/article/1254949-diagnosis. Accessed on: 31 December 2010.
  9. ↑ Skubitz KM, D'Adamo DR (November 2007). "Sarcoma". Mayo Clin. Proc. 82 (11): 1409–32. PMID 17976362. http://www.mayoclinicproceedings.com/content/82/11/1409.long.
  10. ↑ IAV. 26 February 2009.
  11. ↑ DOWLING EA (June 1964). "MESENCHYMAL CHONDROSARCOMA". J Bone Joint Surg Am 46: 747–54. PMID 14161087. http://www.ejbjs.org/cgi/reprint/46/4/747.pdf.
  12. ↑ 12.0 12.1 12.2 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Oberman, Harold A; Reuter, Victor E (2004). Sternberg's Diagnostic Surgical Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 285. ISBN 978-0781740517.
  13. ↑ 13.0 13.1 13.2 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Oberman, Harold A; Reuter, Victor E (2004). Sternberg's Diagnostic Surgical Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 286. ISBN 978-0781740517.
  14. ↑ 14.0 14.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 650. ISBN 978-0781765275.
  15. ↑ PST. 22 February 2010.
  16. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 651. ISBN 978-0781765275.
  17. ↑ PST. 22 February 2010.
  18. ↑ PST. 22 February 2010.
  19. ↑ URL: http://atlasgeneticsoncology.org/Tumors/Ewing5010.html. Accessed on: 23 February 2010.
  20. ↑ PMID: 3163261
  21. ↑ Papalas JA, Balmer NN, Wallace C, Sangueeza OP (June 2009). "Ossifying dermatofibroma with osteoclast-like giant cells: report of a case and literature review". Am J Dermatopathol 31 (4): 379-83. doi:10.1097/DAD.0b013e3181966747. PMID 19461244.
  22. ↑ URL: http://emedicine.medscape.com/article/1253223-overview. Accessed on: 6 January 2011.
  23. ↑ URL: http://www.wheelessonline.com/ortho/pigmented_villonodular_synovitis.
  24. ↑ URL: http://southbaypath.org/CaseImages/sb5260/sb5260.htm. Accessed on: 7 December 2010.
  25. ↑ TN06 Emerg.
  26. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 648. ISBN 978-0781765275.
  27. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 420. ISBN 978-1416002741.
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