Cystic lesion of bones
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cystic lesion of bones
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Cystic lesion of bones
- 1. Dr. Sidharth yadav Orthopaedic dept.
- 2. Diagnosis of cystic lesions in skeletal system is based on radiologic analysis. Radiologic analysis of bone lesion that are lytic 7 question has to be asked :- Where is the lesion? How large is the lesion ? What’s the lesion doing to bone ? What is bone doing in response ? What kind of matrix ? Is the cortex eroded or intact ? Is there any soft tissue extension ?
- 3. Solitary bone cyst Aneurysmal bone cyst Fibrous dysplasia Chondroma Chondromyxoid fibroma chondroblastoma Brown tumour hyperparathyroidism Hydatid cyst Intraosseous Ganglion Epidermoid cyst Giant cell tumour Fibrous cortical defect
- 4. Is a common lesion of unknown cause & pathology Age :- most commonly in 5-15 yrs rarely after 20 yrs Sex :- male predominant (2:1) Location :- long tubular bones particularly humreus & femur -metaphysael region is the preferred site. 2 types :- Active cystic lesion :- develops under 10yrs age -adjacent to the epiphyseal plate. Benign latent cyst :- develops after 20 yrs age - seprated from epiphysis
- 5. Physical findings :- - Usually asymptomatic. -Cyst lying adjacent to growth plate can lead to growth disturbances. X ray findings :- centrally located,lytic lesion. -Expansion of the bone. -Well marginated outline. -Thinning of the cortex( scalloping). - Fallen fragment sign - Periosteal surface is smooth. -loculated appearance is due to presence of ridges over inner surface of cyst.
- 6. Pathology :- Gross :- - Bone displays an area of fusiform expansion. - Underlying bone is egg-shell thin. - Cavity contain yellow fluid. - Thin layer of connective tissue lines the cavity that gives the pseudoloculated apperance on x-rays. Microscopic :- - Connective tissue composed of fibroblast contaning multinucleated giant cells , foam cell. - Cortical wall consist of lossely trabeculated osseous tissue & many thin walled vessels.
- 7. Diagnosis :- -Is establisehed by aspiration , injection of radio-opaque substance & direct operative exposure. Treatment :- Curettage Aspiration Steroid injection
- 8. Solitary expansile Blood filled reactive lesion of bone . Locally destructive. Age :- usually in 1st ,2nd & 3rd decade of life . Sex :- slight female predominance. Location :- any bone may be involved. -Most common is proximal humreus ,distal femur,proximal tibia & spine. Types :- Primary :- apperas de novo following intraosseous A-V fistula. Secondary :- results of cystic changes in GCT ,OSTEOBLASTOMA etc.
- 9. Clinical feature :- -Pt complain of mild to moderate pain. -Swelling -Limitation of joint movements. -Neurological deficit or radicular pain. -Rapid growth may occur which clinically presents as a malignancy. X ray findings :- Affected bone is expanded, cystic & ballooned outward. Ecentricaly placed. Cortex is breached. Surrounded by a faint outline representing new periosteal bone.
- 10. PATHOLOGY :- GROSS :- -Large mass is attached by a broad base to the shaft of long bone . -Growing outwards & displacing the soft tissue. -Thin shell of bone enclosing the blood filled spaces. -Bony shell is easily penetrable with a liver like friable mass interposed with gritty bone particles is encountered. Microscopic :- -Bone & marrow are replaced by the large pool of blood enclosed in fibro osseous septae. -Connective tissue bordering the vascular space contain multinucleated giant cells, new bone formation & calcium deposits.
- 11. Other investigation:- Bone scan :- shows diffuse or peripheral tracer uptake with decreased uptake in center. Ct scan :- helpful in delineating the cyst in complex area ex. Spine ,pelvis . MRI :- shows multi loculated cavities & fluid level. Treatment :- -Currettage & bone grafting. -Marginal resction Is indicated in expendable bone -Low dose radiation has been used effectively ,associated with rapid ossification.
- 12. •Benign lesions of hyaline cartilage. •It can arise with in a bone ( ENCHONDROMA) or on the surface of abone ( PERIOSTEAL /JUXTACORTICAL CHONDROMA). •Usually presents as a solitary lesion but multiple lesion can also be present (enchondromatosis/OLLIER’S disease). •Tumour may be accompanied by a vascular lesion (MAFFUCCI’S SYND.)
- 13. Age :- usually all age group are affected . More commonly young individiual in 2nd -4th decade. Sex :- equally (M:F=1:1) Location:- any bone can be affected but commonly phalanges of hand & feet. -solitary enchondromas involve humreus , tibia & femur. Clinical findings :- -Swelling -Tenderness -Pain
- 14. Pathology :- Gross :- -Tumour is surrounded by a fibrous capsule. -The neoplastic tissue is composed of bluish white translucent cartilage - Areas of calcification. Microscopically :- -Tumour shows stages of cartilage formation. -Mesenchymal tissue is seen at periphery. -Most mature cartilage is seen at center.
- 15. X RAYS FINDINGS :- -small loculated area with well defined margins. -Cortex is thinned & expanded. -Interlesional calcification :- calcification is irregular Stippled ,punctate or popcorn. -no reactive bone formation CT scan :- Evaluate endosteal erosion to rule out chondrosarcoma.
- 16. Treatment of solitary enchondroma consisit of oberservation with serial radiographs. If the lesion apperas to be radiographically stable & asymptomatic then no further investigation is required. If the lesion appers to be unstable , growing then extended curettage is done.
- 17. -Least common cartilage tumour. -Not known to metastasize. -2% of all benign tumour. -Seen in patients <30yrs specially in 2nd & 3rd decade -Tumour is more common in male (M:F=2:1). -Observed in long tubular bones specially in lower extermity.
- 18. Clinical features:- -Pain near the joint without h/o trauma -Occasionally swelling -Pathological fractures ( rare) -May presents with soft tissue swelling. Radiographic findings :- -Translucent mass located eccentrically. -Fusiform expansion in small bones. -Cortex is expanded & thinned. -Margin’s are scalloped & sclerosis +. -Periosteal reaction is uncommon.
- 19. Pathology :- Gross :- -Cut surface reveals solid tumour mass containing small cavities with mucoid tissue. -Calcified areas are unusual. -Surface is sharply demarcated ,lobulated & surrounded by thin scalloped border of dense bone. Microscopic :- -Composed of lobulated areas of stellate cells with indistinct cytoplasmic borders. -At the periphery ,the appearance is more cellular & collagenous.
- 20. -local excision & filling the cavity with autogenous bone. -Curettage is not sufficient as tumour may recure especially childrens. -Wide en- bloc excision gives high rate of cure. -If tumour recure even after en bloc excision then studies has to be done to rule out the malignant transformation.
- 21. -Non inherited, sporadic developmental anomaly. -Replacement of bony tissue with fibrous tissue. Age :- begins in childhood(<10 yrs). Sex :- M:F=1:1 Location :- base of the skull & long bones. Clinical features:- -Pain -Limp -Deformity -Asymmetry of face -Endocrine disorder - Limb length discrepancy.
- 22. Pathology :- Gross :- -Bone is irregular in shape & bent. -Grey tough fibrous tissue that cut with a gritty resistance “SANDPAPER” Micro :- -composed of dense,mature collagenous tissue. -fibroblast are oriented in linear /whorl pattern.
- 23. Radiological findings :- -intramedullay & predominantly diaphyseal. -central or ecentric in location. -Ground glass appearance. -lesion is well defined with sclerotic margins -Cortex thinning & expansion is seen. -Pathological fractures . -Bowing of bones. -HARRISON’S GROOVE.
- 24. - Conservative management includes bracing & modification of activities. Surgical management :- -Pathological fracture usually heals but develops deformity. -Fracture of long bone should be treated preferably with I.M nails along with bone grafts. Large lesion which jeopardize the integrity of bone should be treated with currettage & bone grafting
- 25. -Benign well circumscribed fibrous growth with in a small area of long bone. -A/k/a nonossifying fibroma,fibroxanthoma -Localised form of fibrous dysplasia. Age :- <30yrs Location :- metaphysis of long bone. -usually lower limb. Sex :-M:F=1:1 Clinical feature :- -usually asymptomatic -occasionally presents with pathological fracture.
- 26. Pathology :- Gross :- thin cortex enclose soft /tough rubbery gray –yellow or reddish brown tissue. Microscopic :- Spindle shaped cell distributed in a whorled pattern. Fibroblastic proliferation with high cellularity. Giant & foam cells are present.
- 27. X ray findings :- -well defined lobulated lesion. -Ecentrically placed. -Cortex thinning & expansion -Multilocular appearance or ridges in bony wall. -No periosteal reaction. Treatment :- Excision & curettage
- 28. -Hyperparathyroidism results in disorder of bone & mineral metabolism. -Diffuse & focal lesion may arise in multiple bones. -These lesion are K/as brown tumours due to the presence of haemorrhage in the lesion. Location :- Any bone can be affected. Mainly diaphysis of long bone. Clinical features :- Stones Bones Groans
- 29. Radiological features :- Salt & pepper skull Multiple osteolytic lesions Laboratory findings :- ↑ed levels of PTH Hyper calcemia ↑ed serum phosphate & urate. TREATMENT :- treatment of the primary cause will cause the healing of lesion.
- 30. -Lesion of uncertain pathogenesis. Age :- can occur at any age. -Most commonly seen in 20-60yrs age . Location :- subchondral region of tubular bone , acetabulam & carpel bones. -Simultaneous occurrence of peri osseous ganglion cyst . -This led to the theory of adjacent soft tissue ganglion extension in bone. Clinical feature :-are usually clinically silent. -Chronic pain -Swelling if associated with soft tissue ganglion.
- 31. Radiogaphic findings :- -Well demarcated ,sharply circumscribed osteolytic lesion. -Sclerotic margin is evident. -In para articular location gas may be evident. Treatment :- - Local excision of overlying soft tissue & curettage of involved bone. - Recurrence is rare.
- 32. -Uncommon. -Due to the intraosseous implantation of epidermoid tissue . -M >F Age :- usually in 2nd ,3rd & 4th decade of life. Location :- skull & phalanges of hand are commonly affected. Clinically :- -Pain & swelling Microscopically :- -They resemble epidermal cyst of skin. -Cysts are filled with keratinous material & lined by squamous epithelium.
- 33. RADIOGRAPHIC :- Well defined osteolytic lesion with sclerotic margins . CT & MRI are rarely required. Treatment :- Excision
Hinweis der Redaktion
- The exact pathogenesis is unclear but the most widely accepted theory is that a focal defect in metaphyseal remodelling blocks interstitisl fluid drainage this leads to increased pressure which leads to focal bone necrosis & fluid accumulation. After 20 yrs cyst reveals a predilection for pelvic bone & calcaneus. SBC is called active when they are within 1 cm of PHYSIS & latent when they are closer to diaphysis.
- Physical findings :- untill attention is drawn to it when trauma cause pain which is often due to fracture through cyst wall. There is no periosteal reaction unless there is a fracture. FALLEN FRAGMENT SIGN :- usually a thinned cortex fracture & falls into the base of lesion confirmining its empty cystic nature. This is pathognomonic of sbc.
- Blood filled cystic space linned by fibrous tissue lacking endothelial lining.
- Investigation shows that cystic fluid contain prostaglandins , free oxygen radicals, interlukines,cytokines & metalloprotinases all of which contribute to bone resorption Treatment :- small asymptomatic lesion in upper extremities can be treated with observation with serial plain xrays. Large lesions are usually treated with curettage or aspiration with injections ( steroid , bone marrow aspirate, demineralized bone matrix). Pathological # of upper extremity can be treated conservatively. SBC of proximal femur should be treated with curettage , bone graft & internal fixation. Steroid injection was introduced in 1970 as the recurrence rate after curettage was approx 50%. Dosage is about 80-200 mg. if the lesion does not show radiographic signs of healing in 2 mths then the dose must be repeated
- ABC is most commonly seen in younger patients(&lt; 20 yrs). In spine the posterior element is involved with extension to the vertebral body & adjacent vertebra. Spinal lesion can cause neurological deficit or radicular pain due to nerve root compression. Pathogenesis is uncertain, its likely that ABC develops from local circulatory disturbances leading to increased venous pressure & production of local h’ge.
- Occasionally the soft center may be continuous with the medullary canal. Lining of the cavity spaces consists of Compressed histiocytes & fibroblast. A solid varient of ABC has been described & is k/as GIANT CELL REPARATIVE GRANULOMA
- In differentiating from UBC , presence of double density fluid levels & intralesional septation usually indicates ABC Radiotherapy is not used frequently because of the potential for malignant transformation. Recurrance rate is approx 10%-20%. It has been correlated with younger age&lt;15yrs, centrally located cyst & incomplete removal of cystic cavity.
- Occur in central location of bone Seen in 2-4 decade of life but more commonly in young adults. It can undergo malignant transformation if situated in long bones More commonly seen in phalanges of hand & feet.
- Pain can be due to :- pathological fracture or From the malignant transformation.
- - In small bones cortex may be perforated & the shadow of tumour extends into the surrounding soft tissue although the tumour is benign but if the cortex is broken in large bone then there is malignant transformation of the tumour. Juxta cortical tumours are small &lt; 3mm in size ,well defined & frequently appear to fit in a saucer shaped defect on the bone ,the underlying bone is sclerotic & the edges of the lesion appears to be buttressed by a thick rind of cortical bone. Chondrosarcoma usually involves the metaphysis whereas chondromas occur in diaphysis. An epiphyseal location , cotical erosion,less prominent matrix calcification, periosteal reaction & leasion &gt; 5 cm in diameter suggestive of chondrosarcoma.
- Tibia & femur involvement is approx. 55% Ecentrically located metaphyseal lesion & elongated in shape.
- Both myxoid & chondroid areas stain with toluidine blue & this reaction is absent after hyaluronidase digestion. This is the evidense of its cartilagenous origin. The lobules have a hypocellular center and increased cellularity at the periphery. Benign giants cells may be present at the edge of the lobules. The stroma in between the lobules shows mononuclear cells resembling those seen in chondroblastomas.
- Can be :- 1.monostotic & 2 . Polyostotic. It progress beyond puberity & through adulthood. Lesion usually ceases after the adolescence. Earlier the onset more progessive the disease. 70% are monostotic. RIBS&gt;FEMUR&gt;TIBIA&gt;MAXILLA&gt;MANDIBLE&gt;SKULL&gt;HUMREUS . INTRAMEDULLARY ,ECENTRIC OR CENTRAL LOCATION. CLINICAL FEATURES :-Pain is due to pathological fractures which eventually heals.the fracture fragment does not dsplace coz of the fibrous tissue holding them. 2. Deformity :- bowing of bones. coxa vera deformity of femur neck produce Shepard crook’s deformity of the femur is responsible for the shortening. 3. Asymmetry of face coz of hyperostosis of facial bones. 4. Endocrine disorder :- more commonly females are involved. - Sexual precocity(early mensturation , breast developments & Closed epiphysis) 2 SYNDROMES :- Mc CUNE ALBRIGHT SYND.(polyostotic F.D+Skin pigmentation+Endocrine disorder) & MAZABRAUD ( polyostotic F.D + intramus. Myxomas)
- HARRISON GROOVE FOLLOWING RIB FRACTURE. a horizontal depression along the lower border of the thorax, corresponding to the costal insertion of the diaphragm CT Scan is best as it help to identify the exents of the disease. The extent of the lesion is clearly visible on computed tomography, and the cortical boundary is depicted with more detail than is seen on radiographs or magnetic resonance images. The thickness of the native cortex, amount of endosteal scalloping and periosteal new bone reaction, and homogeneity of the poorly mineralized lesional tissue are demonstrated best with computed tomography imaging.
- Biopsy is sometime required for diagnosis. Sx treated lesion recure in immature skeleton.
- Predominantly seen in lower end of femur & both ends of tibia & fibula.
- Smaller lesion produce focal, superficial,shallow radiolucent area in the cortex with normal or sclerotic adjacent bone & in some a blister like peripheral osseous shell.the lesion are circular or oval & well delineated with smooth or lobulated edge. Large lesion have a more elongated & multilobulated appearance. The axis of the defect lies ll to the axis of the bone. Tendency of this lesion is to grow near the growth plate & then move away from it which gradually become smaller & indistinct & finally disappears. Role of ct & mri is limited in this . They can be used to delineate the extent in complex anatomic areas. TREATMENT:- these lesion are usually asymptomatic hence does not require as they regress by itself in adulthood. Most of the pathological fractures can be treated conservatively. Lesion become symptomatic & require t/t if they become large & are subjected to repeated trauma.some author believs that lesion larger then 50% of the bone diameter require t/t coz of ↑ed risk of pathological fracture.
- Hyperparathyroidism is of 2 types : primary coz of adenoma of glands & secondary due to renal failure led to ↑ed levels of parathyroid harmones. Seen in 3rd to 5th decade of life. Skeletal effect include massive bone resorption , #’s,bone pain or circumscribed lytic lesions. Have a less tendency for the spine. Clinically :- pt presents with kidney stones, bone lytic lesions & gastrointestinal symptoms such as nausea vomiting pancreatitis
- characteristic areas of resorption include symphysis pubis, distal clavicle, vertebral bodies and lamina dura (bone at base of teeth)
- Carpel bones esp. LUNATE . Knee ,medial malleolus ,femoral head are common sites. Continuity between the soft tissue & osseous lesion is consistent with gradual erosion of bone surface as a cause of an introsseous ganglion cyst. Pain increases with physical activity But multiple & b/l lesions are also encountered.
- Show fluid levels on mri & ↑ed uptake of radionuclide in 10% .