An 18 year old patient presented with pain at the lower femur.

Patient tells that the

pain is worse at night. The pain started three months back and gradually it started
to get worsen and the patient currently couldn’t go to work as any activity is
painful to him. There is also a swelling at the lower thigh. He also has associated
joint pain at the knee and basically limps while walking. Recently patient
developed cough and difficulty of breathing. Pathologic findings of the bone are
are composed of large, hyperchromatic, pleomorphic, mitotically active tumor cells
with osteoblastic, and there is also evidence of necrosis. X-ray finding shows the
typical codman’s triangle and sunburst appearance.
Diagnosis= Osteosarcoma
Why???
 The age is correct for osteosarcoma usually patients are between 10-20
although teenagers are the most commonly affected age group
 The presentation goes with osteosarcoma because the most common
presentation for nearly all bone tumors is pain. The pain in osteosarcoma is
also worse at night and worsen with activity. And also if the tumor is big
enough there might be swelling.
 Fatigue, fever, weight loss, anemia, bone fracture are also the other possible
symptoms of bone tumor.
 Although metastatic symptoms are not common still the lung are the most
commonly affected so the patients have cough and difficulty of breathing
 The pathological findings are also plausible because hyperchromasia ,
pleomorphism , mitotic figures are signs of malignancy
 The codmans’s triangle and sunburst appearance are also supportive
although they are not specific enough to be diagnostic.
Case=osteosarcoma
 What is osteosarcoma?
 It is an aggressive malignant neoplasm arising from primitive
transformed cells of mesenchymal origin ( and thus sarcoma) that
exhibits osteoblastic differentiation and produces malignant osteoid.
 It is the most common histological form of primary bone cancer.
 Which part of the bone does osteosarcoma commonly affect?
 At the end of the metaphysisis of long bone
 Specifically the proximal end of the tibia /humerus and the distal end
of the femur
 Mostly it is solitary

 What is the cause of osteosarcoma?

 Largely idiopathic
 But generally there are known risk factors for all bone cancer
o Ionizing radiation
o Paget’s disease
o Ollier’s disease
 What is the histopathological feature of osteosarcoma?
 Microscopically the characteristic feature of osteosarcoma is presence
of osteoid (bone formation) within the tumor
 Tumor cells are pleomorphic (anaplastic) , some are giant numerous
atypical mitoses
 What is the pathogenesis of osteosarcoma?
 Osteosarcomas tend to occur at sites of bone growth (presumably
because proliferation makes cells prone to acquiring mutations), and
they frequently exhibit p53 or RB mutations;
 How do we diagnose osteosarcoma?
 Not only osteosarcoma all bone tumors are diagnosed by
o Histopathology (biopsy)
o X-ray
o sometimes CT scan , MRI , bone scan
 but remember that bone biopsy is the only definitive method to
determine wheather a tumor is malignant or benign
 how do we treat osteosarcoma?
 For all bone tumor the treatment modality is
o Surgery
o Chemotherapy
o Radiotherapy
 Complete radical surgical resection is the treatment of choice for
osteosarcoma
 What is codman’s triangle?
 Subperiosteal lesion that is formed when the periosteum is raised due
to the tumor.
 How do we classify bone tumor?
 Primary
 Seconadary
 What are primary bone tumor?
 Are those which originate in the bone or from bone derived cells
 Are less common compared to secondary ones
 What are secondary bone tumors?
 Are those which originate in other sites and spread to skeleton
 The top common carcinomas which metastasize to the bones are:
- Breast
- Lung
- Prostate
- Thyroid
- Kidney
 They are 50-100 times more common than primary bone tumor
 What is the most common bone tumor?
 Multiple myeloma

 What is multiple myeloma?

 Is a hematologic malignancy which arise from bone marrow which
frequently presents as one or more bone lesions.

 How can we further classify primary bone tumors?

 Benign
 Malignant
 Compare benign and malignant bone tumor?
 Benign bone tumor
- Normal mitotic cells
- Normal but misplaced tissue
- Have capsule
- Unicompartemental
- Long duration (grow within years)
  Malignant bone tumor
- Abnormal mitotic cells
- Have pseudocapsule
- Multicompartment
- Neovascularization
- Short duration (grow within weeks-months)
 What benign bone tumors do you know?
 Osteoma
 Osteoid osteoma
 Osteochondroma
 Osteoblastoma
 Enchondroma
 Some benign bone tumors are not truly neoplasm rather represent
hamartomas namely the osteochondroma
 What malignant bone tumors do you know?
o Osteosarcoma
o Chondrosarcoma
o Ewing’s sarcoma
o Fibrosarcoma
 What other way of classifying bone tumor do you know?
o Cartilage forming
o Bone forming
 List some of the bone forming bone tumor?
o Osteoma
o Osteoid osteoma
o Osteoblastoma
o Osteosarcoma
 List some of the cartilage forming bone tumor?
o Osteochondroma
o Enchondroma
o Chondrosarcoma
 Other miscellaneous bone tumor?
o Giant cell tumor
o Ewing sarcoma
  Table summarizing the common site and common age group for each
bone tumor

Tumor type Common location Age group

Osteoma Facial bone , skull 40-50
Osteoid osteoma Metaphysis of femur,tibia 10-20
Osteoblastoma Vertebrae 10-20
Osteosarcoma Metaphysis of distal femur & proximal tibia 10-20
Enchondroma Small bones of Hand & feets 30-50
osteochondroma Metaphysis of long tubular bones 10-30
chondrosarcoma Bones of shoulder , pelvis 40-60
Gaint cell tumor Epiphysis of long bones 20-40
Ewing sarcoma Diaphysis of long bones 10-20

 What is the difference between ollier’s disease and Maffucci syndrome?

o Ollier disease is characterized by multiple chondromas preferentially
involving one side of the body, and Maffucci syndrome is
Characterized by multiple chondromas associated with soft tissue
spindle cell hemangiomas.
o Ollier disease is also called enchondromatosis.

 What is the difference between the term sessile and pedunculated?

o Sessile is to mean having no peduncle but attached directly by abroad
base
o Pedunculated is to mean attached by stalk to a surface
 What is osteochondroma?
o It is cartiliage capped bony outgrowth attached to the underlying
skeleton by stalk.
 What is unique about osteoma?
o Is a new piece of bone usually growing on another piece of bone
typically the skull
o It is the most common benign neoplasm of the nose and paranasal
sinuses
o It is also found in gardner’s syndrome

 What is gardner’s syndrome?

o It is familial colorectal polyposis characterized by the presence of
multiple polyp in the colon together with tumors outside the colon and
one of the extracolonic tumor is osteoma.

 What is the most common malignant primary bone tumor?

o Osteosarcoma

 what is the most common benign primary bone tumor?

o Osteochondroma

 What is unique about gaint cell tumor?

o composed of a mixture of neoplastic mononuclear cells and reactive
osteoclast-like giant cells
o is a relatively common benign but locally aggressive bone tumor
o Despite the name, molecular analyses have shown that it is the
mononuclear cells in the tumor that are neoplastic
 What is unique about Ewing’s sarcoma?
o primary malignant small round cell tumors of bone and soft tissue.
o It has neurectodermal origin
o The presence of Homer-Wright rosettes (tumor cells circled about a
central fibrillary space) indicates neural differentiation
o There is a characteristic periosteal reaction with deposition of bone in
an onion-skin pattern

 What other common disease of the bone do you know?

 o Osteomyelitis
o Pagets’s disease of the bone
o Osteogensis imperfecta
o Osteoporosis
o Osteomalacia

 What is osteomyelitis?
o It is inflammation of the bones

 What is the most common cause of osteomyelitis?

o Staphylococci aureus (both for the acute and chronic)

 What is pagets’s disease of the bone?

o is characterized by uncontrolled osteoclast activity, causing
widespread bone resorption followed by intense osteoblast activity,
producing woven bone that fills in the erosion.
o The net effect is paradoxically an increase in bone mass that is
architecturally unsound because the woven bone persists.

 What is paget’s disease of the breast?

o It is a malignat condition that outwardly may have eczema with skin
changes involving the nipple of the breast
o It is basically ductal carcinoma insitu cells that migrate to the
lactiferous sinuses and the nipple skin.

 What is osteomalacia?
o OSTEOMALACIA (in adults) and rickets (in children) are
characterized by lack of minerals within osteoid, which
occurs as a result of vitamin D deficiency.

 What is osteoporosis?
 o is a critical loss of bone mass associated with a deficiency of
either GH (senile) or estrogen (postmenopausal).
o Decreased estrogen levels result in increased secretion of
IL-1 (a potent stimulator of osteoclasts) from monocytes and
increased osteoclast activity.

 What is the function of bone?

o Support and protection
o Movement
o Blood cell formation
o Storage of minerals and fat
o Serve as attachment for muscles
 Summarized list of bones of the body
 How can we classify bones according to the shape?
o Long Bones- longer than wide, slender
 Include –the bones of the arms, legs, hands, and feet
(but not the wrists and ankles), and clavicle
o Short Bones- wider than longer
 box-like Cuboidal and are found only in the ankle
(tarsus) and wrist (carpus).
o Flat Bones
 Thin, flattened and usually somewhat curved
 Usually serve protective functions
 the ribs, shoulder blades, hip bones, and cranial bones,
and sternum.
o Irregular Bones
 have complex shapes
 Vertebrae and facial bones
o Sesamoid Bones
 small, flat, sesame seed shaped
 Ex. Patella
o Pneumatic bones
 air filled cavities lined with mucus membrane
 e.g. maxilla, ethmoid, frontal and sphenoidal bones.
o Sutural Bones (Wormian Bones)
 small, flat, irregularly shaped
 Ex. Bones between flat bones of the skull
 How do we classify bones according to microscopic findings?
o non-lamellar ,immature bones-have a network of randomly
oriented large collagen fibers
o lamellar bones- all mature bones

 How do we classify bones according to developmental origin?

 o membranous, mesenchymal or dermal
o cartilaginous or chondral
 How do we classify bones?
o Compact – outer layer provides strength.
 Looks like solid hard layer of bone
 Makes up the shaft of long bones and the external layer
of all bones
 Resists stresses produced by weight and movement
o Spongy (cancellous)– consists of trabeculae containing
marrow for blood cell production or fat storage.
 It forms most of the structure of short, flat, and irregular
bones, and the epiphyses of long bones.
 Spongy bone tissue is light and supports and protects
the red bone marrow.
 What are the major structures of a typical bone?
o Diaphysis
o Epiphysis
o Metaphysis

 What is the diaphysis?

o middle part called shaft, body and
o thicker compacta and the medullary cavity.

 What is the epiphysis?

o usually covered by an articular cartilage and is involved in
the formation of a joint.
o consists of spongy bone covered externally by a thin layer of
compact bone.

 What is the metaphysis?

o consists of a hyalin cartilage is found b/n the diaphysis and
epiphysis of growing bones.
 o At the end of bone growth this cartilage will be replaced by
bone and the remaining site of fusion is called epiphyseal
line.
 What is the difference between endosteum and periosteum?
o Periosteum-
 Covers the entire external surface of each bone except
on the ends of epiphysis where articular cartilage
occurs.
 has two layers
 Outer fibrous layer –capsule like vascularised layer
consisting of collagen and fibroblasts , sharpey’s fibers
bind it to the bone matrix
 Inner cellular layer(osteogenic layer)- Composed of
flattened cells with the potential to divide mitotically
and divide in to osteoblasts
o Endosteum
 Lines all internal surfaces of cavities within the bone
and is composed of a single layer of oteoproginor cells
and a small amount of CT.
 List some of the bone markings you know?
o Capitulum: small, round, articular head
o Condyle: rounded, knuckle-like articular area, usually occurring in
pairs
o Epicondyle: eminence superior to a condyle
o Crest: ridge of bone (e.g., the iliac crest).
o Line: a less prominent ridge of a bone than a crest
o Facet: smooth flat area, usually covered with cartilage, where a bone
articulates with another bone
o Foramen: passage through a bone
o Fossa: hollow or depressed area
o Groove: elongated depression or furrow
o Meatus: a tube-like passage
o Head (L. caput): large, round articular end
o Tubercle: small raised eminence
 o Tuberosity: large rounded elevation
o Trochanter: large blunt elevation
o Malleolus: rounded process
o Notch: indentation at the edge of a bone
o Protuberance: projection of bone
o Spinous process: projecting spine-like part
o Trochlea: spool-like articular process or process that acts as a pulley
o Sinus/antrum: a cavity within a bone
 What arteries of the bone do you know?
o Periosteal arteries - supply periosteum
 branches of Nutrient and epiphyseal aa
o Nutrient arteries - enter through nutrient foramen supplies
compact bone of diaphysis & red marrow
o Metaphyseal & epiphyseal aa.
 supply red marrow & bone tissue of epiphyses