Vol 9 ppt
0 likes701 views
The document provides information on bone cysts, including unicameral bone cysts and aneurysmal bone cysts. Unicameral bone cysts are common pseudotumors in children that occur most often in the humerus and femur and can cause pathological fractures. Treatment involves steroid injections to slow cyst growth or bone grafting if fractures occur. Aneurysmal bone cysts also present as hemorrhagic pseudotumors in children ages 10-20 and have a characteristic aneurysmal appearance on radiographs.
Vol 9 ppt
- 1. Contents for Volume 9 Bone cysts Unicameral bone cyst-------------Case 190-97 & 984-96 Aneurysmal bone cyst------------Case 198-204 & 997-1039 Epidermoid cyst-------------------Case 205-6
- 2. Bone Cysts
- 3. Unicameral Bone Cysts
- 4. Unicameral Bone Cysts The unicameral or solitary bone cyst is a very common pseudo- tumor seen in bone in children and is the most common cause for pathological fracture in that age group. The bone cyst is considered to be a hamartomatous developmental process with an unknown etiology. It may be a degenerative process seen in a pre-existing fibrous lesion of bone, such as monostotic fibrous dysplasia, that occurs between the ages of 5 and 15 years, more common in boys than girls, with half the cases in the proximal humerus and half in the proximal femur. These patients are usually asymptomatic until the time of fracture. The cysts are usually located in the metaphyseal portion of long bones, immediately adjacent to the growth plate during the early years when the lesions are considered active. As the patient approaches maturity, the cyst will start to migrate away from the growth plate and go into what is referred to as the inactive stage. Radiographically, the lesions are well marginated with a thin sclerotic edge at the periphery. They are centrally located in the
- 5. metaphysis with thinning and slight dilatation of the surrounding cortex and no matrix calcification. The cysts are filled with a clear serous fluid with increased pressure during the active phase that some experts feel may cause the cyst to enlarge by a hydraulic dynamic mechanism. The cyst is lined by a fibrous membrane studded with macrophages and, occasionally, foam cells. In some cases, tissue similar to fibrous dysplasia can be found at either end of the lesion. The periosteal covering over the cyst is normal and for this reason, the pathological fractures go on to heal without difficulty. Because of the potential for repeated pathological fractures, surgeons are tempted to carry out some type of bone grafting procedure during the early, active phase of the disease but become frustrated with a recurrence rate of 30-50 per cent. For this reason, the more common and current way to handle bone cysts in the early age group, before bone maturity, is by simple aspiration with a double needle technique with the instillation of methylprednisolone into the cyst cavity that inhibits
- 6. the macrophage activity and reduces the chance of local recurrence. It slows down the active lytic process of the disease. This injection is usually required on multiple occasions, every 3 to 6 months until the patient reaches maturity, at which time the disease tends to become inactive. 3 to 8 injections over this period of time may be required to avoid the necessity of a bone grafting procedure at a later date. The success rate is approximately 85%. In patients over the age 15 years, steroid injections in the inactive phase of the disease are not beneficial because the macrophage activity has disappeared. At this point, the only acceptable treatment would be a classic bone grafting procedure to strengthen the bone and reduce the chance of patho- logical fracture in the future. Physicians must be aware of the possibility that an apparent bone cyst on radiographic examination may masquerade as a malignant tumor such as an osteosarcoma. If one is unable to obtain fluid at time of aspiration, a biopsy should be performed to rule out this possibility.
- 7. CLASSIC Case #190 sclerosis 10 year female unicameral cyst proximal humerus
- 8. Photomic showing giant cells in cyst lining
- 9. X-ray following curettement and bone grafting
- 10. 6 months after bone grafting with nearly complete loss of graft
- 11. 1 year following surgery and even further loss of graft material
- 12. Case #191 9 year female unicameral bone cyst proximal humerus
- 13. Injection of cortisone into cyst
- 14. Healed 10 mos later
- 15. Case #192 9 year male with path fracture thru monostotic fibrous dysplasia
- 16. One year later with cystic changes
- 17. 3 years later with even more cystic changes
- 18. Progressive cystic changes at 4 years
- 19. Age 16 and healed path fracture thru nearly pure cyst
- 20. Surgical window into large cystic lesion
- 21. Fibular strut taken from opposite leg
- 22. X-ray opposite leg where graft was taken reveals another fibrous dysplastic lesion
- 23. Cyst packed with fibular strut & crest graft
- 25. 6 months post op
- 26. Case #192.1 UBC Prox Humerus 52 yr male with incidental finding right humerus
- 27. CT scan Axial prox. pole Cor Sag
- 28. Bone scan
- 29. Cor T-1 STIR Sag gad
- 30. Axial T-1 STIR Gad
- 31. Case #193 15 year female unicameral cyst ilium
- 32. Post op x-ray after bone grafting
- 33. Case #195 9 year female with unicameral cyst prox fem epiphysis
- 34. Case #196 15 year male with unicameral cyst os calcis
- 35. Case #196.1 18 year old female with incidental finding in foot
- 36. Sag gad Axial T-1 T-1
- 37. Cor T-1 T-2 Gad
- 38. PO bone graft
- 39. Case 196.1 Pseudo UBC - rheumatoid synovial cyst 60 yr female with long history of stiff and painful ankle
- 40. Sag T-1 Sag T-2
- 41. Cor PD Axial T-2 FS
- 42. Case #197 16 year female with unicameral cyst os calcis
- 43. Sagittal T-2 MRI
- 44. Coronal T-2 MRI showing fluid-fluid level
- 45. Case #984 14 year male with unicameral bone cyst proximal humerus with pathologic fracture
- 46. 2 months later with healing of upper part of cyst and now a new fracture in lower part
- 47. 4 months after 1st fracture and the two parts have joined with gradual healing in as result of fracture
- 48. 3 years later and nearly complete healing without treatment
- 49. Case #985 16 year male with unicameral bone cyst proximal humerus with path fracture
- 50. Surgical exposure for placement of fibular bone graft
- 51. Scanning lens photomic of curetted lining of cyst showing giant cell activity and recent hemorrhage from fracture
- 52. Café-au-lait noted at site of fibular graft harvesting
- 53. X-ray appearance 3 mos following bone grafting
- 54. Case #986 11 year male with unicameral bone cyst proximal humerus with path fracture
- 55. 18 months later
- 56. Post op x-ray after curettment and packing with plaster of Paris pellets
- 57. 4 months later with gradual resorption of pellets
- 58. 18 months post op and pellets have dissolved
- 59. The pellet treatment did not prevent another fracture seen healing here
- 60. Case #987 15 year female with path fracture thru unicameral bone cyst proximal femur
- 61. 6 months post op fibular strut and fibula DHS fixation
- 62. 3 years post op
- 63. Case #988 44 year female with unicameral bone cyst femoral neck
- 64. Coronal T-1 MRI
- 65. Coronal T-2 MRI
- 66. Case #989 9 year male with unicameral bone cyst femoral neck
- 67. Photomic showing giant cell activity in cyst lining
- 68. 6 weeks post op packing with cancellous allograft
- 69. 3 months later with slight recurrence
- 70. 9 months post op and even more recurrence
- 71. Case #989.1 16 year female with unicameral bone cyst Proximal femur
- 72. Coronal T-1 MRI
- 73. Coronal T-2 MRI
- 74. Coronal gad contrast MRI
- 75. Case #989.2 21 year female with path fracture thru UBC distal femur
- 76. Photomic from bone cyst lining
- 77. 2 yrs post op curettement and cancellous bone grafting
- 78. Case #989.3 12 year female with unicameral bone cyst distal femur
- 79. Lateral view
- 80. Coronal T-1 MRI
- 81. Coronal T-2 MRI
- 82. Axial T-1 MRI
- 83. Axial T-2 MRI
- 84. Case #989.4 10 year male with unicameral bone cyst tibia
- 85. Post op curettement & cementation with cancellous allograft
- 86. Case #989.5 11 year male with unicameral bone cyst tibia
- 87. Coronal T-1 MRI showing multiloculation
- 88. Coronal T-2 MRI
- 89. Axial T-2 MRI showing fluid-fluid level
- 90. Case #989.6 8 year female with unicameral bone cyst proximal tibia
- 91. Case #989.7 5 year female with UBC prox tibia
- 92. Lateral view
- 93. CT scan
- 94. Case #989.8 11 year female with unicameral bone cyst distal fibula
- 95. Case #989.9 53 year male with unicameral bone cyst 4th metacarpal
- 96. Bone scan
- 97. Coronal T-2 MRI
- 98. Case #989.91 6 year female with unicameral bone cyst 5th metacarpal
- 99. Case #990 25 year male with unicameral bone cyst thumb
- 100. Case #991 22 year male with UBC capitate
- 101. Case #992 18 year male with unicameral bone cyst distal ulna
- 102. Case #992.1 3 year male with unicameral bone cyst distal radius
- 103. Lateral view
- 104. Case #993 29 year female with unicameral bone cyst talus
- 105. Lateral view
- 106. Photomic with foam cells and giant cells
- 107. Case #993.1 57 year female with mild ankle pain one year without trauma
- 108. Sag gad Cor STIR
- 109. Axial T-2 Gad
- 110. Case #994 16 year female with bilateral unicameral bone cysts
- 111. Case #995 36 year female with unicameral bone cyst ilium
- 112. Bone scan showing signal Void in bone cyst
- 113. CT scan
- 114. Coronal T-1 MRI
- 115. Axial T-2 MRI with fluid-fluid level posterior
- 116. Case #996 12 year male with unicameral bone cyst ischium
- 117. Photomic showing giant cell activity
- 118. Post op x-ray after packing with cancellous bone graft
- 119. One year later
- 120. Aneurysmal Bone Cysts
- 121. Aneurysmal Bone Cysts The aneurysmal bone cyst is another clinical entity that presents as a hemorrhagic pseudotumor in bones in the pediatric age group, most typically in the femur, tibia, pelvis and spine. It has many of the characteristic clinical features of the giant cell tumor, except in a younger age group, and is frequently associated with other well known neoplastic conditions such as giant cell tumor, chondro- blastoma, osteoblastoma, fibrous dysplasia, or in some cases of osteosarcoma, especially the hemorrhagic type. It is a very lytic, destructive lesion of bone occurring in patients between the ages of 10 and 20 years. Its characteristic feature is an aneurysmal appearance seen on radiograph that, in the early stages, is extremely destructive,osteolytic and permeative, taking on the radiographic features of a malignant tumor such as a hemorrhagic osteosarcoma. In two thirds of the cases in the spine, the aneurysmal bone cyst is seen most commonly in the posterior elements, but in one third they will be seen in the vertebral body. In the case of the giant cell tumor
- 122. in the spine, the lesions are almost always found in the vertebral body. At the time of surgical biopsy, the surgeon will note a large amount of hemorrhage in a cystic lesion that has a very friable, mossy lining at the periphery and one sees reactive bone as it forms a shell around the hemorrhagic cyst. Microscopically, the mossy tissue will be loaded with large, reactive-type giant cells and the background stromal tissue will be made up of benign-appearing spindle cells with a large amount of interstitial hemorrhage and reactive bone formation, and even a few mitotic figures will be noted similar to the situation seen in hemorrhagic osteosarcoma. However, in hemorrhagic osteo- sarcoma, the number of mitotic figures would be very large. One must be very careful when sampling a biopsy of this type of lesion to make sure that one obtains multiple specimens, especially from the more fleshy portion of the tumor, looking for the possibility of an adjacent osteosarcoma. As far as treatment is concerned, this is a lesion that tends to in- volute spontaneously as the child matures into the young adult age
- 123. group. However, because of early progressive destruction and pain associated with these osteolytic lesions, surgeons will usually curette the tumor and then repair the defect with bone graft or, in some cases, bone cement and Steinman pins. In the case of large pelvic lesions or large spinal lesions that are difficult to resect surgically, intra-arterial embolization is a good technique to stimulate rapid involution of the tumor. Radiation therapy is a very effective in controlling massive lesions of the pelvis and spine, however, one runs the risk of a secondary sarcoma arising 5 to 15 years later.
- 124. CLASSIC Case #198 9 year female ABC proximal fibula
- 125. growth plate Resection specimen cut in path lab
- 126. blood osteoid Photomic showing giant cells
- 127. Case #199 9 year male with ABC proximal humerus
- 128. Rapid destruction 3 months later
- 129. Surgical photo of outer reactive bone shell
- 130. Photomic showing large giant cells
- 131. Immediate post op x-ray with bone graft struts
- 132. 7 years later
- 133. Case #200 9 year female ABC distal tibia
- 134. Lateral view
- 135. 18 months following simple curettement
- 136. Case #200.1 ABC 14 year old male with ankle pain for 3 months
- 137. Sag T-1 Cor STIR Sag Gad
- 138. Axial T-2 Gad
- 139. Surgical curettments
- 140. Case #201 12 year male with ABC proximal tibia
- 141. Fluid-fluid level Coronal T-2 MRI
- 142. X-ray following cementation procedure cement
- 143. Case #202 17 year male with ABC mid lumbar vertebra
- 144. Ct scan
- 145. Coronal T-1 MRI
- 146. Axial T-2 MRI with fluid-fluid levels
- 147. Case #203 17 year female ABC ilium
- 148. Increased size 6 months later
- 149. Axial T-1 MRI
- 150. Coronal T-2 MRI
- 151. Reconstruction with large bone allograft and recon plates
- 152. Case #204 17 year female with ABC ilium
- 153. CT scan
- 154. 2 years after curettement, embolization and radiation
- 155. reactive shell CT scan 2 years post treatment
- 156. X-ray at 5 years showing proximal hip migration
- 157. Radiation ulceration of skin over lesion
- 158. 2 months after myocutaneous flap coverage
- 159. 6.5 yrs post radiation with radiation OGS in SI area
- 160. Photomic of radiation sarcoma
- 161. Case #997 25 year male with ABC pelvis
- 162. R Bone scan
- 163. Photomic
- 164. 2 months later with progressive lysis
- 165. CT scan
- 166. ABC CT scan lower level
- 167. ABC CT scan thru pubic area
- 168. ABC Coronal T-1 MRI
- 169. Axial T-2 MRI
- 170. Arteriogram at time of embolization therapy
- 171. 8 months after external beam RT
- 173. Case #998 15 year male with ABC acetabulum
- 174. Photomic from biopsy specimen
- 175. 5 months post op curettement and bone grafting
- 176. CT scan 5 mos post curettage
- 177. CT at a higher level
- 178. Extensive peripheral calcification several mos post RT
- 179. CT at a higher level after RT
- 180. CT scan of chest reveals multiple metastatic nodules
- 181. Photomic of pulmonary lesion biopsy showing OGS
- 182. Case #999 19 year female with ABC pelvis
- 183. 8 months post RT
- 184. Case #1000 17 year female with asymptomatic ABC sacrum
- 185. 2 years later without treatment
- 186. Another 9 months later
- 187. 1.5 years later with burned out inactive lesion without pain
- 188. Case #1001 42 year male with burned out ABC ilium
- 189. CT scan
- 190. Case #1002 11 year male with active ABC pelvis
- 191. 4 years later and nearly inactive without treatment
- 192. Case #1003 14 year male with ABC ischium
- 193. Case #1004 14 year female with ABC pubic area
- 194. Case #1005 8 year male with ABC C-2
- 195. Bone scan
- 196. CT scan with fluid-fluid level
- 197. Photomic
- 198. 3 years post op posterior fusion
- 199. Case #1006 17 year male with ABC T-12
- 200. Lateral view
- 201. CT scan
- 202. Sagittal T-2 MRI
- 203. Axial T-2 MRI
- 204. Case #1007 21 year female with ABC L-2
- 205. Oblique view
- 206. Coronal T-2 MRI
- 207. Sagittal T-2 MRI
- 208. Axial T-2 MRI showing fluid-fluid levels
- 209. Case #1008 4 year male with ABC L-5
- 210. 3 months post op curettement alone
- 211. Case #1009 CT scan 25 year female with ABC lumbar spine
- 212. 5 months post op simple curettement
- 213. Case #1010 13 year male with ABC C-4
- 214. Case #1011 25 year female with ABC C-7
- 215. Case #1012 33 year female with ABC clavicle
- 216. Bone scan
- 217. Sagittal T-1 MRI
- 218. Axial T-2 MRI
- 219. Case #l013 12 year female with ABC clavicle
- 220. CT scan
- 221. Case #1014 11 year male with ABC clavicle
- 222. Case #1015 11 year male with ABC distal femur
- 223. Lateral view
- 224. Coronal T-1 MRI
- 225. Axial T-1 MRI
- 226. Axial T-2 MRI
- 227. 18 months later without treatment
- 228. Lateral view
- 230. 3 years after simple curettement
- 231. Lateral view
- 232. Case #1016 47 year female with ABC arising from a small focus of monostotic fibrous dysplasia seen at ABC upper pole of lytic area
- 233. fibrous dysplasia Lateral view ABC
- 234. Sagittal T-1 MRI
- 235. Coronal T-2 MRI
- 236. Photomic from curettement specimen
- 237. Case #1017 17 year female with ABC proximal femur
- 238. Bone scan
- 240. Coronal T-2 MRI
- 241. Axial gad contrast MRI
- 242. Case #1018 27 year male with ABC distal femur
- 243. Lateral view
- 244. Sagittal PD MRI
- 245. Axial T-2 MRI
- 246. Sagittal T-2 MRI
- 247. Biopsy photomic
- 248. Case #1018.1 ABC second to hyperparathroidism 56 year female with anterior knee pain for 2 years
- 249. Sag T-2 PD FS
- 250. Axial PD FS Cor PD FS
- 251. Case #1019 5 year female with ABC proximal femur
- 252. 3 months later with enlargement
- 253. Lateral view
- 254. CT scan
- 255. Case #1020 12 year female with ABC proximal tibia
- 256. Lateral view
- 257. Coronal T-1 MRI
- 258. Sagittal PD MRI
- 259. Coronal T-2 MRI
- 260. Sagittal T-2 MRI
- 263. Case #1021 14 year male with early ABC distal tibia
- 264. 18 months later
- 265. Lateral view
- 266. Sagittal T-2 MRI
- 267. Coronal T-1 MRI
- 268. Axial T-2 MRI
- 269. Case #1021.1 Bone abscess - ABC pseudo tumor 04 07 04 07 16 yr male with 3 yr history of intermittent pain and swelling at knee
- 270. Bone scan
- 271. 07 Cor T-1 T-2 Gad
- 272. Sag T-1 T-2
- 273. Axial T-2 Gad
- 274. Case #1021.2 Bone abscess - ABC pseudotumor 25 yr Indian male with 3 yr history of intermittent aching pain R leg
- 275. CT Scan
- 276. Sag T-1 PD FS Gad
- 277. Axial T-1 T-2 Gad
- 278. Case #1022 15 year female with ABC proximal tibia oblique view
- 279. AP view
- 280. Case #1023 18 year female with ABC proximal tibia
- 281. Surgical specimen at time of excisional arthrodesis
- 282. Macro section
- 284. Case #1024 AP Lat 4 year male with ABC proximal tibia
- 285. Case #1025 17 year female with ABC proximal fibula
- 286. Resected specimen cut in path lab
- 287. Macro section
- 288. Case #1026 13 year male with ABC distal fibula
- 289. 5 months post op simple curettement
- 290. Case # 1026.1 19 year female with ankle pain 4 mos
- 291. Axial T-1 T-2 Gad
- 292. Sag T-1 PD FS Gad
- 293. Case #1027 7 year female with ABC proximal humerus
- 294. Biopsy photomic
- 295. Rapid progression 6 weeks later
- 296. Another 6 weeks and rapid enlargement
- 297. Photo just prior to forequarter amputation
- 298. Surgical specimen cut open in path lab
- 299. Photomic shows features of hemorrhagic OGS
- 300. Post op chest x-ray shows pulmonary mets
- 301. Case #1028 17 year female with ABC distal humerus
- 302. Lateral view
- 303. Curettement photomic
- 304. Case #1029 54 year male with burned out inactive ABC proximal humerus
- 305. Case #1030 2 year female with ABC distal radius
- 306. Lateral view
- 307. Case #1031 11 year female with ABC distal radius Coronal T-1 MRI
- 308. Coronal T-2 MRI
- 309. Axial T-2 MRI with fluid-fluid level
- 310. blood Photomic
- 311. Case #1032 5 year male with ABC distal ulna
- 312. Lateral view
- 313. Case #1033 17 year male with ABC ulna
- 314. Surgical appearance
- 315. Photomic
- 316. X-ray 1 month following simple curettement
- 317. 3 more months and further healing in
- 318. 3.5 years later and completely healed
- 319. Case #1034 51 year male with ABC 2nd metacarpal
- 320. Case #1035 20 year male with ABC 1st metacarpal
- 321. AP view
- 322. Photomic
- 323. Case #1036 21 year male with ABC 1st metacarpal
- 324. Case #1037 10 year female with ABC distal phalanx
- 325. Biopsy photomic
- 326. Case #1038 16 year male with ABC 3rd metatarsal
- 327. CT scan
- 328. Photomic
- 329. Case #1039 8 year female with ABC 2nd metatarsal
- 330. Case #1039.1 CT scan 16 yr male with painful foot for 4 months
- 331. Axial T-1 T-2 FS Gad
- 332. Cor T-1 T-2 FS Gad
- 333. Sag STIR Gad
- 334. Epidermoid Cysts
- 335. Epidermoid Cyst The least common cyst in bone is the epidermoid cyst. It is usually seen in the distal phalanx or in the skull. In the case of the distal phalanx, the lesion usually occurs as the result of a crushing trauma to the distal phalanx that drives nail bed epithelium down into the subadjacent bone where it implants and produces an ectopic, squamous epithelial cystic lesion formed by a keratinized outer shell. It is filled with clear fluid and creates a surface erosion of the adjacent distal tuft of the phalanx that shows a very characteristic radiographic appearance. The lesions will transluminate with a flashlight. Other lesions that have a similar radiographic appearance include enchondroma, glomus tumors of the distal phalanx and perhaps a neurofibroma. Treatment consists of a simple curettement and packing of the defect with autologous bone graft.
- 336. CLASSIC Case #205 35 year female with epidermoid cyst distal phalanx
- 337. keratin cyst lining bone Photomic
- 338. Case #206 40 year female with epidermoid cyst distal phalanx
- 339. Lateral view