bone tumours .osteoid osteoma, osteosarcoma, chondroma

1. BONE TUMOR
MODERATOR-DR. S. S. THAKUR

2. • A bone tumor, is a neoplastic growth of tissue
in bone. Abnormal growths found in the bone
can be either benign or malignant.

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Bones are classified according to their shapeLong bone
Flat bone
Short bone.

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Long bone anatomy
Diaphysis: long shaft of bone
Epiphysis: ends of bone
Epiphyseal plate: growth plate
Metaphysis: b/w epiphysis and diaphysis
Articular cartilage: covers epiphysis
Periosteum: bone covering (pain sensitive)
Sharpey’s fibers: periosteum attaches to underlying
bone
• Medullary cavity: Hollow chamber in bone
- red marrow produces blood cells
- yellow marrow is adipose.
• Endosteum: thin layer lining the
medullary cavity

5. Diaphysis

6. Epiphysis

7. Metaphysis

8. • Histology of bone tissue
Cells are surrounded by matrix.
- 25% water
- 25% protein
- 50% mineral salts
4 cell types make up osseous tissue
Osteoprogenitor cells
Osteoblasts
Osteocytes
Osteoclasts

9. • Osteoprogenitor cells:
- derived from mesenchyme
- unspecialized stem cells
- undergo mitosis and develop into
osteoblasts
- found on inner surface of periosteum
and endosteum.

10. Osteoblasts:
- bone forming cells
- found on surface of bone
- no ability to mitotically
divide
- collagen secretors
Osteocytes:
- mature bone cells
- derived form osteoblasts
- do not secrete matrix
material
- cellular duties include
exchange of
nutrients and waste with
blood

11. • Osteoclasts
- bone resorbing cells
- bone surface
- growth, maintenance and bone repair
Abundant inorganic mineral salts:
- Tricalcium phosphate in crystalline form called
hydroxyapatite
Ca3(PO4)2(OH)2
- Calcium Carbonate: CaCO3
- Magnesium Hydroxide: Mg(OH)2
- Fluoride and Sulfate

12. Osteoprogeniter cells &Osteoblast

13. Osteoclast

14. Precursors of malignancy in bone
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High Risk
Ollier disease (Enchondromatosis)
and Maffucci syndrome
Familial retinoblastoma syndrome
Rothmund-Thomson syndrome (RTS)
Moderate Risk
Multiple osteochondromas
Polyostotic Paget disease
Radiation osteitis

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Low Risk
Fibrous dysplasia
Bone infarct
Chronic osteomyelitis
Metallic and polyethylene implants
Osteogenesis imperfecta
Giant cell tumour
Osteoblastoma and chondroblastoma

17. Classification of primary tumour involving bones
Histological
type
Hematopoietic
Chondrogenic
Benign
Malignant
Myeloma
Osteochodroma
Chondroma
Chondroblastoma
Chondromyxoid
fibroma
Malignant
lymphoma
chondrosarcoma

18. Histological
type
Benign
Malignant
Osteogenic
Osteoma
Osteosarcoma
Osteoid
osteoma
osteoblastoma
Unknown origin Giant cell
tumour
Ewing tumour
Giant cell tumour
admantinoma

19. Histological
type
Benign
Malignant
Histiocytic
origin
Fibrous
histiocytoma
MFH
Fibrogenic
Metaphyseal fibrous Dysplastic fibroma
defect
Fibrosarcoma
Notochordal
Vascular
Chordoma
Hemangioma
Hemangioendothelioma
Hemangiopericytoma
Lipogenic
Lipoma
Neurogenic
Neurilemmoma
Liposarcoma

20. Distribution of bone tumors in long
bones
• Epiphyseal lesions:
• Chondroblastoma
• Giant cell tumor
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Metaphyseal intramedullary lesions:
Osteosarcoma
Chondrosarcoma
Aneurysmal bone cyst

21. • Metaphyseal lesions centered in the cortex:
• Nonossifying fibroma (NOF)
• Osteoid osteoma
• Metaphyseal exostosis:
• Osteochondroma

22. •
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Diaphyseal intramedullary lesions:
Ewing’s sarcoma
Lymphoma
Myeloma
Fibrous dysplasia
Enchondroma
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Diaphyseal lesions centered in the cortex:
Adamantinoma
Osteoid osteoma

23. Sites of Tumors

25. Important Facts
• 0.001% of all cancers
• MC benign tumor--- Osteochondroma; Osteoid
Osteoma
• MC Skeletal malignancy– Metastasis.
• MC Bone tumor in Pediatric age group & adultsOsteosarcoma
• MC in < 10 y--- Ewing’s sarcoma
• MC Primary bone tumor – Multiple Myeloma

26. PRESENTING SYMPTOMS
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Patient may present with
An abnormal radiographic finding detected during evaluation of unrelated problem
PAIN:- is most frequent symptom
MASS:- rate of enlargement is important
-Fluctuating mass can be cyst,ganglion or hemangioma
-Family H/O masses near the joint may be indicator of Ollier’s disease or Maffucci
Syndrome
NEUROLOGICAL SYMPTOM:- found in few patients such as sacral tumors & with tumors
located near the nerve causing compression of nerve,especially common in sciatic notch
,inguinal canal & popliteal fossa
UNEXPLAINED SWELLING OF THE LOWER EXTREMITY:- found in pelvic
tumors which are painless & without a palpable mass & cause swelling due to
compression of iliac vein.

27. PHYSICAL EXAMINATION
• Evaluation of patient’s general health
• TUMOR MASS should be measured & its location,shape,
consistency,mobility,tenderness,local temp & change with
position should be noted.
• SKIN & SUBCUTANEOUS TISSUE :
• Small dialated superficial veins overlying the mass are produced
by large tumors
• Café-au-lait spots & subcutaneous neurofibromas indicate Von
Recklinghausen’s disease
• A venous malformation Maffucci Syndrome
• REGIONAL LYMPH NODES: sign of metastatic disease
• Atrophy of surrounding musculature should be recorded,also
neurological deficits & adequacy of circulation.

28. HISTORY OF THE PATIENT
• AGE:- most imp information,bcoz of their presentaion in sp age
group.
• 1st decade- usually ABC ,SBC
• 2nd decade-Chondroblastoma,osteosarcoma,Ewings
• 3rd decade- GCT
• 4th decade- chondrosarcoma
• 5th decade- Multiple myeloma
• SEX:- less imp than age
• RACE:- little imp, Ewings rare in african descent
• H/O any exposure to radiation Tt or Carcinogens- bone seeking
radionucleotide can cause sarcoma.
• Various chemical carcinogens- zinc beryllium silicate, beryllium oxide.
• Currently the most worrisome & controversial is Nickel which is used
in many orthopedic devices.

29. LABORATORY TEST
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Alkaline phosphatase – Higher .
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PTH test: Lower.
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Serum phosphorus: Higher
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Ionized calcium and serum calcium: Higher .

30. •
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INVESTIGATIONS
X-RAY
CT SCAN
MRI
TECHNETIUM BONE SCAN-This type of scan uses a
very low radioactive material (diphosphonate) to see
whether or not the cancer has spread to other
bones and the damage suffered by the bone.
• PET- uses radioactive glucose to locate cancer. This
glucose contains a radioactive atom that is absorbed
by the cancerous cells and then detected by a special
camera.

31. BIOPSY
• The biopsy is the most conclusive test because it confirms if
the tumor is malignant or benign, the bone cancer type
(primary or secondary bone cancer), and stage.
• According to the tumor size and type (malignant or benign)
and the biopsy's purpose (to remove the entire tumor or only a
small tissue sample), there are two types of biopsies used in
bone cancer diagnosis. These are: needle biopsy and incisional
biopsy.
• 1. Needle biopsy: During this procedure, a small hole is made
in the affected bone and a tissue sample from the tumor is
removed.
• There are two types of needle biopsies:
• Fine needle aspiration: During this procedure, the tissue
sample is removed with a thin needle attached to a syringe.
• Core needle aspiration: During this procedure, the surgeon
removes a small cylinder of tissue sample from the tumor with
a rotating knife like device.
• 2. Incisional biopsy: During this procedure, the surgeon cuts
into the tumor and removes a tissue sample.

32. BONE FORMING TUMOURS
• Benign:
Osteoma, Osteoid
Osteoma,
• Benign Aggressive:
Osteoblastoma
• Malignant: Osteogenic
Sarcoma

33. Osteoma
• Benign, asymptomatic, slow-growing
osteogenic lesion.
• Age/Sex: 40-50 yr, M:F = 2:1.
• Bones involved: flat bones of the skull and
face; may protrude in the paranasal sinus.
• Parosteal location.
• Gardner’s syndrome.

34. Ivory like bony mass

35. Figure 2: The lesion consists of dense and lamellar cortical
bone with a focal area of active bone modeling.
Figure 3: Photomicrograph of the more solid area of the
lesion to demonstrate the cellular woven character of the
bone.

36. Osteoid osteoma
• Signs/Symptoms:
• Pain, characteristically more intense at night, relieved by NSAID
and eliminated by excision
• Scoliosis
• Age:
• Sex:
• 10-30 years
• M > F (2:1)
• Anatomic Distribution:
• Nearly every location, most frequent in femur, tibia,( Over 50%)
humerus, bones of hands and feet, vertebrae and fibula
• Metaphysis / Diaphysis (cortical) of long bones
• Vertebral lesions may be associated with scoliosis.

37. Small central osteolytic nidus surrounded by dense
bone

38. The small, reddish central nidus is surrounded by a thick layer
of sclerotic bone

39. Wedge
shaped nidus
which is
surrounded
by dense
sclerotic
bone.

40. New osteoid and bone formation by plump osteoblasts.
The stroma is cellular and well vascularized

41. Osteoid osteoma with anastomosing trabeculae of
woven bone

42. Osteoblastoma
• Also called as Giant osteoid osteoma.
• Osteoblastoma is similar to osteoid osteoma with
more aggressive behavior.
• D/D from osteoid osteoma*Pain
*Absence of reactive bone
* Large size
• Location :
– In spine or major bones of lower extremity

43. Well differentiated radiopaque/radiolucent lesion

44. Osteoblastoma.-The histologic appearance is identical
to that of osteoid osteoma.

45. Recurrent osteoblastoma.-The appearance is similar to
that of osteoid osteoma

46. Osteosarcoma
• Most frequent primary malignant bone tumour.
• Age/Sex :10-25 yrs & >40 , M:F = 3:2
• Predisposing conditions:
Paget’s disease
Radiation exposure
Chemotherapy
Benign bone lesion
Foreign bodies
Trauma

48. Codman’s triangle:
“Sunray “ appearance

49. Tumor is located at the typical metaphyseal site. The tumor
shown in A is largely restricted to bone, whereas that illustrated
in B is accompanied by massive soft tissue extension.

50. ‘skip metastasis’ located in the upper half of the femur. The
primary tumor was located in the lower metaphysis of the same
bone

51. The malignant bone is more basophilic and has more
irregular borders than the preexisting bone
trabeculae.

52. Osteosarcoma showing characteristic basophilic thin
trabeculae of neoplastic bone with an appearance that
is reminiscent of fungal hyphae

53. Lace-like osteoid deposition is very
characteristic of this neoplasm.

55. Osteoblastic osteosarcoma with finely ramifying matrix
between tumor cells

56. Microscopic variants
Telangiectatic :
• Blood filled cystic space and thus
radiologically appears as pure lytic lesion.
• Pathological fractures.
• Grossly the lesion simulate aneurysmal
bone cyst.
• Detection of malignant stroma in the septa
that separate the bloody cysts.

57. Telangiectatic osteosarcoma.

58. Telangiectatic osteosarcoma.
A The low-power architecture closely simulates the
appearance of an aneurysmal bone cyst
B Malignant osteoid is present in the septa

59. Telangiectatic osteosarcoma. Spaces containing blood are
separated by septa. The cells appear malignant even at this
level of magnification

60. Fibrohistiocytic

61. Small cell variant:
• Uniform small size tumour cells.
• Diffuse pattern of growth.
• Simulate Ewing’s sarcoma and malignant
lymphoma.

62. Anaplastic

63. Well differentiated intramedullary
.This tumor is microscopically so bland looking as to be often
underdiagnosed as a benign lesion.
In contrast to fibrous dysplasia
1- this tumor shows radiographic evidence of cortical
destruction.
2-Microscopically, atypia is minimal but still present.
3-The invasive growth pattern.

64. Variants defined on the basis of topographic,
clinical and radiographic features:
Juxtacortical (parosteal)
• Slightly older age group
• Juxtacortical position in the metaphysis of
long bones.

65. Juxtacortical osteosarcoma
of upper femur. There is only
minimal involvement of the
cortex
Juxtacortical osteosarcoma
large extracortical component

66. Juxtacortical osteosarcoma--Moderately atypical spindle tumor cells
grow between irregularly shaped bone trabeculae

67. Parosteal osteosarcoma-The spindle cells demonstrate
minimal atypia, and the bone appears to arise directly from
the spindle cells.

68. Periosteal osteosaocoma
• Grows on surface of long bones.
• Upper tibial shaft or femur.

69. Periosteal osteosarcoma. The white shining appearance
is due to the high content of cartilage

70. periosteal chondrosarcoma. There is a predominance of
myxochondroid areas

71. Bone formation in the center of a cartilaginous lobule
in periosteal osteosarcoma

72. Osteosarcoma of jaw:
• Patients affected are slightly older (average age, 34
years),
• And most lesions show a prominent chondroblastic
component.
• The most common sites of involvement are the body
of the mandible and the alveolar ridge of the maxilla.
Osteosarcoma in Paget’s disease.
• Osteosarcoma are of the polyostotic type
• Pelvis, humerus, femur tibia & skull.
• Large number of osteoclasts alternating with atypical
osteoblast.

73. Histochemistry, IHC & molecular
genetics
• Strong alkaline phosphatase activity.
• Vimentin, S-100, keratin & EMA.
• Osteonectin, osteocalcin, osteopontin.

74. Prognostic factors
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Paget’s disease
Irradiation
Specific bone involvement
Multifocality
Various types
Microscopic variants
Serum elevation of alkaline phosphatase
Aneuploidy
Post chemotherapy tumour necrosis
RB gene
HER2/neu expression
P-glycoprotein.

75. CARTILAGE FORMING TUMOURS
• Benign:
Enchondroma, Periosteal
Chondroma, Osteocho
ndroma.
• Benign Aggressive:
Chondromyxoid
Fibroma, Chondroblast
oma.
• Malignant:

76. Chondroma
• Benign tumor of mature hyaline cartilage
• Age – 20-50 yrs
• Usually solitary,30% are multiple.
• Bones involved: small bones of hand & feet.
• Asymptomatic, pain & swelling.
Enchondroma is the most common tumor of
the bones of the hand

77. Enchondromas
• Begin in spongiosa of diaphysis, from which they expand
and thin cortex
• Unusual in ribs and long bones
Juxtacortical Chondroma
• Much less common than enchondroma
• Involve parosteal region of long bone or small bone of
hand or foot

78. 2 syndromes characterized by multiple
chondromas:
• Ollier’s disease
• Maffucci’s syndrome
• Both disorders have 25% risk of malignant transformation to
chondrosarcoma

79. Maffucci syndrome-Innumerable chondromas are seen
concentrated in the distal aspect of the extremity

80. Juxta-cortical - The tumor produces a
semispherical expansion of the involved bone.

81. Enchondroma-The tumor has a typical
lobulated appearance

82. Osteochondroma
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Also known as exostosis.
Most frequent benign cartilaginous tumour.
Age/sex - <20yr, M:F=3:1
Bones involved: lower femur, upper tibia,
upper humerus and pelvis.
• Location: Metaphysis

83. • Probably not a true neoplasm.
• Inactivation of both copies of the EXT gene in
the growth plate chondrocytes.
• Presents as slow growing mass, painful.
• <1% cases show malignant transformation.

84. A- Large osteochondroma of femur with a bilobed appearance.
B Cut surface of osteochondroma of ribthick cartilaginous cup

85. Projection with cortex continuous with underlying bone;
may be pedunculated; cartilaginous cap with frequent
calcification

86. Microscopic-Mature bone is covered by a welldifferentiated cartilaginous cap.

87. Microscopic

88. Chondroblastoma
• Rare benign cartilage producing tumour.
• Age/Sex : 2nd decade M:F=2:1.
• Bones involved: Distal femur ,proximal
humerus and tibia.
• Location: Epiphysis
• Pain is constant .

89. Typical sharply delineated lytic appearance of
chondroblastoma of humeral head

90. Gross appearance of chondroblastoma of upper end of the
humerus, associated with aneurysmal bone cyst-like changes

91. Chondroblastoma. A- Small tumor cells of round shape are
accompanied by scattered osteoclasts.
B-Immunoreactivity for S-100 protein in the neoplastic
component.

92. Chondroblast: Prominent Indented Nucleus
Eosinophilic Cytoplasm Thick Cell Membrane
Uniform Appearance of Cells

93. Chondroblastoma with eosinophilic chondroid matrix,
giant cells, and mononuclear cells

94. Imagine the cells present without the nuclei: The thickened cell membranes
would give a chicken wire fence appearance

95. Chondromyxoid Fibroma
• Benign tumour of cartilaginous origin.
• Age/Sex: 20-30 yr/ M:F=2:1
• Bones involved: Long bones>flat bones
>vertebrae.
• Location: Metaphysis.
• Localised pain with or without tenderness

96. Sharply delimited chondromyxoid fibroma of lower
femoral metaphysis in a young boy.

97. A-Chondromyxoid fibroma of proximal femur extending into
soft tissue
B-The tumor has a lobulated appearance, in which
myxochondroid islands alternate with more cellular foci.

98. Chondromyxoid fibroma- (A) An irregularly shaped
hypocellular center is surrounded by a cellular spindle
cell stroma.
(B) The lobules contain tumor cells with small nuclei
and eosinophilic cytoplasmic extensions within a
myxoid background

99. Chondrosarcoma
• Second most common malignant tumour of bones.
• Arise de novo or from pre-existing benign
cartilagenous tumour.
• Divided into two major categories:
*Conventional chondrosarcoma
*Chondrosarcoma variants

100. Conventional chondrosarcoma
• 30 – 60 yr of age.
• M>F
• Divided according to location:
*Central
*Peripheral
*Juxtacortical

101. Typical chondrosarcoma of femurI-ill defined margins;
fusiform thickening of shaft; perforation of cortex

102. Typical chondrosarcoma

103. Peripheral Variant:
• Tumour is present on the surface of bone.
• May arise de-novo or from cartilaginous cap
of preexisting osteochondroma.

104. Peripheral chondrosarcoma of femur resulting in a huge
exophytic mass

105. Juxtacortical(periosteal) variant:
• Location:
– shaft of long bone (most often femur)
• Cartilaginous lobular pattern with areas of:
– spotty calcification
– endochondral ossification
• Closely related to periosteal osteosarcoma.

106. Microscopic
• Wide range of differentiation and graded into:
– well differentiated
– moderately differentiated
– poorly differentiated

107. Well-differentiated chondrosarcoma. The tumor has a
distinctly lobulated quality

108. Well differentiated- High-power appearance of grade 1
chondrosarcoma. A few doubly nucleated cells and
moderate atypia .

109. Moderately differentiated - High-power
appearance of grade 2 chondrosarcoma with necrosis .
The nuclei are crowded and hyperchromatic

110. Poorly differentiated

111. Grading system
• Grade I : lesions contain hyaline cartilage manifested by
sparse cellularity. The cells typically contain dark, pyknotic
nuclei. <20% of cells contain large nuclei and fine nuclear
chromatin. Mitosis is absent.
• Grade II: A) lesion are slightly more cellular and >20% nuclei
are larger than nucleus of mature lymphocyte. Binucleate
cells are easily found. Mitosis is absent.
B) cellular lesions with numerous binucleated cells and
nuclear atypia. Mitosis is present but not more than
1/ 10hpf.
• Grade III: Mitosis atleast >=2 / 10 hpf

112. • The main differential is of low grade (Grade 1)
chondrosarcoma and enchondroma.
• Features consistent with chondrosarcoma are:
*Pain attributable to lesion
*Age greater than 50
*Cortical destruction and a soft tissue mass
*Periosteal reaction and thickening
*Endosteal erosion>2/3 cortical thickness on a CT scan
*Size greater than 5 cm

113. Chondrosarcoma variants
Dedifferentiated chondrosarcoma:
• Worst prognosis.
• Age/sex: sixth decade/ M:F =1:1.
• Bones involved: pelvis, femur.
• Poorly differentiated sarcomatous component
at periphery of otherwise typical low-grade
chondrosarcoma
– usually central type
– can be peripheral

114. Gross appearance of dedifferentiated
chondrosarcoma of pelvic bone -

115. Microscopic
• Dedifferentiation:
– may be in initial lesion
– more often in specimens from recurrent tumor:
• microscopic appearance of this component may be:
–
–
–
–
rhabdomyosarcoma
fibrosarcoma
osteosarcoma
pleomorphic sarcoma with MFH-like features

116. The edge of an island of well-differentiated cartilage (upper left) is
surrounded by highly pleomorphic sarcoma containing tumor giant
cells

117. Chondrosarcoma is juxtaposed with high-grade
malignant fibrous histiocytoma

118. Clear cell variant:
• Behaves as low-grade malignancy
• Can undergo dedifferentiation
• Age/Sex : 30-40 yrs/M:F= 2.5:1
• Location: proximal end of femur and humerus.

119. Clear cell chondrosarcoma with faint lobulation, woven
bone, and clear cells

120. Mesenchymal variant:
• Usually second or third decade of life
• Great variability in clinical course.
• Location:
– most commonly:
• jaw
• pelvis
• femur
• ribs
• spine

121. Shows an island of well-differentiated cartilage in the
center

122. Cellular, hemangiopericytoma-like component

123. TUMOUR
LOCATION
AGE/M/F
SALIENT PATHOLOGIC FINDING
OSTEOMA
FACIAL
BONE
40-50/2:1
MINERALIZED COMPACT BONE
OSTEOID
OSTEOMA
CORTEX OF 10-30/2:1
LB
OSTEOBLAS VERTEBRA
TOMA
E,CORTEX
OF LB
10-30/2:1
OSTEOSARC METAPHYS
OMA
IS OF LB
ACONVENTI
ONAL .
B-LOW
GRADE
CENTRAL
“NIDUS” OF IMMATURE BONE SURROUNDED BY
SCLEROTIC BONE.
IDENTICAL TO OSTEOID OSTEOMA BUT LARGER AND
OFTEN NO SCLEROSIS
10-25/3:2
A
-OSTEOID FORMED DIRECTLY BY MALIGNAT CELLS
-B- MILDLY ATYPICAL FIBROBLASTIC
PROLIFERATION+THICK BONE TRABECULAE

124. TUMOUR
LOCATION
CTELANGIEC
TATIC
METAPHYS
IS
BLOOD FILLED SPACE+FIBROUS SEPTAE+HIGHLY
MALIGNANT OSTEOID
DPAROSTEAL
CORTEX
30-60 YRS
OUTSIDE
PERIOSTEU
M
MILDLY ATYPICAL FIBROBLASTIC
PROLIFERATION+THICK BONE TRABECULAE
ECORTEX
PERIOSTEAL INSIDE
PERIOSTEU
M
AGE/M/F
SALIENT PATHOLOGIC FINDING
ABUNDAND CARTILAGE MATRIX +VARIABLE
MALIGNANT OSTEOID

125. TUMOUR
LOCATION
AGE/M/F
SALIENT PATHOLOGIC FINDING
CHONDRO
MA
HANDS
,FEET,RIBS
,FEMUR
10-40/1:1
VARIABLY CELLULAR HYLINE CARTILAGE
OSTEOCHO
NDROMA
METAPHYS
ISOF LBS
10-30/1:1
CARTILAGE CAPPED BONY PROTRUSION
CHONDROB EPIPHYSIS
LASTOMA
OF LBS
10-20/2:1
CHONDROID LIKE MATRIX, S-100 POSITIVE CELLS
WITH GROOVED NUCLEI
CHONDRO
MYXOID
FIBROMA
10-30/1:1
HYPOCELLULAR CHONDROMYXOID LOBULES
SURROUNDED BY MORE CELLULAR SPINDLE CELL
AREAS
METAPHYS
IS OF LBS

126. TUMOUR
LOCATION
AGE/M/F
CHONDROSAR PELIVIS.
COMA
RIBS
,FEMUR
ACONVENTION
AL
SALIENT PATHOLOGIC FINDING
/3:1
METAPHYSIS 20-80
VARIABLY CELLULAR HYLINE CARTILAGE WITH
PERMEATING BONE
BMETAPHYSIS >30
DEDIFFERENTI
ATED
CONVENTIONAL CHONDROSARCOMA
+HIGH GRADE SPINDLE CELL SARCOMA
CMESENCHYM
AL
20-50
METAPHYSIS
UNDIFFERENTIATED SMALL TUMOUR CELLS
WITH +HYLINE CARTILAGE
E- CLEAR CELL
EPIPHYSIS
20-70
CONVENTIONAL CHONDROSARCOMA
+ABUNDANT LARGE CLEAR CELLS

127. THANKYOU
PRESENTED BY – DR NARMADA PRASAD TIWARI