OVERVIEW OF BENIGN

BONE TUMOURS

Introduction
Represent a wide group of pathological and clinical

entities
Vary greatly in aggressiveness and clinical behavior &

requiring a broad spectrum of treatment

Many of the lesions can be observed without any form

of intervention while others require complete en bloc

excision and complex reconstruction

 The most serious types can undergo malignant

transformation and metastasis

Some metastatic lesions, while appear benign histologically,

can be fatal

IT IS IMPORTANT TO UNDERSTAND THESE

WIDE VARIATIONS IN ORDER TO MANAGE

PATIENTS PROPERLY

PRESENTATIONS
Painless bone swelling

- solitary or multiple: Osteochondroma

Incidental x-ray finding

- Adults : Enchondroma
- Paediatrics: Nonossifying Fibroma
Painful bone lesion

- stretching of surrounding tissue

- possibly aggressive: GCT, Chondroblastoma
Pathological fracture

CLINICAL CLUE

Age of patient

Age is the most

important clinical
clue in
Differentiating
possible bone
tumors

Investigations
X- ray
MRI

CT scan

X-ray Clues

WHAT IS THE TUMOUR DOING TO THE BONE ?

A benign tumour is generally confined by a natural barrier
In some tumours, such as osteochondromas, are so

characteristic that x-rays alone can establish the diagnosis

ABC

ENCHONDROMA

OSTEOCHONDROMA

FIBROUS DYSPLASIA

OSTEOID OSTEOMA

 Ballooning: a special type of cortical destruction by tumour

In ballooning the destruction of endosteal cortical bone and

the addition of new bone on the outside occur at the same

rate, resulting in expansion.
This 'neocortex' can be smooth and uninterrupted, but may

also be focally interrupted in more aggressive lesions like

GCT

HOW IS THE BONE REACTING TO THE TUMOUR ?

Host bone often responds to a tumor

by combination of resorption and bone

formation
A benign tumour is often slow-growing

& this allows the bone to marginate or

react to the neoplastic process

CHONDROMYXOID FIBROMA

If the bone has opportunity to react to

its expansion by forming mature bone

and a dense sclerotic margin --BENIGN
OSTEOID OSTEOMA

IS THERE PERIOSTEAL REACTIONS?

A benign periosteal reaction is a thick and uniform callus formation

resulting from chronic irritation

In the benign, slow growing lesions, the periosteum has time to lay

down thick new bone and remodel it into a more normal-appearing

cortex.
If the tumour creates subperiosteal new bone formation, which

has laminated or onion skin appearance

-- a rapidly evolving process eg. Ewing Sarcoma
Codmans Triangle --rapid periosteal elevation malignant

Sunburst appearance --malignant

HOW IS THE MARGIN BETWEEN THE TUMOUR AND HOST

BONE ?
Most benign tumour have a geographic type of bone

destruction with a sharp zone of demarcation

A narrow zone of transition results in a sharp, well-defined

margin
Permeative destructions represent a gradual wide zone of

transition > common in malignant lesions

UBC

FIBROUS DYSPLASIA

CHONDROMYXOID FIBEOMA

NONOSSIFYING FIBROMA

ABC

IS THERE ANY MATRIX MINERALISATION WITHIN THE

TUMOUR ?
Calcifications or mineralization within a bone

lesion is an important clue

There are two kinds of mineralization:
- chondroid matrix in cartilaginous
tumors like enchondromas
- Osteoid matrix in osseus tumors like
Osteoid osteomas
Calcification in a lytic lesion in a phalanx
Enchondroma

ANY SOFT TISSUE EXTENSION ?

Extension of tumour into surrounding soft tissue suggest

malignancy or a very rapidly growing benign process

CHONDROBLASTOMA

GCT

WHERE IS THE
LOCATION OF THE
TUMOUR WITHIN THE
BONE ?

Most benign tumours are metaphyseal

Differentiating between a diaphyseal and a metaphyseal

location is not always easy.

Many lesions can be located in both or move from the
metaphysis to the diaphysis during growth
Epiphyseal: Giant Cell Tumour, Chondroblastoma
Metaphysis: NOF, SBC, Enchondroma
Diphyseal: SBC, ABC, Enchondroma, Fibrous Dysplasia,

Eosinophylic granuloma
Posterior elements of spine : ABC, Osteoblastoma
Cortical: Osteoid osteoma, NOF

IS THE EPIPHYSIS CLOSED ? ( age)

Some lesions occur most frequently before epiphyseal

closure, whereas others are seen after the epiphyses

have closed

GCT

CHONDROBLASTOMA

 CT Scans : useful for identifying cortical destruction,

locating the nidus of osteoid osteoma

OSTEOID OSTEOMA

PAROSTEAL OSTEOCHONDROMA

 MRI: identification of neurovascular bundles,

intramedullary/ soft tissue extension, thickness of

cartilage cap

ENCHONDROMA

GCT

OSTEOCHONDROMA

CHONDROBLASTOMA

 Radioisotop imaging ( Tc-99m ) : monostotic/

polyostotic disease, identifying osteoid osteoma

ENCHONDROMA

OSTEOID OSTEOMA

FIBROUS DYSPLASIA

BENIGN BONE TUMOURS ARE

CLASSIFIED BY THE TYPE OF
NEOPLASTIC TISSUE WITHIN
THE LESION

WHO Classification Of Benign Bone Tumours

Group 1: BONE-FORMING TUMOURS

Osteoma, Osteoid Osteoma, Osteoblastoma

Group 2: CARTILAGE-FORMING TUMOURS

Chondroma (enchondroma, periosteal chondroma)

Osteochondroma (solitary, multiple )
Chondroblastoma, Chondromyxoid Fibroma
Group 3: Giant Cell Tumours
Group 4: MARROW TUMOURS - No Benign marrow tum
Group 5: VASCULAR TUMOURS

Haemangioma, Lymphangioma, GlomusTumour

Group 6: CONNECTIVE TISSUE TUMOURS

Desmoplastic Fibroma, Lipoma, Benign Fibrous Histiocytoma

Group 7: OTHERS

Neurilemmoma, Neurofibroma

3 STAGES Enneking 1980

1. LATENT:
- Asymptomatic, no pain unless #
- Does not progress or may heal spontaneously
- Frequently picked up as an incidental x-ray
2. ACTIVE:
- Painful, pain before #
- Progressive growth
- Not self limiting
- Can expand and even deform the bone
3. AGGRESSIVE:
- Painful, pain before #
- Progressive growth
- Not limited by natural barriers
- Invades and destroys the bone & extends into soft tissue

MANAGEMENT
THE TREATMENT OF BENIGN BONE TUMOURS

NEEDS TO BE INDIVIDUALIZED ON THE BASIS OF

THE SPECIAL FEATURES OF EACH LESION, AND IT IS
IMPORTANT TO USE JUDGEMENT AND EXPERIENCE
IN DETERMINING THE BEST METHOD OF
TREATMENT

Treatment options are matched to the aggressiveness of

the lesion

GIANT CELL TUMOUR

 Unknown origin
5 % of all primary bone tumor
Benign but aggressive (2% pulmonary metastasize)

Occurs in 2nd , 3rd , 4th decades

Rare in patient with open epiphysis
Arises in epiphysis of long tubular bones and in flat bones

 Common around the knee, distal femur, proximal tibia,

proximal fibula, distal radius

Patient c/o pain at the end of long bone
Possibility of slight swelling

 Radiolucent (lytic destructive) lesion in metaphysial region

that extend into epiphysis and subchondral bone

Ballooned lesion

Aggressive lesion:

- ill defined
- extend to soft tissue

 Treatment:
Aimed at removing the lesion, with preservation of the

involved joint.
Extensive curettage with hand and power instruments +

Chemical cauterization with phenol

ANEURYSMAL BONE CYST

 A non-neoplastic reactive condition

Expansile pseudotumour consist of a central cavity

containing old blood and blood products surrounded by a

thick membrane of fibrovascular tissue.
Any age and any bone (More often at 10-20 years)
Pathologic fracture is not common
Pain, swelling may present for months or years

 Eccentric , well defined lytic expansile area of bone

destruction in metaphysis.
Ballooning can be possible presentation

 Treatment:
Carful curettage + bone grafting/ bone cement

UNICAMERAL BONE CYST

 A solitary cavity containing clear fluid in the metaphysis of

growing children
Age: 5-15
Most often in proximal humerus, proximal femur
Pain usually after a fracture due to minor trauma

 Childhood: gradual expansion in metaphysis

Early adolescence: become inactive
After skeletal maturation: slowly ossify
Majority spontaneously healing by age 21

Pathological fracture in 30 40% of lesions

 Central and symmetrical lytic area with thinned cortices

Expanded bone but not wider than the physis

Lesion appear trabeculated

 Treatment:
Asymptomatic lesions in older children can be left alone
Aspiration to confirm the diagnosis + methylprednisolone

80 160 mg / autogenous bone marrow injection

Curettage and bone grafting in enlarging cyst or in

pathological fracture

ENCHONDROMA

 Benign cartilage tumour which arises within the shafts of

tubular bones
Only occurs in bones that are formed by endochondral

ossification
Usually located centrally in diaphysis and metaphysis
Short tubular bones of hand: phalanxes, metacarpal

bones, femur, humerus, fibula, ribs

 Any age but common at 2nd to 4th decades

Usually asymptomatic and discovered incidentally on

X-ray
Often present with pathological fracture
Lesions may be solitary or multiple

 Well- defined, centrally placed Lytic lesion, intralesional

calcification

 Complications (malignant change):

- probably less than 2% in solitary lesions

- 30% in those with multiple lesions (Olliers disease)

- up to 100% in patients with associated haemangiomas

(Maffuccis syndrome)
Treatment: observation or intralesional curettage and bone

graft / bone cement if fractured or malignancy

 Signs of malignancy changes:

1) Onset of pain
2) Enlargement of the lesion
3) Cortical erosion

OSTEOCHONDROMA
CARTILAGED-CAPPED
EXOSTOSIS

 The most common benign lesion of bone

Solitary outgrowth of bone or cartilage from edge of the

physial plate and developed by enchondral ossification

Covered by a cap of cartilage
Usually present by age 5 years but may arise at any age

up to skeletal maturation

 Painless mass or discovered incidentally with radiography

Solitary or multiple
Usually occur about knee, proximal femur, proximal

humerus
Watch closely for Malignant change: pain / continuation of

growth after skeletal maturity/ calcification within cartilage

cap

 Well-defined exostosis emerging from the metaphysis.

Its size is x-ray is smaller than its clinical size

 Treatment: If the tumour causes symptoms it should be

excised