1. Orthopaedic Pathology Richard D. Lackman, MD Director Orthopaedic Oncology Center Cooper University Hospital

2. Bone and Soft Tissue Pathology is not as difficult as it appears The key to understanding – Appreciate trends – Pattern recognition – Importance of radiographic differential

3. Bone Forming Tumor Bone – Reactive ( Osteoblastic Rimming ) – Neoplastic ( No Osteoblastic Rimming ) Stroma – Benign Spindle Cell Stroma – Malignant Spindle Cell Stroma

4. Bone Forming 1 st Pattern – reactive woven bone & benign spindle cell stroma 2 nd Pattern – neoplastic woven bone & benign spindle cell stroma 3 rd Pattern – neoplastic woven bone & malignant spindle cell stroma

5. Reactive Woven Bone Showing Osteoblastic Rimming

6. Histologically Benign Appearing Bone Tumors Osteoid Osteoma Osteoblastoma Fibrous Dysplasia Parosteal Ostesarcoma

7. Neoplastic Woven Bone & Benign Spindle Cell Stroma

8. Histologically Malignant Appearing Bone Tumor Osteosarcoma

9. Neoplastic Woven Bone & Malignant Spindle Cell Stroma

10. Malignant Spindle Cell Stroma

11. Cartilage Forming Tumors 1 st Pattern - enchondroma L.G.C H.G.C. 2 nd Pattern – chondroblastoma 3 rd Pattern – chondromyxoid fibroma

12. Low Grade Cartilage

13. Chondrosarcoma

17. Chondroblastoma

18. Chondromyxoid Fibroma

19. Soft Tissue Sarcoma Patterns 1.Liposarcoma – malignant fat cells & lipoblasts 2.Fibrosarcoma – herring bone 3.Synovial Sarcoma – villous nodular 4.Myxo-Fibro Sarcoma – most others

20. Liposarcoma

26. Fibrosarcoma

28. Biphasic Synovial Sarcoma

30. Myxo-Fibro Sarcoma

31. Round Cell Infiltrate 1.Infection 2.LC Histiocytosis 3.Inflammatory condition 4.Primary Round Cell tumor 5.Small cell met adeno CA

32. Round Cell Tumors Children 1. Ewings – uniform round cells 2. Neuroblastoma – uniform round cells with pseudo – rosettes Adults 1. Plasmacytoma – uniform sheets of plasma cells 2. Lymphoma/Small Round Cell CA – everything else

33. Plasma Cells

35. Lymphoma / Met

36. Ewings Sarcoma

37. Neuroblastoma

39. Systematic Approach The key to understanding – Appreciate trends – Pattern recognition – Importance of radiographic differential In a few short minutes we have reviewed most of the basic patterns of bone and soft tissue pathology Add to the above a recognition of individual lesions and suddenly this is not such a difficult topic

40. Individual Lesions

41. 20 y/o with constant pain

43. 32 y/o with Constant Leg Pain

48. Osteoid Osteoma

53. 25 y/o with neck pain

57. Osteoblastoma

58. 25 y/o with Left Hip Pain

61. Osteosarcoma

62. 28 y/o with Knee Pain

66. Parosteal Osteosarcoma

68. 40 y/o with Elbow Pain

69. Center of Lesion

70. Closer to Outer Edge

71. Periphery of Lesion Myositis Ossificans

72. 30 y/o with Hip Pain

74. Fibrous Dysplasia

75. 17 y/o with Left Arm Pain

76. Diaphyseal Permeative Lesion

78. Histologic Findings Osteosarcoma

79. Allograft Reconstruction

80. Incidental Finding – 40 y/o

82. Histologic Findings in Low Grade Cartilage Tumors Increased cellularity Plump Nuclei More than one cell per lacunae More than one nucleus per cell Cells outside lacunae

83. Enchondroma / LG Cartilage Lesion

84. 60 y/o with Hip Pain

87. Chondrosarcoma

88. Hallmarks of Chondrosarcoma Intralesional lysis Endosteal Scalloping Cortical Thinning or Expansion Pain

89. 16 y/o with Shoulder Pain

91. Chondroblastoma

92. Lytic Lesion in the Epiphysis of a Child Chondroblastoma Infection

93. 13 y/o with Knee Pain

95. 20 y/o with Leg Pain

97. Chondromyxoid Fibroma

98. 40 y/o with Wrist Pain

101. Giant Cell Tumor

102. Giant Cell Tumor of Bone Juxta-articular Lytic Lesion Moth Eaten Margin Cortical Thinning or Erosion No Periosteal Reaction

103. 18 y/o with Leg Pain

105. Non-Ossifying Fibroma

106. 14 y/o with Arm Pain

109. Unicameral (Simple) Bone Cyst

110. 20 y/o with Elbow Pain

112. Aneurysmal Bone Cyst

113. 12 y/o with Hip Pain

116. Eosinophilic Granuloma

118. 20 y/o with Leg Pain

121. Ewing’s Sarcoma

122. 50 y/o with Wrist Pain

124. Lymphoma

125. 60 y/o with Hip Pain

127. Plasmacytoma / Myeloma

128. 10 y/o with Arm Pain

129. Metastatic Neuroblastoma

130. 50 y/o with Low Back Pain

131. Hemangioma

132. 60 y/o with Low Back Pain

134. Physiliferous Cells

135. Closely Mimics Chondrosarcoma

136. 40 y/o with Elbow Mass

138. Biphasic Synovial Sarcoma

139. 30 y/o with Leg Pain

141. Adamantinoma

142. Lesions in the Anterior Cortex of the Tibial Shaft Adamantinoma Cortical Fibrous Dysplasia

143. 18 y/o with Elbow Pain

145. Ewing’s Sarcoma

146. Allograft Reconstruction

147. 35 y/o with Knee Pain

150. Parosteal Osteosarcoma

151. Thank You