Orthopedic Pathologic specimen & Histology for orthopedic students

1. MS, DNB, MNAMS
ASSISTANT PROFESSOR
MAMC & SUSHRUTA TRAUMA CENTER
NEW DELHI

2. DESCRIBING GROSS SPECIMEN
A: Identify the part:
 Knee / prox. femur/ prox. tibia/ pelvis /scapula.
 Epiphyseal / Metaphyseal / Diaphyseal.
 Physeal plate visible? – Immature pt.

3. B:Describe the abnormality:
 Nature: solid / soft & friable /cystic / varigated
 Matrix: bony / cartilaginous / fibrous
 Secondary changes: central necrosis/ hemorrhage
/ cystic change
 Cortical destruction, periosteal elevation
 Intramedullary spread
 Tumor margin / capsule: well defined / illdefined
 Extension: into soft tissue / joint; invasion /
infiltration to surrounding tissue

5. C: Give provisional diagnosis.

6. GIANT CELL TUMOR
 Age: 20-40.
 Epiphyseometaphyseal in adults -
Metaphyseal in adolescents.
 Common location: around knee (50%),
distal radius
 Xray: Geographic lytic lesion, thinned &
ballooned out cortex.
Gross pathology:
 Large red - grey - brown tumor
 Soft & friable
 Areas of cystic degeneration / necrosis &
blood filled cavities

7. HISTOPATHOLOGY:
•Uniform oval mononuclear stromal
cells : mesenchymal origin; neoplastic
•Appear to grow in a syncytium
•Numerous osteoclast-type giant
cells: reactive
•Necrosis, hemorrhage, hemosiderin
deposition and reactive bone
formation
•Relatively few mitotic figures in
relation to the dense cellularity of the
tumor

8. GIANT CELL VARIANTS
Includes the tumors which show giant cells in histology-
 A. ABC
 B. Brown tumor
 C. Chondromyxoid fibroma, chondroblastoma
 D. Desmoplastic fibroma
 E. Epulis – Giant cell reparative granuloma
 F. Fibrous dysplasia, non ossifying fibroma
 G. Giant cell rich osteosarcoma
 H. Benign fibrous histiocytoma

9. Giant cell……
Physiological: Megakaryocyte
Pathological
 Langhans : fused epitheliod cells. Peripherally arranged 7-21 nuclei. TB,
histoplasmosis, sarcoidosis, other mycobacteria
 Foreign body: fused macrophages. Numerous nuclei scattered in
cytoplasm
 Aschoff : Rheumatic heart disease
 Reed Sternberg: Hodgkin’s lymphoma
 Touton : xanthoma, xanthogranuloma, dematofibroma
 Viral: Warthin Finkeldy (measles), resp syncitial virus, parainfluenza
 Tumor

10. OSTEOSARCOMA
 Bimodal age distribution: Primary 10-20, secondary 50-70.
 75% around knee
 Bone forming tumor arising from bone
 Several subtypes –
 By location (Central or Juxtacortical)
 Multicentricity
 Degree of differentiation: well to dedifferentiated
 Histologic variance:
osteoblastic/chondroblastic/fibroblastic/telangictatic/small cell
 Associated with Retinoblastoma (rb gene), Li Fraumeni
syndrome (p53 gene), Rothmund Thomsen syndrome.

11. GROSS PATHOLOGY:
 Metaphyseal
 Tan-white solid tumor fills
most of the medullary cavity
of the metaphysis and
proximal diaphysis
 Expanding & infiltrating
through the cortex, lifts the
periosteum (Codman’s
triangle) and forms soft tissue
masses on the side of the bone
 Areas of hemorrhage and
central necrosis.

12. HISTOPATHOLOGY:
 Pleomorphic and anaplastic cell
population- large hyperchromatic
nuclei, mitotic figures
 Abundant fibrous/ chondroid
matrix
 Formation of pink homogenous
osteoid by neoplastic cell:
characteristic.
 The neoplastic bone has a coarse,
lacelike architecture but is also
deposited in broad sheets or as
primitive trabeculae.
 Osteoblastic, chondroblastic or
fibroblastic types
 Osteoclast-like giant cells may
be present

13. CHONDROSARCOMA
 Age: 30-60
 Primary or Secondary ( Enchondromatosis [Ollier 50%,
Maffucci 100%], diaphyseal aclasis 20%, osteochondroma 0.25%)
 Pelvis (30%), Femur (20%)
 Types: Conventional, mesenchymal, clear cell,
juxtacotical, dedifferentiated
 Most common malignant bone tumor of hand

14. GROSS PATHOLOGY:
 Large bulky tumor
 Made up of lobules of gray-white
/somewhat translucent glistening tissue.
 Tumor permeating throughout the
medullary cavity, growing through the
cortex, and forming a relatively well-
circumscribed soft tissue mass.
 At center – necrotic/liquefied/cystic.
Gelatinous appearance secondary to
myxoid changes in matrix.
 May show calcification.
 The adjacent cortex is thickened or
eroded, and the tumor grows with broad
pushing fronts into the surrounding soft
tissue.

15. HISTOPATHOLOGY:
• Tumor cells produce
cartilaginous matrix; well,
moderate or poorly
differentiated.
• May have only minor or
focal atypia
• Intracytoplasmic hyaline
globules common in low
grade tumors

16. EWING’S SARCOMA
James Ewing 1921
GROSS PATHOLOGY:
 Diaphyseal in long bones;
also pelvis, rib, scapula
 White tan grey mass like
brain; or red like red currant
gelly if hemorrhagic
 With necrosis & hemorrhage
 Cortical destruction
 Invasion to soft tissue
around, no capsule

17. HISTOPATHOLOGY:
• Homogenous & densly
packed undifferentiated
small round blue cells like
lymphocytes; regular nuclei,
infrequent mitoses, scant
clear cytoplasm.
• Abundant glycogen: PAS +
diastase digestible
• Rare Homer- Wright
pseudorosettes (7-8 tumor
cells arranged in a circle
about a central fibrillary
space)

18. D/D : Small Round Cell Tumor
 Ewing’s: mic2 overexpression - CD99/013 . t(11;22)(EWS-FLI-1). NSE +
 PNET (Primitive neuroectodermal tumor): CD99/013. S100,
chromogranin, synaptophysin; > 20% Homer Wright rosettes
 Lymphoma (reticulum cell sarcoma, NHL): CD 45, LCA
 Small cell carcinoma: keratin, synaptophysin, chromogranin
 Mesenchymal chondrosarcoma
 Neuroblastoma: neurofilament. S100, chromogranin, synaptophysin.
 Alveolar rhabdomyosarcoma: actin, desmin, vimentin, MyoD1,
myogenin
 Leukemia

19. OSTEOCHONDROMA
GROSS PATHOLOGY:
 Mushroom shaped
 Cartilage-capped bony outgrowth
 Cartilage cap usually regular and
thin
 Sessile / Pedunculated
 Pedunculated : attached to skeleton
by bony stalk; medullary cavity of
the osteochondroma and bone are
in continuity
 Diaphyseal aclasis: multiple
heriditary exostosis
 Trevor’s disease: Epiphyseal side
osteochondroma

21. Painful osteochondroma:
 Fracture
 Bursitis
 Malignant transformation: fluffy calcification in the
cartilage cap, thickness of cartilage cap > 1 cm.

22. CHRONIC OSTEOMYELITIS
 Sequestrum is the necrotic
bone that is embedded in the
pus/infected granulation
tissue.
 Involucrum is the new bone
laid down by the periosteum
that surrounds the sequestra.
 Cloaca is the opening in the
involucrum through which
pus & sequestra make their
way out.

23. Types of sequestrum…..
 Tubular: long bone
 Annular: amputation stump
 Ring: around pin tracts
 Flake, coke, rice grain: tubercular
 Button: histiocytosis
 Feathery: syphilis
 Match stick: sickle cell
 Coloured: fungal
 Black: gun shot
 Bombay: exposed bone after open fracture

24. TUBERCULAR SPONDYLITIS (POTT’S)
SPINE
 Paradiscal
 Loss of height
of vertebra
 Caseating
necrotic tissue
 Bone necrosis;
sequestra
 Sclerosis

25.  Kyphotic deformity
 Internal gibbus
 Severe cord compression

26. Granuloma or LH giant cell is not
pathagnomonic of TB…!
• Foreign body granuloma.
• Fat necrosis.
• Fungal infections.
• Sarcoidosis.
• Crohns disease.

27. MADURA FOOT
 Foot looks like tumor  Multiple circumscribed abcesses;
extensive granulation tissue around.
 Multiple nodules & sinus  Bone destruction

28. • Granulomatous fungal disease; involve subcutaneous tissue
after traumatic inoculation; later spread to deep structures.
• Causes local tissue destruction including bone
Types:
• Actinmycetoma: Actinomadura sps, Nocardia
• Eumycetoma: Aspergillus sps,
• Discharge colored granules: Red (Actinomadura pelletieri),
white / yellow (Actinomadura madurae, Pseudoallescheria
boydii), black (Exophiala jeanselmei, Madurella mycematis)
• Pus contains sulfur granules, a tangled mass of branching
bacteria (Splendore Hoppelli body)