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Bone & Soft Tissue Pathology
Monday, February 28, 2005 - 7:30 PM
Convention Center, Bridge Hall
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Moderator:
Antonio Nascimento
Mayo Clinic
Rochester, MN
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Submitted by:
Cristina R. Antonescu
Memorial Sloan-Kettering Cancer Center
New York, NY
A 36-year old man presented with right thigh pain and swelling. A resection of the mass was
performed.
Case 1 - Figure 1 - MRI showing a large lobulated mass with a high signal on T2-weighted images, located in the right vastus lateralis muscle
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Case 1 - Figure 2 - Gross appearance of the resection specimen showing a 9 cm multinodular mass, with a yellow-tan fleshy cut surface
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Case 1 - Figure 3 - Low power microscopic appearance of the lesion shows a macronodular growth of tightly packed uniform spindle cells
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Case 1 - Figure 4 - High power illustrates compacted fusiform cells with ill-defined cell borders, eosinophilic cytoplasm and hyperchromatic, elongated nuclei
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Submitted by:
Michael J. Klein
University of Alabama Medical Center
Birmingham, AL
A seventeen year old male presented with a three month history of increasing thigh and knee pain. The
pain was localized to his medial thigh and knee and was felt both at rest and during exercise. It
interfered significantly with his daily activities of living.
Physical examination revealed an area of tenderness and a sensation of fullness in his medial knee.
There was some stiffness in the joint and slight limitation in flexion.
Following clinical imaging studies, he was taken to the operating room where he underwent open biopsy
followed by a second procedure six days later.
Case 2 - Figure 1 - Lateral and AP conventional radiographs demonstrate an ovoid, fairly defined lesion just cephalad to the medial femoral condyle. The lesion is more radiolucent in the middle than at the extremes imparting a somewhat beveled appearance. The AP view suggests that the cortex is focally interrupted medially and that there is an ill-defined soft tissue density outside of the cortex. There is an ovoid, smaller lesion medially with scalloped, sclerotic borders abutting the lateral femoral cortex in the metadiaphyseal region of the femur. In the lateral view, the lesions are superimposed and the scalloped, sclerotic edge of the lateral lesion is more easily seen. In addition, there is slight bulging of the cortex posteriorly
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Case 2 - Figure 2 - A fat-suppressed coronal MRI demonstrates that the larger, medial lesion demostrates a mixed signal intensity. Although there is a relatively circumscribed outer edge with low signal, there is a radial high signal surrounding this edge, which may be lesional or edema. The medial edge of the lesion extends through the cortex into a mixed signal soft tissue mass which elevates the periosteum. The second lesion on the lateral side is multilocular and has a circumscribed low signal intensity.. The second coronal view on the left demonstrates the soft tissue mass and emphasizes the high signal about the lesion which extends into the end of the bone
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Case 2 - Figure 3 - Two axial fat suppressed T2 weighted views of the distal femur reveal fluid levels in the soft tissue and intraosseous components of the medial lesion and a hypointense signal in the lateral lesion
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Case 2 - Figure 4 - Four photomicrographs taken from the curettage at first operation demonstrate a lesion characterized by a very vascular spindle cell and giant cell containing solid tissue (lower left) in which there is a progression from very small complete vessels to partially complete large sinusoids containing blood in their lumens and in their walls (upper left and upper right). In addition, there is bone formation of the periosteal type appreciated at low power outside of the vascular tissue (upper right) as well as bone formation in the walls of the sinusoids (lower right)
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Case 2 - Figure 5 - Four additional photomicrographs demonstrate solid areas in which giant cells and vascular tissue can just be appreciated (upper left) and, at higher magnification, the relatively even distribution of the giant cells in the solid areas (lower left) and the hypervascularity of the solid tissue bordering a sinusoid (lower right). The photograph at the upper right, though taken at low power, demonstrates bone formation of reactive type which is partly decalcified (center left) and on the right, more microtrabecular with hemorrhage and background hypercellularity. While the previous seven photographs were typical findings of aneurismal bone cyst, this area looks different at low magnification
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Case 2 - Figure 6 - Higher magnification compares solid area of aneurismal bone cyst (lower half) with an area showing more microtrabecular bone with hypercelluarity seen in the last slide (top). Note that this bone is surrounded by appositional nuclei, which represent osteoblasts. In the right photograph, the field is entirely represented by osteoblastic, hypervascular tissue
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Case 2 - Figure 7 - On the left is a wedge-shaped curetted fragment of purely osteoblastic tissue with small fragments of ABC. On the right, at high magnification is typical osteoblastoma composed of microtrabeculae surrounded by cells having the characteristics of osteoblasts. A few osteoclast like giant cells are present
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Case 2 - Figure 8 - Last photograph at high magnification compares the features of the aneurismal bone cyst component, with an admixture of vessels, spindle cells and multinucleated giant cells (left) with that of osteoblastoma, showing trabecular bone/osteoid surrounded by pear-shaped osteoblasts and multinucleated giant cells (left)
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Submitted by:
Andrew L. Folpe
Emory University Hospital
Atlanta, GA
A 55-year-old man presented with a slowly growing, 8cm, right lower leg and ankle mass.
Case 3 - Figure 1 - Very low power view (2X) showing an extensively myxoid spindle cell proliferation, with diffuse infiltration of fat and focal cellular nodules
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Case 3 - Figure 2 - Low power view (4x) illustrating the admixture of hypocellular myxoid zones and more cellular regions. An unusual damaged blood vessel is also present
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Case 3 - Figure 3 - Medium power view (10X) of a myxoid zone, showing abundant myxoid matrix, small, darkly staining spindled cells and wiry collagen
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Case 3 - Figure 4 - Another medium power view, showing the myxoid matrix, spindled cells and small aggregates of capillaries
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Case 3 - Figure 5 - Medium high power view (20X) showing small, generally uniform, darkly staining spindled cells
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Case 3 - Figure 6 - Medium high power view showing the transition from a myxoid zone (right) into a more cellular zone (left). A small vessel with intramural fibrin deposition is present, as are other aggregates of small blood vessels
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Case 3 - Figure 7 - High power view (440X) showing striking, finely granular hemosiderin deposition in many of the neoplastic cells. Scattered larger cells with intranuclear inclusions are also present
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Case 3 - Figure 8 - Another high power view of the hemosiderin-laden cells, some with intranuclear inclusions. Note that the hemosiderin is in the neoplastic cells themselves, rather than in macrophages
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Case 3 - Figure 9 - Medium high power (20X) view of an aggregate of ectatic, damaged blood vessels with prominent fibrin deposition, thrombosis and recanalization
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Submitted by:
Pancras C. W. Hogendoorn
Leiden University Medical Center
Leiden, Netherlands
A 29-YOF presents with pain in the lower back, extending into the right leg. There is neither a
relation of the pain with coughing nor with position of the vertebral column. Medical and family history
are unremarkable. Neurovascular no abnormalities. Normal routine blood laboratory findings. The
physical examination showed no swelling palpable; pain upon deep palpation of the dorsal back at the
right sacro-iliac area. Bone scan shows a solitary lesion of the right ilium wing with only minimal-mild
activity.
Case 4 - Figure 1 - Plain X ray showing in the cranial right iliac wing a lobulated lytic lesion with sclerotic margins with dimensions of 4 x 3 cm
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Case 4 - Figure 2 - Enlarged plain X ray 4 months later showing essentially the same morphology of the lesion
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Case 4 - Figure 3 - T1 weighted MR image showing the lesion with intermediate signal intensity comparable to the surrounding muscles. The lesion is sharply demarcated. No surrounding oedema
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Case 4 - Figure 4 - T2 weighted MR image showing homogeneous high signal and subtle expansion
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Case 4 - Figure 5 - T1 weighted MR image showing the lesion with intermediate signal intensity and sharp margins in another plain
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Case 4 - Figure 6 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 7 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 8 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 9 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 10 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 11 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Case 4 - Figure 12 - H&E stained sections of open biopsy specimen showing the morphology of the lesion in different areas and at different magnifications
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Submitted by:
Angelo Paolo Dei Tos
Regional Hospital
Treviso, Italy
47 year old male with mass in ileum.
Case 5 - Figure 1 - Section of small bowel (ileum) showing a submucosal, well-circumbscribed, mass
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Case 5 - Figure 2 - The neoplasm is composed of a monomorphous spindle cell proliferation
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Case 5 - Figure 3 - Focally, a hemangiopericytoma-like vascular pattern is observed
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Case 5 - Figure 4 - In some areas the presence of eosinophilic intercellular collagen becomes evident
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Submitted by:
A. Kevin Raymond
MD Anderson Cancer Center
Houston, TX
A 53-year old man presented with a 3-month history of numbness and tingling involving the left
maxillary gingival. He also indicates that he has a sense of "prominent tissue" over the left palate."
Imaging studies show a mixed lytic/blastic lesions involving the left maxilla. His medical history is
significant for nasopharyngeal carcinoma treated some 25 years ago by radiation therapy.
Case 6 - Figure 1 - Imaging: CT-scan. There is a largely radio-opaque lesion involving the left maxilla. Tumor appears to arise from the posterior aspect of the maxilla and largely fills the posterior aspect of the maxillary sinus. Tumor invades both the medial and lateral walls, with extension into overlying connective tissues
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Case 6 - Figure 2 - Imaging: CT-scan. There is a largely radio-opaque lesion involving the left maxilla. Tumor appears to arise from the posterior aspect of the maxilla and largely fills the posterior aspect of the maxillary sinus. Tumor invades both the medial and lateral walls, with extension into overlying connective tissues
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Case 6 - Figure 3 - Imaging: CT-scan. The orbit appears free of tumor
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