Bone Neoplasms

What is the cell of origin of osteoma (benign)

Osteocyte

What are the categories of neoplasms?

Benign and malignant

Name the benign bone neoplasms

• Osteoma

• Osteoblastoma

• Cementoblastoma

Name the malignant bone neoplasms

• Osteosarcoma

• Chondrosarcoma

• Ewing sarcoma

What is the cell of origin of osteoblastoma?

Osteoblast

What is the cell of origin of cementoblastoma?

Cementoblast

What is the cell of origin of osteosarcoma?

Osteoblast

What is the cell of origin of Chondrosarcoma?

Chondroblast

What is the cell of origin of Ewing sarcoma?

Under debate; primitive neuroectodermal cells

What is an osteoma?

A benign bone tumor that continues to grow (vs. exostosis)

What are characteristics of osteoma?

Primarily involve the craniofacial skeleton such as paranasal sinuses

In which population would you find osteoma?

Young adults as asymptomatic, solitary lesions

If you have multiple osteoma, what is that called?

Gardner syndrome

Where would you find osteoma?

Mandibular body is most common but it can be found anywhere

What is the treatment of osteoma?

None if small and asymptomatic, conservative surgical excision for large and symptomatic

Which of the following is correct for osteoma?

Typically small, slow-growing and found in the skull

All of the following are part of Gardner syndrome EXCEPT

Cafe au lait spots

Pano of osteoma

Well circumscribed radiopaque lesion

Radiographic image of osteoma

What is the mode of transmission for Gardner Syndrome?

Autosomal dominant; mutation chromosome #5 (APC)

What are the clinical features of Gardner Syndrome

• Colorectal (adenoma) polyps which can become malignant (100% if not treated)

• Multiple osteoma

• Epidermoid cyst of skin

• 20% have supernumerary teeth

• Thyroid carcinoma

• Pigmented ocular fundus (90%)

• Prognosis: guarded, close follow up

Epidermoid cyst of skin seen in

Gardner Syndrome

Epidermoid cyst of skin

(Back)

Colorectal Polyps seen in Gardner Syndrome

Pano of patient with gardner syndrome

Pano of patient with Gardner Syndrome has supernumerary teeth

Seen in 20% of patients and cleidocranial dysplasia (more common)

What is an osteoblastoma?

A benign bone tumor that arises from osteoblasts and is rare

What is the difference between an osteoid osteoma and osteoblastoma?

• Osteoid osteoma is SMALLER than 2 cm, nocturnal and relieved by aspirin

• Osteoblastoma is LARGER 2-4 cm and not relieved by aspirin, pain and swelling

In which demographic would you find osteoblastoma?

85% occur before age 30

Where would you find osteoblastoma?

Mostly in the posterior region over the anterior; and in the mandibular than the maxilla

What is the treatment for osteoblastoma?

Surgical excision

What would you look for radiographically in osteoblastoma?

Well-defined or ill-defined radiopaque lesion (can be mixed RO and RL)

Which of the following statements about osteoblastoma is FALSE

Relieved by aspirin

What is cementoblastoma

A benign odontogenic neoplasm of cementoblasts

In which demographic would you see cementoblastoma?

• 75% occur before the age of 30

• Pain and swelling are present in 2/3

Where would you find cementoblastoma?

• 75% arise in the mandible, almost always in the molar/premolar region

• Typically, only affect permanent teeth (especially 1st mandibular molars)

What are the radiographic features of cementoblastoma?

• Radiopaque mass that is fused to one or more tooth roots

• Outline of the root or roots is usually obscured

• Surrounded by a thin radiolucent rim

What is the treatment of cementoblastoma?

• Surgical extraction of the tooth and calcified mass

• Recurrence is 20%

Which of the following is INCORRECT for cementoblastoma?

Radiolucent mass

What is ossifying fibroma?

A true bone neoplasm with significant growth potential composed of fibrous tissue that contains a variable mixture of bone & cementum (central vs. peripheral)

—> Large tumors result in painless swelling

Where would you find ossifying fibroma?

Mandible > maxilla

What would you find radiographically in ossifying fibroma?

• Well-defined, unilocular

• Can be completely radiolucent, or more commonly mixed RL-RO

• Depends on amount of calcified material

• Root divergence or resorption of roots can occur

• Characteristic downward bowing of the inferior cortex of the mandible

Histological image of ossifying fibroma

What is osteosarcoma?

A malignant bone neoplasm; there are two kinds: primary, and secondary such as Paget disease or radiation

In which demographic would you find osteosarcoma

• M > F

• Bimodal age distribution

  • Between 10-20 (more common)

  • After 50

Where might you find osteosarcoma?

• Distal femur and proximal tibia

• Jaws 8% of all osteosarcomas, occur at a later age (30s)

• Max = Mand (posterior)

Clinical features of osteosarcoma

Swelling and pain, paraesthesia, loosening of teeth

What is the treatment of osteosarcoma?

Surgery and chemotherapy

What are some radiographic features of osteosarcoma?

• May be RO, RL or mixed

• Ill-defined (MOTH EATEN) peripheral borders

• Spiking resorption causing tapered roots

• Codman’s triangle

• Sunburst appearance (25%)

What is codman’s triangle?

Triangular elevation of periosteum

In which condition do you see Codman’s triangle

Osteosarcoma

Which radiograph will be able to best show osteosarcoma?

A sunburst appearance (d/t bony projections on the surface of the lesion) would be best appreciated using an occlusal x-ray

What is an important early finding of osteosarcoma?

Symmetrical widening of PDL space around one or more teeth

Which of the following radiographic features is NOT typically associated with osteosarcoma?

Radiolucent halo rim

What is this pano showing?

Expansion, subtle sunburst appearance, spiking resorption of 1st molar; seen in osteosarcoma

What is this PA showing?

Widening of PDL seen in osteosarcoma

What is this PA showing?

Calcification filling the sinus, widened PDL, spiked appearance of roots seen in osteosarcoma

What is this PA showing?

Osteosarcoma resembling focal cemento-osseous dysplasia

What is this image showing?

Bone destruction seen in osteosarcoma - cortical plate is destroyed

What are some benign features of osteosarcoma?

• Uninterrupted

• Solid

• Continuous

What are some malignant features of osteosarcoma?

• Interrupted

• Onion skin

• Sunburst (sun ray)

• Codman’s

What is chondrosarcoma

A malignant bone tumor of cartilage

What is the most common location of chondrosarcoma?

Long bones (3% arise in the head and neck)

What are some clinical features of chondrosarcoma?

• Painless mass or swelling of jaw is most common

• Extensive infiltration, poorly defined borders, RL and RO varies

• ± root resorption

• Symmetrical PDL widening

What is the treatment of chondrosarcoma?

Complete resection (resistant to chemo and radiation)

What is this image showing?

Huge expansion and swelling in left mandible area seen in chondrosarcoma

What is this radiograph showing

Mixed radiolucent and radiopaque lesion seen in chondrosarcoma; lacks a well-defined border

What is ewing sarcoma?

A primary malignant tumor of bone, it is highly lethal and known to metastasize (it is the 3rd most common osseous neoplasm)

What gender does ewing sarcoma affect the most?

White male, 80% less than 20 years old

Where would you find ewing sarcoma?

Long bones, jaws are only involved 2% mand > max

What are some clinical features of ewing sarcoma?

• Intermittent pain

• Swelling

• Loosening of teeth

What are some radiographic features of ewing sarcoma?

• Irregular defined borders (moth eaten)

• Onion skin periosteal reaction like “Garre’s osteomyelitis”

• Sunray appearance “like osteosarcoma”

What is the treatment for ewing sarcoma?

Combined surgery, chemo, and radiation

What is Post Radiation Bone Sarcoma?

Sarcoma arising in a bone that has been previously subjected to radiation therapy and is a well-recognized phenomenon

What is the most common type of post radiation bone sarcoma?

Osteosarcoma (50%)

When do post radiation bone sarcoma develop?

Postirration sarcomas may develop 3 years after radiation, but the average is 15 years after therapy

What is metastatic disease?

It is more common of a carcinoma than a sarcoma

What is the difference between carcinoma and sarcoma?

• Sarcoma = origin is mesenchymal stem cells (bone, cartilage, adipose tissue, fat, skeletal muscle, smooth muscle)

• Carcinoma = origin of the epithelium (most common is squamous cell carcinoma)

If metastatic disease does occur, where will it be?

• 2/3 are in bone (80% mandible > maxilla)

• 1/3 in soft tissue (most commonly gingiva)

Common origin of gnathic metastasis:

1. Breast

2. Lung

3. Thyroid

4. Prostate

5. Kidney

What are some common symptoms of metastatic disease?

• Pain

• Swelling

• Loosening of teeth

• Paresthesia (numb chin)

What is this

Metastatic nasopharyngeal carcinoma

What is this?

Widening of PDL and ill-defined RL seen in metastatic disease

What is this?

Metastatic small cell carcinoma of the lung

What is this?

Periapical granuloma (not to be confused with metastatic small cell carcinoma of the lung)

Which of the following statements about metastatic disease to the head and neck is FALSE?

Most common location is gingiva

What is focal osteoporotic bone marrow defect?

Area of hematopoietic marrow that produces a radiolucency

What is the cause of focal osteoporotic bone marrow defect?

Unknown, incidental finding

What is the incidence of focal osteoporotic bone marrow defect?

75% in adult women, typically in posterior mandible

What can focal osteoporotic bone marrow defect be confused with?

Intraosseous neoplasm

What are some clinical features of focal osteoporotic bone marrow defect?

• No jaw expansion

• It is NOT pathology, but the x-ray features may look like it

• Multilocular radiolucency

• May minic botryoid cyst, OKC, ameloblastoma

What is the treatment for focal osteoporotic bone marrow defect?

None, bx to rule out pathology

What is idiopathic osteosclerosis?

Focal area of increased radiodensity that is of unknown cause and cannot be attributed to anything else

Where might you find idiopathic osteosclerosis?

90% in the mandible (molar/premolar) and the tooth is VITAL

What are some clinical and radiographic features of idiopathic osteosclerosis?

• No decay or pulpal involvement, tooth is sound

• Sometimes associated with a tooth

• Asymptomatic

• No cortical expansion

• Radiolucent lesion, no radiolucent rim

What is the treatment for idiopathic osteosclerosis?

Follow-up

What is this?

Idiopathic osteosclerosis after 10 years follow-up

What should be included in your differential diagnosis for idiopathic osteosclerosis?

• Condensing osteitis, which is associated with decay or pulpal involvement (infection)

• Focal cemento-osseous dysplasia, which can have a radiolucent rim + clinical features (gender, age, location)

• Do not confuse with cementoblastoma, which will be fused with the tooth and have a radiolucent halo

Radiographic example of idiopathic osteosclerosis

Tooth is sound; bone scar enostosis

Radiographic example of condensing osteitis

Focal (chronic) sclerosing osteomyelitis —> large restoration, caries, and infection