OSTEOID OSTEOMA. DEFINITION lt is a benign tumor, which is always small in size and painful, often dia- physeal. It is constituted by osteoid tissue and ...
OSTEOID OSTEOMA DEFINITION
lt is a benign tumor, which is always small in size and painful, often diaphyseal. It is constituted by osteoid tissue and surrounded by a halo of reactive hyperostosis. FREQUENCY
0.0. occurs relatively frequently. Among benign tumors of the skeleton it is preceded only by exostosis and histiocytic fibroma (Fig; 286).
SEX There is predilection for the male sex, at a ratio of 2:1 (Fig. 286). AGE
The tumor is typical of late childhoood, adolescence and young adult age. It is rarely observed before 5 years of age and after 30 (Fig. 286).
34
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4 4 3
4
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D-10 11·20 21-30 31-40 41·50 51·60 61·70 7HIO
FIG.
286. - Sex, age and site in 448 cases of osteoid osteoma.
M. Campanacci et al., Bone and Soft Tissue Tumors © Springer-Verlag Wien 1990
5
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OSTEOID OSTEOMA
LOCALIZATION
The most frequent localization is in the lang bones: femur, tibia, humerus, in that order. It may occur in the diaphyseal shaft or towards the metaphysis, with considerable predilection for the proximal femur (neck and intertrochanteric region). lt is observed in the short bones, particularly in the tarsus (where it prefers the talus), often in the vertebral column (where there is preference for the lumbar tract over the cervical one, and it is nearly exclusively localized in the FIG. 287.- Diaphyseal osteoid osteoma in a posterior arch in the area of the pedgirl aged 11 years. icle), in the metacarpals, metatarsals, and phalanges. lt rarely occurs in the flat bones, or in the epiphysis (Fig. 301b), and it is unknown in bones of membranaus origin (cranium and clavicle).
SYMPTOMS
Pain is an almost constant and permanent symptom, and nearly the only one. Pain is of variable intensity, usually enough to require the use of analgesics. lt is independent of function, nearly continuous but more intense during the night. Pain is often exacerbated when alcoholic beverages are drunk (vasodilation) and it is elicited by local pressure. Rather characteristic is the fact that pain is mitigated or regresses totally with aspirin. Pain is not always well-localized, which may lead to the attribution of symptoms to the nearby joint or to a radicular or nervaus irradiation, for example sciatica. 0 .0 . is suspected in the vertebral column when a patient aged under 30 years complains of constant back pain, when there is marked vertebral stiffness and muscular contraction, scoliotic deviation, positive Lasegue, with no signs of nerve root compression. When 0.0. is localized in a diaphysis, a slight fusiform prominence may be palpated, corresponding to the · hyperostosis, covered by normal skin. Same 0.0. of the lang bones, occurring during childhood, cause some considerable lengthening of the hone. The duration of symptoms at surgery usually ranges from a few months to two years or so.
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357
FIG. 288. - Osteoid osteoma in a hoy aged 19 years. Pain for the past 14 months. (a) and (h) CAT revealed intracortical osteoid osteoma (to the left). To the right there was a small osteolytic Iacuna of the cortex which corresponded to the foramen for the nutrient vessels. (c) and (d) Pre- and postoperative radiograms. The minimal Ioss of hone suhstance is ohserved, which was filled with the cortical hone chips removed to expose the osteoid osteoma. This method does not weaken the hone and functional recovery may be immediate. The patient is cured after 3 years.
RADIOGRAPHIC FEATURES
Generally, the radiographic picture is very characteristic. The basic element is a small or very small rounded area of osteolysis («nidus»), the diameter of which hardly ever exceeds 1 centimeter, surrounded by a regular halo of hyperostosis. Within the nidus there may be a central and irregular nucleus of bony opacity. This picture may change considerably, depending on
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FIG. 289. - Osteoidosteoma in a boy aged 15 years. Pain for the past year and a half. (a), (b) and (c) Typical aspect of intracortical osteoid osteoma. CAT showed the nidus which was nearly the same size as the medullary canal and which was covered with a thick layer of sclerosing periosteal reaction. (d) The osteoid osteoma was removed. Only the layer of reactive bone coating it was slivered out, until the nidus appeared. This was evident because of its reddish color against the white of the surrounding bone. Functional recovery and healing occurred immediately (follow-up 2 years).
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359
c FIG. 290.- Osteoidosteoma in a female aged 16 years. Pain for the past 3 months. Two and 1/2 years earlier the patient had been submitted to surgery with temporary regression of pain. On histological examination there had been no trace of osteoid osteoma. (a), (b) and (c). Typical aspect of intracortical osteoid osteoma. The nidus was visualized and excised with minimal hone removal. Immediate functional recovery and healing (follow-up at 2 years).
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FIG. 292. - (a) Diaphyseal osteoid osteoma in a girl aged 12 years. (b) Voluminous metaphyseal osteoid osteoma in a boy aged 11 years.
FIG. 291.- Diaphyseal osteoid osteoma in a female aged 15 years.
293. - Voluminous metadiaphyseal and para-
FIG.
articular osteoid osteoma
of the fibula in a boy aged 12 years.
the site of the tumor and on its stage of progression (Figs. 287-305). In cortical diaphyseallocalizations there is fusiform thickening of a single side of the shaft, with clean and regular surfaces, and compact and intense radiopacity. The osteolytic area of 0.0. is located at the center of this thickening, generally totally contained within the primary cortex, at times oriented towards its endosteal surface, more rarely towards its external one, but
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361
FJG. 294. -Osteoid osteoma in a female aged 10 years. For the past 6 months constant pain, especially at night. (a) and (h) Typical aspect of osteoid osteoma with tomography and hone scan. (c) CAT revealed the intracortical localization of the osteoid osteoma and indicated the surgical approach (anterior). CAT also showed reactive hyperostosis with a wrinkly surface. (d) After surgery, which consisted in removing the hone layer covering the osteoma and thus curetting the nidus, the loss of hone suhstance was minimal. The patient was able to move her hip and hear weight after a few days.
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295.- Osteoidosteoma in a boy aged 13 years, Operated 8 months earlier, with no regression of pain. Surgery had been performed through a lateral approach, and the patient wore a spica cast for 5 months. (a) and (b) Radiogram and CAT showed the typical nidus and reactive capsular ossifications due to the previous operation. CAT showed the posterior localization of the osteoid osteoma which indicated a posterior surgical approach. This approach was used visualizing and curetting the nidus. Immediate functional recovery and healing (follow-up at 3 years). FIG.
always surrounded by the reactive hyperostosis. At times bony reaction is so thick and eburneous that the small nidus cannot be seen except with CAT (Fig. 288). When the tumor is localized in cancellous bone (for example, the femoral
FIG.
296. - (a) Osteoidosteoma of the femoral neck in a girl aged 5 years. (b) The same
case 2 years later.
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363
FIG. 297. - Osteoid osteoma of the 5th thoracic vertebra in a male aged 15 years. Typical aspect on radiographs (a) and hone scan (b). The nidus was contained in the vertebral lamina. The patient was cured after 2 years.
neck, the vertebrae, the bones of the tarsus), the halo of osteosclerosis may be very scarce (Figs. 293, 297); at times diffused and even intense osteoporosis may be associated (Figs. 249, 250a). In cases such as these, if the 0.0. is small, it may be very difficult to reveal on radiographs, and hone scan and CAT are required. In these same sites 0.0. is often nested at the surface of the
FIG. 298. -Osteoid osteoma of the 4th lumbar vertebra in a female aged 18 year. For the past year lumbar pain and for the past 6 months crural pain. (a) and (b) Typical aspect on radiographs and CAT. Localization in the vertebral body is quite rare. The osteoma was excised by extraperitoneal anterior approach. Healed at 3-year follow-up.
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FIG. 299.- (a) Osteoidosteoma of the calcaneus in a female aged 18 years. (b) Osteoid osteoma of the talus in a boy aged 9 years. Observe the intense diffused regional osteoporosis.
FIG. 300. - (a) Superficial osteoid osteoma of the talus in a Fernale aged 14 years. Observe the diffused regional osteoporosis. (b) Osteoid osteoma of the talus which is completely external and lying on the surface of the hone in a female aged 15 years.
hone and appears to be a small niche of the cortex, or a rounded formation with a radiopaque central nucleus, protruding from the hone (Fig. 300). In vertebrallocalizations of the tumor, there is usually a uniform and faded increase in opacity in the pedicular or isthmic area, caused by the reactive osteosclerosis, with little evidence of the nidus. At times, radiograms are nearly totally negative, as 0.0. is nested at the surface of an area in the vertebral arch. Rarely, 0.0. is contained in the vertebral body (Fig. 298). 1t usually causes scoliosis due to anthalgic contraction, which is always concave on the side where the 0.0. is located. Arteriography may demonstrate the rieb vascularity of 0.0. (particularly in the small bones and/or in the cancellous hone). By subtracting the image, which eliminates the radiopacity of the hone and preserves that of the cantrast medium, it is possible to visualize an 0.0. which is invisible on standard radiograms (Fig. 303).
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FIG. 301. - (a) Osteoid osteoma of the patella in a female aged 15 years. (b) Epiphyseal osteoid osteoma (distal tibia) in a male aged 22 years. (c) Osteoid osteoma of the mandible in a female aged 17 years. (d) Osteoid osteoma of the scapula in a female aged 14 years.
But essential tests for diagnosis are bone scan and CAT. Bone scan reveals a rounded area of intense hypercaptation, resemhling a «headlight in the fog» (Figs. 290, 294, 297). If hone scan is negative, diagnosis of 0.0. may he excluded. If it is positive, CAT is carried out, with a window for the hone, in the area of hypercaptation. CAT reveals the nidus and allows for accurate planning of surgery. There are rare cases in which the tumor hecomes of larger size ( 1-2 cm) although it has the same clinical, radiographic and histological features of 0.0. («giant osteoid osteoma»: Figs. 301c, 302b, 304, 305). GROSS PATHOLOGIC FEATURES
0.0. is a small roundish and hyperemic tumor, which is much softer than the surrounding hone, hut somewhat gritty. Its consistency increases in proportion to the degree of calcification of the central part of the nidus. When 0.0. is superficial and there is less reactive hyperostosis, as may he the case in areas of cancellous hone, it may protrude at the surface of the hone;
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FIG. 302. - (a) Diaphyseal osteoid osteoma in a girl aged 8 years, with pain for 1 and 1/2 years. (b) Giant osteoid osteoma of the sacrum in a female aged 15 years with pain for the past year and a half.
in the vertebral site it may thus irritate and compress a nerve root. When the tumor is intraosseous or covered by a sheath of hyperostosis, such as in the diaphysis, it is clearly visualized after removal of the covering hone, due to its reddish color, on the eburneous color of the surrounding hone (Fig. 306). Generally, 0.0. is easily enucleated from its skeletal bed (Fig. 306). The soft tissues and the synovial membrane, covering a superficial or intra-articular 0.0., are often thickened, hyperemic, edematous, the same as around a chronic inflammatory process.
FIG. 303. -Osteoid osteoma of the proximal metaphysis of the tibia in a male aged 16 years. The osteoid osteoma was hardly visible on standard radiograms, as there was hardly any osteosclerosis around the nidus. Arteriography and image subtraction revealed the osteoma on the surrounding hone, with its intense vascular injection.
OSTEOID OSTEOMA
FIG .
367
304. - Giant osteoid osteoma of the posterior arch of the fourth cervical vertebra in a female aged 15 years.
HISTOPATHOLOGIC FEATURES
Because of its small size, 0.0. is frequently observed whole, with the layer of skeletal wall containing it (Fig. 307). Thus, a packed and labyrinthlike whole ofthin and contorted osteoid trabeculae is observed, immersed in a rather cellular tissue, with histio-fibroblasts, osteoblasts, osteoclasts and numerous capillaries which are dilated and filled with blood (Figs. 308, 309). At times, sparse large cells, with giant and bizarre nuclei (cf. osteoblastoma), and rare mitotic figures are observed. The osteoid tissue is more mature at the center (the older part of the tumor) where the trabeculae merge in masses which are more compact, more calcified, poorer in cells. This thicker and more calcified center corresponds
FIG.
305 . - Giant osteoid osteoma in a male aged 47 years.
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OSTEOID OSTEOMA
to the radiopaque nucleus of the nidus (Figs. 307a, 309c, d). The border between the tumor and the surrounding hone is rather sharp (Fig. 307b). In the hone surrounding 0.0. there are aspects of hyperostosis, remodelling, and medullary fibrosis. There may be some light and scattered lymphocytic infiltrations. Similar aspects of hyperplasia and reactive phlogosis, which may even be intense, with marked hyperemia and pseudofollicular lymphocytary infiltrations, may be observed in the synovial membrane, when 0.0. is juxtaarticular, or in the soft tissues near the nidus. By staining the neurofibrillae, thin nerve endings, probably accompanying the vessels, have been shown in 0.0.
HISTOGENESIS AND PATHOGENESIS
The inflammatory nature of 0.0. is not Ionger asserted. It instead seems to be a benign tumor. Its smallness and close delimitation by the host hone do not oppose this interpretation. Isn't glomus tumor just as small? 0.0. produces an intense hyperostotic reaction in the host hone. This, too, may partially explain the limited growth of the tumor. FIG.
306.- Typical surgical finding of diaphyseal osteoid osteoma.
DIAGNOSIS
If one waits to see the characteristic radiographic picture of 0.0., in many cases diagnosiswill be delayed or even missed. The first suspect must be clinical: in a child or youth who complains of sharp, continuous pain, which is more intense at night, of long duration, and which is not influenced by any kind of treatment (except for temporary relief with aspirin), in a hip, a diaphysis, the spine, a foot, 0 .0. is suggested. Based on this suspect, radiography and hone scan are carried out; if hone scan is positive, CAT is obtained. These last two tests will reveal 0.0. even when radiography is negative or doubtful. These tests must never be omitted, not even when radiography seems tobe characteristic of 0.0., as they confirm diagnosis, and as CAT may be of aid to surgery. When clinical data, hone scan and CAT are typical for 0.0., diagnosis may be considered to be nearly certain, even prior to surgery. When the tumor is localized in the long bones, radiographic differential diagnosis may be made with Brodie's abscess. The latter is more often
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369
a FIG.
307. - Two examples of whole osteoid osteoma photographed under small enlargement (Hemat.-eos., 20 x).
FIG.
308. - Histological aspects of osteoid osteoma (Hemat.-eos., 125, 310 x).
370
FIG.
OSTEOID OSTEOMA
309. - Histological aspects of osteoid osteoma (Hemat.-eos., 80, 125, 50, 125 x).
OSTEOID OSTEOMA
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metaphyseal, it has a clinical history of intermittent pain, it causes a larger and more irregular osteolysis (at times with flamelike off-shoots starting from the rounded cavity), a halo of hyperostosis which is more intense and wide in the cancellous hone, and when submitted to surgery the cavity contains pus. Nonetheless, there are exceptional cases of Brodie's abscess with rather small osteolytic lacunae, at times centered by a minute sequestrum (which may simulate the radiopaque nucleus of the nidus) and containing reddish granulation tissue. In these last cases diagnosis may solely be based on histological assessment (Figs. S-7). Inflammatory sclerosing osteo-periostitis is distinguished from 0.0. because pain is less intense and is discontinuous, hone scan is less intensely positive and more diffused, and there is no nidus. Fatigue fracture with circumscribed hone thickening is distinguished from 0.0. by the patient's history (strenuous physical exercise, pain which is initially sharp to then gradually regress) and by the radiographic picture (transverse cortical fissure and band of sclerosis, no nidus) (Fig. 7b). There may be some uncertainty as to diagnosis of an 0.0. or an Osteoblastoma (see osteoblastoma), especially when the histopathologist is availed of small fragments of turnoral tissue. COURSE
0.0. which is left untreated increases very little in volume. Because of the phlogistic reaction which is associated, it may instead determine deformity of the metaepiphysis in growth and joint stiffness, particularly of the hip. In exceptional cases (3 in our experience) an 0.0. became transformed into Osteoblastoma (Figs. 318-320). TREATMENT
Treatment consists in complete, marginal or intralesional surgical removal of the nidus. Removal of the entire area of hyperostosis or of the reactive soft tissues is instead not indicated, as these return to normal after removal of the nidus. The problern consists in 1) reaching and clearly exposing the nidus, so that it may be completely removed; 2) removing as little surrounding hone as possible, in order to avoid weakening it (Figs. 288, 294). The first requirement is that of planning surgery with the aid of CAT. In the femoral neck, for example, 0.0. is generally superficial, more often closer to the anterior cortex, rarely to the posterior one (Fig. 295), and it is often intra-articular. Evidently, depending on the two localizations, the surgical approach and arthrotomy will be either anterior or posterior. Once the nidus has been localized by imaging, if it is located at the surface of the hone, it is immediately visible at surgery. If, as is more often the case, it is intraosseous, it is best to shave off the hone covering it until the nidus is visualized. It will then be easy to excise
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it in toto with a biopsy is carried If this method and restitutio ad
wide, marginal or intralesional margin. Thus, excisional out. is used, postoperative immobilization will not be required integrum is rapid and complete. PROGNOSIS
The surgical treatment of 0.0. causes the patienttobe very satisfied with the surgeon. On awakening, pain is completely and definitively regressed. In rare cases, recurrence may occur, but only if the 0.0. was not totally removed. REFERENCES 1951 MOBERG E.: The natural course of osteoid osteoma. Journal of Bane and Joint Surgery, 33-A, 166-170. 1953 CARROL R. E.: Osteoid osteoma in the hand. Journal of Bane and Joint Surgery, 35-A, 888-893. 1954 DAHLIN D. C., JoHNSON E. W. Jr.: Giant osteoid osteoma. Journal of Bane and Joint Surgery, 36-A, 559-572. 1954 GoLDING J. S. R.: The natural history of osteoid osteoma with a report of twenty cases. Journal of Bane and Joint Surgery, 36-B, 218-229. 1959 FREIHERGER R. H., LORIMAN B. S., HELGERM M., THOMPSON T. C.: Osteoid osteoma. A report on 80 cases. American Journal of Roentgenolof!.y, 82, 194-205. 1959 VICKERS C. W., PuGH D. C., lviNS J. C.: Osteoid osteoma. A fifteen year followup of an untreated patient. Journal of Bane and Joint Surgery, 41-A, 357-358. 1960 LIDBON A., LINDWALL N., SooERBERG G., SPJUT H.l.: Angiography in osteoid osteoma. Acta Radiologica, 54, 327-333. 1961 SPENCE A. J., LLOYD-ROBERTS G. C.: Regional osteoporosis in osteoid osteoma. Journal of Bane and Joint Surgery, 43-B, 501-507. 1966 MARCOVE R. C., FREIHERGER R. H.: Osteoid osteoma of the elhow. A diagnostic prohlem. Report of four cascs. Journal of Bane and Joint Surgery, 48-A, 1185-1190. 1966 RosBORAUGH D.: Osteoid osteoma. Report of a lesion in the terminal phalanx of a finger. Journal of Bane and Joint Surgery, 48-B, 485-487. 1967 MACLELLAN D.l., WILSON F. C. Jr.: Osteoid osteoma of the spine. A review of the Iiterature and report of six new cases. Journal of Bane and Joint Surgery, 49-A, 111-121. 1968 BYERS P. D.: Solitary henign osteohlastic lesions of hone. Osteoid osteoma and henign osteohlastoma. Cancer, 22, 43-57. 1969 GALWAY R., BOBECHKO W. P., HESLIN J.: Osteoid osteoma in childhood. Journal of Bane and Joint Surgery, 51-B, 196-196. 1970 DUNLOP J. A. Y., MoRTON K. S., ELLIOT G. G.: Recurrent osteoid osteoma. Report of a case with a review of the literature. Journal of Bane and Joint Surgery, 52-B, 128-133. 1970 LAWRIE T. R., ATERMAN K., SINCLAIR A. M.: Painless osteoid osteoma. A report of two cases. Journal of Bane and Joint Surgery, 52-A, 1357-1363. 1970 SCHULMAN L., DORFMAN H. D.: Nerve fihres in osteoid osteoma. Journal of Bane and Joint Surgery, 52-A, 1351-1356. 1975 DEJOUR H., LECLERC P., NouRISSAT C.: Osteome-osteoide du fond du cotyle. Revue de Chirurgie Orthopedique, 61, 755-768. 1975 GoRE D. R., MuELLER H. A.: Osteoid osteoma of the spine with localization aided hy 99 mTc-polyphosphate hone scan. Case report. Clinical Orthopaedics, 113, 132-134.
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1975 KEIM H. A., REINA E. G.: Osteoid osteoma as a cause of scoliosis. Journal of Bone and Joint Surgery, 57-A, 159-163. 1975 NoRMAN A., DoRFMAN H. D.: Osteoidosteoma inducing pronounced overgrowth and deformity of hone. Clinical Orthopaedics, 110, 233-238. 1975 O'HARA J. P., TESMEYER C., SwEET E. D., McCuE F. C.: Angiography in the diagnosis of osteoid-osteoma of the hand. Journal of Bone and Joint Surgery, 57-A, 154-159. 1975 SIM F. H., DAHLIN D. C., BEABOUT J. W.: Osteoid osteoma: diagnostic problems. Journal of Bone and Joint Surgery, 57-A, 154-159. 1976 HElMAN M. L., CooLEY CH. J., BRADFORD D. S.: Osteoid osteoma of a vertebral body. Report of a case with extension across the intervetebral disk. Clinical Orthopaedics, 118, 159-163. 1977 LATEUR L., BAERT A. L.: Localisation and diagnosis of osteoid osteoma of the carpal area by angiography. Skeletal Radiology, 2, 75-79. 1977 MEHTA M. H., MURRAY R. 0.: Scoliosis provcked by painful vertebral lesions. Skeletal Radiology, 1, 223-230. 1977 WINTER P., JoHNSON P., HILAL S., FELDMAN F.: Scintigraphic detection of osteoid osteoma. Radiology, 122, 177-178. 1986 CAPANNA R., AYALA A., ßERTONI F., PICCI P., CALDERONI P., GHERLINZONI F., BETTELLI G., CAMPANACCI M.: Sacral osteoid osteoma and osteoblastoma: a report of 13 cases. Archives of Orthopaedic and Traumatic Surgery, 105, 205-210. 1986 HEALEY J.M., GHELMAN B.: Osteoid osteoma and osteoblastoma: current concepts and recent advances. Clinical Orthopaedics, 204, 76-85. 1987 ALANI W.O., BARTAL E.: Osteoid osteoma of the femoral aeck simulating an inflammatory synovitis. Clinical Orthopaedics, 223, 308-312. 1987 HELMS C.A.: Osteoid osteoma: the double intensity sign. Clinical Orthopaedics, 222, 167. 1988 AUGEREAU B., WIOLAND M., DE LABRIOLLE-VAYLET C., PADOVANI J.P., MARTIN TH., VERNERET C., APOIL A., MILHAUD G.: Le reperage isotopique per-operatoire des osteomes osteoides et autres lesions hyperfixantes a la scintigraphie. Revue de Chirurgie Orthopedique, 74, 764-770. 1989 GITELIS S., ScHAJOWICZ F.: Osteoid osteoma and osteoblastoma. Orthopaedic Clinics of North America, 20, 313-325. 1989 KERET D., HARCKE T., MAc EWEN D., BoWEN R.: Multiple osteoid osteomas of the fifth lumbar vertebra. Clinical Orthopaedics, 248, 163-168. 1990 MOSER R.P., KRANSDORF M.J., BROWER A.C., HUDSON T., AOKI J., HUDON BERREY B., SWEET D.E.: Osteoid osteoma of the elbow. A review of six cases Skeletal Radiology, 19, 181-186.
