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Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations.

The benign bone lesions--osteoma, osteoid osteoma, and osteoblastoma--are characterized as bone-forming because tumor cells produce osteoid or mature bone. Osteoma is a slow-growing lesion most commonly seen in the paranasal sinuses and in the calvaria. When it occurs in the long bones, it is invariably juxtacortical and may need to be differentiated from, among others, parosteal osteosarcoma, sessile osteochondroma, and a matured juxtacortical focus of myositis ossificans. Osteoid osteoma and osteoblastoma appear histologically very similar. Their clinical presentations and distribution in the skeleton, however, are distinct: osteoid osteoma is usually accompanied by nocturnal pain promptly relieved by salicylates; osteoblastoma arises predominantly in the axial skeleton, spinal lesions constituting one-third of reported cases. This review focuses on the application of the various imaging modalities in the diagnosis, differential diagnosis, and evaluation of these lesions. Their histopathology also is discussed, and their treatment briefly outlined.

Bone Neoplasms↗

Increased prostacyclin biosynthesis in patients with osteoid osteoma.

Osteoid osteoma is a benign osteoid-forming tumor of the bone characterized by pain which is relieved by nonsteroidal anti-inflammatory drugs. Very high levels of prostaglandins have been found in the lesion. In nine patients with osteoid osteoma, prostaglandin E2 (PGE2) and prostacyclin (PGI2) synthesis in explants from the nidus incubated in vitro yielded 947.3 +/- 482.6 (mean +/- SD) and 340.2 +/- 178.1 pg/mg of wet tissue respectively, values 32 and 49 times higher than in fragments of normal bone. In eight patients the excretion rate of the major urinary metabolite of PGI2, i.e. 2,3-dinor-6-keto-PGF1 alpha, was nearly double the control value (499 +/- 93 vs 257 +/- 117 pg/mg of creatinine; mean +/- SD). In six of them, from whom urine was collected 1 month after surgery, urinary 2,3-dinor-6-keto-PGF1 alpha decreased significantly (P less than 0.01) from 487 +/- 100 to 229 +/- 52 pg/mg creatinine. Urinary 6-keto-PGF1 alpha, largely a reflection of intrarenal PGI2 synthesis, was comparable to the control group (4.6 +/- 0.9 vs 4.5 +/- 1.0 ng/h, respectively) and remained unchanged after operation. These results suggest an enhanced PGI2 biosynthesis in vivo in patients with osteoid osteoma. This abnormality of arachidonate metabolism is consistent with enhanced biosynthetic capacity of the tumor in vitro, and is reversible upon its removal.

6-Ketoprostaglandin F1 alpha↗

Osteoid osteoma.

Osteoid osteoma is a benign skeletal neoplasm composed of osteoid and woven bone that rarely exceeds 1.5 cm in greatest dimension. The lesion is most commonly located in the cortex of long bones where it is associated with dense, fusiform, reactive sclerosis. Less often, it may be cancellous, where reactive osteosclerosis is usually less intense and may be distant from the lesion. Cancellous lesions are frequently intraarticular (most often in the hip) and may be associated with synovitis and joint effusion. Rarely, osteoid osteomas occur in a subperiosteal location. Patients are usually young, and there is a strong male predominance. Pain is the most common symptom. Radiographs of patients with cortical osteoid osteoma are often diagnostic. Intraarticular lesions, however, may be subtle, and scintigraphy may be required to locate the lesion for subsequent computed tomography (CT). CT is useful to identify and precisely locate the lesion and to provide guidance for percutaneous localization or treatment.

Adolescent↗

COX-1 and COX-2 expression in osteoid osteomas.

Osteoid osteoma is a benign bone forming neoplasm that is characterized by its small size (less than 2 cm), self-limited growth, and the tendency to cause extensive reactive changes in the adjacent tissue. The lesion classically presents with severe pain at night that is dramatically relieved by NSAIDs. The tumor has been shown to express very high levels of prostaglandins, particularly PGE2 and PGI2. The high local levels of these prostaglandins are presumed to be the cause of the intense pain seen in patients with this lesion. One generally accepted form of treatment is the prolonged use of NSAIDs. Since the cyclooxygenases are thought to be the source of these prostaglandins, and the central target of NSAIDs, we evaluated the expression of cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in osteoid osteoma tissues from patients following surgery. In the 12 specimens examined we found that the tumor osteoblasts had strong immunohistochemical staining for COX-2, while the staining in the surrounding host osteoblasts in the reactive bone was scant. Significant COX-1 staining was also detected in both tumor and host osteoblasts. For comparison we examined the COX expression in human fracture callus, fibrous dysplasia, osteoblastoma, osteofibrous dysplasia, and myositis ossificans. With the exception of fracture callus, very limited amounts of COX-2 could be detected in these tissues. Taken together, we conclude that the increased production of prostaglandins by osteoid osteomas implicates that COX-2 is one of the mediators of this condition. These findings suggest that the newly selective COX-2 inhibitors could be used to more safely treat osteoid osteomas.

Bone Neoplasms↗

Osteoid osteoma.

Osteoid osteoma is a relatively frequent benign bone tumour, consisting of osteoid and woven bone, and surrounded by a halo of reactive sclerotic bone, with an average size of the nidus less than 1.5 cm. It is a condition of late childhood, adolescence and young adult age. It usually occurs in the appendicular skeleton and the spine, and is generally localised in or near the cortex. The lesion causes pain, especially at night, but can cause joint pain with synovitis and joint effusion if located in the vicinity of chondral structures, or painful scoliosis if located in the spine. Osteoid osteoma may have an unpredictable course, and may require treatment or resolve spontaneously. In some cases, the diagnostic approach is challenging; there are different treatment methods, some of which have been recently introduced, with promising results. We review the literature about the natural history, clinical presentation, diagnostic approach and classical or modern treatment modalities of osteoid osteoma.

Adolescent↗

Percutaneous Laser Photocoagulation of Osteoid Osteomas.

Osteoid osteoma is a painful benign bone tumor. The curative treatment of this tumor consists of complete surgical or percutaneous excision of the nidus with immediate and dramatic relief of symptoms. Interstitial laser photocoagulation (ILP) is a low-invasive percutaneous technique of thermal destruction (coagulation) of deep-seated tumors elsewhere in the body, using low-power laser energy. The aim of ILP is the local destruction of osteoid osteoma without bone weakening. Twenty-two patients with osteoid osteoma were treated with percutaneous ILP of the nidus under computed tomography guidance. The laser energy was provided by a high-power semiconductor diode laser (805 nm) with a 400-&mgr;m optical fiber. Complete pain relief was obtained in 21 patients. Percutaneous ILP of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive technique as an alternative to traditional surgical and percutaneous ablations.

Journal Article↗

Prostaglandins in osteoid osteoma.

Osteoid osteoma is a tumour of bone characterised by pain which is relieved by aspirin and nonsteroidal anti-inflammatory drugs. Very high levels of prostaglandins have been found in the lesion. In five patients with osteoid osteoma, prostaglandin E2 (PGE2) and prostacyclin (PGI2) synthesis in the nidus yielded 1155.6 +/- 496.5 (mean +/- SD) and 245.2 +/- 89.8 pg/mg respectively, values which are 33 and 26 times higher than in fragments of normal bone. The sclerotic bone around the nidus produced both prostaglandins at the same rate as normal bone. In three patients the excretion rate of the major urinary metabolite of systemic PGI1 was reduced to 50% one month after removal of the tumour. The urinary excretion rate of 6-keto-PGF1 alpha, reflecting intrarenal PGI2 synthesis, was not changed after operation. These results offer new insight into the pain mechanism in osteoid osteoma.

6-Ketoprostaglandin F1 alpha↗

[Percutaneous therapy of osteoid osteoma].

Osteoid osteomas are tumors with intense clinical symptoms and extensive reactive bone changes far exceeding the volume of the lesion itself. Because of their small size they can be approached by minimally invasive surgical procedures. We treated ten symptomatic patients with osteoid osteomas (n 6 hip point, n 1 iliac bone, n 1 femoral diaphysis, n 2 tibial diaphysis) by excision of the nidus with a 3-mm Harlow-Wood needle using a percutaneous CT-guided approach. Seven patients with residual tumor were treated with either thermocautery (n 2) or sclerosis with 1 ml of 96% ethanol (n 5). Six patients had instant and constant relief (3 years' observation) of their pain. In two patients a second transcutaneous intervention was successful. Only two patients needed open resection. Compared with the invasive open resection of the tumors, sometimes even putting the stability of the femoral neck at risk, transcutaneous CT-guided enucleation of the nidus of the osteoid osteoma with additional sclerotherapy is a good alternative method, especially in the region of the femoral neck.

Adolescent↗

Percutaneous radiofrequency ablation of osteoid osteoma.

Osteoid osteoma is a benign bone tumor. Patients usually require surgical treatment for reliable pain relief. Difficulties with intraoperative localization of the tumor and anatomic locations that carry a high morbidity with en bloc resection complicate open surgery. Various methods have been developed to lessen the invasiveness of surgery including computed tomography-guided percutaneous radiofrequency thermal ablation. Eleven patients in three different centers were evaluated and diagnosed with osteoid osteoma based on typical histories, physical examinations, and imaging studies. All patients were treated with computed tomography-guided percutaneous radiofrequency thermal ablation after medical treatment failed. Excellent pain relief was reported in 10 patients. One patient suffered recurrence of a femoral neck lesion despite an initial 7-month period without pain. Patients were given a questionnaire to quantify the effectiveness of percutaneous radiofrequency ablation in terms of pain relief and return to function. The current study shows that percutaneous radiofrequency thermal ablation provides reliable, excellent pain relief and early return to function with minimal morbidity as compared with traditional open techniques. The authors suggest that this technique be used for all patients with extraspinal osteoid osteomas that are not immediately adjacent to neurovascular structures.

Adolescent↗

Intra-articular osteoid osteoma.

Osteoid osteomas located within the capsule of a joint are uncommon and present challenging diagnostic difficulties. Twelve patients with an intra-articular osteoid osteoma were studied retrospectively to determine the spectrum of clinical and radiological findings. The features differ significantly from the well known classical hallmarks of the extra-articular lesion. The symptoms are non-specific with pain similar to other common joint disorders and the response to salicylate less precise. On plain radiography intra-articular lesions are difficult to identify, lacking the florid periosteal new bone and intense perifocal sclerotic reaction. A detectable focal lesion is commonly absent with considerable delay between the onset of symptoms and radiological detection of the tumour nidus. Bone scintigraphy and computed tomography (CT) are essential for an accurate and early diagnosis. These imaging techniques reveal abnormalities in bone and cartilage growth, new bone formation and sclerosis distant from the tumour on either side of the joint, and disruption of the articular surface. Radiological follow up after surgery shows that these changes can be reversible, especially when the diagnosis is made early.

Adolescent↗

[Chronic monoarthritis caused by osteoid osteoma].

Osteoid osteoma is a nonmalignant tumour that rarely localizes intraarticularly. When this happens, the tumour provokes arthritis and its recognition is delayed from months to years. We report the case of a 34 year old man with a previously known HIV infection, but no evidence of immunosuppression. He develops a chronic monoarthritis of the left elbow that is initially interpreted as infectious disease. CT provides diagnostic suspicion of osteoma, that is confirmed by pathologic examination two years after the onset of the clinical complaints. CT is the radiologic technique of election in the evaluation of osteoid osteoma. Synovitis is interpreted in the literature as secondary to prostaglandin secretion by the tumour.

Acquired Immunodeficiency Syndrome↗

[Retroauricular approach to complete obliteration of the external ear canal caused by osteoid osteoma].

Osteoid osteoma of the temporal bone is an infrequent benign bone tumor. The suspected diagnosis is based on clinical findings (occasionally pain, cosmetic deformities, repeated external otitis and conductive hearing loss), otoscopy, the radionuclide bone scan, and computerized tomography. Histopathology confirms the diagnosis of osteoma. Pain responds to acetylsalicyclic acid. Treatment is surgical excision by curettage and eburnation of the bone margins using an endaurul approach. We report a complete obliteration of the outer ear canal by an osteoid osteoma in a 32-year-old patient. A postauricular approach was required because of the large size of the tumor.

Adult↗

Percutaneous radiofrequency treatment of osteoid osteoma.

Osteoid osteoma is a small osteogenic tumor usually found in the lower extremity of children and young adults. Although these lesions are benign and rarely progress, they present distinctive pain symptoms that frequently require medical intervention. This article reviews surgical, medical, and percutaneous techniques for treatment of osteoid osteoma, emphasizing the value of percutaneous radiofrequency treatment.

Adolescent↗

Juxta-articular osteoid osteoma.

Osteoid osteomas that arise at the end of a long bone, within the insertion of the joint capsule (juxta-articular, intra-articular), may cause misleading clinical, radiographic, and histologic findings, resulting in unnecessary diagnostic tests and a delay in definitive treatment. To clarify optimum diagnostic procedures, we reviewed 20 cases of juxta-articular osteoid osteomas and found a mean delay from presentation to correct diagnosis of 24 months. Plain radiographs were either negative or showed only secondary changes. A periosteal reaction and proliferative synovitis with chronic inflammation was common, which could be misinterpreted as rheumatoid arthritis. Optimum diagnostic procedures were a bone scan followed by plain tomograms and an excisional biopsy of the nidus.

Adolescent↗

Case reports: an unusual complication of radiofrequency ablation treatment of osteoid osteoma.

Osteoid osteoma is a benign bone tumor traditionally treated nonoperatively or by operative excision. However, radiofrequency ablation is being used increasingly for treatment, as there are several reports supporting its effectiveness. Radio-frequency ablation is precise, minimally invasive, safe, effective, and associated with minimal complications and reduced use of healthcare resources. We report a patient treated with radiofrequency ablation for tibial osteoid osteoma and thermal necrosis of the skin.

Adult↗

Percutaneous destruction and alcoholisation for the management of osteoid osteoma.

Osteoid osteoma (OO) is a small, self-limiting, benign osteogenic tumour. Successful treatment of OO requires complete resection or destruction of the nidus. Surgery, which consists of en bloc excision of the nidus, followed by internal fixation, bone grafting, or both, is successful in almost all cases. In a small percentage of cases the nidus may be missed at surgery, resulting in a failed procedure. The aim of this study was to evaluate the results of percutaneous destruction and alcoholisation as a treatment of OO. Fifteen patients with an osteoid osteoma (10 males, 5 females) were treated in the Oncology Unit, Orthopaedic Department, Mansoura University Hospital. Three OOs were localised in the humerus, 5 in the femur, 6 in the tibia and fibula, and one in the talus. All patients underwent destruction of the nidus by determining the nidus by CT, drilling with a cannulated drill bit, curretting with a speed burr and injecting ethanol. The nidus completely disappeared on the postoperative CT-scan. The average follow-up period was 19 months (6-24 months). There were no postoperative complications. This technique for the treatment of OO is minimally invasive, safe, simple, and cost effective. It allows an early return to normal activities. The procedure is particularly useful for a lesion located deep in the skeleton, which would require an extensive approach with conventional surgery.

Adolescent↗

Percutaneous Resection of Osteoid Osteomas.

Osteoid osteomas in almost all locations may be treated by percutaneous resection under CT scan guidance. The authors give their own experience with a series of 30 cases. The different techniques of percutaneous resection reported in the literature are reviewed. Advantages of the percutaneous resection are compared to those of classical surgery and other percutaneous techniques such as lesion destruction with thermocoagulation, photocoagulation, and intralesional injection of alcohol.

Journal Article↗

[Osteoma osteoid of the trapezoid bone: a case-report and review of the literature].

Osteoid osteomas are often localised in long bones but only rarely in the carpus. This is a case report of an osteoid osteoma in the trapezoid. Diagnosis was difficult and established late, due to misleading initial symptoms. Radiological examination allowed localisation of the nidus. For osteoid osteoma localised in a carpal bone, we recommend total removal without bone-graft or arthrodesis.

Adult↗