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Diagnosing Benign Bone Forming Tumors: A Visual Guideline from Presentation through Treatment

March 01, 2017

Contributors: Ivan Golub; Ian O'Connor, BS; James C Wittig, MD

The most common benign bone forming tumors are an enostosis (bone island), osteoma, osteoid osteoma, and osteoblastoma. The differentiating characteristic between these entities and other bone tumors, is the presence or production of bone, or osteoid as they grow. Radiographically, these tumors display mineralization, indicating the presence or production of bone. Clinically, these tumors may vary in presentation and biological behavior. While a mass such as an enostosis may be asymptomatic and an incidental finding, an osteoid osteoma may present with severe pain, especially at night. Each of these entities are unique in their presentation and biological behavior. For instance, osteoblastomas may be locally aggressive and potentially problematic in differentiating from malignant bone forming tumors. Treatments range from observation to wide resection depending on the natural history of the tumor and its location. Chemotherapy and radiotherapy are rarely, if ever, used in the treatment of the lesions. Of the four aforementioned benign bone forming tumors, they can be further subdivided due to their similarities. Histologically, an enostosis shares many resemblances to an osteoma, while an osteoid osteoma and osteoblastoma can be similarly compared to an osteoblastoma. An enostosis and osteoma both demonstrate mature cortical or lamellar bone, however develop in different locations. Enostoses arises within the medullary canal of the affected bone, while an osteoma grows on the surface of the bone. Radiographically, an enostosis may appear similar to an osteoid osteoma. Osteoid osteoma, and osteoblastoma are noteworthy for their osteogenic growth of immature woven bone or osteoid arranged as interlacing trabeculae. Osteoid osteomas however are self-limiting lesions which rarely grow after presentation. Osteoblastomas are benign, aggressive tumors that destroy bone as they grow and often have a propensity for local recurrence. Thus, much more aggressive treatment is necessary in the treatment of osteoblastomas, including resection of the tumor as well as possible use of local adjuvants to prevent local recurrence. Differentiating between an osteoblastoma and osteosarcoma microscopically can at times be difficult especially without radiographic correlation. Patients should be referred to an experienced orthopaedic oncologist for proper biopsy and ultimate treatment. The diagnosis should be rendered only after close correlation with plain radiographs and other pertinent radiological studies. References 1. Atesok KI, Alman BA, Schemitsch EH, Peyser A, Mankin H. Osteoid osteoma and osteoblastoma. J Am Acad Orthop Surg. 2011;19(11):678-89. 2. Bhusnurmath S, Hoch B. Benign Bone-Forming Tumors: Approach to Diagnosis and Current Understanding of Pathogenesis. Surg Pathol Clin. 2012;5(1):101-16. 3. Cerase A, Priolo F. Skeletal benign bone-forming lesions. Eur J Radiol. 1998;27 Suppl 1:S91-7. 4. Erlemann R. Imaging and differential diagnosis of primary bone tumors and tumor-like lesions of the spine. Eur J Radiol. 2006;58(1):48-67. 5. Green JT, Mills AM. Osteogenic tumors of bone. Semin Diagn Pathol. 2014;31(1):21-9. 6. Hakim DN, Pelly T, Kulendran M, Caris JA. Benign tumours of the bone: A review. J Bone Oncol. 2015;4(2):37-41. 7. Laurence N, Epelman M, Markowitz RI, Jaimes C, Jaramillo D, Chauvin NA. Osteoid osteomas: a pain in the night diagnosis. Pediatr Radiol. 2012;42(12):1490-501. 8. Priolo F, Cerase A. The current role of radiography in the assessment of skeletal tumors and tumor-like lesions. Eur J Radiol. 1998;27 Suppl 1:S77-85.

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