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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 139-144

Pathological evaluation of osteolytic bone lesions: A 7-year experience in a tertiary care center in West Bengal, India


Department of Pathology, Medical College, Kolkata, West Bengal, India

Date of Submission21-Jan-2021
Date of Acceptance24-Feb-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Parul Jain
B 4/8, CMDA Housing Complex, 39 A, PGM Shah Road, Kolkata - 700095. West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_10_21

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  Abstract 


Background: The purpose of our study was to evaluate the osteolytic lesions of bone reported at the department of pathology in a tertiary care hospital in West Bengal. Materials and Methods: We performed a retrospective study over a period of 7 years from February 2013 to January 2020. Entirely osteosclerotic lesions were excluded from our study. The lesions were classified as nonneoplastic lesions, benign lesions, tumor like lesions and malignant lesions. Results: Over 7 years, 147 cases of osteolytic lesions of bone were reported. Of these, 36.1% were malignant lesions. The most common sites of osteolytic lesions were the femur (n = 46), tibia (n = 24), and humerus (n = 20). The most frequent histological diagnosis was of giant cell tumor (GCT) (n = 31), followed by chronic osteomyelitis (n = 19) and osteosarcoma (n = 17). The most frequent benign neoplasm was GCT and osteosarcoma was the predominant malignant lesion. Relatively uncommon lesions like adamantinoma were also reported. Conclusions: Malignant neoplasms are the most common osteolytic lesions. Bones of the extremities are the most frequent sites of involvement by both benign and malignant tumors. In addition to radiological correlation, a thorough knowledge of the age, sex, site of the common bone lesions is required for a correct histopathological diagnosis so that proper treatment can be instituted. Most of these lesions do not require immunohistochemistry for diagnosis. The possibility of rare tumors presenting at a given age and at a particular site is to be considered.

Keywords: Epidemiology, giant cell tumor, osteolytic


How to cite this article:
Jain P, Dasgupta S, Bhattacharyya NK. Pathological evaluation of osteolytic bone lesions: A 7-year experience in a tertiary care center in West Bengal, India. Biomed Biotechnol Res J 2021;5:139-44

How to cite this URL:
Jain P, Dasgupta S, Bhattacharyya NK. Pathological evaluation of osteolytic bone lesions: A 7-year experience in a tertiary care center in West Bengal, India. Biomed Biotechnol Res J [serial online] 2021 [cited 2021 Jul 23];5:139-44. Available from: https://www.bmbtrj.org/text.asp?2021/5/2/139/318425




  Introduction Top


Bone lesions may present a diagnostic challenge to the histopathologists. Proper evaluation requires correlation of age, clinical presentation, site, and imaging. These lesions have varied radiological characteristics and may appear radiolucent or radiopaque. Most lesions are solitary. Plain radiographs are the basic requirements to reveal the nature of these lesions. Computed tomography and magnetic resonance imaging also have their specific advantages and shortcomings. Radionuclide bone scanning is indicated to reveal occult lesions in patients who are at risk of having multiple lesions. There are four types of tissue in the bone that do not contain calcification or ossification-fluid, fibrous tissue, cells without a matrix, and cartilage matrix without calcification or enchondral ossification.[1] These appear totally radiolucent and enable the pathologist to shortlist the diagnostic possibilities. The location within a long bone-epiphysis, metaphysis, or diaphysis helps in the diagnosis.

In this study, we evaluated the osteolytic lesions of bone reported at our department of pathology. As ours is a tertiary care center in West Bengal, the data should be representative of this part of the state. To the best of our knowledge, this is one of the first studies of its kind in India.


  Materials and Methods Top


We performed a study on osteolytic lesions reported at our department of pathology, over 7 years from February 2013 to January 2020. The institutional ethical committee was verbally informed before the commencement of our study. As our study did not involve any patient intervention, the ethical committee asked us to go ahead without any written permission. Our cases included the bone lesions showing evidence of osteolysis in radiological investigations. Some of these lesions showed foci of radiodense opacities due to calcification or ossification. Entirely osteosclerotic lesions were excluded from our study. The incisional and excisional biopsies and fine-needle aspiration cytology (FNAC) specimens were evaluated. FNAC diagnosis was only considered when suspected bone metastasis in known carcinoma patients was confirmed. In six cases, FNAC diagnosis suggested the possibility of metastatic carcinoma with unknown primary. These cases were followed up till the primary site of malignancy was diagnosed. The clinical presentation and radiological and histopathological findings were taken into consideration. Routine H and E stain was used for diagnosis, immunohistochemistry confirmation being considered for selected cases, as necessary. May–Grunwald–Giemsa and Papanicolaou stains were used for FNAC specimens. The lesions were classified as benign tumors, tumor-like lesions, and nonneoplastic and malignant lesions. The demographic findings were recorded.


  Results Top


Over 7 years, 147 cases of osteolytic lesions were reported from our department. Of these, 53 (36.1%) were malignant lesions. Others included 42 (28.6%) benign tumors, 28 (19%) tumor-like lesions, and 24 (16.3%) nonneoplastic lesions. [Table 1] shows the pathological types of bone lesions, their categorization, and percentage of distribution. Fifty-four cases (36.7%) presented between 11 and 20 years of age, followed by 30 cases (20.4%) which presented between 21 and 30 years. There were 17 (11.6%) cases between 31 and 40 years, 14 (9.5%) cases between 41 and 50 years, and 13 (8.8%) cases between 51 and 60 years of age. Twelve cases (8.2%) presented in children aged 10 years or younger and 7 cases (4.8%) in patients aged 61 years and above. The age range and sex distribution of the lesions are enlisted in [Table 2]. Of the 147 cases, 84 were male and 63 were female; male:female ratio being 1.3:1. The clinical features included pain, swelling, and pathological fractures in variable combinations. Only three cases (metaphyseal fibrous defect) were asymptomatic and incidentally detected. The most common sites of osteolytic lesions were femur (n = 49), tibia (n = 24), and humerus (n = 21). Other sites are depicted in [Table 3]. The most frequent histological diagnosis was of giant cell tumor (GCT) (n = 31), followed by chronic osteomyelitis (n = 19) and osteosarcoma (n = 17). Thus, GCT was the most frequent benign neoplasm and osteosarcoma was the predominant malignant lesion reported from our institution. There were 16 cases of metastatic carcinoma. [Figure 1], [Figure 2], [Figure 3], [Figure 4] illustrate plain radiographs of some osteolytic lesions. Most of the GCTs presented between 21 and 30 years of age. Osteosarcoma was found to be more frequent between 11 and 30 years. Metastatic carcinoma was predominantly reported in patients above 50 years of age. [Figure 5] shows the micrograph of the aneurysmal bone cyst (ABC) corresponding to the radiograph depicted in [Figure 2]. [Figure 6], [Figure 7], [Figure 8] show the micrographs of some of the osteolytic lesions. Lesions like osteomyelitis showed no definite relation with age and site. In all eight cases of osteolytic lesions showing histology of small round cell tumor, a panel of immunohistochemistry markers was used primarily for the exclusion of lymphoma. All such cases proved to be Ewing sarcoma/PNET. We also reported two cases of relatively uncommon lesions like adamantinoma.
Table 1: Osteolytic lesions (n=147)

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Table 2: Age and sex distribution of the osteolytic lesions (n=147)

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Table 3: Site distribution of osteolytic lesions (n=147)

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Figure 1: Radiograph showing radiolucent lesion of the radius with characteristic soap bubble appearance

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Figure 2: Radiograph showing radiolucent lesion at the upper end of the humerus

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Figure 3: Radiograph showing pathological fracture midshaft of the femur with an osteolytic lesion, later diagnosed to be Ewing sarcoma

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Figure 4: Radiograph showing radiolucent lesion of midshaft of ulna, later diagnosed to be osteoblastoma

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Figure 5: Aneurysmal bone cyst (H and E, ×200)

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Figure 6: Adamantinoma (H and E, ×200)

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Figure 7: Fibrous dysplasia (H and E, ×200)

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Figure 8: Osteoblastoma (H and E, ×200)

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  Discussion Top


We analyzed the various osteolytic lesions and classified them into subcategories. The age, gender, and anatomical sites of presentation were also recorded.

Shirazi et al. performed a study on osteolytic lesions of hands and feet and found that 75% of patients were asymptomatic.[2] The lesions were categorized into benign tumors, tumor-like lesions, inflammatory and posttraumatic lesions, and malignant tumors. In their study, malignant tumors comprised 5.7% of the cases. Benign tumors accounted for 38.4% of cases, GCT being the most common, constituting 60% of benign tumors involving bones of the hands or feet. The second most common benign tumor reported in their study was chondroblastoma.

Our study was not confined to a particular anatomical location and almost 98% of the cases were symptomatic. We found that most of our cases (36.1%) were malignant lesions. However, benign tumors, tumor-like lesions, and nonneoplastic lesions together outnumbered the malignant lesions. GCT was the most common lesion, constituting 73.8% of benign tumors. Another striking difference was we reported just a single case of chondroblastoma, depicting this tumor is relatively rare in our state.

Bergovec et al. studied the epidemiology of musculoskeletal tumors and found that malignant tumors were seen in 20.7% of patients with male predominance.[3] The most common malignant tumors were osteosarcoma, chondrosarcoma, and Ewing sarcoma. Benign tumors and tumor-like lesions were found in 79.3% of patients, with slight female predominance. The most common benign bone lesions were osteochondroma, simple bone cyst, and enchondroma.

The variation in statistics in our study can be explained by the exclusion of the lesions which were not osteolytic.

An epidemiological study on bone tumors was conducted in Mexico City.[4] In that study, the femur was the most common location of the tumors (39.9%), followed by the tibia (17.7%) and humerus (11.8%). We found similar results for osteolytic lesions as a whole, irrespective of their benign or malignant nature. Likewise, many of our results for osteolytic bone tumors paralleled the findings previously reported in other studies on bone tumors as in Zaria, northern Nigeria, and another tertiary care hospital in Nigeria.[5],[6]

The epidemiological characteristics of bone GCT in the extremity were reviewed by Jiang et al.[7] In their study, GCTs were mostly located around the knee and presented between 20s and 40s. The gender ratio was 1.64 with a male predominance. Xing et al. also found that 58% of these tumors involved the knee region.[8] Likewise, most of the GCTs in our study were located at the femur.

Adeniran et al. found osteosarcoma to be the most common malignant bone tumor found primarily around the knee.[9] The youngest patient was 7 years old and the oldest 43 years. In our study too, osteosarcoma was the most common malignant lesion, presented most commonly at the humerus within the age range of 8–45 years.

Singh et al. studied 151 patients (51.0% men and 49.0% women) with metastatic bone disease, with the highest incidence at the age range of 50–59 years.[10] The most common primary cancer was breast (23.3%), followed by lung (21.2%), prostate (9.3%), thyroid (7.3%), and renal cell carcinoma (5.3%); unknown primary cancer was 6.6%. There was long bone involvement in 52.7% of cases, axial bone in 44.5%, and both long and axial bones in 2.8% cases. Sixty-seven percent of the lesions were osteolytic. Our findings were similar. The femur, scapula, vertebra, humerus, and occipital bone showed evidence of metastatic disease. There were 16 cases of metastatic bone lesions in our records. Of these, the primary sites were the lung (seven), breast (six), kidney (two), and thyroid (one).

Vassiliou et al. found a correlation between the type of bone metastases and the clinical status of patients.[11] They suggested that the patients with osteolytic lesions may be given priority in treatment as they had the highest mean pain score. Similarly, all of our cases with metastatic bone lesions presented with pain of variable intensity.

Our study differed in certain findings from a study by Popat et al.[12] on histopathology of osteolytic lesions. They found benign neoplasms to be the most common of the 70 cases of lytic lesions of bone diagnosed during their 2-year study period. Metastatic lesions were more common than primary malignancies of bone. Among the inflammatory lesions, they found cases of tuberculous osteomyelitis to slightly outnumber the cases of pyogenic osteomyelitis. Hathila et al. also found tuberculous osteomyelitis to be the most common nonneoplastic lesion.[13]

Salunkhe et al. performed a retrospective study on the staging and management correlation of 30 cases of benign osteolytic lesions.[14] They observed GCT, enchondromas, and simple bone cysts to be the most common lesions. Among the tumor-like lesions, we found fibrous dysplasia and ABCs to be more common than simple bone cysts. Similar to our study, they too stressed upon the importance of histopathological and clinicoradiological correlation.

Mascard et al. in their study on bone cysts found that ABCs may develop in all bones of the skeleton, whereas unicameral or simple bone cysts usually involve the proximal humerus and proximal femur.[15] It is mandatory to distinguish these cysts, as prognosis and treatment are different. We found most of these bone cysts at the humerus. One case of ABC was found to involve calcaneum.


  Conclusions Top


Our study highlights the common osteolytic lesions encountered in day-to-day practice in a tertiary care center of West Bengal. Malignant neoplasms are the most common osteolytic lesions. Bones of the extremities are the most frequent sites of involvement by both benign and malignant tumors. The nonneoplastic lesions also commonly involve the extremity bones. Correct histopathological diagnosis necessitates the correlation with clinical presentation and radiological findings. Most of these lesions do not require the aid of immunohistochemistry for diagnosis. Thus, a thorough knowledge of the age, sex, site of the common bone lesions is required for a correct diagnosis so that proper treatment can be instituted. In addition, the possibility of rare tumors presenting at a given age and at a particular site is to be kept in mind.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Springfield DS. Radiolucent Lesions of the Extremities. J Am Acad Orthop Surg 1994;2:306-16.  Back to cited text no. 1
    
2.
Shirazi N, Gupta V, Kapoor I, Harsh M, Chauhan N, Ahmad S. Osteolytic lesions of hand and feet: A seven-year experience from a tertiary referral centre of North India. Malays J Pathol 2014;36:115-24.  Back to cited text no. 2
    
3.
Bergovec M, Kubat O, Smerdelj M, Seiwerth S, Bonevski A, Orlic D. Epidemiology of musculoskeletal tumors in a national referral orthopedic department. A study of 3482 cases. Cancer Epidemiol 2015;39:298-302.  Back to cited text no. 3
    
4.
Baena-Ocampo Ldel C, Ramirez-Perez E, Linares-Gonzalez LM, Delgado-Chavez R. Epidemiology of bone tumors in Mexico City: Retrospective clinicopathologic study of 566 patients at a referral institution. Ann Diagn Pathol 2009;13:16-21.  Back to cited text no. 4
    
5.
Mohammed A, Isa HA. Pattern of primary tumours and tumour-like lesions of bone in Zaria, northern Nigeria: A review of 127 cases. West Afr J Med 2007;26:37-41.  Back to cited text no. 5
    
6.
Obalum DC, Giwa SO, Banjo AF, Akinsulire AT. Primary bone tumours in a tertiary hospital in Nigeria: 25 year review. Niger J Clin Pract 2009;12:169-72.  Back to cited text no. 6
[PUBMED]    
7.
Jiang N, Qin CH, Tan CX, Wen SF, Ma YF, Dong F, et al. A retrospective analysis of 140 patients with giant cell tumor in the extremity: A multicenter study based on four hospitals in South China. Cancer Epidemiol 2013;37:294-9.  Back to cited text no. 7
    
8.
Xing R, Yang J, Kong Q, Tu C, Zhou Y, Duan H. Giant cell tumour of bone in the appendicular skeleton: An analysis of 276 cases. Acta Orthop Belg 2013;79:731-7.  Back to cited text no. 8
    
9.
Adeniran JJ, Samuel EU, Dike OC, Olayinka SO, Ayokunle O, Nnodu OE, et al. Bone malignancies in orthopaedic hospital Igbobi Lagos, Nigeria. Niger Postgrad Med J 2014;21:66-7.  Back to cited text no. 9
  [Full text]  
10.
Singh VA, Haseeb A, Alkubaisi AA. Incidence and outcome of bone metastatic disease at University Malaya Medical Centre. Singapore Med J 2014;55:539-46.  Back to cited text no. 10
    
11.
Vassiliou V, Kalogeropoulou C, Petsas T, Leotsinidis M, Kardamakis D. Clinical and radiological evaluation of patients with lytic, mixed and sclerotic bone metastases from solid tumors: Is there a correlation between clinical status of patients and type of bone metastases? Clin Exp Metastasis 2007;24:49-56.  Back to cited text no. 11
    
12.
Popat V, Sata V, Vora D, Bhanvadia V, Shah M, Kanara L. Role of histopathology in lytic lesions of bone– A study of seventy cases of lytic lesion of bone. Internet J Orthop Surg 2010;19:1.  Back to cited text no. 12
    
13.
Hathila RN, Mehta JR, Jha BM, Saini PK, Dudhat RB, Shah MB. Analysis of bone lesions in tertiary care center-A review of 79 cases. Int J Med Sci Public Health 2013;2:1037-40.  Back to cited text no. 13
    
14.
Salunkhe AA, Raiturker PP. Benign lytic lesions of the bone, staging and management correlations. Indian J Orthop 2003;37:8.  Back to cited text no. 14
  [Full text]  
15.
Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res 2015;101:S119-27.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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