Osteoblastoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2], Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[3]

Synonyms and keywords:Osteogenic fibroma of bone; giant osteoid osteoma

Osteoblastoma
DiseasesDB 31488
MeSH C4557

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Overview

Osteoblastoma is a rare benign neoplasm of the bone, which constitutes for almost 1% of all primary bone tumors and 3% of all benign tumors in the United States. One-third of patients have lesions in the posterior elements of the spine, most often the lumbar and sacral regions. In 1952, Lichtenstein first termed the lesion as osteogenic fibroma of bone. In 1956, Lichtenstein and Jaffe in their independent detailed studies of this neoplasm renamed the lesion as osteoblastoma. Osteoblastoma might be conventional benign or aggressive and malignant. The exact etiology of osteoblastoma is unknown. The osteoblastomas are more aggressive compared to the other benign tumors of the musculoskeletal system. Histologically osteoblastoma is similar to osteoid osteoma and is differentiated on the basis of its large size. Osteoblastoma is a benign tumor of the musculoskeletal system and is associated with little morbidity. The risk factors are not yet established and there is insufficient evidence to recommend routine screening for osteoblastoma. If not treated, it may grow and damage the bone and adjacent structures. If the untreated osteoblastoma invades the spinal canal or neural foramina, it may lead to progressive neurologic deficits. Once the tumor expands outside the bone, the recurrence rate of osteoblastoma reaches to nearly 20%. Biopsy is the diagnostic study of choice for the diagnosis of osteoblastoma which shows similar features to that of osteoid osteoma. The majority of patients with osteoblastoma have a positive history of pain which is dull and achy in nature, and the pain is not relieved by salicylates. There are no diagnostic laboratory, ECG, echocardiography or ultrasound findings associated with osteoblastoma. X-ray is a useful diagnostic tool in the diagnosis of osteoblastoma and may reveal a well circumscribed radiolucent lesion in the bony cortex. CT scan may be helpful in the diagnosis and management of osteoblastoma and may provide the size and extent of osteoblastoma. MRI may be helpful in determining the extent of osteoblastoma that has invaded the surrounding soft tissues, bone marrow, and spine. The most sensitive radiographic examination for the evaluation of osteoblastoma is bone scan. The angiography is performed if the information about the adjacent major ve sel locations or its involvement is needed. Surgery is the mainstay of treatment for osteoblastoma and the treatment with chemotherapy and radiation therapy are still controversial.

Historical Perspective

  • In 1952, Lichtenstein was the first physician who termed the lesion as osteogenic fibroma of bone.[1]
  • In 1954, Dahlin and Johnson, were able to identify 11 tumors of bone origin that shared aggressive but nonetheless benign qualities. Therefore, this made these tumors notoriously difficult to diagnose as benign or malignant.[2]
  • In 1954, Dahlin and Johnson, were the first to notice that an osteoid osteoma and osteoblastoma had many histological characteristics in common and they named it giant osteoid osteoma.
  • In 1956, Lichtenstein and Jaffe in their independent detailed studies of the neoplasm termed the lesion as osteoblastoma.[3][4]
  • In 1977, Jackson published a review of 181 osteoblastomas from the literature and reported that spine is the location of 36% of the osteoblastomas.[5]
  • In 1984, Dorfman and Weiss reported on the aggressive osteoblastoma and termed it as a borderline osteoblastic tumor entity.[6]

Classification

  • Osteoblastoma may be classified into two subtypes:[7]
  • A controversial aggressive tumor is reported which is malignant in nature as compared to the conventional or benign osteoblastomas.[8]

Pathophysiology

  • The exact etiology of osteoblastoma is unknown.
  • The osteoblastomas are composed of several osteoblasts that produce osteoid and woven bone regardless to their origin in the musculoskeletal system.[9]
  • The expansion usually occurs when the primary site of osteoblastoma is within the cortical bone.
  • Typically the external rim of the osteoblastoma is concealed by the covering of periosteum and a thin rim of reactive bone.
  • In a clinicopathologic study conducted at Mayo clinic, the reported sizes of osteoblastomas ranged from 1 to 11 cm, with a mean of 3.2 cm.
  • The osteoblastomas are more aggressive as compared to the other benign tumors of the musculoskeletal system.
  • Due to their aggressive nature, the osteoblastomas may mimic malignancy on radiographic studies.

Causes

The cause of osteoblastoma has not been identified.

Differentiating Osteoblastoma from Other Diseases

  • Osteoblastoma must be differentiated from following bone disorders:
Disease Bone involvement Bone pain Fever Fractures Mechanism ALK level Diagnosis
Osteoblastoma Single Yes No Yes Neoplasm High Radiology and biopsy
Osteosarcoma Single Yes No Yes Neoplasm Normal Radiology and biopsy
Osteoid osteoma Single Yes No Yes Neoplasm High Radiology and biopsy
Aneurysmal bone cyst Single Yes No No Neoplasm High Radiology and biopsy
Stress fracture Multiple Yes No Yes Stress Normal Radiology
Osteomyelitis Single Yes Yes No Infection Normal Radiology and biopsy
Brodie's abscess Single Yes Yes No Infection Normal Radiology and biopsy

Epidemiology and Demographics

Risk Factors

There are no established risk factors for osteoblastoma.

Screening

There is insufficient evidence to recommend routine screening for osteoblastoma.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of choice

Osteblastoma histology.Source: By No machine-readable author provided. Nephron assumed (based on copyright claims). - No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 3.0

Enneking (MSTS) Staging System

  • The Enneking surgical staging system (also known as the MSTS system) for benign musculoskeletal tumors based on radiographic characteristics of the tumor host margin.[22]
  • It is widely accepted and routinely used classification.
Stage Description
I

Latent: Well demarcated borders

II

Active: Indistinct borders

III

Aggressive: Indistinct borders

History and Symptoms

Physical Examination

Laboratory Findings

Some patients with osteoblastoma may have elevated concentration of para-neoplastic beta-human chorionic gonadotropin (β-hCG) , which is usually suggestive of aggressive osteoblastoma.[24]

Electrocardiogram

There are no ECG findings associated with osteoblastoma.

Osteoblastoma causing a marked scoliosis in a 7 year old boy. Case courtesy of Dr Angela Byrne, via Radiopedia.org[25]

X-ray

  • An x-ray may be helpful in the diagnosis of osteoblastoma.
  • Findings on an x-ray suggestive of osteoblastoma include:[26][27][28]
    • A well-circumscribed radiolucent lesion in the bony cortex
    • A thin shell of peripheral new bone separating the tumor from the surrounding soft tissue
    • Typically > 2.0 cm in diameter
    • No reactive zone surrounding the lesion
  • Cortical bone lesions often present with reactive bone formation, more so than those lesions in the spongy bone of the spine, ilium, or talus.
  • Osteoblastoma may have features similar to those of malignancy, such as:
    • Cortical destruction
    • Extraosseous soft-tissue expansion
    • Left acetabular fossa pubic bone expansile predominantly lytic lesion with a rim of reactive sclerosis. Case courtesy of Dr Amr Farouk, [29]
      Associated aneurysmal bone cyst component
  • The usual sites of osteoblastoma and their plain radiographic features are described below:
Site Radiographic features
  • A well-defined destructive process within the cortical bone
  • Tumor is visualized in the posterior elements
  • May bulge into the surrounding soft tissues and spinal column

Echocardiography or Ultrasound

There are no echocardiography or ultrasound findings associated with osteoblastoma.

CT scan

MRI

Other Imaging Findings

  • The most sensitive radiographic examination for the evaluation of osteoblastoma is bone scan.[33]
  • The typical appearance of an osteoblastoma on a technetium bone scan is:[34]
    • A hot spot

Other Diagnostic Studies

  • Angiography is performed if the information about the adjacent major vessels locations or its involvement is needed.

Treatment

Medical Therapy

Surgery

  • Surgery is the mainstay of treatment for osteoblastoma.[36]
  • The total removal of the tumor is the treatment of goal in osteoblastoma.
  • Extensive intra-lesional excision with a use of a high-speed burr is the recommended treatment for enneking stage 1 and 2 lesions.
  • Wide resection for the removal of all tumor-bearing tissue is the recommended treatment for enneking stage 3 lesions, which is considered curative for osteoblastoma.

Recurrence

  • The recurrence risk is related to the adequacy of resection and is about at 10–24 %.[18]

Primary Prevention

There are no established measures for the primary prevention of osteoblastoma.

Secondary Prevention

There are no established measures for the secondary prevention of osteoblastoma.

References

  1. Lichtenstein L. Osteogenic Fibroma of Bone. In: Bone Tumors. St Louis, Mo: Mosby; 1952:82-87.
  2. DAHLIN DC, JOHNSON EW (June 1954). "Giant osteoid osteoma". J Bone Joint Surg Am. 36-A (3): 559–72. PMID 13163088.
  3. Jaffe HL. Osteoid-osteoma: a benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg. 1935;31:709–728.
  4. LICHTENSTEIN L (1956). "Benign osteoblastoma; a category of osteoid-and bone-forming tumors other than classical osteoid osteoma, which may be mistaken for giant-cell tumor or osteogenic sarcoma". Cancer. 9 (5): 1044–52. PMID 13364889.
  5. Jackson RP, Reckling FW, Mants FA (October 1977). "Osteoid osteoma and osteoblastoma. Similar histologic lesions with different natural histories". Clin. Orthop. Relat. Res. (128): 303–13. PMID 598169.
  6. Dorfman HD, Weiss SW (August 1984). "Borderline osteoblastic tumors: problems in the differential diagnosis of aggressive osteoblastoma and low-grade osteosarcoma". Semin Diagn Pathol. 1 (3): 215–34. PMID 6600112.
  7. 7.0 7.1 Yin, Huabin; Zhou, Wang; Yu, Hongyu; Li, Binbin; Zhang, Dan; Wu, Zhipeng; Liu, Tielong; Xiao, Jianru (2013). "Clinical characteristics and treatment options for two types of osteoblastoma in the mobile spine: a retrospective study of 32 cases and outcomes". European Spine Journal. 23 (2): 411–416. doi:10.1007/s00586-013-3049-1. ISSN 0940-6719.
  8. Dorfman HD, Weiss SW (August 1984). "Borderline osteoblastic tumors: problems in the differential diagnosis of aggressive osteoblastoma and low-grade osteosarcoma". Semin Diagn Pathol. 1 (3): 215–34. PMID 6600112.
  9. Lucas, David R.; Krishnan Unni, K.; McLeod, Richard A.; O'Connor, Mary I.; Sim, Franklin H. (1994). "Osteoblastoma: Clinicopathologic study of 306 cases". Human Pathology. 25 (2): 117–134. doi:10.1016/0046-8177(94)90267-4. ISSN 0046-8177.
  10. Greenspan, Adam (1993). "Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma". Skeletal Radiology. 22 (7). doi:10.1007/BF00209095. ISSN 0364-2348.
  11. 11.0 11.1 Lucas, David R.; Krishnan Unni, K.; McLeod, Richard A.; O'Connor, Mary I.; Sim, Franklin H. (1994). "Osteoblastoma: Clinicopathologic study of 306 cases". Human Pathology. 25 (2): 117–134. doi:10.1016/0046-8177(94)90267-4. ISSN 0046-8177.
  12. Arkader, Alexandre; Dormans, John P. (2008). "Osteoblastoma in the Skeletally Immature". Journal of Pediatric Orthopaedics. 28 (5): 555–560. doi:10.1097/BPO.0b013e31817bb849. ISSN 0271-6798.
  13. Marsh BW, Bonfiglio M, Brady LP, Enneking WF (January 1975). "Benign osteoblastoma: range of manifestations". J Bone Joint Surg Am. 57 (1): 1–9. PMID 1123354.
  14. Peabody, Terrance (2014). Orthopaedic oncology : primary and metastatic tumors of the skeletal system. Cham: Springer. ISBN 9783319073224.
  15. Boriani S, Capanna R, Donati D, Levine A, Picci P, Savini R (May 1992). "Osteoblastoma of the spine". Clin. Orthop. Relat. Res. (278): 37–45. PMID 1563167.
  16. Elhawi, Mohamed E.; De La Roza, Gustavo L.; Damron, Timothy A. (2013). "Natural History of Untreated Osteoblastoma". JBJS Case Connector. 3 (4): e110. doi:10.2106/JBJS.CC.M.00130. ISSN 2160-3251.
  17. Aboulafia AJ, Kennon RE, Jelinek JS (1999). "Begnign bone tumors of childhood". J Am Acad Orthop Surg. 7 (6): 377–88. PMID 11505926.
  18. 18.0 18.1 18.2 Peabody, Terrance (2014). Orthopaedic oncology : primary and metastatic tumors of the skeletal system. Cham: Springer. ISBN 9783319073224.
  19. Bettelli G, Tigani D, Picci P (1991). "Recurring osteoblastoma initially presenting as a typical osteoid osteoma. Report of two cases". Skeletal Radiol. 20 (1): 1–4. PMID 2000498.
  20. Bruneau M, Polivka M, Cornelius JF, George B (2005). "Progression of an osteoid osteoma to an osteoblastoma. Case report". J Neurosurg Spine. 3 (3): 238–41. doi:10.3171/spi.2005.3.3.0238. PMID 16235709.
  21. Yin, Huabin; Zhou, Wang; Yu, Hongyu; Li, Binbin; Zhang, Dan; Wu, Zhipeng; Liu, Tielong; Xiao, Jianru (2013). "Clinical characteristics and treatment options for two types of osteoblastoma in the mobile spine: a retrospective study of 32 cases and outcomes". European Spine Journal. 23 (2): 411–416. doi:10.1007/s00586-013-3049-1. ISSN 0940-6719.
  22. Jawad MU, Scully SP (2010). "In brief: classifications in brief: enneking classification: benign and malignant tumors of the musculoskeletal system". Clin Orthop Relat Res. 468 (7): 2000–2. doi:10.1007/s11999-010-1315-7. PMC 2882012. PMID 20333492.
  23. Kirwan EO, Hutton PA, Pozo JL, Ransford AO (January 1984). "Osteoid osteoma and benign osteoblastoma of the spine. Clinical presentation and treatment". J Bone Joint Surg Br. 66 (1): 21–6. PMID 6693472.
  24. Morris CD, Hameed MR, Agaram NP, Hwang S (2017). "Elevated β-hCG associated with aggressive Osteoblastoma". Skeletal Radiol. 46 (9): 1187–1192. doi:10.1007/s00256-017-2647-0. PMID 28396962.
  25. <"https://radiopaedia.org/">Radiopaedia.org. From the case <"https://radiopaedia.org/cases/7593">rID: 7593
  26. Saccomanni, Bernardino (2009). "RETRACTED ARTICLE: Osteoid osteoma and osteoblastoma of the spine: a review of the literature". Current Reviews in Musculoskeletal Medicine. 2 (1): 65–67. doi:10.1007/s12178-009-9047-6. ISSN 1935-973X.
  27. Kroon HM, Schurmans J (June 1990). "Osteoblastoma: clinical and radiologic findings in 98 new cases". Radiology. 175 (3): 783–90. doi:10.1148/radiology.175.3.2343130. PMID 2343130.
  28. Resnick D. Tumors and tumor-like lesions of bone: imaging and pathology of specific lesions. In: Diagnosis of Bone and Joint Disorders.
  29. <"https://radiopaedia.org/">Radiopaedia.org. From the case <href="https://radiopaedia.org/cases/41171">rID: 41171
  30. Yin, Huabin; Zhou, Wang; Yu, Hongyu; Li, Binbin; Zhang, Dan; Wu, Zhipeng; Liu, Tielong; Xiao, Jianru (2013). "Clinical characteristics and treatment options for two types of osteoblastoma in the mobile spine: a retrospective study of 32 cases and outcomes". European Spine Journal. 23 (2): 411–416. doi:10.1007/s00586-013-3049-1. ISSN 0940-6719.
  31. Kroon, H M; Schurmans, J (1990). "Osteoblastoma: clinical and radiologic findings in 98 new cases". Radiology. 175 (3): 783–790. doi:10.1148/radiology.175.3.2343130. ISSN 0033-8419.
  32. Kroon, H M; Schurmans, J (1990). "Osteoblastoma: clinical and radiologic findings in 98 new cases". Radiology. 175 (3): 783–790. doi:10.1148/radiology.175.3.2343130. ISSN 0033-8419.
  33. Galgano MA, Goulart CR, Iwenofu H, Chin LS, Lavelle W, Mendel E (August 2016). "Osteoblastomas of the spine: a comprehensive review". Neurosurg Focus. 41 (2): E4. doi:10.3171/2016.5.FOCUS16122. PMID 27476846.
  34. Kirwan EO, Hutton PA, Pozo JL, Ransford AO (January 1984). "Osteoid osteoma and benign osteoblastoma of the spine. Clinical presentation and treatment". J Bone Joint Surg Br. 66 (1): 21–6. PMID 6693472.
  35. Marsh BW, Bonfiglio M, Brady LP, Enneking WF (January 1975). "Benign osteoblastoma: range of manifestations". J Bone Joint Surg Am. 57 (1): 1–9. PMID 1123354.
  36. de Andrea CE, Bridge JA, Schiller A (2013) Osteoblastoma. In: Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F, editors. WHO classification of tumours of soft tissue and bone. Lyon: International Agency for Research on Cancer; pp. 279-280

Information sourced from the following:

Erin O'Connor, MD, Assistant Professor, Department of Radiology, Temple University | Gregory Scott Stacy, MD, Assistant Professor of Radiology, Department of Radiology, University of Chicago Hospitals | Fred Ortmann, MD, Staff Physician, Department of Orthopaedics, University of South Carolina School of Medicine | John Eady, MD, Chairman, Professor, Department of Orthopedic Surgery, University of South Carolina School of Medicine | Bullough, Peter, Orthopaedic Pathologv (third edition), Times Mirror International Publishers Limited: London, 1997. | Gitelis S., R. Wilkins and EU Conrad, Benign Bone Tumors. Instructional Course Lectures, 45:425-46, 1991. | Huvos, Andrew, Bone Tumors: Diagnosis. Treatment and Prognosis, W.B. Saunders Co., 1991. | Ruggieri, P., RA McLeod, KK Unni and FH Sim, Osteoblastoma, Orthopedics, 19(7):621-4, July 1996.

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