Aneurysmal Bone Cyst

DM Eliza Princila Utami Pakaenoni

2008020009

Consulant:
dr. Su Djie To Rante,Sp.OT
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 Aneurysmal Bone Cyst

1. Aneurysmal bone cysts (ABCs) were first described in 1942 by Jaffe and Lichtenstein, who coined the term aneurysmal cyst because of
the pathologic appearance of the lesion within bone.

2. These bone lesions are benign and are typically associated with pain, swelling, or the presence of an expansile mass.

3. Common lesion sites include the femur, tibia, fibula, humerus, skull, and posterior elements of the spine.

4. Multiple theories have been proposed regarding the pathophysiology of ABC, including vascular, traumatic, and genetic etiologies.

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 Pathophysiology

Growth Phase
Early Phase
Characterized by the progressive destruction of
Osteolysis of the marginal part of the bone
bone. Demarcation of the lesion is poor during this
with discrete elevation of the periosteum
phase; bony shells and septations may not be
obvious on plain radiographs.

Stabilization Phase Healing Phase

Stabilization phase is defined by the classic Progressive ossification of the lesion is obvious and
ABC appearance: an expansile lesion with a results in a bony mass with a somewhat irregular
distinct bony shell and osseous septations. structure.

Dabska dan Buraczewski

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 Pathophysiology

Campanacci et al Ratcliffe and Grimer Lichtenstein

The lesion as a response The fracture altered the ABC is a reactive lesion rather than a
to local hemorrhage. intraosseous blood flow and true neoplasm and that vascular
An initial insult produces subsequently led to formation of disturbances in bone lead to
intraosseous bleeding, the lesion. increased intraosseous pressure,
leading to the formation of causing local destruction and
a cyst. distension of bone

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 Clinical Presentation

Gender Pain and swelling

Age

Age of onset ranges from 1 to 59 Males are affected more often than The patient with primary ABC
years, with the greatest prevalence females, with reported ratios typically reports pain and may
between ages 12 and 13 years. ranging from 1:1.04 to 1.8:1 present with soft-tissue swelling or
a palpable expansile mass

Secondary symptoms Location

Fever, weight loss, malaise, Commonly arises at sites such as the femur, tibia, humerus,
nausea, or vomiting are not and fibula. Other common locations include the skull and
common spinal column,

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 Clasification

Inactive Active Aggressive

The inactive tumor is the most An active lesion typically produces
benign because the lesion is Aggressive tumors are rapidly
mild symptoms such as pain, with expansile and destroy surrounding
contained. Expansion is rare, expansion and cortical thinning as
and there is minimal tissues. This subtype is typically the
well as a layer of reactive bone most symptomatic
inflammation or periosteal separating the lesion from normal
reaction bone visible on radiographs

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 Clasification

Capanna et al
• Type I lesions are centrally located and well contained, with either no outline or a slightly expanded outline.
• Type II lesions have marked expansion and cortical thinning with involvement of the entire bony segment.
• Type III lesions are eccentric and metaphyseal and typically involve only one cortex.
• Type IV lesions are the least common subgroup and develop subperiosteally, expanding away from the bone.
Type V lesions occur periosteally and expand peripherally, ultimately penetrating cortical bone.
 Imaging

AP (A) and lateral

(B) radiographs demonstrating an expansile metaphyseal lesion of the distal ulna with thinning of the bony
cortices and internal septations in a 46-year-old man who presented with a painful mass on the distal forearm.
C, Axial fat-saturated T2-weighted magnetic resonance image demonstrating fluid-fluid levels consistent with an
aneurysmal bone cyst (ABC). Histology confirmed ABC.
D, Postoperative AP fluoroscopic image of the distal ulna following en bloc resection. 9
 Imaging

A, AP radiograph of the distal femur demonstrating a well-defined metaphyseal lytic lesion in a 26-year-old
man who reported left knee pain and swelling for 6 months.
Axial noncontrast CT (B) and axial fat-saturated T2-weighted magnetic resonance image (C) of the same
lesion demonstrating internal septations, fluid-fluid levels, and thinning and erosion of the posterior cortex with
minimal soft-tissue expansion. Curettage with cryotherapy and subsequent bone grafting, cementing, and
internal fixation were performed. D, Postoperative AP radiograph of the distal femur following curettage,
grafting, and internal fixation.
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 HISTOLOGY

Histologic images of the aneurysmal bone cyst (ABC) in the patient shown in Figure 2. A, Low-power image
demonstrating numerous blood-filled cystic spaces lined and separated by fibrous septa, confirming the
diagnosis of ABC (hematoxylin-eosin, magnification ×4). B, High-power image demonstrating abundant
multinucleated osteoclast-type giant cells (arrows) within a dense background of bland fibroblastic cells in
the septae (hematoxylin-eosin, magnification ×20). Cystic cavities may also be appreciated at this power.
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 HISTOLOGY

A, Low-power histologic image demonstrating hypercellularity, a blood-filled cavity, and osteoid formation on
the left in a patient with telangiectatic osteosarcoma (TOS; hematoxylin-eosin, magnification ×10).
B, High-power histologic image demonstrating areas of hypercellularity, blood-filled cystic cavities, and the
presence of a small amount of unmineralized osteoid in a patient with a TOS (hematoxylin-eosin,
magnification ×20). Note the significant cellular atypia that clearly distinguishes this lesion from a benign
ABC.
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 DIFERENTIAL DIAGNOSE

FACTOR ANEURYSMAL BONE CYST

LESIONS
TALENGIECTATIC OSTEOSARCOMA

Typical age at onset year 10-20 10-20

Location Femur, tibia, fibula, humerus Distal femur, proximal tibia, proximal
humerus
Radiographic appearance Radiography demonstrates a Radiography demonstrates a
metaphyseal, eccentric, lucent, metaphyseal, lytic, and invasive lesion
cystic lesion that may have a that may have a balloonlike appearance
balloon-like appearance MRI MRI demonstrates fluid-fluid levels
demonstrates fluid-fluid levels

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 DIFERENTIAL DIAGNOSE

FACTOR ANEURYSMAL BONE CYST

LESIONS
TALENGIECTATIC OSTEOSARCOMA

Histologic appearance Blood-filled spaces separated by Blood-filled spaces separated by thicker

thin fibrous septa with benign- fibrous septa, with malignant-appearing
appearing spindle cells Osteoid with cells more easily noted at higher
or without osteoblastic rimming magnification Pleomorphism, atypical
Inflammatory cells and giant cells mitotic figures, and possible osteoid
may be present formation
Management Curettage with adjuvant Neoadjuvant chemotherapy, wide surgical
sclerotherapy, emobolization, or en resection and reconstruction,
bloc resection postoperative chemotherapy

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 Management

Diagnosis of ABC must be confirmed histologically before

initiating definitive treatment

Intralesional curettage Bone grafting Adjuvant therapy

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 THERAPY

CRYOTHERAPY SKLEROTHERAPY

Use of cryotherapy has been Sclerotherapy is a noninvasive management

found to reduce the recurrence method based on the theory that ABCs arise
rate of ABC. as a vascular malformation and would heal if
the hemmodynamic disturbance were
controlled.

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 THERAPY

Radionuclide Ablation Arterial embolization

Bush et al retrospectively reviewed The results of selective arterial embolization

five patients with large ABCs treated for management of ABC have also been
with a CT-guided injection of chromic evaluated.
phosphate P32.

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 THERAPY

En Bloc Resection
En bloc resection has been
associated with the lowest rate of
recurrence after initial treatment
compared with other management
methods.
Unfortunately, this technique is not
always feasible due to the location of
the lesion and its proximity to other
vital structures

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 Recurrence
1. In a long-term study of 150 ABCs treated over 20 years, Mankin et al34 reported a local
recurrence rate of approximately 20%. Patients in this series were treated primarily with
curettage and either implantation of allograft chips or polymethylmethacrylate.
2. Risk factor: younger age (<12), after curettage with a high speed burr.
3. Aggressive management is warranted because the risk of complications such as violation of
articular cartilage or destruction of the physis could predispose the patient to future angular
deformity or limblength discrepancy.
4. Histologic evaluation may serve as a prognostic indicator of recurrence.

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 MALIGNANT
1. TRANSFORMATION
Malignant transformations of ABCs have been reported. Some reports were associated with the
use of adjuvant radiation in addition to primary treatment.

2. Brindley et al reported on two cases of malignant transformation that occurred 5.5 and 12
years, respectively, after the ABCs were managed with intralesional curettage without adjuvant
radiation. A TOS and fibroblastic osteosarcoma, respectively, were identified at the sites of the
ABC. These cases demonstrate the need for continued long-term follow-up, especially if
symptoms recur or change.

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