Osteoblastoma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

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

Osteoblastoma
DiseasesDB	31488
MeSH	C4557

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Evidence Based Medicine
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Overview

Osteoblastoma is an uncommon primary neoplasm of the bone. It has clinical and histologic manifestations similar to those of osteoid osteoma; therefore, some consider the two tumors to be variants of the same disease, with osteoblastoma representing a giant osteoid osteoma. However, an aggressive type of osteoblastoma has been recognized, making the relationship less clear.

Historical Perspective

• In 1952, Lichtenstein first termed the leision as Osteogenic fibroma of bone.
• In 1954, Dahlin and Johnson, called the tumor a giant osteoid osteoma for its histologic similarity to osteoid osteoma, they reported 11 aggressive but benign tumors that were commonly difficult for less experienced pathologists to differentiate from malignancy.
• In 1956, Lichtenstein and Jaffe in their independent detailed studies of the neoplasm termed the leision as Osteoblastoma.
• In 1977, Jackson et al. published a review of 181 osteoblastomas from the literature and reported that spine is the location of 36% of the osteoblastomas.
• In 1984, Dorfman and Weiss reported on the aggressive Osteoblastoma and termed it as a borderline osteoblastic tumor entity.

Classification

• Osteoblastoma may be classified into two subtypes:
  • Conventional/benign Osteoblastoma
  • Aggressive/malignant Osteoblastoma
• A controversial aggressive tumor is reported which is malignant in nature as compared to the conventional/benign Osteoblastomas.
• On histological examination the aggressive/malignant Osteoblastoms contain:
  • A large number epithelioid osteoblasts with abnormal appearance of the cell nuclei.

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.
• The expansion usually occurs when the primary site of Osteoblastoma is with in 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 clinico pathologic 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 aggresive nature the Osteoblastomas can sometimes mimic malignancy on radiographic studies.

Causes

The cause of Osteoblastoma has not been identified.

Differentiating Osteoblastoma from Other Diseases

• Osteoblastoma must be differentiated from:
  • Osteosarcoma
  • Osteoid osteoma
  • Aneurysmal bone cyst
  • Stress fracture
  • Osteomyelitis
  • Bone abscess

Epidemiology and Demographics

• In the United States, Osteoblastoma constitutes for almost 1% of all primary bone tumors and 3% of all benign tumors.
• Patients of all age groups may develop Osteoblastoma.
• The mean age reported in a literature study conducted by Lucas DR at the time of diagnosis is 20.4 years, but it may be seen at any age.
• Males are more commonly affected by Osteoblastoma than females.
• The male to female ratio is 2 to 1.
• Osteoblastoma is a benign tumor of the musculoskeletal system and is associated with little morbidity.

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

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Criteria

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

History and Symptoms

• The majority of patients with Osteoblastoma have a positive history of pain which is dull and achy in nature.
• The pain is not relieved by salicylates.
• Neurologic conditions occur often due to compression of either the spinal cord or nerve roots and lead to:
  • Paralysis
  • Spinal stiffness
• The frequently associated conditions are:
  • Scoliosis
  • Torticollis

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

There are no diagnostic laboratory findings associated with Osteoblastoma.

Electrocardiogram

There are no ECG findings associated with Osteoblastoma.

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography or ultrasound findings associated with Osteoblastoma.

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

• The most sensitive radiographic examination for the evaluation of Osteoblastoma is a bone scan.

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

The first route of treatment in Osteoblastoma is via medical means. Although necessary, radiation therapy (or chemotherapy) is controversial in the treatment of osteoblastoma. Cases of postirradiation sarcoma have been reported after use of these modalities. However, it is possible that the original histologic diagnosis was incorrect and the initial lesion was an osteosarcoma, since histologic differentiation of these two entities can be very difficult.

The alternative means of treatment consists of surgical therapy. The treatment goal is complete surgical excision of the lesion. The type of excision depends on the location of the tumor. For stage 1 and 2 lesions, the recommended treatment is extensive intralesional excision, using a high-speed burr. Extensive intralesional resections ideally consist of removal of gross and microscopic tumor and a margin of normal tissue. For stage 3 lesions, wide resection is recommended because of the need to remove all tumor-bearing tissue. Wide excision is defined here as the excision of tumor and a circumferential cuff of normal tissue around the entity. This type of complete excision is usually curative for osteoblastoma.

In most patients, radiographic findings are not diagnostic of osteoblastoma; therefore, further imaging is warranted. CT examination performed with the intravenous administration of contrast agent poses a risk of an allergic reaction to contrast material.

The lengthy duration of an MRI examination and a history of claustrophobia in some patients are limiting the use of MRI. Although osteoblastoma demonstrates increased radiotracer accumulation, its appearance is nonspecific, and differentiating these lesions from those due to other etiologies involving increased radiotracer accumulation in the bone is difficult. Therefore, bone scans are useful only in conjunction with other radiologic studies and are not best used alone.

Medical Therapy

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Surgery

Surgical intervention is not recommended for the management of [disease name].

OR

Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]

OR

The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].

OR

The feasibility of surgery depends on the stage of [malignancy] at diagnosis.

OR

Surgery is the mainstay of treatment for [disease or malignancy].

Primary Prevention

There are no established measures for the primary prevention of [disease name].

OR

There are no available vaccines against [disease name].

OR

Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

OR

[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

Secondary Prevention

There are no established measures for the secondary prevention of [disease name].

OR

Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].

References

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.