1. Volume 8
Round Cell Tumors of Bone
Ewing’s sarcoma-----------------Case 169-175 & 861-900
Large cell lymphoma------------Case 176-178 & 901-933
Hodgkin’s lymphoma-----------Case 179-180 & 934-936
Leukemia-------------------------Case 181 & 937-944
Plasma cell tumors
Solitary plasmacytoma-------Case 182-185 & 946-957
Multiple myeloma------------Case 186-188 & 958-976
Metastatic neuroblastoma------Case 189 & 977-983

2. Round Cell
Tumors Of Bone

3. Ewing’s Sarcoma

4. Ewing’s Sarcoma
The Ewing’s sarcoma is the second most common primary
malignant bone tumor seen in children and is the fourth most
common malignant tumor overall. This tumor is a very primitive
mesenchymal sarcoma that has a mysterious etiology. However,
with the advent of the electron microscope and immunohisto-
chemical studies, most experts today feel that this tumor probably
represents a poorly differentiated member of a larger family of
neural tumors, distinct from the neuroblastoma. In 90% of cases,
cytogeneticists will find reciprocal translocation in chromosome
11 and 22. That also is found in patients with the diagnosis of
primative neuroectodermal tumor (PNET) and Askin’s tumor.
Other round cell tumors that have a similar histological appearance
include the embryonal rhabdomyosarcoma, the mesenchymal
chondrosarcoma, and the metastatic neuroblastoma. It is very
important to separate out the large group of histiocytic lymphomas

5. seen in an older age group that have a similar appearance with
H & E staining. With special staining techniques, most lymphomas
will be positive for leukocyte antigen. Likewise with metastatic
embryonal rhabdomyosarcoma, specific immunohistochemical
studies will reveal muscle markers such as actin, desmin, and
myoglobin not found in the Ewing’s sarcoma.
Ninety percent of patients with Ewing’s sarcoma will be from 5
to 25 years of age, with males being affected slightly more than
females. The two most common locations for Ewing’s sarcoma are
the femur and pelvis, followed by the tibia, humerus and scapula,
but it can be found in any location in the body that includes
myelogenous tissue, including the spine, ribs, foot and hand. Radio-
graphically, the Ewing’s tumor will be found typically in a meta-
diaphyseal location in the medullary canal with very diffuse,
permeative lytic destruction of the surrounding cortical structures
that looks like hematogenous osteomyelitis. Likewise, the clinical
appearance of Ewing’s sarcoma can mimic infectious disease

6. with elevated temperature, white count and sed rate. Because of the
high incidence of necrosis with the Ewing’s sarcoma, it is common
to find liquefied necrotic debris in the tumor site that gives the
clinical appearance of osteomyelitis. With early breakthrough into
the subperiosteal tissues, the radiographic finding of a reactive
periostitis is quite common, creating a multilaminated “onionskin”
appearance on a routine radiograph. Another characteristic radio-
graphic finding is the “hair-on-end” appearance that is created
by reactive new bone formation along the perpendicular periosteal
blood vessels running between the periosteum and the subadjacent
cortex.
Prior to 1970, the prognosis for survival in Ewing’s sarcoma was
extremely poor with approximately 10% of patients surviving their
disease. Currently with the use of adjuvant systemic chemotherapy
in non-metastatic Ewing’s sarcoma, the survival prognosis now runs
approximately 70%. However, in about 20% of patients with
Ewing’s sarcoma that present with metastatic disease to other bones

7. or to the lung, the survival rate drops to about 30%. Whenever
possible, the orthopedic oncologist will attempt a wide resection of
the primary tumor site, a technique similar to that used for osteo-
sarcoma. If wide surgical margins are obtained, the chances for
survival is probably better than if radiation therapy and chemo-
therapy had been used without surgery. However, in cases where
the surgical margins are positive at the time of surgical resection,
postoperative radiation therapy is indicated. The chance for local
recurrence with chemotherapy and radiation therapy alone is 20%
or higher. A devastating complication of radiation therapy is path-
ological fracture that frequently results in intramedullary fixation
that may fail and can result in amputation. Secondary sarcomas can
occur with the use of radiation therapy for Ewing’s sarcoma in 10%
of cases. The primative neuroectodermal tumor accounts for 10%
of all Ewing’s-like tumors and carries the same prognosis for
survival. The clinical management for this entity is essentially the
same as for Ewing’s sarcoma.

8. CLASSIC
Case #169
13 year female
Ewing’s sarcoma
distal femur
onion skin
periostitis

9. Bone scan

10. Coronal proton
density MRI

11. Coronal T-2 MRI

12. Coronal T-2 MRI
showing multifocal
disease

13. necrotic
Macro section Ewing’s
sarcoma distal femur
viable

14. Photomic showing pseudo-rosette formations

15. Same patient with
multifocal involvement
proximal humerus

16. Case #170
15 year female
Ewing’s sarcoma
proximal tibia

17. Lateral view

18. Sagittal T-1 MRI

19. Axial T-1 MRI

20. Compress
system
Photo of resected proximal tibia & prosthesis

21. Placement of rotating
hinge Compress prosthesis

22. Attachment of
patellar ligament with
double tooth washers

23. X-ray 2 mos post op
anchor plug

24. 5.5 years post op
with excellent
osseointegration at
bone-prosthetic
interface

25. 11 years post op

26. Case #171
19 year female
Ewing’ sarcoma
proximal femur

27. Bone scan

28. 1 year later with
path fracture thru
radiated bone

29. Persistent non union
after IM nailing

30. X-ray 1 year post op
placement of cemented
long stem custom
bipolar prosthesis

31. Case #172
permeative
lysis
13 year male with
“hair-on-end”reactive
subperiosteal new
bone formation

32. Macro section resected
proximal femur

33. periostium
Closeup macro section
showing “hair-on-end” necrosis
reactive subperiosteal
new bone
permeation

34. periostium
Closeup macro section
“hair-on-end” subperiosteal
reactive bone formation

35. Photomic Ewing’s sarcoma

36. Case #173
hair-on-end
15 year male Ewing’s
sarcoma femur
onion skin

37. Case #174
28 year male with Ewing’s sarcoma pelvis

38. tumor
CT scan

39. Case #175
14 year male with Ewing’s sarcoma pelvis

40. ilium
Macro section from
tumor
autopsy specimen
acetabulum

41. Photomic

42. Case #861
34 year female with Ewing’s sarcoma pelvis

43. Close up hip

44. Coronal Gad contrast MRI

45. Coronal T-2 MRI

46. Axial T-1 MRI

47. Axial proton density MRI

48. Photomic

49. Case #862 Coronal T-1 MRI
tumor
28 year male with Ewing’s sarcoma pubis

50. tumor
Coronal T-2 MRI

51. tumor
T-2 MRI

52. tumor
Coronal T-2 MRI

53. tumor
Axial PD MRI

54. Photomic

55. Axial PD MRI following successful chemotherapy

56. Coronal T-2 MRI post chemo

57. Case #863
10 year female with Ewing’s sarcoma pelvis

58. 6 months later

59. Coronal T-1 MRI

60. Coronal T-2 MRI

61. Case #864
19 year male with Ewing’s sarcoma SI area

62. Axial gad contrast MRI

63. Axial T-2 MRI

64. Photomic

65. Post op cementation

66. Case #865
19 year male
Ewing’s sarcoma
sacrum

67. Close up

68. Myelogram showing
nerve root pressure

69. tumor
CT scan

70. Photomic

71. Case #866
12 year male
Ewing’s sarcoma
L-5

72. Oblique view

73. Case #867
37 year male
Ewing’s sarcoma
proximal femur

74. Coronal T-1 MRI

75. Photomic

76. X-ray allograft
prior to implantation
lateral
AP

77. Post op alloprosthetic
reconstruction

78. Case #868
14 year male
Ewing’s sarcoma
mid femur
Bone scan

79. Coronal proton
density MRI
Pre chemo

80. Axial PD MRI pre chemo

81. Photomic

82. Axial PD MRI post chemo

83. Amputation following good chemo response

84. cement
Post op x-ray with modified bipolar reconstruction

85. Case #869
21 year male with Ewing’s sarcoma pelvis and femur

86. Coronal T-1 MRI

87. tumor
Coronal T-2 MRI

88. Coronal T-2 MRI

89. Case #870
7 year male
Ewing’s sarcoma
distal femur

90. Bone scan

91. Sagittal proton
density MRI

92. tumor
Axial T-1 MRI

93. Photomic

94. Axial T-2 MRI post chemo

95. Coronal T-2 MRI post chemo

96. Case #871
13 year male
Ewing’s sarcoma
femur

97. 5 years after
radiation & chemo
with recurrence &
path fracture

98. Post op x-ray with
IM nail for path
fracture

99. tumor bulge
Total femur replacement specimen

100. Custom total femur replacement prosthesis

101. Placement of custom prosthesis

102. Post op X-ray

103. Case #872
16 year male
Ewing’s sarcoma
proximal femur

104. Lateral view

105. Coronal T-1 MRI

106. Coronal T-2 MRI

107. Axial proton density MRI

108. Case #873
9 year male with Ewing’s sarcoma tibia

109. Bone scan

110. Sagittal T-1 MRI T-2 MRI

111. Post op reconstruction
allograft over IM nail

112. 8 years later

113. Case #875
onion skin
laminated
2.5 year male periostitis
Ewing’s sarcoma
distal tibia

114. Lateral view entire tibia

115. Coronal T-1 MRI

116. Axial T-1 Gad contrast MRI

117. Case #876
17 year male with
Ewing’s sarcoma tibia

118. Different view

119. Post op alloprosthetic allograft
reconstruction

120. Multifocal lesion prox
femur 6 mos later

121. Case #877
19 year female with tumor
Ewing’s sarcoma
proximal humerus
hair on
end

122. Post op alloprosthetic
reconstruction

123. Case #878
39 year male
Ewing’s sarcoma
proximal humerus

124. X-ray one year later
without treatment

125. Photomic

126. Case #879
10 year male with Ewing’s sarcoma scapula

127. Scapular view

128. Bone scan

129. CT scan

130. Special CT scan scapula

131. Case #880
9 year male with Ewing’s sarcoma scapula

132. Case #881
20 year male with Ewing’s of scapula

133. Soft tumor
Special soft tissue technique x-ray

134. Case #882
16 year male with Ewing’s sarcoma clavicle

135. Case #883
16 year female with Ewing’s sarcoma clavicle

136. Case #884
7 year female with Ewing’s sarcoma 3rd posterior rib

137. Case #885
17 year female with Ewing’s sarcoma post 7th rib

138. Case #886
11 year male with Ewing’s sarcoma rib

139. Case #887
12 year female
Ewing’s sarcoma
fibula

140. Macro section from
resected specimen

141. Scanning lens
photomic

142. Higher power

143. Case #888
20 year female
Ewing’s sarcoma
distal fibula

144. tumor
Axial T-2 MRI

145. Case #888.1 Ewing’s Fibula
15 yr male with pain and swelling of leg for 3 months

146. Cor T-1 T-2 Gad

147. Axial T-1 T-2
Gad

148. Case #889
15 year female
Ewing’s sarcoma
proximal fibula

149. Case #890
18 year male
Ewing’s sarcoma
distal fibula

150. Bone scan

151. Case #891
17 year male with Ewing’s sarcoma 4th metatarsal

152. Coronal T-1 MRI

153. tumor
Axial T-1 MRI

154. tumor
Axial T-2 MRI

155. Photomic with pseudo-rosettes

156. CT scan thoracic spine shows multi focal lesion

157. Coronal CT scan

158. Case #892
35 year female with Ewing’s sarcoma os calcis

159. tumor
Several months later

160. tumor
T-1 MRI

161. tumor
Gad contrast MRI

162. Case #893
21 year male
Ewing’s sarcoma
mid tarsal area

163. Case #894
20 year male
Ewing’s sarcoma
2nd toe

164. Case #895
5 year female
Ewing’s sarcoma
proximal ulna

165. Lateral view

166. Axial T-1 MRI

167. Sagittal T-1 MRI

168. Coronal T-2 MRI

169. Photomic

170. Case #896
50 year female with Ewing’s sarcoma proximal ulna

171. Case #897
2 year old with Ewing’s
sarcoma middle finger

172. Lateral view

173. Sagittal T-1 MRI

174. Photomic

175. Case #898
15 year male with Ewing’s sarcoma thumb

176. Case #898.1 Parosteal Ewing’s sarcoma
18 year male with lateral knee knee for 3 months

177. Bone scan

178. Axial T-1 Axial Gad C+

179. Coronal STIR Gad C+ Sagittal Gad C+

180. Case #898.2 Parosteal Ewing’s sarcoma
13 year male with painful mass in forearm for 3 months

181. Bone scan

182. Cor T-1 T-2 FS

183. Sag T-1 Gad

184. Axial T-2 Gad
Post chemo T-2 Gad

185. Case #898.3 Parosteal Ewing’s Sarcoma Humerus
27 yr female with firm tender mass in upper medial arm for 2 mos.

186. Axial T-2 Gad

187. Cor T-1 T-2 Gad

188. Ewing’s Sarcoma
Pseudotumors

189. Case #899
onion skin
periostitis
11 year female
osteomyelitis distal femur
looking like Ewing’s
sclerosis
sarcoma

190. Lateral view

191. Bone scan

192. Coronal T-2 MRI

193. Axial T-2 MRI

194. Photomic of reactive periostitis

195. polys
lymphs
Photomic showing inflammatory cells

196. Case #899.1 Ewing’s pseudotumor Osteomyelitis
3/06 7/07 7/07
14 year old male with pain right arm for 17 months

197. Cor T-1 T-2 Gad

198. Axial T-1 T-2 Gad

199. Case #900
8 year male with acute
fracture thru prior
femoral stress fracture
stress
periostitis
Day of fracture

200. 3 days after acute fracture
Stress
periostitis

201. At 3 weeks looking
like Ewing’s sarcoma

202. 6 mos later with solid
union unlike Ewing’s
sarcoma

203. Case #900.1 Stress Periostitis Radius
Axial T-2
16 yr male with forearm pain
for 6 weeks
Gad

204. Case #900.2 Stress Periostitis Femur
May June
10 yr male with pain in thigh for 2 months

205. Cor T-1 T-2 Sag T-2

206. Axial T-2
Axial CT

207. Case #900.5
Eosinophillic granuloma
fibula looking like
Ewing’s sarcoma in a
5 year male

208. Lymphoma of
Bone

209. Lymphoma of Bone
Lymphoma of bone accounts for approximately 7% of all primary
malignant tumors of bone and can be divided roughly into two
clinical groups: Hodgkin’s lymphoma of bone and non-Hodgkin’s
lymphoma of bone. Hodgkin’s lymphoma carries a much better
prognosis for survival. It tends to be localized and presents with a
radiographic appearance that frequently includes a dense, sclerotic
response. The non-Hodgkin’s lymphomas can be divided into
two categories. The systemic form, the most common form with
generalized involvement of the entire lymphatic system including
soft tissue and bone, carries a poor prognosis. The less common
form that is found in bone and does not have systemic manifestations
carries a better prognosis for survival. To meet the strict criteria for
a primary lymphoma of bone, the disease must be contained within
the skeletal system for at least six months before becoming
disseminated to other lymphatic organs such as lymph nodes and

210. spleen, at which time the prognosis for survival becomes much
worse. The age group for primary lymphoma of bone is between
25 and 50 years. The most common bones involved are the spine
and pelvis in 50% of cases. In the extremities, the most common
location is the femur followed next by the humerus and tibia with
multiple skeletal sites involved in approximately 25% of cases.
Radiographically, the primary lymphoma takes on a permeative
lytic appearance in cortical bone in a metadiaphyseal location,
but can also involve epiphyseal bone as well. Because of the
permeative nature of the bone destruction, pathologic fractures are
common, similar to the situation with Ewing’s sarcoma. In both
primary lymphoma and Ewing’s sarcoma, large soft tissue masses
can be found. With H&E staining, the histological appearance
of lymphoma and Ewing’s sarcoma can be quite similar but with
specific immunohistochemical staining techniques, B cell and T cell
subtypes of lymphoma can be identified and clearly separated
from Ewing’s sarcoma. As in the case of Ewing’s sarcoma, the

211. advent of chemotherapy dramatically improved the prognosis for
survival that, for a solitary primary lymphoma of bone, is similar to
Ewing’s sarcoma with a 70% five year survival. However, with more
disseminated involvement of multiple bones or other lymphatic
organs, the prognosis drops dramatically to 10-25%. As with Ewing’s
sarcoma, the lymphoma of bone is quite sensitive to external beam
radiation therapy. However, the complications (including path-
ological fracture) are a problem and the orthopedic oncologist will
attempt a wide resection of the tumor if possible or, in more extensive
involvement, an intralesional approach with a long stem cemented
prosthesis with adjuvant bone cement may be indicated to avoid
pathological fracture. In cases of systemic involvement with extensive
metastatic disease, patients can be considered for bone marrow
transplantation. The same holds true for Ewing’s sarcoma.

212. CLASSIC
Case #176
45 year male
lymphoma proximal
femur
path fracture

213. Frog leg lateral

214. signal void
Bone scan

215. tumor
Coronal T-1 MRI

216. tumor
Coronal T-2 MRI

217. Axial T-2 MRI

218. High power photomic showing folded nuclear forms

219. Case #176.1 Large cell lymphoma
47 yr old male smoker with 4 mo history of left hip pain

220. Bone scan

221. Coronal
T-1 T-2

222. Axial
T-1 T-2

223. Post op recon nailing

224. Case #176.2 Large cell lymphoma
69 yr female with painful hip for 3 months

225. Cor CT scan Axial

226. Case #177
83 year female with lymphoma right pelvis

227. 6 months later with pathologic fracture

228. Another 6 mos later

229. Bone scan

230. Photomic

231. Case #178
40 year female
lymphoma lower
spine
Sagittal T-2 MRI

232. Sagittal T-2 MRI
upper spine

233. Sagittal T-2 MRI
mid spine

234. Case #178.1 Lymphoma sacrum
72 year male with LBP for many years

235. Bone scan

236. Axial T-1 MRI
T-2 Gad

237. T-1
T-2
Sagittal
Gad
STIR

238. Case #901
17 year male with lymphoma acetabulum

239. tumor
Coronal T-1 MRI

240. tumor
Axial T-1 MRI

241. tumor
Axial T-2 MRI

242. Photomic

243. Good response from
chemotherapy

244. Case #902
49 year male with lymphoma pelvis

245. tumor
CT scan

246. Case #902.1 Lymphoma of pelvis
69 year male with 2 month history of left hip pain

247. tumor
Coronal T-1 T-2 Gad C+

248. Sagittal T-1 T-2 Gad

249. Axial
T-1
T-2
Gad

250. Case #903
44 year male with
lymphoma pelvis

251. Case #904
31 year male with lymphoma pelvis

252. Bone scan

253. Case #905
40 year male
lymphoma pelvis

254. Case #906
47 year male
lymphoma
distal femur

255. Lateral view

256. Bone scan
6 months later

257. Sagittal T-1 MRI

258. Sagittal T-1 MRI thru notch

259. tumor
Sagittal T-2 MRI

260. tumor
Axial T-2 MRI

261. Photomic

262. Case #906.5
49 year male with lymphoma distal femur

263. Lateral view

264. Bone scan

265. Sagittal T-1 MRI

266. Coronal T-1 MRI

267. tumor
Coronal STIR MRI

268. Case # 906.6 Large cell lymphoma knee
48 year female with medial knee pain 1 year and history of
torn medial meniscus & 18000 WBC & elevated cholesterol

269. Bone scan

270. Sag T-1 Cor T-2

271. Axial PD
Femoral cut Tibial cut

272. Case #906.7 Lymphoma Bone scan
58 year male with painful swelling above knee for 3 months

273. Cor T-1 T-2 FS

274. Axial PD T-2

275. Sag PD T-2

276. Case #906.8 Lymphoma Path Fracture Distal Femur
55 yr female with recent severe knee pain & prior breast CA

277. Axial CT scan
Bone scan

278. Cor T-1 T-2

279. Case #907
23 year female
lymphoma
distal femur

280. Lateral view

281. Bone scan

282. Sagittal T-1 MRI

283. Coronal T-1 MRI
tumor

284. tumor
tumor
Coronal STIR MRI

285. Positive silver stain for reticulum fiber

286. Case #908
28 year male
lymphoma femur

287. Macro section
resected specimen

288. Photomic

289. Case #909
34 year male with
lymphoma prox femur

290. Frog lateral

291. Case #910
38 year male
pathologic fracture
lymphoma prox femur

292. Case #911 Axial T-1 MRI
tumor
77 year male with parosteal lymphoma femur

293. tumor
Axial T-2 MRI

294. Case #912
17 year male
lymphoma distal
femur

295. AP view

296. Coronal T-1 MRI
tumor

297. tumor
Sagittal T-1 MRI

298. Case #913 Coronal T-1 MRI
54 year male with HIV lymphoma proximal femur

299. tumor
Axial proton density MRI

300. Case #914
65 year female
ORIF hip fracture
prior history of
lymphoma 5 yrs ago

301. 5 years later with
OGS at healed
fracture site

302. Bone scan shows multifocal OGS

303. Case #915
41 year male
lymphoma
proximal tibia

304. Lateral view

305. Oblique view
3 months later

306. Pathologic fracture
following radiation
therapy at 6 months

307. Photomic

308. Custom total knee
prosthesis for
reconstruction

309. Post op x-ray with
prosthetic reconstruction

310. Case #916
34 year female
lymphoma prox tibia

311. Sagittal T-1 MRI

312. Sagittal T-2 MRI

313. Case #917
21 year female with lymphoma proximal tibia

314. Coronal T-1 MRI

315. tumor
Sagittal T-1 MRI

316. Case #918
26 year female
lymphoma distal
tibia

317. tumor
Coronal T-1 MRI

318. Sagittal T-1 MRI
tumor

319. tumor
Axial T-2 MRI

320. Case #919
29 year female
lymphoma proximal
humerus

321. Bone scan

322. Coronal T-1 MRI

323. tumor
Axial proton density MRI

324. Photomic

325. Case #920
Pathologic fracture
lymphoma proximal
humerus in a 64 year
female

326. Bone scan

327. Coronal T-2 MRI tumor

328. Case #921
38 year female with
lymphoma humerus

329. Bone scan

330. Coronal T-2 MRI

331. Case #922
27 year male
lymphoma distal
humerus

332. Sagittal T-1 MRI

333. tumor
Axial T-2 MRI

334. Photomic

335. Case #923
28 year male with lymphoma proximal ulna

336. Axial T-1 MRI

337. Axial T-2 MRI
tumor

338. Case #924 Laminogram x-ray
50 year female with lymphoma proximal ulna

339. Case #925 Sagittal T-1 MRI
tumor tumor
64 year female with soft tissue lymphoma forearm

340. tumor
Axial proton density MRI

341. Axial T-2 MRI

342. Case #926
70 year female with
lymphoma distal radius

343. Case #927
Tumor defect
20 year male with lymphoma sacrum
1 year post resection and radiation therapy

344. 2.5 years post op

345. Case #928
43 year male with lymphoma 11th posterior rib

346. Resection specimen cut in path lab

347. Photomic

348. Lymphoma
Pseudotumors

349. Case #929
pain
73 year female with radiation osteitis 2nd to radiation
therapy for ovarian carcinoma 19 years ago

350. 9 days later with path fracture looking like lymphoma;
biopsy negative for sarcoma

351. 2 weeks later with progressive collapse

352. 6 weeks later and more collapse

353. Coronal T-1 MRI with low signal like a lymphoma

354. Coronal proton density MRI

355. Case #929.1 Lymphoma pseudotumor
transient osteoporosis
25 year male alcoholic and smoker with R hip pain 4 mos

356. Cor T-1
Cor T-2

357. Axial T1
Axial T-2

358. Case #930
52 year male
radiation osteitis
humerus 2nd to
radiation for soft
tissue sarcoma
years ago now looking
like a lymphoma

359. Pathologic fracture
later requiring
IM nail

360. Case #931
54 year male tennis player with stress fracture sacrum

361. R L
Bone scan

362. CT scan showing fracture callus

363. pseudotumor
Coronal T-1 MRI showing low signal like lymphoma

364. Coronal T-2 MRI showing high signal from fracture

365. Case #932
22 year male
stress fracture thru
lateral plateau looking
like a lymphoma

366. Bone scan hot like lymphoma

367. Sagittal T-1 MRI
showing fracture
edema looking
like lymphoma

368. Case #933
32 year female
mastocytosis spine &
pelvis looking like
large cell lymphoma

369. Femoral mastocytosis
looking like lymphoma

370. Similar lesions
distal femur

371. Same changes
in humerus

372. Changes in ribs &
humerus

373. Hodgkin’s
Lymphoma

374. CLASSIC
Case #179
40 year male
blastic form of
Hodgkin’s lymphoma
L-4

375. Photomic showing Reed-Sternberg cell

376. Case #180
33 year female with Hodgkin’s disease SI area

377. Photomic with Reed-Sternberg cells

378. Case #934
58 year male with blastic form Hodgkin’s lymphoma pelvis

379. Left iliac lesions

380. Right iliac lesion

381. Photomic with Reed-Sternberg cells & eosinophils

382. Case #935
38 year male with
blastic form of lymphoma
L-3

383. Case #936
51 year male
lytic form of
Hodgkin’s lymphoma
L-4

384. eosinophil
Photomic with Reed-Sternberg cell

385. Case #936.1 Hodgkin’s lymphoma
28 year old male with hip pain for past 3 months

386. Bone scan

387. Cor T-1 T-2 Gad

388. Axial T-1 T-2
gad

389. Case #936.2 Hodgkin’s of Scapula
25 yr male with pain in shoulder 1 year

390. Cor T-2 Gad

391. Axial T-2 Axial Gad
Sag T-2 Sag Gad

392. Leukemia

393. CLASSIC Case #181
10 year female with hemorrhagic purpura second to
acute lymphoblastic leukemia

394. Transverse radioleucent metaphyseal bands seen in
acute lymphoblastic leukemia

395. Lymphoblasts in peripheral blood smear

396. Case #937
59 year male
chronic lymphocytic
leukemia
Bone scan

397. Coronal T-1 MRI

398. Sagittal T-1 MRI

399. Coronal T-1 MRI

400. Coronal T-1 MRI

401. Coronal T-2 MRI

402. Lymphoblasts seen in marrow smears

403. Case #938
4.5 year male
acute lymphoblastic
leukemia

404. Bone scan

405. Axial T-2 MRI

406. Lymphoblasts in peripheral blood smeer

407. Case #939
40 year male
5 year history of
chronic lymphocytic
leukemia with chronic
reactive periostitis

408. Lateral view

409. Case #940
14 month female with
acute lymphoblastic
leukemia femur showing
laminated periostitis

410. Casswe #941
43 year male with
tumor
chronic granulocytic
leukemia with focal
lesion in femur

411. tumor
Another view

412. Case #941.1 Acute lymphocytic leukemia
3/06 4/06 6/06
12 year female with wrist pain and elevated sed rate 3 mos

413. 6/06
Coronal T-1 T-2 Sagittal T-2

414. Case #942
4 year female
acute lymphocytic
leukemia with
laminated periostitis
fibula

415. Case #943
4 year male
acute lymphocytic
leukemia hand

416. Case #944
40 year female
chronic lymphocytic
leukemia with
osteoporotic codfish
shaped vertebral bodies

417. AP view

418. Plasma Cell
Tumors

419. Solitary
Plasmacytoma

420. Solitatary Plasmacytoma
To fit the strict criteria for the diagnosis of a solitary plasmacytoma,
the patient should present with a single bony involvement, as
demonstrated by a bone skeletal survey, and remain free of other
bony site involvement for at least six months after the initial
diagnosis. Unfortunately, in approximately 70% of cases, the
solitary form of the disease will disseminate into the more common
form of multiple myeloma. Likewise, in the case of pure solitary
plasmacytoma, the serum protein electrophoresis study is
completely normal in 75% of cases with the remaining 25%
showing a mild abnormality. The age group for solitary plasma-
cytoma is slightly younger than multiple myeloma, typically before
the age of 40 years. The most common sites of involvement
include the spine, pelvis and proximal femur with radiographic
evidence of a solitary lytic destruction of bone that may take on the
appearance of a benign lesion such as a solitary form of fibrous

421. dysplasia. Because the disease is purely lytic in nature, the bone
isotope scan may be negative.
Since the disease is considered localized at first, the treatment is
localized with a wide surgical resection and prosthetic replacement,
with or without bone cement, followed by local radiation therapy
if the margins are positive. No systemic chemotherapy is used until
the disease becomes more disseminated as demonstrated by increased
levels of abnormal myeloma protein found by serum electrophoresis
studies. The prognosis for survival is quite good until the disease
becomes more disseminated which is usually within three years
after the initial diagnosis.

422. CLASSIC Case #182
40 year male with solitary plasmacytoma pelvis

423. Bone scan showing
signal void

424. Axial T-1 MRI

425. Axial T-2 MRI

426. Photomic showing plasma cells

427. High power

428. Case #183
42 year male with solitary plasmacytoma pelvis

429. Axial T-1 MRI

430. Axial T-2 MRI

431. Post op x-ray after
radiation therapy &
total hip replacement

432. Case #184
53 year male
solitary plasmacytoma
proximal femur

433. Pathologic fracture one year later

434. Post op x-ray with
cemented long stem
biopolar prosthesis

435. Case #185
55 year male
solitary plasmacytoma
proximal femur

436. Case #185.1 Solitary plasmacytoma
40 year male with
increasing pain in
thigh for 6 mos

437. Bone scan

438. Sag T-1 PD FS Cor STIR

439. Axial T-1
T-2
Gad

440. PO interlocking nail
and cementation

441. Case #946
49 year male
solitary plasmacytoma
acetabulum

442. tumor
CT scan

443. Bone scan

444. Photomic

445. Steinman pin
Reconstruction with
metal cage

446. Cementation over metal
and completed THA
inside cage

447. Post op X-ray

448. Case #947
tumor
32 year male with solitary plasmacytoma acetabulum

449. Coronal T-1 MRI

450. Case #948
53 year male with
solitary plasmacytoma
sacrum

451. R L
Bone scan shows signal void in tumor

452. tumor
CT scan

453. Sagittal T-2 MRI
tumor

454. Case #949
52 year male with large solitary plasmacytoma pelvis

455. CT scan at sacral level

456. tumor
CT scan at lumbar level

457. Case #950
45 year male with solitary plasmacytoma sacrum

458. Lateral view
tumor

459. Bone scan shows signal void in tumor site

460. tumor
Bone scan

461. tumor
Axial T-2 MRI

462. Sagittal PD MRI
tumor

463. Sagittal T-2 MRI
tumor

464. Photomic

465. Case #951
Axial T-1 MRI
tumor
56 year male with solitary plasmacytoma sacrum

466. Sagittal T-1 MRI
tumor

467. Case #952
28 year female with path fracture thru supra acetabular
Solitary plasmacytoma

468. Case #953
46 year male with
solitary plasmacytoma
proximal femur

469. Coronal T-1 MRI

470. Coronal T-2 MRI

471. Case #954
65 year female with
solitary plasmacytoma
femur

472. Post op x-ray with
blade-plate fixation

473. Case #955
41 year male with
solitary plasmacytoma
femur

474. Case #956
40 year female with
solitary plasmacytoma
proximal fibula

475. Case #957
tumor
24 year male with solitary plasmacytoma scapula

476. Bone scan showing signal void in center of tumor

477. tumor
CT scan

478. Multiple Myeloma

479. Multiple Myeloma
Multiple myeloma is considered to be the most common primary
tumor of bone, accounting for approximately 45% of all malignant
bone tumors. It is usually seen in patients over 40 years of age and
is two times more common in blacks than whites. Radiographically,
the lytic lesions seen in multiple myeloma are typically punched-out
with fairly sharp margins but no sclerotic response at the periphery
and thus are not frequently picked up on a total body bone isotope
study. The diagnosis is usually made by a combination of a bone
marrow biopsy and a serum protein electrophoresis that reveals
the elevated monoclonal immuninoglobulin at either the alpha or
gamma spike. Bence-Jones protein is found in the urine examination
secondary to a light chain immuninoglobulin spillover.
Three per cent of patients with myeloma have a sclerotic form
(seen on the radiographic examination) associated with a peripheral
neuropathy. This type of multiple myeloma has a better prognosis

480. for survival and is referred to as the Poems syndrome. Skeletal
lesions are more typically seen in the spine and pelvic area and
proximal long bones, but rarely seen distal to the elbow or knee. In
aggressive forms of myeloma with extensive bony destruction by
osteoclastic erosion, the patients will develop hypercalcemia that
can result in a semi-comatose state and sometimes is associated
with nephrocalcinosis. Renal damage also results from excessive
proteins plugging the renal tubules. Pathological fractures are
common because of excessive osteoclastic activity (osteoclysis)
that can be inhibited by drugs such as Aredia. Even though large
concentrations of imminoglobulin are produced by the malignant
plasma cells, the patient’s resistance to infection is markedly
inhibited and surgical complications resulting from infection should
be anticipated when operating on patients with this disease.
Systemic chemotherapy has greatly improved the prognosis
for survival in this disease. The drugs used include Malphalan and
cortisone which have increased the chance for survival to three years.

481. Local treatment consists of external beam radiation therapy and
intramedullary devices, such as long stem prostheses and inter-
locking nails supplemented with bone cement, for pathological
fractures. Excessive bleeding at the time of surgery is typical with
myeloma patients, similar to the problem faced with patients with
metastatic renal cell disease and thyroid carcinoma. It is important
to radiate the entire long bone involved when considering intra-
medullary device fixation because of the potential for newer lesions
arising distal to the fixation device at a later date.

482. CLASSIC Case #186
fracture
65 year male with multiple myeloma pelvis and hips

483. Photomic showing plasma cells

484. R L
Post op x-ray with THR right & ORIF left

485. Case #187
72 year male with multiple myeloma skull

486. Punched out
lesions femur

487. Case #188 Sagittal T-2 MRI
55 year male with multiple myeloma spine

488. Sagittal T-2 MRI
lumbar spine with
evidence of cord
compression

489. Case #958
37 year male with
multiple myeloma
dorsal spine

490. Lumbar spine

491. Autopsy specimens

492. Photomic

493. Case #959
55 year male with multiple
myeloma dorsal spine

494. Lateral view

495. CT scan showing tumor in vertebra and vertebral canal

496. CT of adjacent vertebra

497. Anterior vertebrectomy specimen

498. Photomic

499. Case #960
48 year male with
multiple myeloma
dorsal spine with
cord involvement
tumor
Sagittal T-2 MRI

500. Axial T-2 MRI showing tumor in pedicle & costovertebral joint

501. tumor
Another axial T-2 cut

502. Biopsy photomic

503. Case #961
55 year male with
multiple myeloma
cervical spine and
compression fracture

504. Post op posterior
spinal fusion and
radiation therapy

505. Case #962
38 year male with
multiple myeloma
lumbar spine

506. Post op anterior
curettement and
cementation

507. AP view

508. Case #963
41 year male with
multiple myeloma
with collapsed vertebral
body and paraplegia

509. Lateral view

510. Case #964
16 year male with multiple myeloma lumbar spine

511. Case #965
tumor
59 year female with multiple myeloma pelvis

512. tumor
CT scan showing large aneuysmal lesion

513. tumor
Another CT cut

514. Post op x-ray with THA
with cement and
Steinman pins

515. Skull x-ray showing multiple punched out lesions

516. Case #966
72 year female with severe multiple myeloma pelvis

517. Case #967
59 year female with multiple myeloma skull

518. Same patient with scapular and humeral lesions

519. Thumb lesion

520. Case #967.1 Multiple Myeloma
55 yr male with a painful swollen wrist for 6 months

522. Case #968
55 year female with
multiple myeloma
with path fracture
femur

523. Post op x-ray with cemented
long stem THA

524. Case #969
75 year male with
multiple myeloma
and path fracture
femur

525. Case #970
68 year female with multiple myeloma shoulder area

526. Same patient with
tibial lesions

527. Punched out
femoral lesions

528. Punched out humeral
lesions as well

529. Path fracture later on
with IM nail fixation

530. Photomic

531. Case #971
62 year male with
multiple myeloma
humerus

532. Post op cemented Neer
prosthesis

533. Case #972
37 year male with
multiple myeloma
upper extremity
with punched out lesions

534. Case #973
48 year female with multiple myeloma shoulder

535. Bone scan with
scapular and
rib lesions

536. Coronal T-1 MRI

537. tumor
Axial T-2 MRI

538. Case #974
72 year male with
multiple myeloma
lumbar spine

539. Same patient with
punched out lesions
in femur and ischium

540. Also punched out lesions
in tibia and fibula

541. Case #975
29 year male with blastic form of multiple myeloma

542. Close up

543. Case #976
40 year male with a
variant of multiple
myeloma known as
fibrogenesis imperfecta
ossium

544. Multiple collapsed
lumbar vertebra as in
multiple myeloma

545. X-ray at a later date
with progressive disease

546. X-ray of pelvis shows diffuse lytic changes

547. Bone scan

548. Metastatic
Neuroblastoma

549. Metastatic Neuroblastoma
Neuroblastoma is a primitive tumor of childhood taking its origin
from the medullary portion of the adrenal gland or in other parts of
the sympathetic nervous system and is considered to be the third
most common malignancy in childhood. This tumor is usually seen
under the age of five years and typically metastasizes to bones
including the vertebra, ribs, skull, femur, pelvis, humerus, tibia, and
radius. These patients usually have systemic symptoms including
weight loss, fever, generalized pain and anemia. Radiographically,
the lesions in bone have a permeative destructive pattern typically
in the metaphyseal portion of long bones. Histologically, the
characteristic feature of the neuroblastoma is a rosette formation
with neurofibrils. However, on routine H&E stains the histology is
quite similar to that of rhabdomyosarcoma, non-Hodgkin’s
lymphoma and Ewing’s sarcoma. Diagnostic studies include
cytogenetics that will reveal a chromosomal abnormality in the

550. number 1 chromosome. A CT scan of the abdomen will frequently
pick up a neoplastic abnormality in the kidneys. Chemotherapy and
sometimes bone marrow transplantation is used in the treatment
protocol for this aggressive, extensive metastatic disease but with
only a a 20-25% chance for survival at five years after diagnosis.

551. CLASSIC
Case #189
4 year male
metastatic neuroblastoma
distal femur with
pathologic fracture

552. Lateral view showing
hair-on-end reactive
subperiosteal bone
formation

553. Bone scan

554. Bone scan shows abnormal
collection in kidney where
the primary tumor was
found

555. Sagittal T-2 MRI
showing metastatic
tumor in tibia

556. tumor
Abdominal CT scan showing primary neuroblastoma
in the kidney area

557. Chest x-ray showing multiple pulmonary mets

558. Femoral biopsy photomic showing rosette pattern

559. Higher power showing rosette pattern

560. Case #977
7 year male with
metastatic neuroblastoma
proximal humerus and
path fracture

561. Bone scan showing
primary tumor in kidney
and met to shoulder &
base of skull

562. Photomic from humeral biopsy

563. Case #978
9 year male with
metastatic neuroblastoma
proximal humerus

564. Another view

565. Case #979
1 year old female with
metastatic neuroblastoma
proximal humerus

566. Case #980
5 year female with
metastatic neuroblastoma
proximal femur

567. Case #981
11 year female with
metastatic neuroblastoma
femur treated with wide
resection and fibular strut
& IM nail reconstruction

568. Macro section from
resected specimen
showing tumor inside
and outside the femur

569. Scanning lens photomic

570. Higher power photomic

571. Case #982
7 year male with
metastatic neuroblastoma
distal femur

572. Case #983
7 month male with large
calcific renal mass which
on biopsy proved to be
neuroblastoma

573. Lateral view