Department of Pathology College of Medicine, Yeungnam...
Transcript of Department of Pathology College of Medicine, Yeungnam...
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Joon Hyuk Choi, M.D.
Department of Pathology
College of Medicine, Yeungnam University
Grading of Bone Tumors
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Introduction to grading system of bone
tumor used at Mayo Clinic
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Bone-forming tumorsBenign
OsteomaOsteoid osteoma and osteoblastoma
IntermediateAggressive (malignant) osteoblastoma
MalignantConventinal central osteosarcomaTelangiectatic osteosarcomaIntraosseous well differentiated (low grade) osteosarcomaRound-cell osteosarcomaParosteal (juxtacortical) osteosarcomaPeriosteal osteosarcomaHigh grade surface osteosarcoma
Cartilage-forming tumorsBenign
EnchondromaPeriosteal (juxtacortical) chondromaSolitary osteochondromaMultiple hereditary osteochondromasChondroblastoma (epiphyseal chondroblastoma)Chondromyxoid fibroma
MalignantChondrosarcomaJuxtacortical (periosteal) chondrosarcomaMesenchymal chondrosarcomaDedifferentiated chondrosarcomaClear cell chondrosarcomaMalignant chondroblastoma
Giant cell tumor (osteoclastoma)Marrow tumors (round cell tumors)
Ewing sarcomaPrimitive neuroectodermal tumor of bone (PNET)Malignant lymphoma of boneMyeloma
Vascular tumorsBenign
HemangiomaLymphangiomaGlomus tumor (glomangioma)
Intermediate or indeterminateHemangioendotheliomaHemangiopericytoma
MalignantAngiosarcomaMalignant hemangiopericytoma
Other connective tissue tumorsBenign
Benign fibrous histiocytomaLipoma
IntermediateDesmoplastic fibroma
MalignantFibrosarcomaMalignant firbrous histiocytomaLiposarcomaMalignant mesenchymomaLeiomyosarcomaUndifferentiated sarcoma
Other tumorsChordomaAdamantinoma of long bonesNeurilemomaNeurofibroma
Unclassified tumorsTumor-like lesions
Solitary bone cyst (simple or unicameral bone cyst)Aneurysmal bone cystJuxta-articular bone cyst (intraosseous ganglion)Metaphyseal fibrous defect (nonossifying fibroma)Eosinophilic granuloma (histiocytosis X, Langerhans cell granulomatosis)Fibrous dysplasiaOsteofibrous dysplasiaMyositis ossificans (heterotopic ossification)Brown tumor of hyperparathyroidismIntraosseous epidermoid cystGiant cell (reparative) granuloma
WHO Histologic Classification of Bone Tumors (1993)
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OsteochondromaChondromaChondroblastomaChondromyxoid fibromaOsteoid osteomaOsteoblastomaGiant cell tumor
Fibrous histiocytomaHamartoma
Hemangioma
LipomaNeurilemoma
Tumor No.of CasesBenign
872335119
45331
87568
91
108
714
2,496
3,749694775120120
341,649
69512
35348312
255356
8013
1
8,591
MyelomaLymphomaChondrosarcomaSecondary chondrosarcomaDedifferentiated chondrosarcomaMesenchymal chondrosarcomaOsteosarcomaParosteal osteosarcomaEwing’s sarcomaMalignancy in giant cell tumorAdamantinomaMalignant fibrous histiocytomaDesmoplastic fibromaFibrosarcomaChordomaHemangioendotheliomaHemangiopericytomaLiposarcoma
40.07
21.83
19.27
10.36
0.832.42
3.211.81
0.070.13
100.00
4,443
2,420
2,136
1,149
92268
356201
814
11,087
Hematopoietic
Chondrogenic
Osteogenic
Unknown
HistiocyticFibrogenic
NotochordalVascular
LipogenicNeurogenicTotal
Tumor No.of Cases%No.MalignantTotal cases
Classification of tumors of bone in Mayo Clinic patients
( Unni KK: Dahlin’s Bone tumor, 5th ed., 1996)
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Grading of squamous cell carcinoma of lip (Broders, 1920)
Grade 1 : <25% undifferentiated cells
Grade 2 : 25 - 50%
Grade 3 : 50 - 75%
Grade 4 : >75%
(JAMA 74:656-64,1920)
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Osteosarcoma : G1∼4
Chondrosarcoma : G 1∼3
Fibrosarcoma : G1∼4
Angiosarcoma : G1∼3
Graded bone tumors
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Benign tumors
Ewing's sarcoma
Mesenchymal chondrosarcoma
Chordoma
Adamantinoma
Giant cell tumor
Not graded bone tumors
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Cellularity (+)
Cytologic atypia (+)
Mitosis (-)
Necrosis (-)
Histological parameters
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Conventional osteosarcoma : G 3, 4OsteoblasticChondroblasticFibroblasticOther
Giant cell richEpithelioid
Small cell : G 4Telangiectatic : G 4
Classification of osteosarcoma
(Hematol Oncol Clin North Am 9:545-69,1995)
Low-grade central : G 1Parosteal : G 1, 2Periosteal : G 2, 3High-grade surface : G 3, 4Secondary : G 4
Paget's sarcomaPostirradiationOther
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Grade No. of cases 5 y. SR(%)
1 2
2 63 27.0
3 218 19.7
4 128 17.2
Total 411
Survival according to Grade in osteosarcoma
(J Bone Joint Surg 49A:101-10,1967)
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Grade No. of cases Death during first 3 yr(%)
1 11 0.0
2 49 10.2
3 132 28.0
4 207 30.4
Total 399
Survival according to Grade in osteosarcoma
(J Natl Cancer Inst 81:21-30, 1989)
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Grade Histologic features
1 Relatively hypercellular compared with enchondroma
moderate cytologic atypia
2 More cellular than Grade 1
cytologic atypia is more pronounced
3 Extreme cellularity
marked cytologic atypia
Grading of chondrosarcoma
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Dahlin Evans Gitelis
Cellularity + + +
Cytologic atypia + + +
Mitosis - + +
Necrosis - + +
Growth pattern - - +
Histologic parameters used in different grading system of chondrosarcoma
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No. of cases %
No mitosis 311 92.0
1∼3/tumor 20 5.9
1/1 HPF 7 2.1
Total 338 100.0
Mitosis in chondrosarcoma
(Cancer 83:2105-19,1998)
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Grade No. of cases %
1 207 61.2
2 120 35.5
3 11 3.3
Total 338 100.0
Grades of chondrosarcoma
(Cancer 83:2105-19,1998)
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Grade Recurrence rate(%) Metastatic rate(%)
1 15.2 4.6
2, 3 36.2 29.3
Recurrence and metastatic rate according to Grade
in chondrosarcoma
(Cancer 83:2105-19,1998)
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Grade 5 y. SR(%)
1 88.5
2, 3 57.1
Survival according to Grade in chondrosarcoma
(Cancer 83:2105-19,1998)
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Grade Histologic features
1 Marked collagen production, elongated nuclei with
tapered ends, mitotic figures are uncommon
2 Greater cellularity than do Grade 1 tumor, nuclei are
somewhat more atypical appearing, mitotic figures
3 Darkly stained spindle cells in a herringbone pattern with
little collagen production, mitotic figures are abundant, necrosis
4 The cells are closely packed together,
prominent mitotic figures, necrosis
Grading of fibrosarcoma
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Grade No. of cases %
1 1 0.9
2 35 30.7
3 48 42.1
4 30 26.3
Total 114 100.0
Grades of fibrosarcoma
(Cancer 23:35-41,1969)
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Grade No. of cases 5 yr SR(%) 10 yr SR(%)
1 1
2 35 40.0 25.0
3 48 30.8 27.3
4 30 13.6 10.0
Total 114 28.7 21.6
Survival according to Grade in fibrosarcoma
(Cancer 23:35-41,1969)
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Grade Histologic features
1 Well formed vascular spaces lined by tumor cells
slight cytologic atypia
2 Vasoformative features are less readily identified
cytologic atypia is more pronounced
3 Little to no recognizable vasoformation
marked cytologic atypia
Grading of angiosarcoma
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Grade No. of case %
1 33 29
2 51 46
3 28 25
Total 112 100
Grades of angiosarcoma
(Am J Surg Pathol 6:59-70,1982)
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Grade No. of cases Disease free survival(%)
1 22 95
2 45 62
3 25 20
Survival according to Grade in angiosarcoma
(Am J Surg Pathol 6:59-70,1982)
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• The grade of bone tumors depends on the cellularity and cytologic
atypia.
• Grading is simple, fairly reproducible and useful.
• Grading is important for many of the primary sarcomas of bone,
especially osteosarcoma, fibrosarcoma, chondrosarcoma, andangiosarcoma
Summary