Updated: 6/21/2021

Aneurysmal Bone Cyst

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https://upload.orthobullets.com/topic/8036/images/Case A - femur - xray - parsons_moved.png
https://upload.orthobullets.com/topic/8036/images/Case C - calc - xray - parsons_moved.png
https://upload.orthobullets.com/topic/8036/images/Case C - calc - ct- parsons_moved.gif
https://upload.orthobullets.com/topic/8036/images/Case C - calc - MRI b - parsons_moved.gif
https://upload.orthobullets.com/topic/8036/images/4B_moved.JPG
https://upload.orthobullets.com/topic/8036/images/Histology A_moved.png
  • summary
    • Aneurysmal Bone Cysts are benign, non-neoplastic, reactive bone lesions that most commonly occur in the femur and tibia. The condition typically presents in patients less than 20 years of age with focal pain and swelling. 
    • Diagnosis is made with radiographs showing an expansile, eccentric, and lytic lesion with bony septae and a biopsy showing blood-filled spaces without endothelial lining.
    • Treatment is usually nonoperative for lesions associated with a fracture. Aggressive curettage, with adjuvant treatment and bone grafting, is indicated for symptomatic lesions without associated fracture. 
  • Epidemiology
    • Demographics
      • 75% of patients are < 20 yrs.
    • Anatomic location
      • 15% in spine
      • >60% in long bones (Femur and tibia being most common)
      • 51% occured in the lower extremities, 22.5% in upper extremities
      • usually in metaphysis
      • metatarsal and calcaneus are the most common locations in the foot
      • posterior elements of pelvis
      • may be found in similar location as telangiectatic osteosarcomas
  • Etiology
    • Pathophysiology
      • primary and secondary forms
        • primary ABC
          • driven by upregulation of the ubiquitin-specific protease USP6 (Tre2) gene on 17p13 when combined by a translocation with a promoter pairing
          • most commonly described translocation t(16;17)(q22;p13) leading to juxtaposition of promoter region CDH11 on 16q22
        • secondary ABC
          • not considered a neoplasm because no known translocation has been identified
    • Associated conditions
      • associated with other tumors 30% of time
        • giant cell tumor
        • chondroblastoma
        • fibrous dysplasia
        • chondromyxoid fibroma
        • NOF
  • Presentation
    • Symptoms
      • pain and swelling
      • may present with pathologic fracture
    • Physical exam
      • neurologic deficits possible with spine lesions
  • Imaging
    • Radiographs
      • expansile, eccentric and lytic lesion with bony septae ("bubbly appearance")
      • usually in metaphyseal
      • classic cases have thin rim of periosteal new bone surrounding lesion
      • no matrix mineralization
    • MRI or CT scan
      • will show multiple fluid lines
      • lesion can expand into soft tissue
  • Studies
    • Histology
      • Characteristic findings
        • cavernous space
        • blood-filled spaces without endothelial lining
      • cavity lining
        • numerous benign giant cells
        • spindle cells
        • thin strands of woven (new) bone present
  • Differential
    • Radiographic differential includes
      • UBC
      • telangiectatic osteosarcoma
    • Histologic differential includes
      • telangiectatic osteosarcoma
      • giant cell tumor
      • Differential of Aneurysmal Bone Cyst
        "Bubbly" lytic lesion on xray
        "Lakes of Blood" on histology
        Treatment is curettage and bone grafting 
        Aneurysmal Bone cyst
        UBC

        NOF
        Giant Cell Tumor
        Chondroblastoma
        Chondromyoid fibroma
        Osteoblastoma
        Telangiectatic osteosarcoma
  • Treatment
    • Nonoperative
      • nonoperative fracture management
        • indications
          • ABC with acute fracture
            • indicated until fracture has healed. Once healed, treat as an ABC without fracture unless the fracture has led to spontaneous healing of the ABC
    • Operative
      • aggressive curettage (+/- adjuvant) and bone grafting
        • indications
          • symptomatic ABC without acute fracture
        • technique
          • possible adjuvants
            • phenol
            • argon beam
            • liquid nitrogen
        • outcomes
          • local recurrence in up to 25% and more common in children with open physes

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Flashcards (7)
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Questions (17)
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(OBQ13.267) A 14-year-old girl complains of persistent ankle pain and intermittent swelling that is worse after playing lacrosse. Figure A is a radiograph and Figures B and C are low-power microscopy images of the lesion. What is the diagnosis and best next treatment step?

QID: 4902
FIGURES:
1

Curettage and bone graft for giant cell tumor

14%

(708/5094)

2

Aspiration and steroid injection for unicameral bone cyst

9%

(453/5094)

3

Curettage and bone graft for aneurysmal bone cyst

71%

(3595/5094)

4

Wide resection for telangiectic osteosarcoma

1%

(61/5094)

5

Chemotherapy and wide resection for telangiectic osteosarcoma

5%

(249/5094)

L 3 A

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(SBQ12FA.41) A 21-year-old male presents with gradual foot pain over the past several months. There is no history of trauma. Figures A and B are his plain radiographs and subsequent biopsy specimen. Which of the following is the most likely diagnosis?

QID: 3848
FIGURES:
1

Unicameral bone cyst

3%

(49/1470)

2

Enchondroma

13%

(198/1470)

3

Chronic osteomyelitis

0%

(7/1470)

4

Aneurysmal bone cyst

76%

(1121/1470)

5

Giant cell tumor

6%

(90/1470)

L 2 C

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(OBQ12.111) A 12-year-old boy presents with pain in the left hip for 6 weeks duration. Physical exam shows he is afebrile. He has a WBC of 12.2, and an ESR of 16. A radiograph is shown in Figure A. A T2-weighted MRI is shown in Figure B. A T1-weighted MRI with and without contrast is shown in Figure C and D respectively. What is the most appropriate next step in treatment.

QID: 4471
FIGURES:
1

Curettage and bone grafting

72%

(3316/4574)

2

Phenol injection

3%

(128/4574)

3

Observation

6%

(261/4574)

4

Percutaneous high-frequency ablation

2%

(75/4574)

5

Wide resection and perioperative chemotherapy

17%

(767/4574)

L 3 A

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(OBQ09.236) You are seeing a 16-year-old female with shoulder pain. She is otherwise healthy and denies trauma. Based on the radiograph, MRI, and histology shown in Figures A-C, what is your diagnosis?

QID: 3049
FIGURES:
1

Ewings sarcoma

1%

(26/2856)

2

Osteosarcoma

3%

(97/2856)

3

Simple bone cyst

0%

(13/2856)

4

Aneurysmal bone cyst

92%

(2639/2856)

5

Unicameral bone cyst

3%

(74/2856)

L 1 C

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(OBQ09.250) A 10-year-old male presents with knee pain after a collision with another soccer player. Knee radiographs are taken and show a cystic-appearing lesion in the metaphyseal region of the proximal tibia without evidence of fracture. An MRI is performed and is shown in Figure A. If a biopsy is performed, the histology would most likely resemble which Figure (B-F)?

QID: 3063
FIGURES:
1

Image B

77%

(1785/2306)

2

Image C

9%

(200/2306)

3

Image D

6%

(138/2306)

4

Image E

5%

(112/2306)

5

Image F

2%

(53/2306)

L 2 B

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(OBQ07.7) A 12-year-old female is involved in a low speed motor vehicle accident and presents with a pathologic fracture in the ulna. A radiograph is shown in Figure A. A needle biopsy is performed and histology is shown in Figure B. What is the best next step in treatment?

QID: 668
FIGURES:
1

Open biopsy for adequate diagnostic tissue

8%

(163/1968)

2

Open reduction internal fixation of the distal ulna

4%

(82/1968)

3

Immediate curettage and adjuvant chemo/radiotherapy

13%

(262/1968)

4

Nonoperative fracture management

67%

(1321/1968)

5

Preoperative chemotherapy and resection of tumor

7%

(128/1968)

L 2 D

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(OBQ06.79) Intralesional curettage and bone grafting is an accepted component of the treatment plan for all of the following conditions EXCEPT?

QID: 190
1

Giant cell tumor

10%

(174/1749)

2

Aneurysmal bone cyst

4%

(62/1749)

3

Chondroblastoma

18%

(315/1749)

4

Chondromyxoid fibroma

18%

(316/1749)

5

Osteofibrous dysplasia

50%

(874/1749)

L 4 C

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(SBQ04PE.7) A 6-year-old male presents with pain and swelling in his proximal tibia after twisting his knee. AP and lateral radiographs are shown in Figures A and B. Figure C shows a sagittal section from an MRI, and Figure D shows the high-power histology specimen from biopsy. What is the most likely diagnosis?

QID: 2192
FIGURES:
1

Unicameral bone cyst

7%

(54/768)

2

Aneurysmal bone cyst

88%

(679/768)

3

Chondrosarcoma

1%

(10/768)

4

Giant cell tumor

2%

(14/768)

5

Non ossifying fibroma

1%

(5/768)

L 1 C

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CASES (5)
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