Updated: 4/27/2018

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/4B_moved.JPG
https://upload.orthobullets.com/topic/8036/images/Histology A_moved.png
https://upload.orthobullets.com/topic/8036/images/Case C - calc - MRI b - parsons_moved.gif
 
Introduction
  • benign and non-neoplastic reactive bone lesion filled with multiple blood-filled cavities
    • can be locally destructive to normal bone and may extend to soft tissue
  • Epidemiology
    • demographics
      • 75% of patients are < 20 yrs.
    • location
      • 25% in spine
      • 20% in long bones (distal femur, proximal tibia)
      • usually in metaphysis
      • posterior elements of pelvis
      • may be found in similar location as telangiectatic osteosarcomas
  • Pathophysiology
    • primary and secondary forms
      • primary ABC:
        • now known to be neoplasms driven by upregulation of the ubiquitin-specific protease USP6 (Tre2) gene on 17p13 when combined by 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
  • Prognosis
    • good
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
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 
Differential & Groups
 
"Bubbly" lytic lesion on xray
 
"Lakes of Blood" on histology
 
Treatment is curretage and bone grafting (1) 
Aneurysmal Bone cyst
 
 
UBC
       
NOF
       
Giant Cell Tumor        
Chondroblastoma        
Chondromyoid fibroma        
Osteoblastoma        
Telangiectatic osteosarcoma    
   
ASSUMPTIONS: (1) assuming no impending fracture
 
IBank
  Location
Xray
Xray
CT
B. Scan
MRI
MRI
Histo(1)
Case A tibia
       
Case B calcaneus
 
 
Case C pelvis
   
Case D femur
 
   
Case E femur
   
 
(1) - histology does not always correspond to clinical case
 
 

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Questions (15)
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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. Review Topic

QID: 4471
FIGURES:
1

Curettage and bone grafting

72%

(2761/3834)

2

Phenol injection

3%

(109/3834)

3

Observation

6%

(229/3834)

4

Percutaneous high-frequency ablation

2%

(59/3834)

5

Wide resection and perioperative chemotherapy

17%

(652/3834)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 3049
FIGURES:
1

Ewings sarcoma

1%

(20/2172)

2

Osteosarcoma

3%

(75/2172)

3

Simple bone cyst

0%

(8/2172)

4

Aneurysmal bone cyst

92%

(2006/2172)

5

Unicameral bone cyst

3%

(56/2172)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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)? Review Topic

QID: 3063
FIGURES:
1

Image B

79%

(1339/1703)

2

Image C

8%

(143/1703)

3

Image D

5%

(93/1703)

4

Image E

5%

(79/1703)

5

Image F

2%

(36/1703)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 668
FIGURES:
1

Open biopsy for adequate diagnostic tissue

9%

(129/1498)

2

Open reduction internal fixation of the distal ulna

4%

(62/1498)

3

Immediate curettage and adjuvant chemo/radiotherapy

11%

(172/1498)

4

Nonoperative fracture management

69%

(1031/1498)

5

Preoperative chemotherapy and resection of tumor

6%

(94/1498)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 2192
FIGURES:
1

Unicameral bone cyst

7%

(21/289)

2

Aneurysmal bone cyst

89%

(256/289)

3

Chondrosarcoma

1%

(3/289)

4

Giant cell tumor

1%

(3/289)

5

Non ossifying fibroma

1%

(3/289)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 190
1

Giant cell tumor

10%

(127/1296)

2

Aneurysmal bone cyst

3%

(44/1296)

3

Chondroblastoma

18%

(238/1296)

4

Chondromyxoid fibroma

19%

(252/1296)

5

Osteofibrous dysplasia

49%

(629/1296)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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VIDEOS (1)
CASES (5)
Topic COMMENTS (9)
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