A CLINICOPATHOLOGICAL STUDY OF LESIONS OF BONE

Objective: The objective is to study the clinico-pathological diagnosis of bone lesions. Methods: The present study was a prospective and observational (non-interventional) type of study. A total of 100 patients from March 2012 to April 2013 were recruited. All excised bone specimens received in the Department of Pathology, SBKS MI and RC, Pipariya, constituted the study material. The specimens were subjected to a detailed histopathological examination. In each case, the pathological reaction pattern was studied carefully and documented. Results: The total number of cases studied was one hundred, of which 63 were males and 37 were females in the age group of 3 years–65 years. The most common presenting symptoms were pain and swelling in all bone lesions. Out of 100 cases, non-neoplastic cases were 54% and neoplastic cases were 46%. Among 46% of neoplastic lesions, we found that 30% were benign and 16% were malignant. Among non-neoplastic lesions, 14% were tumor-like lesions, 13% were non-specific osteomyelitis, 12% were tuberculosis inflammation, and 15% were avascular necrosis. The most common benign lesion was a giant cell tumor (17%). The most common malignant lesion was osteosarcoma (6%). The most common tumor-like lesion was fibrous dysplasia (9%). The majority of bone tumors were located in the epiphysis of long bones. Conclusion: Light microscopy or histopathological examination is the gold standard in the diagnosis of bone lesions and is invariably accurate when correlated with clinico-radiological features.


INTRODUCTION
Bone is a dynamic, heterogeneous tissue that is structurally important and plays a major role in mineral homeostasis and hematopoiesis.Together, bones and joints provide mechanical support for movement, protect the viscera, and determine the attributes of body size and shape [1].
Bone lesions are diverse in size, grossness, and histologic features and range in their natural history from innocuous to rapidly fatal.This diversity makes it critical to diagnose tumors and tumor-like lesions correctly, stage them accurately, and treat them appropriately so that the patients not only survive but also maintain optimal function of the affected body parts [1].Apart from secondary tumors, a variety of primary malignant tumors of different histogenesis arise in the bone because of its structural complexity [2].
As a group, these neoplasms affect all ages and arise virtually in every bone, but most develop during the first few decades of life [1].One important group of cancer patients with special needs are those diagnosed during adolescence and young adulthood.Cancers in this age group, even if cured, can have a devastating effect on future life, including the development of secondary cancers [3].A systematic approach to clinical history, radiographic evaluation, and histopathology is necessary for an accurate diagnosis [4].

METHODS
The present study was a prospective and observational (noninterventional) type of study.
The study was conducted from March 2012 to April 2013 at Dhiraj General Hospital and Medical Research Institute, Pipariya, Taluka-Waghodia, District-Vadodara.Who caters to the patients from the districts of Vadodara, Bharuch, and Chotaudaipur in Gujarat state and also from other states, viz., Rajasthan, Maharashtra, and Madhya Pradesh.The study was conducted after taking the consent of patients.
Patients come from orthopedic OPD and wards.A thorough clinical examination, including a history, general examination, and local examination of the lesion, was performed and recorded in the proforma.Routine investigations like hemograms and biochemical investigations were done and recorded.
All the patients were subjected to a radiological (X-ray) examination.Sonography, CT scans, and MRIs were also done whenever required.All the patients' biopsy or radical surgery specimens were sent to our Histopathological Department.
The specimens were studied in gross detail.Tissue sections were given for fixation, decalcification, and routine processing.The sections of 5 microns in thickness were cut from paraffin blocks.The tissue sections were stained with routine Hematoxylin and Eosin stain and special stain wherever necessary.

RESULTS AND ANALYSIS
The present study was a prospective and observational (noninterventional) type of study.The total number of cases studied was one hundred, of which 63 were males and 37 were females in the age group ranging from 3 years to 65 years.
The age-and sex-wise distribution of the cases was carried out as shown in Tables 1 and 2 (Graph 1 and 2).
In the present study, the patients observed were of a wide age range, from 3 years to 65 years.The maximum number (28%) of cases was seen in the age group of 11-20 years.The minimum number (3%) of cases was seen in the age group of 61-70 years.
From Table 2, it is observed that there was a male preponderance for bone lesions (63%) as compared to females (37%).The M: F ratio was 1.7:1.
In the present study, benign lesions were common in females, and malignant and metastatic lesions were common in males.Tumor-like lesions were more common in females, whereas inflammatory lesions were more common in males (Figs 1-3).
In the present study, the incidence of benign and malignant lesions was higher in males.Whereas tumor-like lesions and other bone lesions were common in females.
In the present study, the maximum number of benign lesions was found in the 2 nd and 3 rd decade, and malignant lesions were found in the 4 th and 5 th decade.Whereas tumor-like lesions were seen in the 3 rd decade.Other bony lesions like osteomyelitis, avascular necrosis, and tuberculosis inflammation were more common in the 6 th decade (Figs 4,5).Most common benign lesion was giant cell tumor (17%), followed by osteochondroma (4%).Most common malignant lesion was Osteosarcoma (6%).Most common tumor like lesion was fibrous dysplasia (9%).
In the present study, the majority of bone tumors were located in the epiphysis of long bones.Giant cell tumors and avascular necrosis were commonly found in the epiphysis of long bones (Figs From the above Table 7, it is observed that the common presenting symptoms were pain and swelling in all bone lesions.

DISCUSSION
In the present study, patients of a wide range of ages, from 3 years to 65 years, were observed.In the present study, the majority of the lesions (23%) were in the second decade of life, which is similar to the studies conducted in Nigeria by Obalum et al. [5] (36.4%) and in India by Popat and Sata [6] (34.3%), as shown in Table 8.
In our study, we found that males were affected more than females.Out of 100 cases, there were 63 males and 37 females in the ratio of 1.7:1, which was similar to the studies conducted in Nigeria by Obalum et al. [5] (1.5:1) and in India by Popat and Sata [6] (1.9:1), as shown in Table 8.
Among the 100 cases of bone biopsies analyzed in the present study, non-neoplastic cases were 54% and neoplastic cases were 46%.Among
In the present study, non-neoplastic lesions were more commonly encountered, constituting 54% of the total lesions.Our findings were similar to those of the study carried out by Popat and Sata [6].The incidence of non-neoplastic lesions differed from other studies because inflammatory and other bony lesions were excluded from their study, as shown in Table 9.
The incidence of benign lesions in our study was 30%, which was similar to the studies conducted in Malaya by Peh et al. [7], Camarron [8], Bahebeck et al. [9], and in India by Popat and Sata [6], as shown in Table 9.
In the present study, 16% of cases were malignant tumors, which was similar to the study conducted in India by Popat and Sata [6], as shown in Table 9.In the present study, the most common benign tumor was a giant cell tumor, which was similar to the study conducted in Malaya by Peh et al. [7] and in India by Popat and Sata [6], as shown in Table 10.

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The second most common benign bone tumor encountered during our study was osteochondroma, which was similar to the study conducted in India by Popat and Sata [6].However, the incidence of osteochondroma was higher in other studies than ours, most probably due to the small sample size as shown in Table 10.
In the present study, osteosarcoma was the most common tumor, accounting for 37.5%.This was similar to the study conducted in Malaya by Peh et al. [7,8] and in Cameroon by Bahebeck et al. [9].Our study does not correlate with the study of Obalum et al. [5], he reported a higher incidence of osteosarcoma because the frequency of osteosarcoma and other bone tumors was higher in their center.Popat and Sata [6] showed a lower incidence of osteosarcoma because they had taken all osteolytic lesions.They reported 62.5% cases of bone metastasis, as shown in Table 11.
In the present study, we reported 54% of case of non-neoplastic lesions.Among non-neoplastic lesions, 14 cases were tumor-like lesions, 13 cases were non-specific osteomyelitis, 12 cases were of tuberculosis inflammation, and 15 cases were avascular necrosis.Popat and Sata [6] reported 29.4% of cases of osteomyelitis, which is similar to our study.In our study, the incidence of avascular necrosis of bone was 27.2%.As shown in Table 12.
A few of the interesting cases encountered during the present study are discussed below: • Out of 10 cases 4 were of Koch's spine.A 17-year-old female presented with a history of pain and difficulty in movement of the neck and a past history of pulmonary tuberculosis before 3 months.A radiographic study showed wedging of the C1, C2, and C3 vertebra with necrosis and osteolysis of bone.Histological examination revealed a granulomatous reaction • We studied 3 cases of aneurysmal bone cysts, of which one was misdiagnosed as chondrosarcoma on X-rays.The patient presented with H/O pain and swelling at the left foot.Radiology revealed an eccentric expansion of the left talus.The microscopic findings revealed the diagnosis of aneurysmal bone cysts • Another interesting patient was a 30-year-old male who presented with H/O pain and swelling over the left lower end of the femur.Radiological examination showed osteoblastic foci with a sun-ray appearance.Histopathology examination showed osteoid along with other features, revealing a diagnosis of osteosarcoma • One 19-year female presented with H/O pain and swelling in the left mandible, which was clinically diagnosed as ossifying fibroma.
Radiology revealed fusiform thickening with lytic mass in the left lingual region of the mandible.Microscopically, it showed typical features of chondrosarcoma • One case presented here was a 45-year-old male who presented with a H/O fall 5 days ago with a fracture neck of the femur on the left side and a non-healing ulcer over the right sole for the last year.Radiology examination revealed a fracture in the upper one-third of the left femur.Histopathology examination revealed a nest of spindleto-round shape tumor cells with pleomorphism and prominent melanin pigment.