Treatment of Osteoid Osteoma

First described by Bergstrand in 1930, osteoid osteomas are benign lesions of bone.[1] The cause of osteoid osteoma is unknown, but suggested etiologies include benign neoplastic cells, trauma, and inflammation. Histologically, osteoid osteomas are composed of mature lamellar bone and have a simple karyotype with FOS and FOSB rearrangements on cytogenetic studies.[2] [3] This can be utilized as diagnostic markers for osteoblastoma and osteoid osteoma. There is no known potential for malignant transformation.[3] Osteoid osteomas account for approximately 5% of all primary bone lesions and 10% of benign bone tumors. These lesions measure less than 2 cm in diameter and commonly occur between the first and third decades of life, with a male predilection of 3:1.[4] Lesions with a diameter larger than 2 cm are referred to as osteoblastoma, which has an increased incidence in patients with Gardner's syndrome, as they harbor a germline mutation in the APC gene.[2] Lesions have a predilection for long bones, particularly the diaphysis and metaphysis of the femur and tibia.[5] In the upper limb, the phalanges of the hand are the most commonly affected sites.[6]

The typical clinical presentation is a dull persistent ache that gradually increases on intensity. The pain tends to be higher at night and is responsive to nonsteroidal anti-inflammatory drugs. Other symptoms include limping or progressive scoliosis with spinal lesions.

Radiological imaging is the standard of reference for diagnosis. Radiography is the first-line imaging modality and displays oval lytic lesions in cortical bone with minimal surrounding reactive sclerosis.[7] Despite the characteristic features of lesions, radiographs can often be inconclusive or normal in the presence of an osteoid osteoma ([Fig. 1]). Differential diagnostic considerations on radiographs include a Brodie's abscess and/or an osseous stress reaction.[8] Chondroblastoma and clear cell chondrosarcoma are additional differential diagnoses of epiphyseal lesions in pediatric and young adult populations. Computed tomography (CT) is often the most accurate imaging modality, due to the ability to delineate subtle areas of sclerosis around small nidus lesions centrally. Physiological imaging such as bone scintigraphy is highly sensitive for identifying an active nidus, but the specificity is reduced due to the absence of morphological information and broad differential diagnosis of lesions and processes that present with increased radiotracer activity.[9] Single-photon emission CT (SPECT-CT) combines the metabolic information and morphological detail for characterization of lesion size, shape, anatomical location (juxta-articular, intra-articular, diaphyseal, etc.), and the extent of sclerosis. Magnetic resonance imaging (MRI) affords similar diagnostic performance than CT, with the added advantage of the absence of ionizing radiation, which is a mandatory consideration in this often young patient population.[10]

Fig. 1 A 16-year-old boy presenting with left hip pain, which was worse at night and relieved with aspirin. (a) Anteroposterior pelvic radiograph was normal. The diagnosis of osteoid osteoma can sometimes be made on standard radiographs; however, as in this case, radiographs are often normal. MRI (b, c) characteristically demonstrated extensive bone marrow edema (white arrows) around the osteoid osteoma. However, as in this case, a high degree of bone marrow edema may mask the nidus. Note the synovitis with large joint effusion (black arrow) associated with the lesion. In such patients, CT imaging may be more sensitive in identifying a subtle nidus. Tc-99m bone scintigraphy may be useful for identifying a metabolically active lesion; however, SPECT-CT (d) is superior in localizing the active nidus (d, arrow), while the CT component provides morphological information for procedural planning.

Histopathological examination can also be used in the diagnosis of osteoid osteomas ([Fig. 2]). With hematoxylin–eosin staining, there is typically a 1- to 2-cm yellow or red nidus of osteoid and woven bone, which is surrounded by a rim of vascularized, fibrous connective tissue. There may also be sclerotic bone surrounding the lesion. Histologically, osteoid osteomas are similar to osteoblastomas and often differ only by size.[11]

Fig. 2 (a) CT-guided core bone biopsy and radiofrequency ablation of an osteoid osteoma (arrow) in the posterior aspect of the proximal tibia of a young male patient. (b) Two core bone biopsy specimens (arrows) were obtained, which under microscopy (c) demonstrated a distinct boundary between the nidus and reactive bone (arrows).

Publication History

Article published online:
04 May 2023

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