Dosen Pengampu :

dr. Fairuz C.Quzwain, SpPA

NIP.132313010
 Berdasarkan bentuknya tulang dibagi menjdi
: tulang panjang (mis. femur, humerus),
tulang pipih (mis. Pelvis), dan tulang pendek
( mis, phalang).
 Tulang panjang dibagi menjadi beberapa
regio : diaphysis, epiphysis, metaphysis.
 Penumbuhan tulang berawal dari epiphyseal
plate, dimana dimulainya endochondral
ossification.
 Epiphyseal plate  most common site of
occurrence of most primary bone tumors.
 Histologi : tulang matur terdiri dari outer compact
layer ( cortex, cortical bone, compact bone) dan
central spongy region ( spongiosa, medulla,
cancelous bone)
 Osteoporosis
- Penurunan massa tulang
- Tidak dapat memperbaiki maupun
mempertahankan massa tulang
- After menopause  estrogen deficiency
- Causes : multiple
 Osteomalacia
- Unmineralized bone matrix resulting from a
diminished rate of mineralization
- Congenital and acquired metabolic
abnormalities
- Penurunan serum calcium, phosphorus, dan
keduanya.
 Bacterial osteomyelitis may be caused by a large variety of
microorganisme
 70 – 90% due to coagulase-positive staphylococci. Other
microorganisme : klebsiella, proteus, pseudomonas,
streptococcus, etc.
 Local or exogenous causes, or through to hematogenous route.
 Can be acute, subcute or chronic
 Lytic lesion in metaphysis with periosteal reaction. In spine, the
disc space is narrowed and the vertebral end plates are eroded.
Can resemble malignant bone tumor because of lytic and
regenerative changes.
 May see bone necrosis of central region (sequestrum) and new
bone forming around it (involucrum). Inflammation dominated by
lymphocytes and plasma cells. Infection of a prosthesis is a
different process, usually neutrophilic.
 Bacterial stains are rarely helpful.
 Treatment is antibiotics and surgical drainage. About 5% of acute
cases develop into chronic osteomyelitis.
 Merupakan infeksi oleh Mycobacterium
tuberculosis.
 Hematogenous infection
 Dapat terjadi dimana saja, biasanya spine and
hip pada anak-anak dan knee pada orang
dewasa.
 Radiologi  joints, destruction of subchondral
bone.
 Mikroskopis  Organisms, bacilli, 0.3 - 4
microns. BTA (+) . Ditemukan pembentukan
tuberkel, terdiri dari serbukan limfosit,
proleferasi sel epithelioid, sel datia langhans dan
nekrosis perkijuan.
 Infarct
 Aseptic (avascular) bone necrosis
 Osteochodritis dissecans
 Radiation necrosis
 Usually ages 30's - 40's.
 Predominantly male.
 Either medullary (in marrow), or subarticular bone. Usually
femoral or humeral head.
 80% associated with alcohol abuse or steroid therapy. Joint pain
and osteoarthritis when near joint.
 MRI shows marrow edema early. Conventional x-ray shows no
abnormalities for months, followed by increased density. If
involving joint, possibly subchondral radiolucent crescent sign.
 Loss of nuclei in bone. Necrosis of marrow fat and hematopoietic
tissue may be easier to appreciate. Surrounding granulation
tissue and sclerotic bone. Complications include secondary
osteoarthritis, fracture, secondary infection, sarcoma. The terms
avascular/aseptic necrosis are often used when the infarct
involves the end of a long bone. See also Osteochondritis
dessicans.
 If infarct underlies joint, it leads to osteoarthritis.
 Usually young adults.
 Most common site is the lateral aspect of
medial femoral condyle.
 Most cases are probably related to trauma.
 Small area of bone necrosis adjacent to
articular surface, totally or partially
separated from original site.
 Specimen is a portion of bone with articular
cartilage. A loose body is formed when the
detached fragment remains viable in the
joint space (the bone dies but the cartilage
survives)
 90% > 55 tahun
 Focal or diffuse. Lumbosacral spine, pelvis, skull, and long
bones. Rare in ribs.
 Most common in England, Australia, and Western Europe.
May be caused by slow virus (seen by electron microscopy)
in osteoclasts.
 Radiolucent early, then radiodense due to coarse
trabeculae. One of the few lesions that can uniformly
enlarge bone.
 Resorptive phase (early), increased osteoclast and
osteoblast activity with fibrous stroma. Intermediate and
late phase, excessive osteoblast activity with poorly
organized bone, thick trabeculae, and numerous,
prominent, scalloped remodeling lines in a mosaic pattern.
 Benign by itself, but carries a high risk of sarcoma, usually
osteosarcoma, 1% for single lesions, 10% for multiple
lesions (accounts for 3% of osteosarcomas).
Early changes. There is prominent osteoclastic
activity, resulting in bone resorption.
A well-established case, with thick, irregularly
shaped bone trabeculae.
 = Osteoarthrosis, Degenerative joint disease.
 Increasing frequency with age.
 Most commonly hip and knee.
 Charcot joint, older patients. Gradual onset of joint pain
and stiffness.
 X-ray reveals loss of cartilage, sclerosis of subchondral
bone, possibly osteophytes, and subchondral cysts.
 Early/mild changes occur on surface of cartilage,
decreased basophilia, vertical clefts, loss of chondrocyte
nuclei, reparative changes (chondrocyte clones).
Late/severe changes include erosion of cartilage, myxoid
cysts within trabecular bone (subchondral cyst), thickening
of underlying bony trabeculae, formation of bone spurs at
joint edge. Loose bodies are pieces of broken off cartilage
and bone.
 Affects about 1% of world's population.
 Peak incidences occur in 30's and 50's, though
can affect all ages.
 Affects women 3 - 5 times more often than men.
 Joints of feet and hands are nearly always
affected. Frequently affected joints include
elbows, knee, wrists, ankles, hips, spine and
temporomandibular articulations.
 Typically slow and insiduous onset in more than
half of patients. 10% have acute onset. Often
family history. 70% are HLA-DR4. Combined
features of RA, splenomegaly and neutropenia
known as Felty's syndrome.
 Earliest changes occur in synovium,
hyperemia, proliferation of synovial lining
cells and infiltration by plasma cells and
lymphocytes (forming pannus, causing
erosion of joint cartilage).
 Second phase, synovium and granulation
tissue penetrate bone forming erosions,
subchondral cysts and osteoporosis, resulting
in fractures. Following cartilage destruction,
pannus bridges apposing bones, forming
fibrous ankylosis and eventually bony
ankylosis.
 Extraarticularmanifestations include
rheumatoid nodules, composed of necrotic
center with fibrin, surrounded by histiocytic
inflammatory reaction, often arranged in
palisading fashion. Other pathologic findings
include necrotizing arteritis and amyloidosis.
 Klasifikasitumor yang direferensikan banyak
center adalah klasifikasi menurut WHO.
 Pada umumnya keganasan pada tulang
terjadi de novo.
 Terdapat beberapa lesi jinak pada tulang
yang dapat menjadi predisposisi menjadi
keganasan, antara lain paget’s disease,
chondromatosis, osteochondromatosis,
fibrous dysplasia dan osteofibrous dysplasia.
 Limaparameter yang penting diketahui
dalam keganasan tulang adalah : umur, jenis
tulang, area tulang ( epiphysis, diaphysis,
metaphysis ), Ro appearance, microscopic
appearance.
 Osteoma merupakan tumor jinak tulang, yang
biasanya terjadi pada daerah tulang pipih
misalnya tengkorak dan tulang wajah.
 Biasanya terjadi pada umur 40 – 50 tahun
dengan ratio laki-laki dan wanita adalah 2:1
 Penderita dengan Gardner’s syndrome ,
biasanya terjadi multipel osteoma dgn
beberapa kelainan ( intestinal polyposis dan
soft tissue tumors)
 Secara mikroskopis tampak tulang matur, padat
dengan gambaran lamellarnya, tumbuh
hiperplastis.
 Benign bone neoplasm
 10 – 30 yrs
 2:1 male-female ratio
 Inntense pain  most prominent symptoms, more
intense at night, relieved by NSAID
 Every bone
 Most are centered in the cortex (85%)
 X-ray : radiolucent central nidus, seldom larger than
1,5 cm. This nidus is surrounded by a peripheral
sclerotic reaction
 Microscopically : sharply delineated central nidus is
composed of more or less calcifiedosteoid lined by
plump osteoblasts and growing within highly
vascularized connective tissue
 Osteosarcoma
 Osteosarcoma atau osteogenic sarcoma merupakan
tumor ganas primer tulang yang paling banyak terjadi.
 Biasanya mengenai penderita usia muda yaitu 10 – 25
tahun. Pada usia tua, insidensi terbanyak terjadi pada
usia lebih dari 40 tahun. Tumor ini lebih sering terjadi
pada laki-laki dibandingkan wanita.
 Predisposing factor :
1. Paget’s disease
2. Radiation exposure
3. Chemotherapy
4. Preexisting benign bone lesion
5. Foreign bodies
6. Trauma
 Arising de novo
 Metaphyseal area of the long bones, particularly the lower
end of the femur, the upper end of the tibia, and the
upper end of the humerus.
 From its usual origin in the metaphysisof a long bone, the
tumor may :
1. Spread along the marrow cavity
2. Invade the adjacent cortex
3. Elevate or perforate the periosteum
4. Extend into the soft tissues
5. Extend into the epiphysis
6. Extend into the joint space
7. Form satellite nodules independent from main tumor
mass
8. Metastasize trough the bloodstream to distant sites,
particularly the lung
 Molecular genetic features :
1. The most common cytogenetic
abnormalities detected in osteosarcoma
involve chromosomes 1,2,6, 12and 17.
2. Mutations of p53 have been found in about
20% of osteosarcoma
 The key feature for the diagnosis in the
detection of osteoid and/or bone (calcified
osteoid) produced directly by the tumor cells
without interposition of cartilage.
 Osteoid is recognized by its eosinophilic-
staining quality, its glassy appearance,
irregular contour, surrounded by a rim of
osteoblast.
 Microscopic variants and special types :
1. Telengiectatic
2. Small cell
3. Fibrohistiocytic
4. Anaplastic
5. Well differentiated intramedullary
Other variant of osteosarcoma are defined on the
basis of t0pographic, clinical, or radiographic
features, or combination of them :
1. Parosteal osteosarcoma
2. Periosteal osteosarcoma
3. Osteosarcoma of the jaw
4. Osteosarcoma in paget’s disease
 Pathologic diagnosis before instituting
definitive therapy : biopsy
 Needle biopsy in experienced hands is
extremely reliable
 Laboratory test are of no great value in the
diagnosis of osrteosarcoma. The only
abnormality detected with some frequency is
elevation of serum alkaline fosfatase
 The therapy of osteosarcoma of the
extremities has usually consisted of
amputation or disarticulation, depending on
the location of the tumor.
A common benign cartilaginous tumor
 Most frequently in the small bones of hands
and feet, particularly the proximal phalanges
 About 30% chondromas are multiple.
 Multiple enchondromas having predominantly
unilateral distribution  ollier’s disease
 The association of multiple endchondromas
with soft tissues hemangiomas  Maffuci’s
syndrome
 Microscopically are composed of mature
lobules of hyaline cartilage.
 Osteochondroma
 Osteochondroma atau disebut osteochondromatosis bila
terjadi multipel, merupakan tumor jinak tulang yang paling
banyak terjadi.
 Biasanya mengenai usia muda yaitu 10 – 30 tahun. Tumor ini
terjadi pada daerah metafise pada tulang panjang yaitu
femur, tibia, maupun humerus.
 Secara radiologis tampak tulang dengan exostosis, sessile
atau dengan tangkai. Biasanya kurang dari 5 cm. Adanya
kemungkinan keganasan apabila cartilagenous cap lebih dari
3 cm, irregular margins of cartilage cap, lucent zones pada
lesi.
 Mikroskopis tampak cartilage cap ( jarang lebih dari 1 cm)
yang diliputi oleh jarinagn fibrosa. Dibawah cartilage cap,
terdapat endochondral ossification zone yang berhubungan
dengan bony pedicle. Pedicle menyambung dengan medulla
tulang.
 Chondrosarcoma

 Chondrosarcoma merupakan tumor ganas

tulang rawan.
 Biasanya terjadi pada usia 30 – 60 tahun.
 Predileksi tumor ini adalah tulang pelvis,
costa, femur, humerus dan vertebrae.
 Dibagi menjadi 2 kategori mayor yaitu :
conventional chondrosarcoma dan
chondrosarcoma variants
 Conventional chondrosarcoma : central,
peripheral, juxtacortical
 Microscopically : show remarkably wide
range of differentitation, the common
denominator being the production of
cartilaginous matrix and the lack of direct
bone formation by the tumor cell. This range
in differentiation is the basis for the grading
of these tumor into well, moderately, and
poorly differentiated.
 Chondrosarcoma variants :
1. Clear cell chondrosarcoma
2. Dedifferentiated chondrosarcoma
3. Mesenchymal chondrosarcoma
 Giant Cell Tumor of the Bone
 Giant Cell Tumor atau disingkat dengan GCT pada
tulang, b iasanya terjadi pada usia 20 – 40 tahun.
Tumor ini paling sering terjadi pada wanita. Biasanya
terjadi pada tulang panjang, dan dapat mengenai
metafisis ataupun epifisis.
 Radiologis ditemukan lesi osteolitik dengan batas
tegas, dan memberikan gambaran ‘soap bubble’
 Secara mikroskopis tampak massa tumor terdapat
banyak osteoclast-type giant cells dengan jumlah inti
yang banyak (20-30). Ditemukan pula sel bentuk
spindel yang plump (gemuk ) dengan inti mempunyai
karateristik yang sama dengan inti pada giant cell,
mitosis normal dan tidak ditemukan pleomorphism.
Dapat ditemukan daerah yang nekrotik maupun
perdarahan.
 Rhabdomyosarcoma merupakan tumor ganas
yang berasal dari sel otot lurik. Tumor ini dapat
terjadi pada anak-anak maupun usia tua. Pada
anak-anak biasanya mempunyai predileksi
terutama di kepala, sedangkan usia tua biasanya
di ekstremitas. Terdapat 3 kategori mayor
rhabdomyosarcoma yaitu pleomorphic,
embryonal, dan alveolar rhabdomyosarcoma.
 Secara mikroskopis diagnosis rhabdomyosarcoma
adalah ditemukan adanya sel rhabdomyoblast,
yaitu sel dengan sitoplasma yang eosinofil dan
dengan inti yang pleomorifk, hiperkromatis dan
banyak ditemukan mitosis. Dapat ditemukan pula
sel limfosit, sel plasma dan sel eosinofil
 Fibrosarcoma

 Fibrosarcoma adalah tumor ganas jaringan

lunak yang berasal dari sel fibroblas. Tumor
ini paling banyak mengenai usia 30 – 50
tahun dengan lokasi tersering adalah
ekstremitas bawah. Gambaran mikroskopis
fibrosarcoma secara khas ditemukan sel-sel
spindel yang tumbuh hiperplastis dan
membentuk susunan fasikulus yang
memberikan gambaran khas herringbone
appearance.
 Radiologis ditemukan gambaran yang khas yaitu
sun burst appearance, periosteal reaction dan
codman’s triangle.
 Secara mikroskopis pada tumor ini harus
ditemukan adanya pembentukan osteoid ganas,
yaitu dengan gambaran eosinofilik, glassy
appearance, irregular countours, dan dikelilingi
oleh osteoblast. Gambaran lain adalah seperti
gambaran keganasan pada umumnya yaitu sel
dengan inti yang pleomorfik, hiperkromatis
dengan mitosis yang banyak dan adanya struktur
microtrabeculae yaitu massa berwarna basofil
dan menyerupai hifa jamur.