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SECOND EDITION
NIELSEN | ROSENBERG
DESHPANDE • HORNICEK • KATTAPURAM • ROSENTHAL
ii
SECOND EDITION
G. Petur Nielsen, MD
Pathologist, Department of Pathology
Director of Electron Microscopy
Director of Bone & Soft Tissue Pathology
Massachusetts General Hospital
Professor of Pathology
Harvard Medical School
Boston, Massachusetts
Andrew E. Rosenberg, MD
Professor and Vice Chair
Department of Pathology
Miller School of Medicine
University of Miami
Miami, Florida
Vikram Deshpande, MD Susan V. Kattapuram, MD

Associate Pathologist Associate Radiologist
Department of Pathology Massachusetts General Hospital
Massachusetts General Hospital Associate Professor of Radiology
Associate Professor of Pathology Harvard Medical School
Harvard Medical School Boston, Massachusetts
Daniel I. Rosenthal, MD
Francis J. Hornicek, MD, PhD Associate Radiologist-in-Chief
Chief, Orthopaedic Oncology Service Massachusetts General Hospital
Co-Director, Center for Sarcoma and Professor of Radiology
Connective Tissue Oncology Harvard Medical School
Massachusetts General Hospital Boston, Massachusetts
Director, Stephan L. Harris Chordoma Center
The Henry J. Mankin, MD, Endowed Scholar
Professor
Co-Leader, Dana Farber/Harvard Cancer
Center Sarcoma Program
iii
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
DIAGNOSTIC PATHOLOGY: BONE, SECOND EDITION ISBN: 978-0-323-47777-2
Copyright © 2017 by Elsevier. All rights reserved.
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Notices
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Publisher Cataloging-in-Publication Data
Names: Nielsen, G. Petur (Gunnlaugur Petur) | Rosenberg, Andrew, 1953-

Title: Diagnostic pathology. Bone / [edited by] G. Petur Nielsen and Andrew E. Rosenberg.
Other titles: Bone.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2017] | Includes
bibliographical references and index.
Identifiers: ISBN 978-0-323-47777-2
Subjects: LCSH: Bones--Tumors--Handbooks, manuals, etc. | MESH: Bone Neoplasms--pathology--Atlases. |
Bone Neoplasms--diagnosis--Atlases.
Classification: LCC RC280.B6 N54 2017 | NLM WZ 17 | DDC 616.8’4--dc23
International Standard Book Number: 978-0-323-47777-2

Cover Designer: Tom M. Olson, BA
Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
iv
Dedications
To my wife and family.
GPN
To my daughters, Olivia and Miranda, who are my lifelong joy; my parents,

Philip and Evelyn, who did their best; my siblings, David, Stuart, and Elaine,
who have been supportive; my friend and colleague, Al, who always has my
back; my teachers who have helped show me the way; my colleagues with
whom I have had the honor to be in the trenches; and the patients who
have given me their trust.
AER
To my father, Dhirendra, and mother, Shashi.

VD
v
vi
Preface
The pathology of the skeleton is complex and is the morphologic expression of a broad spectrum of
diseases, including those caused by genetic (sporadic and inherited), malformative, inflammatory, metabolic,
circulatory, traumatic, iatrogenic, and neoplastic disorders. Bone tumors, including both neoplasms
and various conditions that may simulate them, are the focus of our book. This topic is one of the most
challenging areas in surgical pathology for several reasons: Bone tumors are uncommon, making it difficult
to acquire the necessary experience with their histological variants and mimics; the correct diagnosis usually
requires the careful integration of radiological imaging studies and clinical findings; the implications of a
diagnosis on a patient can be life changing; and medical schools and pathology training programs often have
insufficient expertise to provide medical students and young pathologists with the skills needed to diagnose
these lesions accurately and precisely.
This book reflects the philosophy and high standards practiced by the truly multidisciplinary team of
physicians at the Massachusetts General Hospital and University of Miami, who have diagnosed and surgically
treated tens of thousands of patients with bone tumors for many decades. Also important to acknowledge
are the contributions of the many fellows and residents who participated in the efforts of patient care.
The authors are subspecialized physicians who have dedicated their professional lives to the diagnosis and
surgical management of bone tumors. As a result, the figures include beautiful and classic examples and
unusual variants of many of the diseases discussed and are the product of painstaking correlations between
the clinical, imaging, macroscopic, histological, immunohistochemical, and molecular characteristics of bone
tumors. The text synthesizes the literature and our combined extensive experience, and the images have
been selectively culled from the patient files of the Massachusetts General Hospital, the University of Miami
Miller School of Medicine, and the private consultations of the authors. The book is constructed in a thematic
format with sections representing groups of related diseases and the chapters discussing individual entities
and their differential diagnosis.
Accordingly, this textbook serves as an excellent resource for medical students, residents, fellows, and
practicing physicians in the disciplines of pathology, radiology, and orthopedics. Medical and radiation
oncologists who treat bone tumors will also find it valuable. Our opportunity to participate in the care
of patients with bone tumors has been our call and honor, and we hope to do it justice by sharing our
experience with the medical community—our goal is to enhance diagnostic accuracy and to provide the
biological basis for optimal treatment.
G. Petur Nielsen, MD
Pathologist, Department of Pathology
Director of Electron Microscopy
Massachusetts General Hospital
Professor of Pathology
Professor and Vice Chair
Department of Pathology
Miller School of Medicine
University of Miami Hospital
Miami, Florida
vii
viii
Acknowledgments
Text Editors
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Lisa A. Gervais, BS
Karen E. Concannon, MA, PhD
Matt W. Hoecherl, BS
Megg Morin, BA
Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS
Illustrations
Laura C. Sesto, MA
Richard Coombs, MS
Lane R. Bennion, MS
Art Direction and Design

Tom M. Olson, BA
Laura C. Sesto, MA
Lead Editor
Terry W. Ferrell, MS
Production Coordinators
Angela M. G. Terry, BA
Rebecca L. Bluth, BA
Emily C. Fassett, BA
ix
x
Sections
SECTION 1: Benign Bone-Forming Tumors
SECTION 2: Malignant Bone-Forming Tumors
SECTION 3: Benign Cartilage Tumors
SECTION 4: Malignant Cartilage Tumors
SECTION 5: Fibrous and Fibrohistiocytic Tumors
SECTION 6: Fibroosseous Tumors
SECTION 7: Malignant Small Round Cell Tumors
SECTION 8: Notochordal Tumors
SECTION 9: Giant Cell-Rich Tumors
SECTION 10: Cystic Lesions of Bone
SECTION 11: Vascular Tumors
SECTION 12: Hematopoietic Tumors
SECTION 13: Miscellaneous Mesenchymal Tumors
SECTION 14: Metastatic Tumors
SECTION 15: Bone Tumor Mimics
xi
TABLE OF CONTENTS
SECTION 1: BENIGN BONE-FORMING SECTION 4: MALIGNANT CARTILAGE

TUMORS TUMORS
4 Bone Island/Osteopoikilosis 138 Conventional Chondrosarcoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
10 Osteoma 150 Dedifferentiated Chondrosarcoma
16 Osteoid Osteoma 156 Clear Cell Chondrosarcoma
22 Osteoblastoma 162 Mesenchymal Chondrosarcoma
SECTION 2: MALIGNANT BONE-FORMING SECTION 5: FIBROUS AND

TUMORS FIBROHISTIOCYTIC TUMORS
32 Conventional Osteosarcoma 172 Fibrous Cortical Defect/Nonossifying Fibroma
52 Well-Differentiated Intramedullary Osteosarcoma 178 Desmoplastic Fibroma
58 Parosteal Osteosarcoma 184 Myofibroma and Myofibromatosis
68 Periosteal Osteosarcoma 188 Fibrosarcoma
72 High-Grade Surface Osteosarcoma 194 Benign Fibrous Histiocytoma
76 Secondary Osteosarcoma 196 Solitary Fibrous Tumor/Hemangiopericytoma
Vikram Deshpande, MD, G. Petur Nielsen, MD, and G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
SECTION 6: FIBROOSSEOUS TUMORS
SECTION 3: BENIGN CARTILAGE TUMORS 200 Fibrous Dysplasia
82 Vascular Cartilaginous Hamartoma of Chest Wall G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 212 Liposclerosing Myxofibrous Tumor
84 Osteochondroma G. Petur Nielsen, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD
94 Multiple Hereditary Osteochondromatosis
Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and SECTION 7: MALIGNANT SMALL ROUND
G. Petur Nielsen, MD CELL TUMORS
98 Enchondroma 218 Ewing Sarcoma and Related Tumors
110 Enchondromatosis 230 Melanotic Neuroectodermal Tumor
116 Periosteal Chondroma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD SECTION 8: NOTOCHORDAL TUMORS
120 Chondroblastoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 234 Ecchordosis
128 Chondromyxoid Fibroma Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD
236 Benign Notochordal Cell Tumor
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
242 Chordoma
xii
TABLE OF CONTENTS
400 Leiomyosarcoma
SECTION 9: GIANT CELL-RICH TUMORS G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
256 Giant Cell Tumor 404 Myoepithelioma
270 Brown Tumor 410 Schwannoma
274 Giant Cell Reparative Granuloma 414 Myxopapillary Ependymoma
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD, G. Petur Nielsen, MD, and
SECTION 10: CYSTIC LESIONS OF BONE 416 Phosphaturic Mesenchymal Tumor
282 Intraosseous Ganglion G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
286 Unicameral Bone Cyst SECTION 14: METASTATIC TUMORS
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 420 Metastatic Tumors
294 Aneurysmal Bone Cyst Vikram Deshpande, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD G. Petur Nielsen, MD
306 Epidermoid Inclusion Cyst
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD SECTION 15: BONE TUMOR MIMICS
428 Bizarre Parosteal Osteochondromatous
SECTION 11: VASCULAR TUMORS
Proliferation and Related Lesions
310 Conventional Hemangioma G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 434 Melorheostosis
318 Lymphangioma/Lymphangiomatosis G. Petur Nielsen, MD and Andrew E. Rosenberg, MD
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD 438 Amyloidoma
320 Epithelioid Hemangioma G. Petur Nielsen, MD, Andrew E. Rosenberg, MD, and
G. Petur Nielsen, MD and Andrew E. Rosenberg, MD Vikram Deshpande, MD
328 Pseudomyogenic Hemangioendothelioma 440 Gaucher Disease
334 Epithelioid Hemangioendothelioma
340 Angiosarcoma
SECTION 12: HEMATOPOIETIC TUMORS

346 Langerhans Cell Histiocytosis (Eosinophilic
Granuloma)
352 Primary Lymphoma
360 Plasma Cell Myeloma
Vikram Deshpande, MD, G. Petur Nielsen, MD, and
368 Mast Cell Disease
370 Erdheim-Chester Disease
376 Rosai-Dorfman Disease
SECTION 13: MISCELLANEOUS

MESENCHYMAL TUMORS
382 Osteofibrous Dysplasia
Vikram Deshpande, MD, G. Petur Nielsen, MD, and
386 Adamantinoma
392 Adipocytic Tumors
xiii
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SECOND EDITION
NIELSEN | ROSENBERG
DESHPANDE • HORNICEK • KATTAPURAM • ROSENTHAL
SECTION 1
Benign Bone-Forming Tumors
Bone Island/Osteopoikilosis 4
Osteoma 10
Osteoid Osteoma 16
Osteoblastoma 22
Bone Island/Osteopoikilosis
KEY FACTS
TERMINOLOGY • Homogeneously radiodense lesions with spiculated

• Enostosis margins, which merge with surrounding cancellous bone
CLINICAL ISSUES MACROSCOPIC

• Incidental radiographic finding • Hard, solid, tan-white
• Large bone islands in children may be concerning for • Periphery blends with surrounding cancellous bone
osteosarcoma MICROSCOPIC
• Rarely need to be biopsied • Consist of cortical-type bone containing haversian-like
• Multiple bone islands represent osteopoikilosis canals
• Observation for small solitary characteristic lesions, but • Predominately lamellar but may be focally woven
those that are large or have unusual features may require • Osteopoikilosis bone island tumors are identical to
biopsy sporadic, solitary bone islands
IMAGING TOP DIFFERENTIAL DIAGNOSES
• Most frequent sites include pelvis, proximal femur, and ribs • Well-differentiated osteosarcoma
• In osteopoikilosis, usually involve epiphyses of short tubular • Sclerotic metastases
bones
• Generally not much larger than 1 cm in diameter
Specimen Radiograph of Bone Island Gross Photograph of Bone Island

(Left) Specimen radiograph
shows excised femoral head
containing a bone island. The
bone island is oval and
radiodense. The periphery has
a stellate margin merging with
the neighboring cancellous
bone. (Right) Gross
photograph of femoral head
shows bone island beneath the
articular surface. The bone
island is dense, tan-white, and
has a spiculated border as it
merges with the adjacent bony
trabeculae.
Bone Island Involving Pelvis CT Scan of Pelvic Bone Island

(Left) Radiograph of the pelvis
demonstrates a uniformly
dense bone island ﬈. The
spiculated margins represent
extensions from the lesion,
which merge with the
surrounding cancellous bone.
(Right) CT of a bone island ﬈
demonstrates that it is of the
same density as cortical bone.
The absence of a lytic
component can be difficult to
confirm without additional
cross-sectional imaging, an
important feature to
distinguish bone island from
other, more sinister bone-
forming lesions.
4

TERMINOLOGY Radiographic Findings
• Small
Synonyms • Oval
• Enostosis ○ Long axis of oval is usually parallel to mechanical stresses
• Spotted bone disease on bone, representing adaptation to Wolff law
Definitions • Single or multiple
• Larger variants may abut or be based on endosteal surface
• Benign bone-forming tumor composed of cortical-type
bone that develops within medullary cavity ○ Do not involve cortex and do not elicit periosteal
reaction
• Osteopoikilosis
• Homogeneously radiodense lesions with spiculated
○ Syndrome characterized by presence of multiple (usually
margins that merge with surrounding cancellous bone
many) bone islands
○ Can be associated with Buschke-Ollendorff syndrome MR Findings
and melorheostosis-like lesions • Dark on T1WI and T2WI, similar to normal cortical bone
ETIOLOGY/PATHOGENESIS CT Findings
• Small stellate medullary lesion with characteristics of
Neoplasm
cortical-type bone
• Cause of bone island is unknown
• Osteopoikilosis may be inherited in autosomal dominant Bone Scan
fashion • Can show some uptake of radionuclide
○ Associated with mutations and loss of function in LEMD3
located on 12q14 MACROSCOPIC
General Features
CLINICAL ISSUES
• Hard, solid, and tan-white; periphery blends into
Presentation surrounding trabeculae, which accounts for irregular
• Incidental radiographic finding and asymptomatic spiculated margins
○ Large bone islands may be painful
• Uncommon in children MICROSCOPIC
• Lesions in osteopoikilosis may undergo slow, progressive Histologic Features
enlargement or involution
• Consist of cortical-type bone containing haversian-like
Treatment canals
• Observation for small solitary lesions with classic • Predominately lamellar but may be focally woven
radiographic features • Osteoblasts lining surfaces are flat and quiescent
• Larger variants or cases in adolescents may require biopsy • Osteocytes are small and cytologically banal
to exclude more aggressive lesions, such as well- • Bone islands in osteopoikilosis are identical to sporadic,
differentiated osteosarcoma and sclerotic metastases in solitary bone islands
adults
DIFFERENTIAL DIAGNOSIS
Prognosis
• Excellent Well-Differentiated Osteosarcoma
• Malignant transformation does not occur • Infiltrative, composed of proliferating mildly atypical
spindle cells and woven bone
IMAGING Sclerotic Metastases
General Features • Usually in adults and contain histologically malignant cells
• Location
○ Most frequent sites are pelvis, ribs, and proximal femur DIAGNOSTIC CHECKLIST
○ In adults, incidence in pelvic bones (1.0%) and ribs (0.5%) Clinically Relevant Pathologic Features
○ Epiphyseal in tubular bones • Multiple lesions raise differential diagnosis of blastic
○ Osteopoikilosis is bilateral and symmetrical in metastases; multiple bone islands seen in osteopoikilosis
distribution and in metaphyseal and epiphyseal regions
of tubular bones Pathologic Interpretation Pearls
– Any bone may be affected, including tarsal and carpal • Lesion is intramedullary, cortical in type, and predominately
bones lamellar in architecture
• Size
○ Usually < 1 cm in diameter SELECTED REFERENCES
○ Infrequently, "giant" bone islands several cm in diameter 1. Korkmaz MF et al: Osteopoikilosis: report of a familial case and review of the
occur literature. Rheumatol Int. ePub, 2014
5
CT Scan of Bone Island MR of Bone Island

(Left) CT scan of the shoulder
demonstrates a very large
bone island ﬅ of the scapula
at the base of the coracoid
process. The lesion is
uniformly and completely
dense and abuts the cortex
but does not invade or
transgress it. (Right) MR of a
round bone island ﬅ shows
that it is uniformly
hypointense and abuts the
cortex but does not invade or
transgress it. The marrow
adjacent to the ossified lesion
is completely normal.
Bone Island of Spine Bone Island of Spine

(Left) A bone island of the
central portion of the
vertebral body shows
characteristic features:
Uniform density and
spiculated margins ﬅ. The
lesion is surrounded by
unremarkable cancellous
bone, and the cortex is
uninvolved. (Right) A giant
bone island of the vertebra is
shown ﬅ almost filling the
entire vertebral body. Such
large lesions can show uptake
on isotope bone scans due to
their size. In other respects,
the features are similar to
conventional bone islands.
Bone Island Involving Pedicle Bone Island of Pedicle

(Left) Sagittal CT scan shows a
large bone island involving the
pedicle and facet joint of T12
ﬅ. The lesion fills a
significant portion of the
medullary cavity and merges
with the overlying cortex. The
intramedullary margin is
undulating and focally
spiculated. Smaller lesions are
seen in the adjacent vertebra.
(Right) Axial CT of a large
bone island involves the
pedicle and facet joint of T12
ﬅ. The tumor has the same
density as the cortex, which is
unremarkable.
6

Large Bone Island of Femur Large Bone Island of Femur
(Left) AP radiograph of the
distal femur demonstrates a
large bone island involving the
metaphysis ﬈. Note the
spiculated margin proximally.
In this particular lesion, the
elongated shape of the lesion
is apparent, representing
adaptation to mechanical
stresses. (Right) Lateral
radiograph of the distal femur
demonstrates a large bone
island of the posterior portion
of the bone ﬅ. The lesion
appears to be based on the
endosteal surface and extends
into the medullary cavity.
CT of Bone Island of Femur Bone Scan

(Left) Axial CT shows a giant
bone island of the distal femur
ﬅ with uniform density of
compact bone and spiculated
margins. The broad base of
the tumor is attached to the
endosteal surface of the
posterior cortex. (Right)
Isotope bone scan shows a
small amount of uptake ﬅ in
the lateral aspect of the right
proximal humerus. A small
amount of uptake can be
present in bone islands
because they are actively bone
forming. It should not be
considered a marker of
malignancy.
Large Bone Island of Proximal Humerus MR of Bone Island of Humerus

(Left) CT scan demonstrates a
large bone island of the
proximal humerus ﬅ. The
lesion is eccentric, abuts the
endosteal surface of the
cortex, and extends in the
medullary cavity in an
irregular fashion. (Right)
Coronal T1-weighted MR of
the bone island of the
humerus demonstrates the
homogeneous low signal
intensity of the lesion ﬈. The
bone island is based on the
inner surface of the cortex and
has irregular margins. The
adjacent marrow is
unremarkable.
7
Osteopoikilosis Osteopoikilosis
(Left) AP radiograph
demonstrates osteopoikilosis
with multiple bone islands
involving the ends of the short
tubular bones. The small
lesions cluster at the ends of
the bones. (Right) AP
radiograph of the knees shows
the typical features of
osteopoikilosis. A large
number of small bone islands
are symmetrically distributed
in a primarily juxtaarticular
and metaphyseal distribution.
Despite their multiplicity, each
lesion individually has the
features typical of a bone
island.
Osteopoikilosis MR of Osteopoikilosis
(Left) Reformatted coronal CT
scan of the hip shows multiple
small bone islands that are
juxtaarticular and
metaphyseal in distribution.
Each lesion is individually
indistinguishable from a
solitary bone island. (Right)
T1-weighted MR of the knee in
a patient with osteopoikilosis
demonstrates that the bone
islands are small, rather
uniform in size, oval in shape,
and uniformly dense. Each
lesion is individually
indistinguishable from a
solitary bone island.
Bone Island of Mandible Gross Photo of Bone Island Arising in Rib

(Left) Coronal CT
demonstrates an
intramedullary bone island
involving the right mandible
ﬅ. The lesion is sclerotic with
the same density as the
surrounding cortex. (Right)
Gross photograph shows rib
and adjacent costal cartilage.
An elongate, dense, and tan-
white bone island fills the
involved segment of the
medullary cavity ﬅ. The
adjacent cortex and costal
cartilage are unremarkable.
8

Gross Photograph Whole-Mount Section
(Left) Gross photograph shows
an excised femoral head with
an incidental bone island ﬈.
The tumor is located beneath
the articular cartilage and
merges with the surrounding
trabecular bone. The
neighboring marrow is fatty
and unremarkable. (Right)
Low-power view shows a bone
island involving the medullary
cavity of the proximal femur
﬈. The lesion is composed of
cortical-type bone that blends
imperceptively with the
surrounding trabecular bone.
Light Microscopy Light Microscopy

(Left) Histologic section of a
solitary bone island is shown.
The bone island is composed
of cortical-type bone with
haversian-like canals and
transitions into the adjacent
cancellous bone. The
surrounding marrow is
predominately fatty with
scattered islands of
hematopoietic cells. (Right)
Bone island with numerous
haversian-like systems
scattered throughout the
lesion is shown. The bone of
the tumor is sharply
demarcated from the adjacent
marrow.
Periphery of Bone Island Osteopoikilosis

(Left) Close view of the
transition between the
periphery of the bone island is
shown as it merges with an
adjacent bone trabeculum.
The bone is woven and
lamellar and has a sharp
border with the surrounding
fatty and hematopoietic
marrow. (Right) Resected
femoral head from a patient
with osteopoikilosis shows
that numerous bone islands
are present within the
medullary cavity. The lesions
are round to oval and vary in
size. The margins are irregular
and spiculated.
9
Osteoma
KEY FACTS
TERMINOLOGY MACROSCOPIC
• Benign surface bone-forming tumor, usually composed of • Generally < 2 cm in diameter; round, tan-white, and hard
cortical-type bone • Resembles cortical bone with which it merges
CLINICAL ISSUES MICROSCOPIC
• Usually small and solitary • Consists mainly of lamellar bone admixed with some woven
• Commonly asymptomatic and incidental finding bone
• Most frequently develop in craniofacial skeleton • Bone has cortical-type architecture
• Appendicular tumors are very uncommon • Minority of osteomas composed of trabecular bone
• Multiple lesions raise possibility of Gardner syndrome • Lesional osteoblasts and osteocytes usually inconspicuous
• Asymptomatic lesions can be observed
DIAGNOSTIC CHECKLIST
• Symptomatic lesions can be conservatively excised
• Well-formed cortical bone and banal cytology distinguishes
IMAGING osteoma from osteosarcoma
• Small and uniformly radiodense • Intact cortex and absence of cartilage excludes
• Sharply marginated with well-formed periosteal reaction osteochondroma
• Oval to dome-shaped with broad attachment to cortical • Hypocellularity of lesion is evidence against myositis
surface ossificans
• Underlying cortex is not involved • Melorheostosis and osteoma are histologically similar
Osteoma of Fibula Osteoma of Long Bone Resection Specimen
Radiograph of proximal lower leg shows a dense, well- Osteoma is composed of hard, dense, compact bone with a
defined ossific mass on the surface of the proximal fibula. broad attachment to the underlying cortex. A triangular-
There is thick, periosteal bone apposition proximal to the shaped zone of subperiosteal bone is present proximal and
mass that is triangular in shape. distal to the osteoma.
10
Osteoma

TERMINOLOGY CT Findings
• Well-delineated surface mass with cortical density
Abbreviations
• Osteoma (OS) Bone Scan
• May show increased or no radiotracer uptake
Synonyms
• Torus palatinus (palate) and mandibularis (mandible) MACROSCOPIC
Definitions General Features
• Benign surface tumor composed of cortical-type bone • Generally < 2 cm in diameter
○ Minority composed of trabecular bone (trabecular • Oval, round, or hemispheric
osteoma) • Hard
• Tan to white
CLINICAL ISSUES • Resembles cortical bone with which it merges
Epidemiology • Well-formed, triangular-shaped subperiosteal reactive bone
• Incidence may surround attachment site to cortex
○ Paranasal sinus osteoma: 3-4%
○ Cranial osteoma at autopsy: 4-5%
MICROSCOPIC
○ Accounts for 0.03% of biopsied primary bone tumors Histologic Features
• Age • Admixture of lamellar and woven bone with haversian-like
○ Most common in 4th to 6th decades of life systems
• Sex • Infrequently composed of trabecular bone
○ No predilection • Growing lesion may have fibrous component mimicking
fibroosseous tumor
Site
• Osteoblasts rimming bone are inconspicuous and elongate
• Craniofacial skeleton most common ○ Growing lesions lined by plump metabolically active
○ Often located in frontal and ethmoid sinuses (75%) osteoblasts
○ Sphenoid sinus, cranium, jaw – Abundant eosinophilic cytoplasm and nuclei polarized
• Appendicular skeleton rare away from bone-forming surface
○ Long tubular bones • Inactive osteoblasts and osteocytes have small round dark
– Femur and tibia most common nuclei and no nucleoli
Presentation
DIFFERENTIAL DIAGNOSIS
• Slow-growing small lesions; usually incidental finding
• Large lesions: Symptoms related to anatomic location Bone-Forming Lesions
○ Sinus tumors: Obstruction and mucocele • Parosteal osteosarcoma
○ Orbital tumors: Exophthalmos and vision disturbances ○ Contains prominent spindle cell component
○ Oral tumors: Interfere with dentures and mastication • Juxtacortical myositis ossificans
○ Appendicular tumors: Palpable hard mass ○ Composed of hypercellular cancellous bone
• Usually solitary • Melorheostosis
○ Multiple tumors may be seen in Gardner syndrome ○ Dripping candle wax configuration
• Osteochondroma
Treatment
○ Has cartilage cap
• Observation
• Simple excision DIAGNOSTIC CHECKLIST
Prognosis Pathologic Interpretation Pearls
• Excellent, no recurrence • Well-formed cortical bone and banal cytology distinguishes
osteoma from osteosarcoma
IMAGING • Intact cortex and absence of cartilage excludes
General Features osteochondroma
• Uniformly radiodense surface lesion well demarcated from • Hypocellularity is evidence against myositis ossificans
soft tissue • Melorheostosis and osteoma are histologically similar
• Ovoid with broad base of attachment to cortex
• Dense periosteal reaction along margin of attachment may
SELECTED REFERENCES
be present 1. Halawi AM et al: Craniofacial osteoma: clinical presentation and patterns of
growth. Am J Rhinol Allergy. 27(2):128-33, 2013
MR Findings 2. Greenspan A. Benign bone-forming lesions: osteoma et al: clinical, imaging,
pathologic, and differential considerations. Skeletal Radiol. 22(7):485-500,
• Low signal intensity on T1- and T2-weighted images 1993
○ Lesion does not enhance with contrast 3. O'Connell JX et al: Solitary osteoma of a long bone. A case report. J Bone
Joint Surg Am. 75(12):1830-4, 1993
11
Osteoma
Osteoma of Femur Large Osteoma of Femur

(Left) Anteroposterior view
of the left thigh shows a
dense, well-defined ossific
mass on the surface of the
medial femur. There is
periosteal bone apposition
proximal and distal to the
attachment site ﬅ. (Right)
CT shows a well-defined,
homogeneously sclerotic
mass ﬈ contiguous with the
outer cortex of the femur
and extending into the soft
tissues. The underlying
cortex contains cylindrical
lucencies ﬉, which contain
feeding blood vessels that
branch into the tumor.
Osteoma Resembling Cortical Bone Osteomas in Gardner Syndrome

(Left) Gross photograph
shows osteoma of femur cut
in a sagittal plane. The mass
merges imperceptibly with
the underlying cortex. Notice
how the proximal and distal
portions of the cortex
adjacent to the mass are
thickened by reactive, well-
formed bone both proximally
and distally ﬅ. (Right) AP
radiograph of femur in a
patient with Gardner
syndrome shows 2 elongated
sessile osteomas. The masses
protrude from the medial
and lateral surfaces of the
cortex ﬅ and merge with
the underlying bone.
12
Osteoma

Osteoma Displacing Eye Marble-Like Mass
(Left) CT shows a well-defined,
oval, homogeneously sclerotic
osteoma. The tumor is
contiguous with the outer
cortex of the orbital roof,
extends into the periorbital
soft tissues, and displaces the
globe inferiorly. The
underlying cortex is intact.
(Right) Gross photograph of
resected osteoma shows a
marble-like mass that
protrudes from the cortex. The
tumor is covered by a
translucent layer of
periosteum and is tan-white,
hard, and well circumscribed.
Osteoma of Sinus Producing Mucocele MR of Mucocele Caused by Osteoma

(Left) Axial CT shows a
homogeneously dense
osteoma projecting into the
frontal lobe from the inner
table of the skull. Note the
low-density area representing
a mucocele ﬅ surrounding
the lesion adjacent to the
frontal lobe of the brain.
(Right) T2-weighted MR shows
a heterogeneous, mostly
hypointense mass projecting
from the inner table of the
skull. There is a lobulated,
hyperintense mucocele ﬅ
adjacent to the lesion. The
mucocele distorts the adjacent
brain parenchyma.
Osteoma of Palate Osteomas in Gardner Syndrome

(Left) In this clinical
photograph of torus palatinus,
the mass appears as a midline,
oval, tan-white lesion ﬈
beneath the oral mucosa
lining. The mucosa is intact
and translucent. (Courtesy T.
Dodson, MD.) (Right) AP
radiograph shows gnathic
bones in a patient with
confirmed Gardner syndrome.
Multiple large, lobulated
osteomas arise from the
surface of the mandible
bilaterally ﬆ. The radiodense
masses are well circumscribed
from the surrounding soft
tissues.
13
Osteoma
Osteoma at Surgery Osteoma Having Cortical-Like Features

(Left) Surgical exposure of an
osteoma of the forehead
shows that the small round
lesion is pearly white. The
tumor easily separates and is
sharply demarcated from the
neighboring soft tissues. The
vascularized periosteum ﬈
can be seen covering a portion
of the periphery of the lesion.
(Right) Hematoxylin & eosin
section of osteoma shows that
the tumor has cortical-like
architecture. The bone is
composed of an admixture of
woven and lamellar bone ﬅ.
Note the haversian-like canals
that are scattered throughout
the mass ﬆ.
Woven and Lamellar Bone Osteoma With Haversian-Like Canals

(Left) Hematoxylin & eosin
section of osteoma shows that
the bone is both woven ﬅ
and lamellar ﬆ in pattern.
The osteoblasts lining the
surface of the haversian-like
canal are not well seen ﬈,
and the osteocytes in the
matrix are small and randomly
distributed. (Right)
Hematoxylin & eosin of
osteoma shows haversian-like
canals ﬅ that are prominent
and vary in size and shape. The
lining osteoblasts are small
and osteocytes are numerous.
Some of the spaces are filled
with fatty marrow.
Multinodular Mass on Calvarium Trabecular Osteoma

(Left) Gross photograph shows
cancellous osteoma arising
from the inner table of the
skull. The bilobed tumor ﬅ
has a spongy appearance with
the intertrabecular spaces
filled with marrow. (Right)
Cancellous osteoma of the
skull merges with the
underlying inner table. The
surface of the lesion is
composed of a thin plate of
cortical-type bone, and the
central component consists of
interconnecting trabeculae of
mainly lamellar bone.
14
Osteoma

Mixture of Cortical and Cancellous Bone Osteoma Composed of Trabecular Bone
(Left) Hematoxylin & eosin
section shows osteoma with
cortical ﬅ and cancellous ﬉
patterns. The intertrabecular
spaces are filled with loose
connective tissue, which
contains dilated feeder blood
vessels. (Right) Hematoxylin &
eosin section of cancellous
osteoma shows that the
interconnecting trabeculae
are covered by prominent
osteoblasts ﬈. The bone is
surrounded by loose
connective tissue.
Trabeculae Surrounded by Marrow Cap of Osteochondroma

(Left) Interconnecting
trabeculae in osteoma are
composed of collagen fibers
that are arranged in a lamellar
pattern. The surface
osteoblasts are inconspicuous.
The osteocytes ﬅ are small.
The marrow spaces are filled
with hematopoietic elements.
(Right) Osteochondroma has a
cap of hyaline cartilage that
resembles disorganized
growth plate cartilage. This
feature and the continuity of
the center of the tumor with
the underlying medullary
cavity of the originating bone
distinguishes osteochondroma
from osteoma.
Myositis Ossificans Parosteal Osteosarcoma

(Left) Myositis ossificans is
hypercellular with primitive-
appearing trabecular woven
bone that merges with more
mature-appearing bone
peripherally. The appearance
of the bone and
hypercellularity helps
distinguish it from osteoma.
(Right) Parosteal
osteosarcoma is composed of
long trabeculae of woven
bone surrounded by fascicles
of spindle cells. The
architecture of the bone and
spindle cells distinguish the
tumor from osteoma.
15
Osteoid Osteoma
KEY FACTS
TERMINOLOGY • Excellent prognosis as lesion is not locally aggressive and

• Benign bone-forming tumor characterized by its small size, does not metastasize
limited growth potential, classic pattern of pain, and IMAGING
composition of woven bone trabeculae rimmed by
• Does not exceed 1-2 cm in diameter
osteoblasts
• Lesion has well-defined margins and is round, lucent, and
CLINICAL ISSUES often contains variable amount of patchy central
• Accounts for ~ 13% of all primary benign bone tumors and mineralization
3% of all other primary bone tumors • Nidus is surrounded by zone of subperiosteal or medullary
• Peak incidence: 5-25 years (76%) sclerosis
• Located in long tubular bones, especially lower extremity, • Increased uptake on bone scan
followed by posterior elements of spine and tubular bones ANCILLARY TESTS
of hands and feet
• S100 and neurofilament show nerve fibers within and
• Presents as severe localized pain that is often worse at
adjacent to tumor
night, which is relieved by aspirin or related medications
• Induces joint pain that may mimic primary articular disorder TOP DIFFERENTIAL DIAGNOSES
• Most common cause of painful scoliosis • Osteoblastoma
• Treatment of choice is radiofrequency ablation with • Intraosseous abscess (Brodie abscess)
surgical removal in select patients • Stress fracture
Oval Radiolucency Red-White Tumor
AP plain radiograph of the distal femur shows an osteoid Osteoid osteoma appears as a well-circumscribed, oval,
osteoma on the surface of the medial metaphyseal cortex. hemorrhagic, red, solid mass. The tumor is surrounded by a
The oval tumor (nidus) manifests a small lucency with thick rind of reactive bone.
subtle central mineralization surrounded by a very thick
16 layer of periosteal new bone formation.
Osteoid Osteoma

• Usually solitary and rarely multifocal
TERMINOLOGY
Abbreviations Radiographic Findings
• Round, radiolucent with central mineralization
• Osteoid osteoma (OO)
• Peripheral sclerosis frequent and may be extensive
Definitions
MR Findings
• Benign bone-forming tumor characterized by small size,
limited growth potential, classic pattern of pain, and • Isodense to skeletal muscle on T1-weighted images
composition of woven bone trabeculae rimmed by • Lucent components and surrounding edema have
osteoblasts increased signal intensity on T2-weighted images
CT Findings
CLINICAL ISSUES • Well-demarcated, small, round with central mineralization,
Epidemiology bordered by reactive bone
• Incidence Bone Scan
○ Accounts for 13% of benign bone tumors
• Marked uptake of radionuclide
• Age
○ Usually develops in adolescents and young adults MACROSCOPIC
– Peak incidence: 5-25 years (76%)
• Sex General Features
○ M:F = 2-3:1 • Round, well demarcated, gritty, dark red with central tan-
white speckles and < 2 cm
Site • Surrounded by dense sclerotic bone
• Long tubular bones (75% of cases)
○ Proximal femur is most common location MICROSCOPIC
○ Diaphysis and metaphysis (65-80%), infrequently
Histologic Features
epiphysis
○ Subperiosteal and intracortical (70-80%), intramedullary • Haphazard, interanastomosing trabeculae of woven bone
(25%); intraarticular is uncommon rimmed by osteoblasts
• Vertebral column (10-14% of cases) ○ Neoplastic bone may be sheet-like or solid
○ Posterior elements (90%), body (10%) ○ Some osteoblasts may be epithelioid
• Short tubular bones of hands and feet (8-10%) ○ Cartilaginous foci are rare
• Scattered osteoclasts often on surfaces of trabeculae
Presentation • Vascular stroma containing loose connective tissue
• Severe localized pain worse at night, relieved by aspirin or
nonsteroidal antiinflammatory medications ANCILLARY TESTS
○ High levels of prostaglandin E2 and prostacyclins
Immunohistochemistry
○ COX-2 overexpression by osteoblasts
• Joint pain and effusion can mimic articular disorder • S100 and neurofilament show nerve fibers involving tumor
• Swelling can simulate infection with tumors in phalanges Genetic Testing
• Painful scoliosis due to spasm of paravertebral muscles • Monosomies and chromosome 22q abnormalities
○ Most common cause of painful scoliosis
• Overgrowth of bone when located near growth plate Hormone Production
• Limp and limitation of range of motion • Produces osteocalcin, which can raise blood glucose
Treatment DIFFERENTIAL DIAGNOSIS

• Radiofrequency ablation
Osteoblastoma
○ No removal of normal tissue and outpatient procedure
• Curettage, burring, cryoablation, ultrasound therapy, • > 2 cm; morphologic overlap
resection Intraosseous Abscess (Brodie Abscess)
• Medical therapy and observation in select patients • Rich in inflammatory cells and granulation tissue
Prognosis Stress Fracture
• Excellent; local recurrence rate 0-10% • Reactive woven bone network well oriented (not
haphazard) around fractured trabeculae
IMAGING
General Features SELECTED REFERENCES
• Lytic tumor (nidus) is 1-2 cm in diameter 1. Abboud S et al: Long-term clinical outcomes of dual-cycle radiofrequency
ablation technique for treatment of osteoid osteoma. Skeletal Radiol.
• Well-defined margins and central patchy mineralization 45(5):599-606, 2016
• Surrounded by reactive sclerosis and edema 2. Boscainos PJ et al: Osteoid osteoma. Orthopedics. 36(10):792-800, 2013
○ Extensive reactive changes simulate aggressive 3. Trotta B et al: Benign osteoid-producing bone lesions: update on imaging
neoplasm, obscures lesion and treatment. Semin Musculoskelet Radiol. 17(2):116-22, 2013
17
Osteoid Osteoma
Cortical Thickening Marked Edema

(Left) A child presents with leg
pain that is worse at night,
and a radiograph shows a
region of cortical thickening
﬈. Within the area of
sclerosis is a subtle oval
lucency that represents an
osteoid osteoma ﬉. (Right)
Coronal T2-weighted MR of
the right hip shows an osteoid
osteoma ﬉ on the surface of
the bone. The tumor is
partially obscured by extensive
intramedullary, periosteal, and
soft tissue edema ﬈ (bright
white areas).
Oval Lucency With Surrounding Sclerosis Round Intracortical Tumor

(Left) Osteoid osteoma is oval,
radiolucent, and often has a
mineralized central portion
﬈. This tumor involves the
cortex and has elicited
abundant subperiosteal well-
formed reactive bone that is
sclerotic ﬅ. (Right) In this
axial CT, the osteoid osteoma
is intracortical and has elicited
reactive new bone within the
medullary cavity beneath the
periosteum. The tumor is
round and lytic with a small
central mineralized region.
Eccentric Tumor Intracortical Tumor

(Left) This radiograph shows
an osteoid osteoma of the
distal ulnar metaphysis. The
oval, well-demarcated, lytic
tumor ﬅ eccentrically
involves the cortex and is
surrounded by reactive new
bone ﬈. (Right) This axial CT
exhibits the features
characteristic of osteoid
osteoma. The tumor is small,
round, and lytic ﬅ with
central mineralization and is
surrounded by abundant
subperiosteal reactive bone
﬈.
18
Osteoid Osteoma

Osteoid Osteoma of Posterior Elements Intense Uptake
(Left) AP radiograph of the
cervical spine demonstrates a
round osteoid osteoma ﬅ of
the left posterior elements of
C7. The lesion is mostly lytic,
although a small amount of
central hazy mineralization is
visible. (Right) Radionuclide
bone scan (posterior view)
shows a small focus of intense
uptake ﬆ in the left posterior
elements of C7, representing
the osteoid osteoma. A larger,
but much less intense, "halo"
of uptake surrounds the lesion
representing reactive tissue
changes.
Tumor in Base of Pedicle Surrounding Edema

(Left) Osteoid osteoma often
develops in the posterior
elements of the spine. In this
case, the oblong lytic tumor is
well circumscribed ﬅ and
involves the base of the
pedicle. (Right) Osteoid
osteoma often produces
edema of the surrounding
tissues. In this axial T2-
weighted fat-saturated image
a rim of bright intensity ﬅ
edematous tissue encircles the
tumor ﬆ.
Round Tumor in Posterior Elements Osteoid Osteoma of Vertebral Body

(Left) Sagittal reformation of
a CT scan demonstrates an
osteoid osteoma of the
posterior elements of T12. The
lesion is 1 cm in diameter ﬈,
contains ring-like internal
mineralization, and is
surrounded by dense sclerosis
﬉ of the pedicle and articular
facets. (Right) It is uncommon
for osteoid osteoma to be
centered in the vertebral body.
In this axial reformatted CT,
the eccentric lytic tumor ﬈ is
surrounded by a rim of
sclerosis ﬉.
19
Osteoid Osteoma
Marked Sclerosis Intramedullary Tumor

(Left) Axial CT of the ilium
shows an osteoid osteoma
within the cancellous bone ﬉.
It is surrounded by very dense
sclerosis ﬈, which merges
with the endosteum of the
cortex. Little or no periosteal
reaction is present. (Right)
Axial CT of the distal femur
shows a purely intramedullary
lytic osteoid osteoma ﬈. This
location is relatively
uncommon, and when it
occurs, periosteal reaction
may be minimal. Note the
irregular rim of surrounding
sclerosis.
Arthroscopic View of Tumor Red-White, Well-Demarcated Mass

(Left) Arthroscopic view of
osteoid osteoma shows the
round, bulging, red tumor. The
white tissue surrounding the
mass is smooth articular
cartilage. (Right) Gross
photograph of a resected
osteoid osteoma of the fibula
shows that the oval, red,
intramedullary tumor has a
central tan-white mineralized
region. The adjacent cortex on
one side of the mass is
thickened by subperiosteal
reactive new bone. The
periosteum is intact.
Specimen Radiograph of Osteoid Osteoma Round Tumor Straddling Cortex

(Left) Specimen radiograph of
intracortical osteoid osteoma
reveals the small, round,
lucent tumor has a central
area of mineralization ﬅ and
is sharply demarcated from
the surrounding reactive bone
﬈. The involved portion of
cortex has been trabecularized
ﬆ. (Right) Cross section of
intracortical osteoid osteoma
of long bone reveals the
round, red-white nidus. The
lesion has scattered white
areas and is sharply
demarcated from the
peripheral reactive bone ﬈. A
portion of the cortex is
uninvolved ﬆ.
20
Osteoid Osteoma

Osteoid Osteoma With Sharp Margins Haphazardly Interconnecting Trabeculae
(Left) Low-power image of a
resected osteoid osteoma
shows a small, round nidus ﬆ
located adjacent to the
surface of the cortex ﬈. The
lesion is surrounded
peripherally by abundant
reactive bone. (Right)
Trabeculae of osteoid
osteoma are randomly
arranged and interconnect
haphazardly. Large
osteoblasts rim the woven
bone surfaces, and
intertrabecular spaces contain
loose fibrovascular tissue.
Osteoblastic Rimming Osteoid Osteoma With Sheet-Like Bone

(Left) Large osteoblasts ﬈ rim
the surface of the bone in
osteoid osteoma. The
intertrabecular spaces are
filled with very vascular loose
connective tissue. (Right)
Osteoid osteoma composed of
sheet-like bone matrix entraps
bone-forming cells. The matrix
varies in color from pink to
purple, depending on its state
of mineralization. The
neoplastic matrix does not
encase preexisting bony
trabeculae.
Plump Osteoblasts Cartilage in Osteoid Osteoma

(Left) Plumb osteoblasts ﬅ
rim the woven bone ﬆ in this
osteoid osteoma. Some of the
osteoblasts have a perinuclear
huff that represents a
prominent Golgi apparatus ﬈.
(Right) Some osteoid osteomas
rarely have cartilage as a part
of the matrix. In this example
the basophilic cartilage ﬅ is
focally mineralized and is
adjacent to the eosinophilic
woven bone of the tumor ﬆ.
21
Osteoblastoma
KEY FACTS
CLINICAL ISSUES MICROSCOPIC

• Benign bone-forming neoplasm > 2 cm in dimension • Sharply demarcated from adjacent preexisting and reactive
• Diagnosed in young adults with male predominance of 2:1 bone
• Commonly arises in tubular bones and posterior elements • Composed of haphazardly interconnecting trabeculae or
of spinal column sheet-like aggregates of woven bone rimmed prominently
• Presents with pain and swelling with neurologic symptoms by metabolically active osteoblasts
in some spinal lesions • Intertrabecular tissue consists of loose, richly vascular
• Treated by curettage or en bloc excision connective tissue
• Excellent prognosis with local recurrence rate of 20% • Variants contain cartilage, epithelioid osteoblasts,
degenerative nuclear changes, and aneurysmal bone cyst-
IMAGING like changes
• Expansile, well-defined mixed lytic and blastic mass with
sclerotic margins
TOP DIFFERENTIAL DIAGNOSES
• Osteoid osteoma
MACROSCOPIC • Aneurysmal bone cyst
• Well-circumscribed, gritty, tan-white, dark red mass • Osteoblastoma-like osteosarcoma
• Usually 2-5 cm in size
Radiograph of Osteoblastoma Gross Photograph of Osteoblastoma
Radiograph of the humerus shows a lytic osteoblastoma of A long bone with an osteoblastoma involves the cortex
the mid shaft surrounded by solid periosteal new bone. It and surface of bone. The well-circumscribed tumor is oval
extends into periosseous soft tissues where cloud-like and red with speckled tan-white foci, which correspond to
neoplastic ossification is noted. areas rich in neoplastic bone.
22
Osteoblastoma

TERMINOLOGY MR Findings
• Well-delineated mass low to intermediate signal intensity
Abbreviations on T1 and intermediate to high signal intensity on T2
• Osteoblastoma (OB) ○ Mineralized areas manifest as signal void (dark)
Synonyms ○ Tumor and edema enhance with contrast
• Giant osteoid osteoma CT Findings
Definitions • Expansile lytic and sclerotic mass with circumscribed
margins and surrounding reactive bone
• Benign bone-forming neoplasm > 2 cm composed of
woven bone trabeculae lined by osteoblasts Bone Scan
• Intense uptake on scintigraphy
ETIOLOGY/PATHOGENESIS
Etiology MACROSCOPIC
• Neoplasm: Some have deletion of portion of chromosome General Features
22q12; does not upregulate miRNA-210 • Solitary, well circumscribed, tan-white, dark red, gritty
○ Rarely multifocal/multicentric
CLINICAL ISSUES • Cystic changes prominent in 10% of cases
Epidemiology • Periosteal shell of reactive bone
• Incidence Size
○ Uncommon; accounts for 1% of primary bone tumors • Range: 2-20 cm; most measure between 3-5 cm
• Age
○ Adolescents and young adults (2nd-4th decades) MICROSCOPIC
– 75% younger than 25 years old at diagnosis
• Sex Microscopic Features
○ Males affected more frequently than females (2:1) • Sharply demarcated
• Trabeculae in haphazard, interconnecting, sheet-like
Site patterns
• Most commonly arise in tubular bones ○ Woven bone rimmed by plump osteoblasts and
○ ~ 60% develop in appendicular skeleton scattered osteoclasts
– Metadiaphyseal region of tubular bones • Vascular connective tissue fills intertrabecular space
– Cortical: 65%; medullary cavity: 35% of cases • Scattered mitoses with no atypical forms
– Femur: 12%; tibia: 10%; bones of foot and ankle: 9% • Necrosis usually absent or focal
• Axial skeleton frequently affected • Occasional cystic change mimicking aneurysmal bone cyst
○ 30% arise in spinal column • 75% epithelioid osteoblasts: Aggressive OB
– Posterior elements: Lamina, pedicles; vertebral body ○ Large, polyhedral, abundant eosinophilic cytoplasm,
occurs secondarily vesicular nucleus, and prominent nucleolus
– Cervical > lumbar > thoracic > sacral • Cartilaginous variant (5%) contains hyaline cartilage
• Craniofacial bones: 10% of cases; mandible most common • Pseudomalignant: Degenerative large, hyperchromatic,
vacuolated nuclei
Presentation
• Pain, swelling, decreased range of motion DIFFERENTIAL DIAGNOSIS
• Spine tumors: Paresthesias, paraparesis, paraplegia
• Rarely associated with systemic "toxic" symptoms Osteoid Osteoma
• < 2 cm; characteristic clinical symptoms
Treatment
• Curettage or selective en bloc resection Aneurysmal Bone Cyst
• No haphazardly joining trabeculae of woven bone
Prognosis
• Curettage: Local recurrence in 20% of cases Osteoblastoma-Like Osteosarcoma
• Aggressive variant behaves similar to conventional type • Grows with infiltrative pattern
• Malignant transformation is exceptionally rare
DIAGNOSTIC CHECKLIST
IMAGING Pathologic Interpretation Pearls
Radiographic Findings • Well demarcated: Neoplastic bone rimmed by osteoblasts
• Expansile, well-defined, oval mixed lytic and blastic mass
○ Peripheral lucent halo and central mineralization SELECTED REFERENCES
○ Poorly defined margins in small minority 1. Lucas DR et al: Osteoblastoma: clinicopathologic study of 306 cases. Hum
• Periosteal reactive bone; solid, laminated or spiculated Pathol. 25(2):117-34, 1994
23
Osteoblastoma
Avid Uptake on Bone Scan Osteoblastoma Expanding Bone

(Left) AP bone scan shows a
small oval focus of intense
isotope uptake on the left of
T2 ﬅ. (Right) CT scan through
osteoblastoma of pedicle and
lamina of the vertebra
demonstrates a well-
circumscribed, expansile, oval
mass, which contains
substantial internal fine
ossification ﬈. The tumor
impinges upon the spinal
canal. Thick periosteal
reaction is present along the
surface of the lamina and the
base of the spinous process
ﬅ.
Subtle Tumor in Wing of Sacrum Large Osteoblastoma of Sacrum

(Left) The sacral wing contains
a large osteoblastoma ﬅ that
is difficult to appreciate on the
plan film. The tumor is mixed
lytic and blastic and has a
well-defined margin. (Right)
This is the axial CT that
corresponds to the
accompanying plain film. The
round tumor ﬈ is mixed lytic
and blastic with a fine pattern
of mineralization.
Osteoblastoma Expanding Mandible Osteoblastoma of Mandible

(Left) Axial CT of a mandibular
osteoblastoma shows a well-
demarcated lytic lesion arising
in the anterior symphyseal
portion of the mandible. The
tumor has faint internal
ossifications and is surrounded
by a shell of periosteal new
bone formation ﬅ. (Right) A
3D reformation of a CT scan of
an osteoblastoma of the
mandible demonstrates a lytic
lesion involving the inferior
margin of the body, causing
irregular elevation of the
periosteum ﬅ. Several teeth
were previously removed.
24
t t ppss : t t ps
ps :
hhtt Osteoblastoma hhtt
rrss rrss

o k e
k e Subperiosteal Osteoblastoma
o ke
ke
Subperiosteal Osteoblastoma
o
eebb o o e bboo o e b o o
(Left) Radiograph of the
b
m ee/ /e m ee/ / e
humerus shows a lytic
osteoblastoma ﬈ of the mid
: / /
/ t
/ .t.m : / /
/ t
/ .t.m shaft surrounded by solid
periosteal new bone ﬅ. It
t t p
t ss:
p t t p
t ss:
p
extends into periosseous soft
tissues where cloud-like
hht hht neoplastic ossification is

noted. (Right) Coronal T2-
weighted MR demonstrates
osteoblastoma ﬅ of the outer
surface of diaphyseal cortex
k eers
rs k e r
erss
surrounded by periosteal
bone. No mineralization is
o o
o ok oooo k detected.
oo
eebb e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
Osteoblastoma With Rim Reactive Bone
hht t t
Red Oval Osteoblastoma
hht t (Left) Specimen radiograph

demonstrates an oval lytic
osteoblastoma arising in the
cortex. Superior spatial
resolution is possible because
keerrss k eers
r s
of the absence of overlying
soft tissues. The tumor is well
b ooook b o ook
o
demarcated, contains faint
oo
mineralization ﬅ, and is
b
eeb ee/ e
/ e b e / e
/e b
surrounded by well-formed
reactive bone ﬆ. (Right) A
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
surface osteoblastoma is
shown. The red-gray, sharply
t p ss
p : / t p ss
p : / demarcated, solid tumor is
t
hht t t
hht t
surrounded by a thick rim of
reactive periosteal new bone
ﬆ. The medullary cavity is
filled with yellow fat.
k eers
rs
Abundant Reactive Woven Bone
k e rrss
Osteoblastoma Extending Through Cortex
e
b ooook b o ook
o
(Left) Osteoblastoma is
b oo
eccentrically located in the
eeb ee/ e
/ e b ee/ e
/e b
distal femur ﬈. The tumor is
oval, lytic, and well
: / / t
/ m
.t.m : / / t
/ m
.t.m demarcated. There is
t ppss : / t ppss : / abundant reactive bone that

forms a zone of sclerosis
t
hhtt t
hhtt
around the tumor ﬆ. (Right)
Axial CT scan accompanying
the radiograph shows a lytic
tumor that contains a small
area of central mineralization
ﬅ. The well-demarcated
rrss rrss
tumor is surrounded by a zone
o k e
k e o ke
k e
of sclerosis of varying
radiodensity ﬉.
o
eebb o o e bboo o e b o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 25
t t ppss : t t ps
ps :
rrss rrss
o k e
k e o ke
ke
Large Osteoblastoma of Humerus Osteoblastoma Eroding Cortex
o
eebb o o (Left) AP radiograph
e bboo o e b o
b o
demonstrates an unusually
large and invasive
m ee/ /e m ee/ / e
osteoblastoma of the proximal
:
humerus. The tumor is lytic
/ /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
with faint mineralization,
p
involves the metadiaphysis,
t t p
t ss:
p
hht
and extends into the
surrounding soft tissues ﬅ.
(Right) T2-weighted MR shows
hht
a large osteoblastoma arising
in the proximal humerus and
k eers
rs
extending into the adjacent
soft tissue. The soft tissue
k e r
erss
o o
o ok mass engulfs a portion of the
cortex ﬈. Low signal intensity
oooo k oo
eebb areas correspond to foci of
ossification.
e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
(Left) A large osteoblastoma
spans the distal epiphysis,
t
Osteoblastoma With Sharp Margins
hht t Heterogeneous Osteoblastoma
metaphysis, and diaphysis of

the distal femur. The oval
tumor ﬅ is lytic with fine
keerrss
trabeculations. The tumor is
well demarcated and has a
k eers
r s
b ooook sclerotic margin ﬈. The
differential diagnosis includes
b o ook
o b oo
eeb giant cell tumor of bone.
(Right) Coronal T2 fat-
ee/ e
/ e b ee/ e
/e b
saturated weighted MR shows
/
a large oval osteoblastoma ﬈
: / t
/ .
t m
. m : / / t
/ .
t m
. m
ss : /
of the distal femur. The tumor
t p p t p ss
p : /
t
has a nodular architecture and
hht t
is heterogeneous in intensity.
The tumor is well
circumscribed with mild
t
hht t
surrounding edema ﬆ.
k eers
rs k e rrss
Osteoblastoma Expanding Metatarsal
e
Multifocal Osteoblastoma
b ooook (Left) Plain radiograph of the

foot demonstrates a large
b o ook
o b oo
eeb intramedullary, expansile
osteoblastoma arising within
ee/ e
/ e b ee/ e
/e b
the 4th metatarsal. The lesion
: / / t
/ m
.t.m : / / t
/ m
.t.m
exhibits faint ground-glass
s
opacity of the sort more
t pp s : / t ppss : /
t
hhtt
characteristic of fibrous
dysplasia, indicating
microscopic internal
t
hhtt
ossification. (Right) Sagittal
T1-weighted MR through the
lower leg and foot shows a
rrss rrss
rare example of multicentric
o k e
k e
osteoblastoma. Individual low
and mixed signal intensity oval
o ke
k e
o
eebb o o lesions are present in the
anterior distal tibia ﬅ and
e bboo o e b o
b o
talus ﬈.
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
26
hht hht
t t ppss : t t ps
ps :
rrss rrss

o k e
k e Large Cystic Osteoblastoma
o ke
ke
Large Osteoblastoma With Hemorrhage
o
(Left) Large round
b
m ee/ /e m ee/ / e
osteoblastoma from the spine
is shown. The hemorrhagic
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
tumor has undergone
extensive cystic change
t t p
t ss:
p t t p
t ss:
p
causing it to mimic an
aneurysmal bone cyst. Some of
hht hht the cystic spaces are filled

with clotted blood. (Right) A
large, solid and cystic
osteoblastoma arises in the
proximal fibula in a growing
k eers
rs k e r
erss
child; note the growth plate
ﬆ. The tumor involves the
o o
o ok oooo k medullary cavity and extends
o
through the cortex and into
o
eebb e/
e e
/ b
e b e / e
/ b
eb
the soft tissues where it is
covered by reactive bone ﬅ.
e
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
Osteoblastoma With Abundant Bone
hht t t
Osteoblastoma Expanding Bone
hht t (Left) An osteoblastoma of the

scapula is shown. The oval,
well-delineated tumor is solid
tan-red and contains abundant
neoplastic bone ﬈. The
keerrss k eers
r s
adjacent cortex is thickened by
reactive bone ﬅ. (Right) A
b ooook b o ook
o
resected osteoblastoma is
oo
shown involving the distal
b
eeb ee/ e
/ e b e / e
/e b
sacrum. The tan hemorrhagic
tumor involves 2 consecutive
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
vertebral bodies crossing the
intervertebral disc and
t p ss
p : / t p ss
p : / protruding into the anterior
t
hht t t
hht t
soft tissues where it is
surrounded by reactive bone
﬈. The spinal canal is visible
﬉.
k eers
rs
Expansile Osteoblastoma of Rib
k e rrss
Subperiosteal Tumor
e
b ooook b o ook
o
(Left) Expansile
b oo
osteoblastoma of the rib has
eeb ee/ e
/ e b ee/ e
/e b
well-circumscribed margins.
The tumor is red-tan and the
: / / t
/ m
.t.m : / / t
/ m
.t.m
tan areas correspond to
t ppss : / t ppss : / mineralized matrix. (Right)

This osteoblastoma arises on
t
hhtt t
hhtt
the surface of a long bone.
The tumor is tan-white, gritty,
and contains scattered
hemorrhagic cysts that are
peripheral in location. The
tumor is well defined from the
rrss rrss
adjacent cortex ﬈ and is
o k e
k e o ke
k e
covered by periosteum ﬅ.
o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 27
t t ppss : t t ps
ps :
rrss rrss
o k e
k e o ke
ke
Sharply Demarcated Osteoblastoma Sharp Margin
o
eebb o o (Left) Low-power view shows
e bboo o e b o
b o
margin of an osteoblastoma.
The tumor contains abundant
m ee/ /e m ee/ / e
haphazardly interconnecting
trabeculae of woven bone,
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t
﬈ from the surrounding ss:
which is sharply demarcated
p t t p
t ss:
p
hht
uninvolved cancellous and
cortical bone. (Right) A sharp
margin of an osteoblastoma is
hht
shown with adjacent
cancellous bone. The cellular
k eers
rs
tumor contains many small
neoplastic bony trabeculae ﬉
k e r
erss
o o
o ok with intervening loose
fibrovascular tissue. The
oooo k oo
eebb uninvolved bony trabeculae
are large and well formed.
e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
(Left) An osteoblastoma is
composed of irregular
t
Woven Bone Trabeculae of Osteoblastoma
hht t Interconnecting Trabeculae of Bone
trabeculae of woven bone.

The surfaces of the bone are
rimmed by prominent
keerrss
osteoblasts. The
intertrabecular space is filled
k eers
r s
b ooook with loose fibrovascular tissue.
Many blood vessels are
b o ook
o b oo
eeb congested with red blood cells.
(Right) Plump osteoblasts ﬈
ee/ e
/ e b ee/ e
/e b
line the surfaces of the
neoplastic bone. Scattered
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
ss :
osteoclasts ﬅ are also found
t p p / t p ss
p : /
t
on the surfaces of the woven
hht t
bone. Many dilated, blood-
filled capillaries course
amongst the bony trabeculae.
t
hht t
k eers
rs k e rrss
Osteoblastoma With Epithelioid Cells
e
Epithelioid Osteoblasts
b ooook (Left) A cellular

osteoblastoma is shown with
b o ook
o b oo
eeb irregular trabeculae of woven
bone. Scattered large
ee/ e
/ e b ee/ e
/e b
epithelioid osteoblasts ﬈ are
: / / t
/ m
.t.m : / / t
/ m
.t.m
present. Some of the
ss : /
neoplastic bone is mineralized
t pp t ppss : /
t
hhtt
and dark magenta in color ﬅ.
(Right) In an aggressive
osteoblastoma composed of
t
hhtt
epithelioid osteoblasts, tumor
cells are large, polyhedral, and
contain abundant eosinophilic
rrss rrss
cytoplasm and vesicular nuclei
o k e
k e
with prominent nucleoli. The
neoplastic bone is coarse and
o ke
k e
o
eebb o o lace-like in appearance.
e bboo o e b o
b o
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
28
hht hht
t t ppss : t t ps
ps :
rrss rrss

o k e
k e
Prominent Osteoblastic Rimming
o ke
ke
Large Osteoblasts of Osteoblastoma
o
(Left) Interconnecting
b
m ee/ /e m ee/ / e
trabeculae of bone are
characteristic of
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
osteoblastoma. The pink-
purple bone is covered by a
t t p
t ss:
p t t p
t ss:
p
layer of osteoblasts. The
nuclei of the osteoblasts tend
hht hht to be polarized away from the

bone-forming surfaces. (Right)
High-power H&E shows
neoplastic osteoblasts in an
osteoblastoma. The
k eers
rs k e r
erss
polyhedral cells have
abundant purple cytoplasm,
o o
o ok oooo k which contain a prominent
o
perinuclear Golgi apparatus
o
eebb e/
e e
/ b
e b e / e
/ b
eb
﬈ and eccentric nuclei. The
pink tumor bone is woven in
e
: // t
/ .
t m
. m : / /t/.tm. m
architecture.
t p ss
p : / tp pss : /
t
Cystic Change
hht t t
Hemorrhagic Cystic Change
hht t (Left) Low-power view shows

a cystic osteoblastoma. The
cystic spaces are small and
contain red blood cells. The
solid portion consists of
keerrss k eers
r s
woven bone. Cystic spaces can
b ooook b o ook
o
cause confusion with
oo
aneurysmal bone cyst. (Right)
b
eeb ee/ e
/ e b e / e
/e b
A cystic osteoblastoma is
shown with a large cystic
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
space filled with red blood
cells and fibrin. Areas
t p ss
p : / t p ss
p : / diagnostic of osteoblastoma
t
hht t t
hht t
are visible in the cyst wall
consisting of haphazardly
woven bone lined by
osteoblasts.
k eers
rs
Osteoblastoma With Cartilage
k e rrss
Pseudomalignant Change
e
b ooook b o ook
o
(Left) An osteoblastoma with
b oo
a nodular cartilaginous
eeb ee/ e
/ e b ee/ e
/e b
component is shown. The
neoplastic blue cartilage is
: / / t
/ m
.t.m : / / t
/ m
.t.m
hyaline in type, moderately
t ppss : / t ppss : / cellular, and adjacent to the

bone-forming component of
t
hhtt t
hhtt
the tumor. The neoplastic
bone has a trabecular pattern
and is lined by osteoblasts.
(Right) An osteoblastoma is
seen with pseudomalignant
change. Pseudomalignant
rrss rrss
features manifest as enlarged
o k e
k e o ke
k e
nuclei that are dark and
hyperchromatic. Surrounding
o
the bone is collagenous tissue
b o
with small blood vessels.
m ee/ / e m ee/ / e
: / /
/t/.t.m : / /
/ t
/.t.m
t t p
t ss:
p t t p
t ss:
p
hht hht 29
t t ppss : t t ps
ps :
hhtt hhtt
k e rrss
e keerrss
o o
o o k oooo k o o
eebb ee/e/ebb ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k eers
rs k e r
erss
o o
o ok oooo k oo
eebb e/
e e
/ b
e b ee/ e
/ b
eb
: // t
/ .
t m
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss k eers
r s
b ooook b o ook
o b oo
eeb ee/ e
/ e b ee/ e
/e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k eerrss
b ooook b o ook
o b oo
eeb ee/ e
/ e b ee/ e
/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : /
t
hhtt t
hhtt
k e rrss
e ke rrss
e
o o
o o k oooo k o o
eebb ee/e/ b
eb ee/ e
/ b
e b
: / /t/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
Another random document with
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given a tilt to the bucket. At all events down they went together to the
bottom, a distance of thirty feet.
The mother, who had seen him at the moment when the descent
began, ran, half shrieking to the well, where she was joined by Mrs.
Templin a moment after.
“Oh, Mis’s, Mis’s, my po’ ophing chile have fell in de well and
broke his naik, and drown hese’f on top o’ that, an’ he my precious
baby—an’ de las’ one I got!”
Mrs. Templin said: “I’m sorry for you, Judy. But maybe he has
been mercifully saved from drowning. Lean over and look down as I
turn the windlass.”
After a few turns, she knew by the feeling that the bucket had risen
to the surface of the water, which was some four feet deep.
“Now call him,” she said.
“Li’ll Iky! Li’ll Iky!” shouted Judy.
“Ma-a-a-a-me!” came a sharp, plaintive answer from the great
deep.
“Is you down dar, precious?”
“Eth, e-e-eth, ’m.”
“Well, well, is you drownded?”
“No—no—no, ’m!”
“Well, well! Is you done gone all to pieces?”
“No—n-n-no, ’m!”
“Is anything de matter wid mammy’s precious boy baby?”
“I k-k-k-co-co-o-ld!”
“Well, well, where is you now?”
“In—in de—b-b-bucket!”
Mrs. Templin then directed the mother to urge the child to hold fast
to the rope while she herself would turn the windlass.
“Dar now, you heah dat? Mis’s say she wan’ my nice li’ll darky to
ketch tight hold to der rope—tight as a tick; an’ she say she gwine
draw him up with her own blessed hands. Mis’s say she can’t ’ford to
lose likely li’ll fellow like my li’ll Ike, dat she can’t. Ye heah, mammy’s
precious suga’ lump?”
“E-e-e-e-th, ’m!”
The winding began, and the mother, being urged to encourage Ike
as much as possible during the ascent, did as well as she could by
such cheering remarks as these:
“Jes’ look at dat! Mis’s givin’ her li’ll niggah such a nice ride! En
Mis’s done tole mammy tah kill six chickens, an’ fry one o’m an’ brile
one o’m an’ make pie out of de rest, an’ all for li’ll Iky’s dinner; an’
she say she gwine make daddy barb’cue two pigs dis very evenin’,
and nobody ain’t to tech a mou’f’l on’m cep’n li’ll Iky if he’ll holt on tah
de well-rope. An’ she say, Mis’s do, she jes’ know her great big li’ll
Ike ain’t gwine to let dat rope loose an’ not get all dem goodies!”
It is possible that in so brief a time never was promised a greater
number of luxuries to a child born to loftiest estate. Chickens, ducks
—indeed the whole poultry yard was more than exhausted; every pig
on the plantation was done to a turn. During the ascent little Ike was
informed that eatables of every description would be at his disposal
forever. The time does not suffice to tell of other rewards promised in
the name of the munificent mistress, in the way of cakes, pies,
syllabubs, gold and silver and costly apparel. All this while, Mrs.
Templin, without uttering a word, turned the windlass, slowly,
steadily.
When the bucket with its contents reached the top, and was safely
lodged upon the ledge, the mother seized her precious darling, his
teeth chattering the while with chill, and dragging him fiercely forth,
said in wrathful tones:
“A cold is yah? Well, ef I be bressed wid strength an’ ef dey is
peachy trees ’nough in de orchard, an’ de fence corners, I’ll wa’m
yah. You dat has sceert me intah fits, an’ made me tell all dem lies—
dem on Mis’s—dat I jes’ knows I never ken git fahgivin’ fo’ ’em.” And,
still holding him, she began striding toward the kitchen door.
“Judy!” called her mistress sternly, “Judy, put down that child this
minute! Aren’t you ashamed of yourself? Instead of being thankful
that he wasn’t killed, here you stand and are so angry with him that
you look as though you wished to kill him yourself. Now take him into
your house and put some dry clothes on him; then send him to me in
the house, where I will have some coffee ready for him. And mind
you, Judy, if you lay your hands on that child in anger, that won’t be
the last of it. Do for goodness’ sake try to learn some reason about
your children.”
Judy led him away sullenly, and in spite of her mistress’s warning,
muttered direful threatenings, louder and louder, as she approached,
ending thus, as, having clothed him, she dispatched him to the big
house:
“Nevah yah min’, sah; wait till Sunday come, when Mis’s go tah
meetin’, an’ you’ll see! An’, boy, ef yah skeers me dat way ag’in, I’ll
put yah whar yah won’t wan’ no mo’ watah an’ no mo’ nothin’. The
idee! people all talkin’ ’bout my chile gittin’ drowned same as puppies
an’ kittens! Ought to be ’shamed o’ yourself! I is. I jes’ ’spises to look
at yah! G’long out my sight!”
Ten minutes afterwards, while little Ike was in the big house,
luxuriating in coffee, biscuit and fried chicken, she was singing in
cheerful voice one of her favorite hymns:
Nobody knows the trouble I see, Lord;

Nobody knows the trouble I see;
Nobody knows the trouble I see, Lord;
Nobody knows like Jesus.
THE RETURN OF THE HOE

“Goliath Johnsing, why you so late? Supper been a sp’ilin’ on de
stove dis half hour,” and Aunt Lucy faced her liege lord with stern
dignity.
“Old Daddy Moses an’ me been a havin’ it out.”
“Havin’ what out? You ain’t been an’ had a fuss wid Mr. Benson,
’Liah Johnsing?”
“Yes, I have. Ole Skincher. Here I have been a hoein’ hard in the
fiel’ all day, and he mean enough to dock my wages ten cents ’cause
I warn’t back at noon jest at de minnit. I warn’t late more’n half an
hour or three-quarters of an hour. But I give him piece of my mind.”
“I s’pose he don’ want to pay for work he don’ git.”
“Don’ git? Why, thar was Sam Stevens an’ Bill Jenkins; they talk
more’n half de time, an’ rested on they handles more’n t’other half,
an’ did he dock them any? Not he. He got spite ’gin me, I know dat.”
“Whar’d you git dat new hoe?” queried Aunt Lucy, as ’Liah hung
that implement up in the woodshed.
“Neber you mind. Women always want to stick their nose into
ebbert’ing.”
“An’ what you done wid your ole hoe you took away this noon?
You didn’t trade that off for a new one?”
“Yes, I did, ’f ye will know.”
“’Liah Johnsing,” blurted out Aunt Lucy, as a sudden suspicion
flamed in her eyes, “dat ain’t one of Moses Benson’s hoes? You ain’t
gone and changed off yo’ ole hoe for one his’n, I hope? You wouldn’t
do dat, if he is a skincher, an’ you a member ob de church, ’Liah
Johnsing?”
“Mis’ Johnsing, you jes’ ten’ to yo’ own bus’ness. Don’ you let me
hear not one mo’ word ’bout dat hoe.”
Suddenly, as bedtime drew near, ’Liah rose and went into the
house, saying as he went:
“Got to go down to de sto’, Lucy. I forgot I got to mow Dawkinses
fiel’ to-morrow, an’ my whetstun’s clear down to de bone, an’ I’ve got
to start off to-morrow ’fore sto’s open.”
’Liah had been gone hardly a minute, when Aunt Lucy called in a
tragic whisper to Paul, her oldest boy, six years of age.
“You Paul, come here quick, by yo’self.”
Paul, used to obeying, came promptly, and was drawn close up to
his mother on the settee. “Now, you Paul, I wonder kin I trust you to
do something for me?”
Paul, somewhat disturbed, kept discreetly silent.
“I wish you’s a little bigger, but de Lord will hol’ you up. Paul, you
listen. When yo’ paw comes home from the sto’ an’ we’s all gone to
bed and got to sleep—you hearin’, Paul?”
“Yes’m.”
“You get up still’s a mouse, an’ you go git dat hoe yo’ paw brought
home, an’ don’t you make no noise takin’ it down, an’ you kerry dat
hoe ober to Mr. Benson’s; an’ you take de hoe what’s hangin’ dar—
dat’s our hoe, Paul, dat yo’ paw left dar by ’stake—you take dat hoe
an’ bring it in the woodshed, an’ don’t you nebber tell yo’ paw nothin’
’bout it.”
The first sun rays were shining in at the window through the
morning-glories, the early breakfast was smoking on the table, the
six young Johnsons were struggling down in various stages of
sleepiness, Aunt Lucy was bending over the stove and ’Liah washing
at the sink, when a loud knock was heard at the kitchen door, which,
being open, disclosed Mr. Benson. By his side stood the village
constable. In his hand was an old and much battered hoe. ’Liah saw
the hoe and his upper jaw fell. Aunt Lucy’s gaze also was riveted on
it.
“Goliah Johnson,” said the constable, “you’re my prisoner. You
stole Mr. Benson’s hoe.”
“’Fore de Lord, Mr. Benson, I ain’t got yo’ hoe. What you doin’ wid
mine?”
“You needn’t pretend that you left your old hoe in my barn
yesterday by mistake, ’Liah Johnson,” burst in Mr. Benson, “as if you
couldn’t tell this old thing from my hoe. What have you got to say for
yourself?”
“You may search dis place, Mr. Benson, from top to bottom an’
side to side, an’ you won’t find no stiver of yo’ old hoe. How you got
mine I ’clare I give up, but you kin see fo’ yourself. Now, here’s
where I keeps my hoe,” and ’Liah swung open the woodshed door.
There hung Mr. Benson’s new hoe.
“You Paul!” fairly shouted Aunt Lucy, pouncing on her young
hopeful, “what did you do las’ night?”
“Did jist what you tol’ me. Took back dat hoe an’ changed it for de
one in Mr. Benson’s barn.”
“Took back what hoe?” shouted ’Liah in his turn. “Lucy Johnsing,
what you been stickin’ yo’ fingers in?”
“Well, ’Liah, I ’lowed I warn’t gwine to have no hoe in dis house
what didn’t b’long to us by rights, ’n’ so I tol’ Paul to get up las’ night
an’ change de hoes back again, an’ if he did it, how dis one comes
heah beats me.”
“You Lucy Johnsing, see what you’s been an’ done wid yo’
meddlin’. I took back dat hoe ’fore I went to bed, when I made ’s
though I was gettin’ de whetstun, an’ then you went and changed
’em back ag’in.”
“’Liah Johnsing, why you keep secrets from yo’ wedded wife? Why
didn’t you tell me ’bout dat?”
By this time Mr. Benson saw that there was something more in the
matter than he supposed, and sending away the constable he got
from the worthy couple, with much circumlocution, the story of the
night’s mistakes. Being a man with some sense of humor, he was
quite mollified by the comicalities of the situation, and even went so
far as to take breakfast with the Johnsons.
“An’ after dis, ’Liah Johnsing,” was Aunt Lucy’s moral, “you’d
better think twice ’fore you keep any mo’ secrets from yo’ lawful
wedded wife!”
PATHETIC SELECTIONS
WHEN THE LITTLE LADY FELL ILL

Anonymous
“Once upon a time,” there was a little lady, gentle and sweet. One
day she sent for the doctor. She was ill. She lay upon her bed with
her bronze hair afloat upon the pillow. She smiled as the doctor
came in and held out a hand tiny and soft and very white. Her teeth
shone between her crimson lips and there were beautiful violet lights
in her brown eyes. She was always full of life and spirit. Now here
she was in bed and sending for the doctor, she who had almost
never before needed a doctor. A great operation was decided upon.
She only asked how long she would be out of the sun. They thought
the operation would heal. But it did not—and there was another and
another. For a little while after each operation she did get back to the
sun and was very happy, just as a butterfly might be.
But at last they who watched knew that the frail little body could
not withstand another operation and that the end was near—very
near. Then came the fourteenth day of December, when, they told
the young doctor, it was his duty to tell the little butterfly. That night
he walked the streets—all the long night. It rained. But he did not feel
it. In the morning he understood why some must die, for in the rain
and the night he had unconsciously been with the God who gives
and who takes away. He went, gaunt with the night’s agony, but
smiling, and took the two little hands into his.
“Did you ever wonder,” he asked her, “as I have, why God gives
life only to take it away?”
“Just for love,” she smiled. “He wants the best Himself.”
“Do you know,” he said, “that you are very ill?”
“Am I?” she said, suddenly turning her great, startled eyes upon
him.
“Haven’t you noticed,” he tried to go on, “that you—”
“No,” she said breathlessly. “You said I would get well—always
said it. And I knew that you knew, and I trusted you.”
“Doctors must do those things,” he pleaded, “because it keeps up
the patient’s courage. There is no medicine like hope.”
“I have never thought till now,” she halted, “that I would not get
well.”
“I have known it for a long time.”
“And you have been so sweet and brave so as to—”
“No, I have deceived you only that you might live a little longer.”
They were silent for a long time. Then she reached out and
touched his hand.
“Then you mean,” she whispered, “that—”
He closed her lips, and she understood.
“Poor doctor! It is dreadful to make you the bearer of such a
message.” She thought silently a long while. “At first I was inclined to
be cross at you for deceiving me. But now—” a tear presently stole
down each pale young cheek “—but now,” she ended in a whisper, “it
is wonderful—beautiful—very, very beautiful! One can hardly believe
that there are people who willingly bear the sorrows of others.”
“I have been only selfish, I wanted to keep you.”
“Yes,” she whispered, “I understand.”
“How long?”
“Only a few days, perhaps a week—two weeks.”
“No,” she cried suddenly, “for that is Christmas. And the house will
be sad—in mourning. No! You must make me live. You must make
them think I am getting well.”
“Ah, if we only could! But I must not deceive you any longer. I said
two weeks—but it will not be that long.”
“It will—it must be!” she said, suddenly rising in bed. “We will pray
God, and you will help, and I will. There must be some sort of tonic—
a stimulant—tell me—tell me there is! You must not spoil their
Christmas—on—on my account!”
She smiled a little at the odd ending of her phrase and dropped
back upon the pillow, flushed and brilliant, splendid, so that even the
doctor was deceived, and hoped.
“If you can do that—keep up such a vigor by hope and happiness,
the hope of happiness for others—perhaps, with God’s help, we can
—do what you wish.”
“Of course we can. I know it!”
“Then so do I, and you shall have the uttermost minute.”
“And when it is done,”—the young spirit weakened,—“this, which
you gave me so long ago, shall be yours again—for a memory!”
She put his hand upon the ring which fitted her middle finger.
“A memory?” he whispered.
“Of the bravest and sweetest man in the world,” she said, putting a
kiss upon the ring. “Oh! but I don’t want to go.”
She was so wonderful—with such a tremendous spirit in that brave
little body. The doctor thought she might even then get well.
And when he came again, she did seem well—quite well. Her
cheeks were pink, her lips crimson, her hair was coiled and dressed.
She smiled and said: “Paint!”
But the trick had deceived her family even more than it had
deceived the doctor. For, one by one they came in and, standing at
the foot of the bed, seeing the pretty little painted creature, they were
sure that she was getting better rapidly—was, in fact, almost well!
Her younger sister romped in and leaped upon the bed, crying: “See,
doctor! It is all as it used to be! And it has been so long since it was
all as it used to be. Dearest, soon we will be out on Saint George’s
Hill again, rolling together on the grass, down, down and—”
“Yes,” cooed the little patient rapturously, “soon—very soon—.” But
a sudden sob ended the incident.
“Thank you—oh! thank you so much, doctor, dear, for giving back
to me the sweetest sister in all, all the whole world!”
Day by day more paint was required to cover the growing pallor,
and always more and more. And always more drugs to keep the
eyes bright and the spirits from flagging. When the young doctor
wasn’t by her side he was studying—searching—until there was
nothing in all medical science for prolonging life which he did not
know.
The house became gay again because of the lie that was
practiced. The noises which had been hushed when there was
danger were resumed.
There was at last a day when the doctor helped at the dressing
and painting; so near was the shadow that she might have flown at a
breath.
And so they put upon her, lying in their hands, wonderful garments
and ribbons and embroideries. And even the little hands on that day
had to be carefully “made up” to conceal the livid blue. Then when all
was ready, they sat her royally up in bed, lighted the candles, closed
the blinds and let the waiting family enter—for it was the day before
Christmas.
They came to music—the moment the door was opened—bursting
with joy. A processional they made of it!
“Guide me, O Thou great Jehovah,

Pilgrim through this barren land;
I am weak, but Thou art mighty;
Hold me with Thy powerful hand.”
Standing about her bed they sang that, and each separate heart
was welling a song of joy, because they thought she had come back
to them!
Like those great ladies at Versailles, in the reign of the Grand
Monarch, who received in bed, she laughed, happy as the happiest
of them.
Then came another procession, down to the last servant in the
house, bearing gifts. Then flowers and green things—until the
beautiful rose-embroidered covering of her bed was lost to sight
under the load of flowers, and these in turn were blotted out with the
gifts. Wonderful gifts they were! How could they not be? They were
welcoming with them their best beloved back to life! On her neck
was girded a chain, on her fingers were put rings, and in her ears
were hung gems, so that she blazed with jewels. Before her lay a
splendid, filmy dress, and with it were hat and gloves and a gay
parasol.
All—all, gifts of life!
And yet another procession came, bearing holly and mistletoe and
garlands and crimson berries, and last of all, a Christmas tree, all
lighted and glowing with a hundred pretty things. And almost in a
moment they transformed the room into a Christmas bower. The
bed, the walls, the floor, bloomed in the red and white and green of
Christmas.
So Christmas came—the gayest, the maddest, the saddest that
house had ever known.
But she had barely carried it through, and when the excitement
would pass the doctor knew that no stimulant devised by man could
keep her on the earth she had blessed an hour longer. Before the
collapse quite came, the doctor said:
“My patient is tired—”
“A little tired, yes,” she smiled at them. “To-morrow.”
So they all kissed the painted lips good-night and, wishing her a
happy to-morrow, went away.
The doctor moved to take the heavy gifts off the bed. She stopped
him with a tired smile and a shake of the head. It was all she could
do just then. Life was very low.
“No,” she shook, “I want them all just as they are. Mamma said to-
morrow—” she halted.
“Yes.”
“Poor mamma!”
O CAPTAIN! MY CAPTAIN!
By Walt Whitman
O Captain! my Captain! our fearful trip is done,

The ship has weather’d every rack, the prize we sought is won,
The port is near, the bells I hear, the people all exulting
While follow eyes the steady keel, the vessel grim and daring;
But O heart! heart! heart!
O the bleeding drops of red,
Where on the deck my Captain lies,
Fallen cold and dead.
O Captain! my Captain! rise up and hear the bells;

Rise up—for you the flag is flung—for you the bugle trills,
For you bouquets and ribbon’d wreaths—for you the shores a-
crowding,
For you they call, the swaying mass, their eager faces turning;
Here, Captain, dear father!
This arm beneath your head!
It is some dream that on the deck
You’ve fallen cold and dead.
My Captain does not answer, his lips are pale and still;
My father does not feel my arm, he has no pulse nor will;
The ship is anchor’d safe and sound, its voyage closed and done,
From fearful trip the victor ship comes in with object won.
Exult, O shores, and ring, O bells!
But I, with mournful tread,
Walk the deck my Captain lies,
Fallen cold and dead.
—Written as a funeral poem for Lincoln, and one of the great
poems of the nineteenth century.
THE FACE OF THE MASTER

By Myrtle Reed
In a little town in Italy there lived an old violin-maker whose only
pride and happiness was in the perfect instruments he made. He had
a little son called Pedro. Pedro was a dark little fellow with large,
brown eyes which seemed to hold a world of feeling and sometimes
sadness. He loved his mother dearly, but shrank somewhat from his
stern father, who was always so busy he hardly noticed him.
Pedro was errand boy for the little shop and tried to do his work
patiently, cheerfully and obediently. One day an unusually fine
instrument had been finished and the old man, in his joy and pride,
held it in position and touched the strings softly with the bow. Pedro,
who was sitting outside on the porch, heard the music and came
running in to hear it, but in his haste he did not see an exquisite
piece of carving on the floor and stepped upon it. Crack! it broke in
two. Pedro’s father became very angry and pushed him into his little
bedroom and turned the key in the lock.
In the morning Pedro’s father called him very early, as he had
many errands for the boy to do. All day Pedro trudged wearily back
and forth for his father. He went about his work as if in a dream,
thinking always of the music he had heard and wishing with all his
heart that he might play. Night was coming on and Pedro was sitting
on the step outside resting, when his father told him he had yet
another errand for him to do. Pedro was very tired, yet he did not say
anything but went immediately on the errand. When he had delivered
the message, the man showed him a short cut home. As Pedro was
walking slowly home, he stopped suddenly as he heard the sound of
music. Could it be a violin? He listened to find from whence it came.
At last he decided it came from the little vine-covered cottage across
the lane. He walked slowly over and sat down under the open
window. The music was exquisite. As he listened he heard the soft
wind rustling through the trees, the sound of birds calling to one
another in the forest, the sound of rushing water as that of a river as
it flowed headlong into the ocean.
The music changed as he listened; he heard a soft, dreamy
lullaby, then again the sound of the ocean, of the waves beating
upon the sand. As he listened the music grew fainter, the moon
came out from behind the cloud and Pedro saw the face of the
Master.
He was a bent old man with white hair and beautiful blue, shining
eyes. As the music ended in one long, sweet, trembling chord, Pedro
saw the Master bend his head over his violin, and as he quietly
slipped away he thought he heard the sound of sobbing.
Pedro walked the rest of the way home in a dream. As he came
into the work-shop he saw the beautiful violin and touched it tenderly,
caressingly. Oh, if he could only play! He went to bed, but could not
sleep. The beautiful music kept coming back again and again. At last
he arose, dressed himself and went into the work-shop. He picked
up the violin tenderly, lovingly, and went out to the orchard to where
a little brook ran merrily by. It was a beautiful night, calm and
peaceful, a soft wind whispered through the trees, through the
stillness the sweet, clear notes of a bird were heard. The witchery of
the night, its calmness and quiet beauty, seemed to want him to play.
So placing the violin in position, he ran the bow gently over the
strings; at first the notes were short, trembling, and broken. Soon it
became very beautiful, and still he played on and on. He did not
notice that day was dawning, and upon looking up he was frightened
at seeing his father standing before him. But his father smiled at him
and said:
“My son, you are then a musician? The music was wonderful!”
Pedro smiled, but said nothing.
“You shall have lessons from the Master,” his father said. Pedro
could hardly believe it. Lessons from the Master! To learn to play!
After the day’s work was done Pedro and his father walked down
the same little, narrow street to the little vine-covered cottage that he
had seen the night before. Soon Pedro found himself in a little
sitting-room awaiting the Master. Soon the Master came, and
Pedro’s father said, “If you will teach my son to play I will make you
the most beautiful violin in the world.”
The Master was very well satisfied with his violin and he did not
like to teach. But he said to Pedro, “Do you like music?” Pedro
smiled, his whole soul in his eyes. The Master said, “Yes, you love it,
you shall play.”
The next day Pedro came for his first lesson. He enjoyed it very
much and soon mastered the tedious exercises.
So the years passed and Pedro had become famous. The Master
was growing old; still the most beautiful violin had not been
completed. One day Pedro came to visit the Master and the
housekeeper told him he was ill. Pedro waited, hoping the Master
might want him. Soon he returned home and began to play. While he
was playing his father told him that the Master’s violin was finished.
Pedro smiled sadly and said, “The Master is ill.” That evening as he
sat playing a messenger came and summoned him to the Master’s
house. He took the finished violin with him, and as he looked into the
Master’s room he saw him lying there on a couch, so thin, and still,
and white. He smiled as Pedro entered, and said, “You have come to
play for me, my son? The night is so long and I am so tired. Play,
Pedro, play!” Pedro showed him the newly finished violin, but he only
smiled as he nodded for Pedro to begin.
Pedro played, and played, and played. In the music he interwove
all the trials, sorrows and happiness of his childhood, and his love for
the Master. A soft wind rustled through the trees, the sound of a little
brooklet was heard and the birds calling to one another in the forest.
It all ended with one trembling chord. When he had finished the
Master was sitting up in bed. “Pedro, where did you learn to play
that?”
Pedro smiled. “You taught me, Master. I always knew you must
have had some sorrow in your life or you never could have played so
exquisitely.”
The Master said: “You are right.” And then he told him of his
sorrowful and suffering life. “Play it again, Pedro. Now you
understand.”
Pedro played, and played, and played. This time there was a
sweetness that somehow made the sad strain less noticeable. The
Master lay looking out of the window; day was breaking. As the last
sweet, trembling note died away, Pedro looked into the face of the
Master. There was a beautiful smile on his face. For the Master the
trials and sorrows of the world were over. Pedro knelt down before
the Master and kissed the thin, white hand reverently, the hand that
had made so many sad lives happy with beautiful music.
VOICE FROM A FAR COUNTRY

The old couple were very lonely as they sat in their little kitchen
that wintry afternoon. It was their daughter’s birthday, their only child,
who had left them to go to the great, glittering world on the far side of
the water. There she had won fame with her voice, while they had
stayed behind in the little village and tried to be cheerful without her.
Usually they succeeded pretty well, but this birthday, of all days in
the year, was the hardest to bear; even Christmas was not so hard
as this birthday, which brought so vividly to their minds the memories
of other birthdays—the first one when the baby’s coming had found
them awe-struck with the joy and wonder of it all, and each
succeeding year, as their treasure grew to girlhood and from a girl to
a sweet and winning woman, then faded from their sight.
They had not seen her since, for money was scarce and time
valuable. She must work very hard, so she wrote them. The old
couple tried to keep up a conversation as they sat in the kitchen that
wintry afternoon, but failed miserably. Finally after a long silence the
old man rose and said:
“Guess I’ll get the chores done before it storms, mother. Coming
on to snow fast.”
“All right, father, I’ll have supper ready for you when you come in.”
“You needn’t hurry about supper. Guess I’ll go to the post-office
after I get the critters fed. There might be a letter from Milly.”
“All right, father.”
There was a new note in the woman’s voice, for this was just what
she had been wishing her husband to do, but had not liked to have
him take the long trip to the post-office with the weather so
threatening.
The old man went out, and the woman began to prepare the
supper. Twilight had come and she lighted an old-fashioned lamp, so
clean that it sparkled. As she set the table she hummed the refrain of
a lullaby, a little song she had often crooned when her arms had not
been empty.
Suddenly the door flew open, letting in great gusts of wintry wind.
“Hurry and get that door shut, Pa. Warn’t there no letters?”
“No, but there’s this.”
The old man was carrying an old box almost too large for him to
handle.
“When I went to the post-office I found there warn’t no letter and I
was considerably disappointed, but as I was going by Jones’s store,
Jones he comes to the door and says he, ‘Say, Si, there’s a box in
here fer you!’ ‘Fer me?’ says I.
“‘It come this afternoon by express, and I guess by the looks of it,
it’s from your daughter in forin’ parts,’ said he.
“So here ’tis, and now, mother, where’s the hatchet?”
The hatchet was brought and the box was opened.
“My, what a funny lookin’ thing! Looks like a small size sewing
machine, and here’s a brass horn, too. I wonder if Milly sent that for
a joke or what?”
Silas set the carved case of polished wood on the table, and the
old couple gazed in puzzled astonishment at what they saw under it.
After a silence the old man said:
“Perhaps there are some directions.” Going over to the box he
found, as he had prophesied, a paper of instructions.
“It’s a—P-H-O-N-O-G-R-A-P-H, and them there things air records.
Well, I know about as much as I did afore. I’ll follow out the directions
and see what happens. Wish I knew what it was; ’tain’t no kind of a
farm implement, that’s sartin, nor a potater parer, nor sewing
machine. Well, we’ll follow these rules and see what she does.”
The faces of the old couple were full of interest, as Silas attached
the spring and set the phonograph in motion. At first there was a
peculiar buzzing sound, but nothing unusual happened, and the old
people were beginning to look disappointed when, after the buzzing,
came the sound of a voice singing. Surprise, wonder, amazement,
succeeded each other on the old faces, as the first notes of “Home,
Sweet Home” fell on their startled ears.
“’Mid pleasures and palaces though we may roam—”
The old couple listened breathlessly.

“Silas, that’s Milly singing.”
“No, ’tain’t!”
But the denial died on his lips as he recognized the voice.
“A charm from the skies seems to hallow us there,

Which seek through the world is ne’er met with elsewhere.”
Clear and sweet came the tones, like pearls in their rounded
purity. The mother was crying bitterly.
“An exile from home, splendor dazzles in vain.”
These words came with ringing force, and it seemed to the old
folks that Milly, far away in Paris, stretched out her hands to them
across the water.
“Home, home, sweet, sweet home,

Be it ever so humble, there’s no place like home.”
The old man was crying too, but the tears of father and mother
were not tears of sorrow, for the sting had gone out of their
loneliness, and as the music ceased peace fell like a mantle on the
little country home.—From The Ladies’ Home Journal.
LITTLE BROTHER
By Madeleine Z. Doty
A TRUE STORY
It was a warm summer’s day in late August. No men were visible
in the Belgian hamlet. The women reaped in the fields; the insects
hummed in the dry, warm air; the house-doors stood open. On a bed
in a room in one of the cottages lay a woman. Beside her sat a small
boy. He was still, but alert, his eyes following the buzzing flies. With
a bit of paper he drove the intruders from the bed. His mother slept.
It was evident from the pale, drawn face that she was ill.
Suddenly the dreaming, silent, summer day was broken by the
sound of clattering hoofs. Some one was riding hurriedly through the
town.
The woman moved uneasily. Her eyes opened. She smiled at the
little boy.
“What is it, dear?”
The boy went to the window. Women were gathering in the street.
He told his mother and hurried from the room. Her eyes grew
troubled. In a few minutes the child was back, breathless and
excited.
“Oh, mother, mother, the Germans are coming!”
The woman braced herself against the shock. At first she hardly
grasped the news. Then her face whitened, her body quivered and
became convulsed. Pain sprang to her eyes, driving out fear; beads
of perspiration stood on her forehead; a little animal cry of pain broke
from her lips. The boy gazed at her paralyzed, horrified; then he
flung himself down beside the bed and seized his mother’s hand.
“What is it, mother, what is it?”
The paroxysm of pain passed; the woman’s body relaxed, her
hand reached for the boy’s head and stroked it. “It’s all right, my
son.” Then as the pain began again, “Quick, sonny, bring auntie.”
The boy darted from the room. Auntie was the woman-doctor of B
——. He found her in the Square. The townspeople were wildly
excited. The Germans were coming. But the boy thought only of his
mother. He tugged at auntie’s sleeve. His frenzied efforts at last
caught her attention. She saw he was in need and went with him.
Agonizing little moans issued from the house as they entered. In
an instant the midwife understood. She wanted to send the boy
away, but she must have help. Who was there to fetch and carry?
The neighbors, terrified at their danger, were making plans for
departure. She let the boy stay.
Through the succeeding hour a white-faced little boy worked
manfully. His mother’s cries wrung his childish heart. Why did babies
come this way? He could not understand. Would she die? Had his
birth given such pain? If only she could speak! And once, as if
realizing his necessity, his mother did speak.
“It’s all right, my son; it will soon be over.”
That message brought comfort; but his heart failed when the end
came. He rushed to the window and put his little hands tight over his
ears. It was only for a moment. He was needed. His mother’s moans
had ceased and a baby’s cry broke the stillness.
The drama of birth passed, the midwife grew restless. She
became conscious of the outer world. There were high, excited
voices; wagons clattered over stones; moving-day had descended
on the town. She turned to the window. Neighbors with
wheelbarrows and carts piled high with household possessions
hurried by. They beckoned to her.
For a moment the woman hesitated. She looked at the mother on
the bed, nestling her babe to her breast; then the panic of the
outside world seized her. Quickly she left the room.

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Vikram Deshpande, MD Susan V. Kattapuram, MD

DIAGNOSTIC PATHOLOGY: BONE, SECOND EDITION ISBN: 978-0-323-47777-2

Copyright © 2017 by Elsevier. All rights reserved.

Publisher Cataloging-in-Publication Data

Names: Nielsen, G. Petur (Gunnlaugur Petur) | Rosenberg, Andrew, 1953-

International Standard Book Number: 978-0-323-47777-2

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my daughters, Olivia and Miranda, who are my lifelong joy; my parents,

To my father, Dhirendra, and mother, Shashi.

Art Direction and Design

SECTION 2: Malignant Bone-Forming Tumors

SECTION 3: Benign Cartilage Tumors

SECTION 4: Malignant Cartilage Tumors

SECTION 5: Fibrous and Fibrohistiocytic Tumors

SECTION 6: Fibroosseous Tumors

SECTION 7: Malignant Small Round Cell Tumors

SECTION 8: Notochordal Tumors

SECTION 9: Giant Cell-Rich Tumors

SECTION 10: Cystic Lesions of Bone

SECTION 11: Vascular Tumors

SECTION 12: Hematopoietic Tumors

SECTION 13: Miscellaneous Mesenchymal Tumors

SECTION 14: Metastatic Tumors

SECTION 15: Bone Tumor Mimics

SECTION 1: BENIGN BONE-FORMING SECTION 4: MALIGNANT CARTILAGE

SECTION 2: MALIGNANT BONE-FORMING SECTION 5: FIBROUS AND

SECTION 12: HEMATOPOIETIC TUMORS

SECTION 13: MISCELLANEOUS

Benign Bone-Forming Tumors

TERMINOLOGY • Homogeneously radiodense lesions with spiculated

CLINICAL ISSUES MACROSCOPIC

Specimen Radiograph of Bone Island Gross Photograph of Bone Island

Bone Island Involving Pelvis CT Scan of Pelvic Bone Island

Benign Bone-Forming Tumors

CT Scan of Bone Island MR of Bone Island

Bone Island of Spine Bone Island of Spine

Bone Island Involving Pedicle Bone Island of Pedicle

Benign Bone-Forming Tumors

CT of Bone Island of Femur Bone Scan

Large Bone Island of Proximal Humerus MR of Bone Island of Humerus

Bone Island of Mandible Gross Photo of Bone Island Arising in Rib

Benign Bone-Forming Tumors

Light Microscopy Light Microscopy

Periphery of Bone Island Osteopoikilosis

Osteoma of Fibula Osteoma of Long Bone Resection Specimen

Benign Bone-Forming Tumors

Osteoma of Femur Large Osteoma of Femur

Osteoma Resembling Cortical Bone Osteomas in Gardner Syndrome

Benign Bone-Forming Tumors

Osteoma of Sinus Producing Mucocele MR of Mucocele Caused by Osteoma

Osteoma of Palate Osteomas in Gardner Syndrome

Osteoma at Surgery Osteoma Having Cortical-Like Features

Woven and Lamellar Bone Osteoma With Haversian-Like Canals

Multinodular Mass on Calvarium Trabecular Osteoma

Benign Bone-Forming Tumors

Trabeculae Surrounded by Marrow Cap of Osteochondroma

Myositis Ossificans Parosteal Osteosarcoma