sentative
examples
are included
here.
-@llpatients
reported
have
l)eefl
examined
by
one
of
us
(R.D.M.).
Thirty
cases of osteoid
osteoma
were diagnosed
at this
institution
l)et\veen
1952
and
1974.
Of
these
patients,
22 (74%) were
2() @Tearsof age or
less@4 of the 22 were operated
on elsewhere
after
the clinical
diagnosis
had been
made
and are not
included
in this report.
Four
of the renlaining
18
1)atie1@tshave been
previously
reported
from
this
institution 1)\' Kendrick and Evarts and are not
included
in this report.
RESULTS
The
pertinent
features
of the
14 patients
reported
here
are summarized
in Table
I. These
patieilts
ranged
in age from 5 to 20 years.
In the
patients
reported
previously
from this institution
l)\' Kendrick
and Evarts,'
the \‘oungestwas 23
nionths
and the oldest was 62 @‘¿ears
of age. The sex
distribution
of our
patients
was
11 males
atid :3
females.
Pain
was
the
presenting
complaint
of
each patient.
The pain
was generally
of a boring
or aching nature and was characteristically worse
at night
than during
the day. In several
instances,
P@'@'@
would
abruptly
awaken
the patient.
Pain
had been
present
from
as little
as 1 month
to as
@ Rt'('ei\t'(l :\imgiist 13: dc('el)te(l for i@mblicatiomi .\ugust 18,
1976.)
ADDRESS FOR REPRIN1'S: R.1),\l.@ 1)epartment of Pedi atrics amid .@dolescemit \ledicine, The ( :les'el@tmid ( :limik' FolIo
datioll, 950() Euclid Avenue, Cleveland, ()hio 44106.
.\BSTR.@CT. Osteoid osteoma is a relatively coiiimon benign
tumor of bone ss'hich occurs most often in adolescents amid
\‘ounga(ltllts. The pattern of the pain svith its characteristic response to aspirin and the roemitgenogm'aphic findings niake
the clinical diagnosis easy and virtually certain. An example
is 1)resemited to help the pediatrician l)ecomfle familiar with the tumor amid its diagnosis. Pediatrics, 59:526—532, 1977,
OSTEOI I) O5TEOMA. BONE TUMORS.
Osteoid
osteonia
is a benign
tunior
of bone
which
is easily
diagnosed.
.‘\lthough approxi
matelv
70% of reported
instances
have
been
in
patients
20
@‘¿ears
old or \‘ounger, the disease
has
l)een
seldom
mentioned
in the
pediatric
litera
ture,
many
pediatricians
are
not
aware
of the
existence of such a disorder. The purpose of this
article
is to point
out the classic,
clinical
features
of osteoid osteoma
and the ease with which the
diagnosis
can be established.
The
treatment
and
the cure of osteoid
osteonia
is surgical
removal
of
the titnior.
MATERIALS AND METHODS
-.‘ coniputer search was niade of all instances of
osteoid
osteoma
diagnosed
at
The
Cleveland
Clinic
Foundation,
and this was conipared
with a
list
of all
pathologic
specimens
signed
out
as
osteoid
osteonias.
All charts
were
reviewed,
and
only those
cases with
biopsy-proven
diagnoses
were
included
in this stud@.
The
roentgenogranis
were
studied,
and repre
OsteoidOsteoma in Children and Young Adults
James P. Orlowski,M.D., and Robert D. Mercer, M.D.
!‘rumutIm('l)epartiiu'imtofPediatrics(111(1.@(lol(-.s('(-ut.@!ediciue.lime(:h't('!(z;m(!(;!@,@JOU?idOfjOfl(111(1‘¿J'h('
(:l('t('l(,,m(l(:li,1i('L(1U('(ItiOlI(Il1'()UU(latiOli.(;!(‘I('!(,?l(l
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Sijmptom.s’ 1)1,ration Aspirin Relief
Surgical Relief
1 M/19 Pain R hip I yr Yes No report No report R proximal femur Yes
2 M/1() Pain L thigh 8 mo Yes Yes, 2 cm Yes L femoral head Yes :3 XI I I 1 m2 Pain R knee I yr Yes Yes, 4 cm Yes R distal femur Yes
4 M/5 Pain L knee 2 yr Yes Yes, 4 cm Yes L distal femur Yes
5 MIS Pain R lower leg
and R foot
3#{189}yr Yes No report Yes II lateral
ctmnei-form
Yes
6 M/6 Pain L knee 3 mo Yes Yes, 2.5 cm Yes L distal femoral Yes
7 F/ 1 1
cond’,le
Pain R thigh 18 030 Ye5 Yes, 2 cmii Yes B femnoral neck Yes
S \1/15’2 Pain L ankle 6 mimo Yes No report Yes L distal tibia Yes 9 NI/ifi Pain L thigh 1 urn No report No No_report L femur midshaft Yes 10 M/2() Pain R knee and
R hip
I yr Yes Yes, 2 cm Yes R femur mnidshaft Yes
11 \1/15 Pain L thigh No report Yes Yes, 3 cm No report L 1)roximiial femur Yes 12 M/612 Pain L knee :3 mo Yes Yes, 2 cmii Yes L femur midshaft
H proximmial femur Transverse process
(:-4 vertebra
Yes Yes Yes 1:3 M/12 Pain R knee 2 yr Yes No report Yes
14 F/1:3 Painful stiff neck 1 yr Yes No No TABLE I
OSTEOID OsTEomA
P(Iti(’Ilt Sux/ .‘ge (i,r)
long as :31/i 7ears before the diagnosis was made
and surgical relief provided. Pain was generalh’
located in the region of the bone tumor but was
referred to the thigh from lesions in the proximal feiiiur in cases 2, 3, and 1 1. It was referred to the
knee from lesions in the midshaft or proximal
femur in cases 10, 12, and 1:3.
Coiiiplete relief of pain with the use of aspirin ‘as a striking feature of the history in niost of the
l)atiellts. These patients found out on their own
that aspirin was needed almost every four hours.
Iii sonic instances, the demand for aspirin was insistent enough to suggest addiction. Patient 5
would steal aspirin from neighl)ors when his
parents tried to limit his consumption of this
drug. Patient 20 reported relief of pain with
aspirili l)Ut not with codeine. The relief of pain
with the use of aspirin is so specific that it is one of the diagnostic features of this disease.
The findings on physical examination were
usual1’ niiniiiial. Liniping was present when the
lesion was located in the lower extremities, as it
was in most of the patients reported here.
.-troph of muscle was also commonly present.
Pain on pressure over the area of the involved bone ‘as present, but it was relatively minimal.
Visible enlargement of the involved bone was
noted only in the one patient (case 8) in whom the
Atrop/mij Limp IA)C(ItiOfl of Tumor
osteoid osteoma was located in the distal part of
the til)ia.
The results of laboratory studies in these
patients were remarkable only in that they were
nornial. The ervthrocvte sedimentation rate
(ESR) was moderately elevated in one patient
(case 9). The white l)lood cell (WBC) count;
alkaline phosphatase, calcium, phosphorus, and
fibrinogen levels; and results of other laboratory
studies were normal in every patient.
CASE REPORT
There are at present more than 500 instances of
osteoid osteonia reported in the surgical and
radiological literature. Because of this
redun-dancv, only one case selected for teaching value is
described here in more detail.
Case 7
..‘ white girl, 1 1 years 3 months old, had complained of pain in her right thigh for 18 miionths. Aspirin relieved the
pain vithin niimiutes; she was taking approximately 6(X) mg
of aspirimi ever four to five hours. 11cr parents attempted to
Pre’emit her constant ingestion of aspirin, I)ut she would steal the drug froni her parents and from her neighbors. She attenipted to snitiggle a l)ottle of aspirin into the hospital l)eCatmse she was afraid she could not get it from her
Fmc. 1. .trophv of right thigh of 1 1-year-old girl with osteoid osteoma of right femnimr (case 7).
On 1)hvsical exaniination she sas found to be a hea1th child who walked with a slight limp. Localized pain amid temidermiess were pm’esemit at the mrmidportiomi of the right thigh.
The right thigh was 2.0 cm smiialler in circumference thami the
left thigh (Fig. I).The \‘BC cotimit, ESR, amid results of other
routimie lal)orator\ st udies sere nornial . Roemitgenogramus
demiionstrated a radiolucent area 1 .0 cmii in diamneter in the
neck of the right femur iFig. 2). A sniall miidus of increased
density commld be seen within the lucent area. Surgical curettage of this lesion with a homiiogenous bone graft m’esulted in promnpt amid complete relief of svmiiptoms.
There are earlier reports of patients which we
would now recognize as having osteoid osteoma.
The first clear recognition that this was a disease
separate from localized osteoniyelitis and
belong-ing in a class of “benign osteoblastic
osteoid-tissue-forniing tumors” was the report by Milch in
19:34. \Iilch described lesions in the right radius
of a 22-year-old man, the left astragalus of a
23-year-old man, the left fibula of a 15-year-old boy,
and the distal phalanx of the third right toe of a
20-year-old woman. Much felt that the history,
clinical findings. and roentgenograms were
pathognomonic of this condition and he advised
that the tuilior be treated by complete excision.
Jaffe in 1935 introduced the term
“osteoid-osteonia. ‘
‘
He redescrihed three of the patientsreported by Milch and added two more. Jaffe is
often given credit for the original description of
osteoid osteonia. His article is a classic description
of the pathologic anatomy of this disease. He
pointed out that there was no evidence to support
the concept of inflammatory origin of the lesion,
Fm;. 2. Osteoid osteomima of neck of temnur svitli curt ical thickemiimmg case
and he concluded that this ssas a l)enign hone
neoplasul. Iii 19:36, Jaffe’ suirimarized the
prin-cipal clinical and roentgenographic features of
osteoid osteoiiia as follovs:
a) The l)ttiemits ssere all adolescemits or votmng adults
1)) The )m’imi(.’ipal(‘OmilI)laimit\vas local paimi
C,) Umiiformnlv. the lesion originated in songv bone areas
(1) As observed radiographicallv. the )athological areas
sere roumidish and .‘learly cirdumflscril)ed
e) The lesions were smuall amid (‘Ioselv simnilar in size f) Imi ever case operation svas performed on the
assuniption that the lesion vas an inflamnmnatorv one
g) Comuplete eradicatiomi resimlted in the evemitual disap-pearamice of all svmrII)tonis. vithout rt’(’1mrremu’t- of the local
lesiomi.
B\ 1940, jaffe and Lichtenstein were able to
report on a total of33 patients. and 1w 1945, jaffe’
had data on 62 pioveu instances. The generally
voting age of the patients. the preponderance of
niales over feniales, and the relief of pain 1w the
use of aspirin had been noted. The lesion had been
ol)served within and adjacent to the cortex as vell
as in the spongiosa of l)one. The pathologic
anatonlv and roentgenogra)h ic features were
svell described. Since 1945 there has beeii a flood
of reports on osteoid osteoma, and hundreds of
I76
I55 I 75
t50
25-H
2
75-,
2 50-’
95
CLINICAL FEATURES
25-33
29
AGE IN YEARS
Fi;. :3, .ge distribution of 647 cases of osteoid osteoma collected from the literature.
reports are in the orthopedic, roentgenographic, and )atliologic literature. The pediatric literature
has been strangely devoid of reports on this
disease of adolescents and young adults. The
solitary report that we have been aI)le to find is
that of Purcell et a!. in l952. They surveyed the
findings iii 1:3 children froni 22 months to 15 years
of age from the records of the Mayo Clinic, and,
in an addenduni they mentioned a patient in
vhoni there were probably two separate osteoid osteoirias.
Osteoid osteoma occurs iiiainly in older
chil-dren, adolescents, and young adults. It is
unconinion l)eyond the age of 30 years. A survey
of 674 patients reported in the literature showed
that 66.8#{176}4of theni were less than 20 years of age,
and 80.9% were less than 25 ‘ears of age. Half the
patients were between ages 1 1 and 20 ‘ears (Fig.
3). Seventy percent of these reported patients
were niale. The lesion is not rare in the general
population, l)lIt it is rare in blacks.’
Pain is the chief complaint of nearly all
patients. The pain is moderate or mild; neverthe-less. it is often severe enough to cause the patient
to cry. It is described as a boring pain, or “like a
toothache,
‘‘
and it generally appears to lessensvitli activity and to l)ecome vorse with rest. It is
often niore intense at night and interferes with
rest. “Starting pain” is frequently described. This
terni is used when the patient awakens suddenly
at night. crying out in pain.
Iii our experience, niassage and the application
of heat were iiot helpful in the relief of pain. The
response to aspirin was proiiipt and dramatic. The
unusual response to aspirin was noted as early as 194() b’ jaffe and Lichtensteiii, and it has
subse-quentlv been confiriiied and conimented on by
iiianv authors.
Pain is usually located in the approximate
position of the tumor, and it may be localized
with extreme I)recision by the patient. However,
referral of pain to a nearby joint is not unusual.
.‘\trophv of niuscie is a common occurrence
when the osteoid osteoma involves an extreniity.
Significant atr01)h’ was noted in eight of our
patients. \Ve regard atrophy as a significant
diagnostic feature of this disease. Limping is also
present ss’hen the osteoid osteoma occurs in an
extreniity. Palpable swelling ma’ l)e present
when the lesion has produced cortical
thicken-ing.
Osteoid osteoma has been described in virtually
every l)one iii the body, including the skull.’’ In
roost patients, the lesion has been found in the
lower extremities. A review of 94 patients
reported in the pediatric age group,7’m”
includ-ing our patients, showed that 34 occurred in the
feimir and 35 in the tibia, for a total of 73.4% of all
patients.
\Then osteoid osteoma occurs near or within a
joint, special prOl)lems of diagnosis and prognosis
arise. Sherman’7 iii 1947 was the first to comment
on this situation. She described one case in which
a 16-year-old girl had an osteoid osteoma of the
neck of the feiiiur. There were mild degenerative
changes of the hip joint, and the synovial
nieml)ralie showed severe villous proliferation
and intense chronic inflammation. Sherman’s
second patient was a 13-year-old boy with osteoid
osteoma of the olecranon fossa. The synovial
IlielTnl)rane of the elbow joint was injected and thickened, and showed a chronic inflammatory
reaction. Sherman felt that these cases
repre-sented a secondary reaction to the nearby osteoid
osteoma.
Flahertv et (ii. S mentioned three patients in
whoni there were degenerative changes in the hip
associated with a tumor in the femoral neck. Others have emphasized the diagnostic
prob-lems,’’” the changes in the joints,m and the
concern that intraarticular osteoid osteoma in a
child can lead to serious disturbances of growth
func-Fi;. 4. Ostenid osteommia of neck of femnur vitli calcification of
nidims.
tion.
“
Th ree patients vith intraarticular osteoidosteomua have re’ittsi l)een reported froni this inst iti it IOU .
Osteoid osteonia of the spine is not particularly
tinconinion. Recently. Keim and Reina0 stated
that there ‘ere more than 50 patients with
osteoid osteonia of the spine described in the
literature, and tlie’ added nine patients.
Osteoid osteoma of the spine is usually
asso-ciated svitli painful scoliosis. The coiiiplaint of
1)ainful scoliosis is unusual in voting people and
must always be considered with extrenie care.
This is I)artic11lt1lY true when there are no
associated signs of inflammation and when the
In”’ is strikingly relieved with the use of aspirin.
Scoliosis has also been seen vith osteoid osteoma
of the ril)S.’ \Vhen osteoid osteonia is present in
the spine, there is often localized tenderness,
restriction of motion, spasni of paravertebral
nuiscies, and sonietinies an awkward gait. A head
tilt iua be seen in osteoid osteoma of the cervical
sl)ine. Radicular pain down the arni or down the
leg may l)e present and can be confused with the
P1’ of a protruding disc. If patients with benign
osteoblastoma are excluded. significant cord
compression with transverse mvelit is has not l)een
described as a result of osteoid osteoma of the
spine.
The treatnient of osteoid osteoma of the spine
is surgical excision of the lesion. Complete
renioval of the nidus results in complete relief of
pain. The tumor niav recur following incomPlete
removal of the nidus.
In niost instances of recurrent osteoi(l osteoma,
n-iost likely the nidus was not completely
renioved. Of niore interest are those ratients in
whoni the tumor has reappeared after what seems
to have been complete renioval of die nidus.
Dunlop et (ii. o: described a maii who had en 1)1o(’
excision of an osteoid osteoiiia at the base of the
right second metacarpal. .\ second resection was
needed a sear and a half later, and a central nidus
was again identified. Nineteen months later. a
third large excision was required for return of
svmptonis. \Vorland et a!. recentl’ described a
23-month-old girl with an osteoid osteoma of the
proxiiiial part of the left tibia. The tumor
recurred one year after the first en bloc excision,
and recurred for the second tinle eight ‘ears after
the second en bloc excision.
Multifocal osteoid osteonias ma also occur and
account for some of the reported recurrences of
this tumor.
‘
The concept that l)enign osteol)lastoma is an
entity distinct froni osteoid osteonia has been
confusing since the original description of what
we would not terni l)enign osteol)lastonia l)\ jaffe
and NIaver in 19:32.-s This is a tumor
characteris-tically larger than osteoid osteonia. It tends to
occur in the spine or long l)ones. The pain pattern
is less t’pical, and roentgenogranis demonstrate
less sclerosis than those of osteoid osteonia.
Benign osteoblastoma was described as
“os-teogenic fibroma” by Lichtenstein in 1951,’ and
Golding and Sissons in 1954. Dahlin and
John-son’ ‘ used the term “giant osteoid osteoma” in
1954, and, in 1956, Lichtenstein and Jaffe’
independently proposed the name
‘
‘benignosteo-blastonia. ‘ ‘ This has l)ecome the accepted
desig-nation in the irianv case reports that have
followed. \Iarsh et a!. have recently thoroughly
reviewe(l the range of nianifestations of this
tumor. They report the characteristics of 1 72
patients with I)enign osteOI)ldstollia found in the
literature and add 25 new patients of their own.
The histologic similarit between benign
osteo-l)lastonia and osteoid osteonia was noted as early
as 19:32 when jaffe and \Iayei (lescril)ed the
recognized that tile pathologic findings were of
the sanie nature as the l)atients described by
Bergstrand Patie11ts that we would now accept
a.s having classic osteoid osteomas. Schajowicz
and Lemnos ‘ and (leSouza Dias and Frost ‘ ‘
#{149}
believe that both lesions represent a COflhIiiOii
basic P1cess. deSotiza Dias and Frost suggest that
these (lisorders I)e classified according to their
location in l)One, since the location determines
the nature of the reaction evoked in the
surround-ing hea1th’ i)one and also the size: (1 ) cortical
osteobiastonia, (2) spongious osteoblastoma, (:3) I)e1iStecul osteoblastoma, and (4) iiiultifocal
osteo-l)lastOiiia.
ROENTGENOGRAPHIC FINDINGS
The characteristic 1)icttlre of an osteoid
O5teOIflt is that of a sniall, rounded nidus
stirFOUll(ie(l i)\’ a reactive layer of sclerotic l)One
amid associated with thickening of the cortex (Fig.
4). The iiidtis is small and usual1’ not more than
0.5 ciii in diameter. It is most often radiolucent, bitt it may l)e calcified. Calcification of the nidus il-lay l)e s1)ott\’, 01 it iiia i)e uniformly dense.
There is no apparent relationship i)et’Veen the
age of the lesion and its appearance. At times, a nidus niav l)e 1)Ie5e1lt svith no sclerotic rini around
it. l)llt ill most instances it is surrounded by a zone
of sclerotic l)Olie. The sclerosis surrounding a
nidus miia’ l)e uneven iii distribution. ‘
Osteoid osteonia is characteristically associated \vi tii l)eriOsteal ile\V l)one format ion, causing
cortical thickening. The cortical thickening is
usually fusiform and niav be extensive, with its
greatest svidth in relation to the site of the osteoid osteonia. The l)e1istetl reaction is greatest \shen the osteoid osteoma is located l)eneatll the
perios-teumu OI vithin the cortex, and least or even
al)sent ss’iien the osteoid osteonia is located within
cancellous l)one. The new bone max’ have a
lalilinate(l 1l)I)ear1n1’e, and erosion of the cortex
can occur. Osteoid osteonia never produces the
irregular infiltrative areas of hone destruction
associated svith malignant l)one ttllilors.s
The importance of obtaining roentgenograms
of high (ItlalitY and I)ersistellce in the search for a
nidus must l)e stressed. Laminograph’ is by far
the most satisfactory method of depicting
morphologic (letail . As Freiburger amid
co-work-ers have suggested, roentgenographic
localiza-tioii of the tunior in the operating rooni to
facilitate 1)k’(’ renioval and examination of the
excised bone l)lock to confirm the presence of a
nidims aie valtial)le I)1oced11Ies.
. .,. .
-
,,
‘.:---.-.
-
i-.-:‘‘! S
..--‘_.4
‘r
--
-
- - - -- -.7’ .-. ‘.*.-------.“..- -
:,,
-- .
:;:4::z.:’
;: , ;‘ --- - .
-
- ;- -, -- _.J_-Fmc. 5. Osteoid osteonia renioved en bloc. Smmiall tumnor is
clearly demnarcated fromii heal thy bomie. Tumimor nieasmmres 0.5 x 0:3 cmii.
HISTOLOGIC FEATURES
The typical osteoid osteonia is a small, round,
or oval tumor-like nidus composed of osteoid and
miniature. irregularly niineralized trabeculae of
newly formed 1)Ofle developing within a
sul)stra-tiii-ii of highly vascularized osteogenic connective
tissue (Fig. 5). Tins’ unmvelinated nerve fibers
accompanying 1)100(1 vessels miia’ l)e seen in the
periphery i#{149}witiiii-i the muatrix of the nidus. The
pain of these lesions is )rol)al)ly niediated by the autonoiiiic nervous system via these fibers.
Varia-tions in the proportion of osteoid and in the
calcification of newly formed trai)eculae account
for the fact that the nidus is sometimes
radiolu-cent and sometiiiies dense. Scattered foci of
osteol)lastic reabsorption of bone max’ be
observed. Between the ttmnior nodule and the
surrounding l)OIie is a zone of loosely arranged
cellular and vascularized connective tissue. Less
niineralization is present toward the periphery of
the tunior. The surrounding host I)one varies froni
slighti thickened to densely sclerotic i)one tissue.
\Vhere thickened cortex exists, it is composed of a
layer of niore oi less transfornied original cortex
and a layer of compacted, newl’ deposited
pen-osteal l)oiie.
CONCLUSION
Osteoid osteonia is a l)enign tumor of bone that
com lm)nlv occurs in cli ildren and adolescents.
Pediatricians should 1)e familiar with the
s’nip-toms of this tumor. They should suspect the
presence of the tumor on the basis of the clinical
symptoms and confirm its presence
roentgeno-graphically. Because the average length of time
l)etWeen onset of symptoms and
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i(. diagnosis is about two ‘ears, the importance of persistence in the search for roentgenographic evidence of the tumor is stressed. Four important
aspects of osteoid osteonia in children are
empha-sized: ( 1 ) The prompt and dramatic relief of pain
l)\’ the use of aspirin is so striking that it is a
diagnostic feature of the disease. (2) “Starting
pain” at night, which suddenly avakens the child,
is a characteristic feature of the disease. (3)
Because pain ma\ l)e referred to a nearby joint,
the entire extremity should l)e examined by
roentgenographv if osteoid osteonia is suspected.
(4) Painful scoliosis iii vhich the pain is relieved 1w aspirin is suggestive of osteoid osteoma.
Surgical excision of the lesion effects
imme-diate and lasting relief from pain if the nidus is conipletelv nenioved.
REFERENCES
I. Kendrick JI, Evarts C\l: Osteoid-osteomua: A critical
amial’sis of 40 ttmmnors. Clin Orthop 54:51. 1967.
2. \lik’h II : Osteoid-tissmme-tormnimig tumimor simnulating
annular sequestriumn. J Bone Joint Stirg 16:681,
19:34.
:3. Jaffe IlL: “Osteoid-osteomna: A 1)emugn osteoblastic tumnor (‘omupused of osteoid and atypical bone. .rch
Smmrg :31:709. 193.5.
4. JaHe I IL: Osteoid osteomna. .ni j Pathol 12:796, 1936.
5. Jaffe II L, Lichtemisteimi L: ()steoid-osteomna: Further
experiemice vith this bemiigmi tiLmilor of 1)omie. j Bomie joint Simmg 22:645, 1940.
6. JaHe IlL: Osteoid-osteommma of bone. Radiolog’ 45:319,
1943.
7. Purcell 11\t. \Iills Sl). Lipscomnb PR: Osteoid-osteommma in childhood. Pediatrics 9:293. 1932.
8. Fmeiberger 1111. Loitmmman BS. Ilelpern \l. Thomupson TC:
Osteoid-osteomiia: A report omi 80 cases. .Amn J
1)emitgema)l 52: 194. 1939.
9. \Immnk j. Pevser E. Gellei B: Osteoid osteomiia of the
frontal bone. Br j Radiol :3:3:328, 196().
10. Dtl J(: Osteoid-osteomna of the skull. Br J Radiol
46:392, 197:3.
1 1. deSouza DM5 L. Frost I l\1: Osteoid
osteomna-osteohlas-tomna. (:mmic&r :3:3: 1073. 1974.
12. Lichtemistein L: Classification of PrimliarY tumnors of
bone. ( ;imi’er 4:33.5. I95 1.
13. (;oldimig JSR, Sissons 1 1.-s: (isteogenic fibroma of hone: .\
report of t’s o (.‘ases. j Bone joimit Surg :36B:428,
1934.
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