Epiphyses Of Long Bones Research Articles

Denosumab-treated giant cell tumor of bone. Its histologic spectrum and potential diagnostic pitfalls

Giant cell tumor (GCT) of bone is a locally aggressive, rarely metastasizing primary bone neoplasm that occurs most frequently in the epiphysis of long bones of young adults. It is composed of round, oval, or elongated mononuclear cells admixed with osteoclast-like giant cells that express receptor activator of nuclear factor κB (RANK). The mononuclear stromal cells express RANK ligand, a mediator of osteoclast activation. Denosumab, a monoclonal antibody that reduces tumor associated bone lysis by inhibiting the action of RANK ligand, has been used to treat selected cases of GCT. We reviewed the clinical records and histologic slides of 9 patients with GCT who had received denosumab therapy and were subsequently surgically treated. There were 5 men and 4 women aged 20 to 66 years (mean, 36 years). Duration of treatment varied from 2.5 to 13months (mean, 5.9 months). In all cases, different degrees of ossification, fibrosis, depletion of giant cells, and proliferation of mononuclear cells were seen. With this combination of changes, denosumab-treated GCT may mimic other lesions such as fibrous dysplasia, juvenile ossifying fibroma, nonossifying fibroma, and osteoblastoma. Less frequent but more relevant is the presence of cellular atypia or patterns of ossification that resemble an undifferentiated pleomorphic sarcoma, a conventional osteosarcoma, or a low-grade central osteosarcoma. The presence of clinical and radiologic response to denosumab, along with the lack of high mitotic activity, atypical mitotic figures, extensive necrosis, or a permeative pattern of growth, represents clues to achieve a correct diagnosis.

Anisotropic Permeability of Trabecular Bone and its Relationship to Fabric and Architecture: A Computational Study.

Trabecular bone is a porous, mineralized tissue found in vertebral bodies, the metaphyses and epiphyses of long bones, and in the irregular and flat shaped bones. The pore space is filled with bone marrow, a highly cellular fluid. Together, the bone and marrow behave as a poroelastic solid. In poroelasticity theory, the permeability is the primary material property that governs the momentum transfer between the solid and fluid constituents. In the linearized theory, the permeability of a material depends on the shape and connectivity of the pores. Developing a model of the relationship between trabecular microarchitecture and permeability could lead to improved simulations of trabecular bone mechanical response, which can be used to investigate bone adaptation, mechanobiological signaling, and progression of diseases such as osteoporosis. This study used finite element models of the trabecular pore space to calculate the complete anisotropic permeability tensor of 12 human and 18 porcine femoral trabecular bone samples. The sensitivity of the simulations to model assumptions and post-processing was analyzed to improve confidence in the result. The orthotropic permeability tensor depended on the fabric tensor, trabecular spacing, and structure model index through a power law relationship. Porosity and fabric alone also provided a reasonable prediction, which may be useful in cases where the image resolution is insufficient to obtain detailed measures of architecture.

Non Traumatic Hip Osteonecrosis Treated By Non Vascularised Bone Graft Versus Core Decompression

Background: Avascular necrosis (AVN) is defined as cellular death of bone components due to interruption of the blood supply; the bone structures then collapse, resulting in bone destruction, pain, and loss of joint function. AVN is associated with numerous conditions and usually involves the epiphysis of long bones, such as the femoral head. In clinical practice, AVN is most commonly encountered in the hip. Early diagnosis and appropriate intervention can delay the need for joint replacement. However, most patients present late in the disease course. Without treatment, the process is almost always progressive, leading to joint destruction within 5 years.Treatment of a vascular necrosis depends mainly on early diagnosis which mainly based on clinical findings, x-ray finding & MRI.A variety of non vascularized bone grafting techniques have been proposed with varying degrees of success as treatment alternatives for osteonecrosis of the femoral head. The success of these procedures may be enhanced using ancillary growth and differentiation factors. Objectives: To treat non traumatic hip osteonecrosis by non vascularized bone graft versus core decompression. Type of the study: A retrospective study. Methods: We retrospectively reviewed 72 patients (88 hips) with osteonecrosis of the femoral head between May 2009, and March 2014,divided into two groups . Group A include 34 patients (44 hips) with osteonecrosis of the femoral head who had non vascularized bone grafting procedures done for them . Minimum follow-up was 12 months. We compared the outcomes in this cohort to similar hip number (44 hips) in 40 patients treated with core decompression only (group B). We used Phemister technique to make a window at the posterior aspect of greater trochanter to remove necrotic bone and packed the excavated area with autogenous cancellous bone graft taken from ipsilateral iliac crest or leave it without bone graft (decompression only). Results: We report the result of treatment for femoral head avascular necrosis depending on Ficat classification stage I, II, & III. The minimum follow up was 12 months (12m-36m). The success percentage of hips in our cohort of patients with non vascularized bone grafting group A are 86% (38 of 44 hips), which is higher than group B 63% (28 of 44 hips) with core decompression alone. Conclusions: These procedures core decompression and autogenous cancellous bone graft may defer joint arthroplasty in selected patients & it is more effective than core decompression alone in treating early stages of femoral head osteonecrosis.

Discriminant model possibility of occurrence pubertal uterine bleeding in girls depending on the characteristics of the structure and size of the body

Abstract In this paper, based on the performance characteristics of the structure and size of the body, and through step discriminant analysis, we have built an accurate and highly informative model of the possibility of pubertal uterine bleeding in a general population of girls aged from 14 to 18 years, and as broken down into groups 14-15 and 16-18 years. In the total group of girls of 14-18 years and notably in girls 16-18 years, indicators of skin thickness and fat fold are consistent with such a possibility, while in girls 14-15 years old, indicators of body diameter, width of distal epiphysis of long bones of the limbs and encompassing body size, show correlation with pubertal uterine bleeding. The largest contribution to discrimination, regardless of the age groups, is, however, the value of the fat component of body weight.

Progress on the Rule of Clavicle Epiphyseal Closure Using Multi-Imaging Technology

People aged 18 years could be punished lightly or diminished criminal responsibility, even be spared the death sentence, which has important meaning in Chinese judicatory adjudication. The epiphysis of long bones from human limbs and the secondary sexual characteristics almost have developed completely before 18 years old. Clavicle epiphysis is one of the articular metaphysis which has a late epiphyseal closure. The recent studies in exploring the rule of clavicle epiphyseal by multi-imaging technology shows that the development of clavicle epiphysis has some value in age estimation of 18 years old. CT, especially thin-section CT, is widely used at present. However, thin-section CT scanning has great net radiation, which is not ethically acceptable if it is not for diagnosis and treatment. MRI is nonradioactive tomographic imaging and easy to evaluate, which is one of the future research directions in forensic age estimation using the medial clavicle. This paper summarizes the progress on the rule of clavicle epiphyseal closure, and analyzes and summarizes the feasibility of rule of clavicle epiphyseal closure applies on age estimation.

Chondrogene Knochentumoren

Primary cartilage-forming tumors of the bone are frequent entities in the daily work of skeletal radiologists. This article describes the correlation of pathology and radiology in cartilage-forming skeletal tumors, in particular, enchondroma, osteochondroma, periosteal chondromas, chondroblastoma and various forms of chondrosarcoma. After reading, the radiologist should be able to deduce the different patterns of cartilage tumors on radiographs, CT, and MRI from the pathological aspects. Differentiation of enchondroma and chondrosarcoma is afrequent diagnostic challenge. Some imaging parameters, e. g., deep cortical scalloping (more than two thirds of the cortical thickness), cortical destruction, or asoft-tissue mass, are features of asarcoma. Osteochondromas are bony protrusions with a continuous extension of bone marrow from the parent bone, the host cortical bone runs continuously from the osseous surface of the tumor into the shaft of the osteochondroma and the osteochondroma has acartilage cap. Chondromyxoid fibromas are well-defined lytic and eccentric lesions of the metaphysis of the long bones, with nonspecific MRI findings. Chondroblastomas have astrong predilection for the epiphysis of long tubular bones and develop an intense perifocal bone marrow edema. Dedifferentiated chondrosarcomas are bimorphic lesions with alow-grade chondrogenic component and ahigh-grade noncartilaginous component. Most chondrogenic tumors have apredilection with regard to site and age at manifestation.

Radiographic Examination of Rabbit Foeti Under the Effect of Hypervitaminosis A

Fifteen full term rabbit foeti representing control and four treated groups (three from each group) were inspected by X-rays device at dorsoventral, ventrodorsal and bilateral views to assess the normal developmental process of the skeleton (control group) and skeletal malformations after excess dosage of vitamin A (treated groups). There were ossification centers represented by two radiolucent lines extending along the vertebral column as well as two radiolucent spots representing the ossification centers in the pelvis in all groups. The secondary ossification centers of the extremities were radiographically investigated in the proximal and distal extremities of humerus, femur and proximal extremity of tibia. Incomplete fusion, leaving an epiphyseal line, was found in the proximal and distal epiphyses of long bones. The results of our study provide a schematic atlas of normal examinations of the rabbit skeleton and its ossification centers. Such findings are useful in the interpretation of any cross- sectional pictures in this species and elucidate the impact of hypervitaminosis A on skeletal development.

Chondroblastoma: An Unusual Cause Of Shoulder Pain In Adolescence.

Chondroblastoma is a rare benign bone tumor, most often localized in the epiphysis of long bones. We report a case of atraumatic shoulder pain in a 17-year old soccer player. This chondroblastoma case demonstrates the difficult differentiation of chondroblastoma from giant cell tumor and clear cell chondrosarcoma and highlights possible pitfalls and clinical importance.

What Happens to the Articular Surface After Curettage for Epiphyseal Chondroblastoma? A Report on Functional Results, Arthritis, and Arthroplasty.

Chondroblastoma is an uncommon, benign, but locally aggressive bone tumor that occurs in the apophyses or epiphyses of long bones, primarily in young patients. Although some are treated with large resections, aggressive curettage and bone grafting are more commonly performed to preserve the involved joint. Such intralesional resection may result in damage to the growth plate and articular cartilage, which can result in painful arthritis. Prior studies have focused primarily on oncologic outcomes rather than long-term joint status and functional outcomes. (1) What local complications can be expected after aggressive intralesional curettage of epiphyseal chondroblastoma? (2) What is the joint survival of a joint treated in this way for chondroblastoma? (3) What additional procedures are used in treating symptomatic joint osteoarthritis after treatment of the chondroblastoma? (4) What are the functional outcomes in this group of patients? A retrospective study of our prospectively collected database between 1975 and 2013 was done. We found 64 patients with a diagnosis of chondroblastoma of bone. After applying our selection criteria, 53 patients were involved in this study. We excluded seven patients with tumors initially treated with en bloc resection (five located in the extremities and two in the axial skeleton) and two patients with apophyseal tumors. One patient who underwent nonsurgical treatment and one patient lost to followup were also excluded. The mean age was 18 years (range, 11-39 years); the minimum followup was 2 years with a mean followup 77 months (range, 24-213 months). We analyzed all patients with a diagnosis of epiphyseal chondroblastoma of the limb treated with aggressive curettage and joint preservation surgery. During the period in question, our general indications for curettage were patients with active, painful tumors and those with more aggressive ones that remained intracompartmental, whereas initial wide en bloc resection was indicated in patients who had tumors with an extracompartmental extension breaching the adjacent joint cartilage and massive articular destruction. The tumor location was the distal femur in 14 patients, proximal tibia in 11, proximal humerus in 10, proximal femur in eight, the talus in seven, and elsewhere in the lower extremity in three. Local complications including joint degeneration and tumor recurrence were evaluated. Based on radiographic analysis, secondary osteoarthritis was classified by using the Kellgren-Lawrence grading system from Grade 0 to Grade IV. Patients who underwent joint replacement resulting from advanced symptomatic osteoarthritis were considered to have had joint failure for purposes of survivorship analysis, which was estimated using the Kaplan-Meier method. Functional results were evaluated with the Musculoskeletal Tumor Society functional score by the treating surgeon, who transcribed the results on the digital records every 6 months of followup. Twenty-two patients (42%) developed 26 local complications. The most common local complication was osteoarthritis in 20 patients (77% [20 of 26 complications]); tumor recurrence was observed in four patients; an intraarticular fracture and superficial infection treated with surgical débridement and antibiotics developed in one patient each. Joint survival was 90% at 5 years (95% confidence interval [CI], 76%-100%) and 74% at 10 years (95% CI, 48%-100%). Proximal femoral tumor location was associated with lower survivorship of the joint than other locations showing a 5-year survival rate of 44% (95% CI, 0%-88%; p = 0.000). Of the 20 patients with osteoarthritis, four were symptomatic enough to undergo joint replacement, all of which were for tumors in the proximal femur. The mean Musculoskeletal Tumor Society functional score was 28 of 30 points (93%). Osteoarthritis was a frequent complication of aggressive curettage of epiphyseal chondroblastoma, and tumors located in the proximal femur appeared to be at particular risk of secondary osteoarthritis and prosthetic replacement. Because chondroblastoma is a tumor that disproportionately affects younger patients, the patient and surgeon should be aware that arthroplasty at a young age is a potential outcome for treatment of proximal femoral chondroblastomas. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Aneurysmal Bone Cyst: An Uncommon Secondary Event in Calcaneal Chondroblastoma

Chondroblastoma is an uncommon benign bone tumour, involvement of epiphysis of long bones is typical. Chondroblastoma of the calcaneum is uncommon and its association with secondary aneurysmal bone cyst is even rarer. Only two cases of calcaneal chondroblastoma associated with secondary aneurysmal bone cyst have been reported till date. A 22-year-old male presented to the department of orthopaedics with complains of pain and swelling in the left heel since the last 10 months. On clinico-radiological grounds differentials considered were giant cell tumour of bone and aneurysmal bone cyst. In view of the histopathological findings of bone curettage and results of special stain and immunohistochemical marker, final diagnosis of chondroblastoma with secondary aneurysmal bone cyst, left calcaneum was rendered. Although rare, chondroblastoma should always be considered in osteolytic lesions of calcaneum. The identification of secondary aneurysmal bone cyst component is important as it has higher chances of recurrence than usual chondroblastoma.

Bacille Calmette-Guérin Osteomyelitis.

Tuberculosis is an essential problem for healthcare systems especially in developing countries. All newborns are given Bacillus Calmette-Guérin (BCG) vaccine in Iran which is prepared from live bovine tuberculosis bacillus, and is given to protect against tuberculosis. Osteomyelitis secondary to BCG vaccination is rare and usually involves epiphysis of long tubular bones. 4 patients, 3 males and a female entered this study and were between 11 to 24 months old. The involved bones were first metatarsi, talus, humerus and tibia bone. The main radiologic finding was lytic lesion with cortical destruction and periosteal reaction. 3 patients underwent core needle biopsy and the one with the proximal tibia involvement, underwent open surgery. Pathology report suggested granulomatous osteomyelitis and typical caseous necrosis compatible with tuberculosis. Surgical treatment for these patients was curettage and debridement of the bone lesion and involved tissues around. The patients got standard anti TB pharmacotherapy, were completely cured and no short term complication was seen in a one year follow up. BCG osteomyelitis and cold abscess, should be kept in mind when assessing a child presenting chronic symptoms like pain, limping or local swelling of extremities. The long interval time between BCG vaccination and outbreak of the culture-negative abscess is a major point which emphasizes on pathologic evaluation. Image guided tissue biopsy and PCR studies confirm diagnosis. Early use of a surgical curettage and debridement along with chemotherapy soon afterwards, enabled these children to enjoy a satisfactory clinical outcome.

Chondroblastoma of the Clivus: Case Report and Review

Background and Importance Chondroblastoma is a benign primary bone tumor that typically develops in the epiphyses of long bones. Chondroblastoma of the craniofacial skeleton is extremely rare, with most cases occurring in the squamosal portion of the temporal bone. In this report, we describe the first case of chondroblastoma of the clivus presenting with cranial neuropathy that was treated with endoscopic endonasal resection. We review the literature on craniofacial chondroblastomas with particular emphasis on extratemporal lesions. Case Presentation A 27-year-old woman presented with severe headache, left facial dysesthesias, and diplopia. Physical examination revealed hypesthesia in the left maxillary nerve dermatome, and complete left abducens nerve palsy. Imaging demonstrated an expansile intraosseous mass originating in the upper clivus with extension superiorly into the sella turcica and laterally to involve the medial wall of the left cavernous sinus. The tumor was completely resected via an endoscopic endonasal approach, with postoperative improvement in lateral gaze palsy. Histopathology was consistent with chondroblastoma. Conclusion Chondroblastoma is a rare tumor of the craniofacial skeleton that should be included in the differential diagnosis of an osteolytic lesion of the clivus. Complete surgical resection remains the mainstay of treatment.

Multiple epiphyseal dysplasia.

Multiple epiphyseal dysplasia is a genotypically and phenotypically heterogeneous disorder affecting the epiphysis of long bones. Inheritance may be autosomal dominant or autosomal recessive. Autosomal dominant variants include mutations of the collagen oligomeric matrix protein, collagen type IX α-1, collagen type IX α-2, collagen type IX α-3, and matrilin-3 genes. The autosomal recessive variant is caused by a mutation of the sulfate transporter gene SLC26A2. These mutations cause disorganized endochondral ossification of the epiphysis, ultimately leading to destruction of the articular cartilage. Patients typically present in childhood, but some may not present until early adulthood. A presumptive diagnosis can be made with clinical history, physical examination, detailed family history, and radiographic findings. Definitive diagnosis requires genetic testing. Treatment is based on the age of the patient, the amount of limb deformity, the level of joint destruction, and the needs of the patient. Children can greatly benefit from limb realignment procedures, and adults can have excellent outcomes with joint arthroplasty.

English

Rhizomelic chondrodysplasia punctate (RCDP) is a rare autosomal recessive peroxisomal disease. The main features of the disease are shortening of the proximal long bones (Rhizomelia), punctate calcifications located in the epiphyses of long bones (Chondrodysplasia) and in the soft tissues around joints and vertebral column, vertebral clefting, dysmorphic face, and severe growth retardation, cervical spinal stenosis may also rarely be present. Imaging of the brain and spinal cord in patients with this disorder may aid prognosis and guide us to take management decisions. We report a rare case of RCDP diagnosed in a newborn. Our aim is to discuss current knowledge on etiopathogenesis as well as radiological and clinical symptoms of diseases associated with CDP.

Long-Term Outcome of Endoprosthetic Replacement for Proximal Femur Giant Cell Tumor.

Introduction:Giant cell tumor (GCT) of bone is locally aggressive benign tumor involving the epiphysis of long bones in young adults. Various treatment options include intralesional curettage, extended curettage, wide resection, resection and reconstruction and amputation. The main variables to be considered for planning treatment include the site of involvement and Campanacci stage of the tumor. Functional and oncological outcomes of these treatment options vary widely, the predominant detrimental factor being tumor recurrence rate.Aim:A study was conducted to evaluate the long-term oncological and functional outcome of patients with GCT of the proximal femur that underwent tumor resection and endoprosthetic replacement.Materials and Methods:Eleven patients with Campanacci stage-III GCT of proximal femur who underwent wide excision of tumor and endoprosthesis replacement with a mean follow-up the duration of 10.6 years were assessed using standard proforma. The treatment outcome was evaluated using the Revised Musculoskeletal Tumor Society Rating Scale for the lower extremity.Results:At mean follow-up the duration of 10.6 years, none of the cases had tumor recurrence, infection, prosthesis loosening or dislocation. All the patients were community ambulators among whom eight patients were walking without support while three patients were using a cane for support. The mean total Musculoskeletal Tumor Society Score was 26.8 out of 30 indicating the good outcome.Conclusions:The authors recommend that wide resection and endoprosthetic replacement should be considered as a preferred treatment option for proximal femur GCT as the functional, and oncological outcome is satisfactory with this modality of treatment.

Biomechanics and mechanobiology of trabecular bone: a review.

Trabecular bone is a highly porous, heterogeneous, and anisotropic material which can be found at the epiphyses of long bones and in the vertebral bodies. Studying the mechanical properties of trabecular bone is important, since trabecular bone is the main load bearing bone in vertebral bodies and also transfers the load from joints to the compact bone of the cortex of long bones. This review article highlights the high dependency of the mechanical properties of trabecular bone on species, age, anatomic site, loading direction, and size of the sample under consideration. In recent years, high resolution micro finite element methods have been extensively used to specifically address the mechanical properties of the trabecular bone and provide unique tools to interpret and model the mechanical testing experiments. The aims of the current work are to first review the mechanobiology of trabecular bone and then present classical and new approaches for modeling and analyzing the trabecular bone microstructure and macrostructure and corresponding mechanical properties such as elastic properties and strength.

Spatial regulation of gene expression during growth of articular cartilage in juvenile mice.

In juvenile mammals, the epiphyses of long bones grow by chondrogenesis within the articular cartilage. A better understanding of the molecular mechanisms that regulate the growth of articular cartilage may give insight into the antecedents of joint disease, such as osteoarthritis. We used laser capture microdissection to isolate chondrocytes from the superficial, middle, and deep zones of growing tibial articular cartilage in the 1-wk-old mouse and then investigated expression patterns by microarray. To identify molecular markers for each zone of the growing articular cartilage, we found genes showing zone-specific expression and confirmed by real-time PCR and in situ hybridization. Bioinformatic analyses implicated ephrin receptor signaling, Wnt signaling, and bone morphogenetic protein signaling in the spatial regulation of chondrocyte differentiation during growth. Molecular markers were identified for superficial (e.g., Cilp, Prg4), middle (Cxcl14, Tnn), and deep zones (Sfrp5, Frzb). Comparison between juvenile articular and growth plate cartilage revealed that the superficial-to-deep zone transition showed similarity with the hypertrophic-to-resting zone transition. Laser capture microdissection combined with microarray analysis identified novel signaling pathways that are spatially regulated in growing mouse articular cartilage and revealed similarities between the molecular architecture of the growing articular cartilage and that of growth plate cartilage.

New therapy approaches for giant cell tumors

Giant cell bone tumors (GCT) are benign but partially locally aggressive osteolytic tumors which typically occur around the knee joint in the epiphysis and metaphysis of long bones after maturation of the skeleton is completed. Due to the locally aggressive growth behavior with destruction of the bone structure, the rare possibility of pulmonary metastases in recurrent cases and a very rare possibility of malignancy, GCTs were previously also described as semimalignant bone tumors. The established therapy of these tumors at the typical locations consists of intralesional curettage, extension of resection margins using a high speed trephine and defect reconstruction with bone cement. The local recurrence rate is high (10-40 %) and lowest after using thermal extension of resection margins with a high speed trephine and defect reconstruction with bone cement. For uncommon localizations, such as the spinal column and the sacrum as well as in cases of recurrence, surgical treatment is more complicated. Histologically, GCTs consist of osteoclastic giant and oval-shaped stromal cells which show a high expression of receptor activator of nuclear factor-κB ligand (RANKL) and decisively contribute to the osteolytic activity of the tumor. Novel pharmaceutical therapy approaches with human monoclonal RANKL antibodies interfere in this osteodestructive process in an inhibitory manner and can represent alternative treatment options just as the osteosupportive therapy with bisphosphonates. After unsatisfactory attempts at surgical treatment of GCT patients, the new treatment option with denosumab is a promising alternative due to its effect as a monoclonal RANKL inhibitor.

Trevor's Disease: A Literature Review regarding Classification, Treatment, and Prognosis apropos of a Case.

Background. Dysplasia epiphysealis hemimelica (DEH) is rare and its main characteristic is osteochondromas of the epiphysis of long bones. Methods. We report a case of DEH of the ankle in an 8-year-old boy that was resected in 2005. Additionally we collect all the reported cases of DEH. The literature is reviewed regarding the treatment, prognosis, long term function, and patterns and areas affected by DEH. Results. In our case no complications were noted and our patient remains asymptomatic. Reviewing the literature we found that 73 authors have reported 144 cases from 1926 to 2013. We propose and describe a new classification that correlates with prognosis. According to our classification DEH is classified as types 1 with single lower limb involvement, 2 with multiple lower limb, 3 with single upper limb, 4 with multiple upper limb, 5 with upper and lower limb, and 6 with spine. Conclusions. All single lesions should be followed up and if indicated a whole body nuclear bone scan can be useful in identifying the existence of multiple affected joints. Type 1 lesions have better prognosis than 2 and have less chances of developing OA even if not resected. Resection, even if partial, can be a successful treatment for DEH.

Images in Medicine: Giant Cell Tumour of the Talus in a 7-Year-old Boy.

Giant cell tumours (GCT) are locally aggressive lesions that primarily affect the epiphyses of long bones. They typically present in the third to fourth decades of life and are rare under 20 years of age. Involvement of the foot is uncommon, frequently affecting the calcaneus and metatarsals, rarely the talus. We report a case of GCT of the talus in a 7 year old boy which was diagnosed by imaging and confirmed by histopathological analysis.