1 Location of the lesion 2 Extent of the lesion 3 What is the lesion doing to the bone 4 What is the bone doing to the lesion 5 Hint as to its tissue type matrix ID: 912959
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Slide1
Radiology of Bone Tumors
Slide2(1) Location of the lesion (2) Extent of the lesion (3) What is the lesion doing to the bone? (4) What is the bone doing to the lesion? (5) Hint as to its tissue type / matrixX-rays - the question need to ask:
Slide3A. LocationLocation and age of patient most important parameters in classifying a primary bone tumor.Simple to determine from plain radiographs.
Slide4Location
Slide5EPIPHYSEALChondroblastomaClear cell chondrosarcomaGiant cell tumorAneurysmal bone cystGeode (subchondral cyst)
Infection
Eosinophilic
granuloma
Location in Longitudinal Plane
DIAPHYSEAL
Adamantinoma
Leukemia, Lymphoma, Reticulum cell sarcoma
Ewing sarcomaMetastasis Osteoblastoma/ osteoid osteoma Nonossifying fibroma
METAPHYSEAL
Nonossifying
fibroma
(close to growth plate)
Chondromyxoid
fibroma
(abutting growth plate)
Solitary bone cyst, ABC, GCT
Osteochondroma
Brodie
abscess
Osteogenic
sarcoma,
chondrosarcoma
Slide6Location in Transverse PlaneCentral: EnchondromaEccentric: GCT, CMF, osteosarcomaCortical: osteoid
osteoma
, NOF
Parosteal
:
osteochondroma
,
parosteal
osteosarcoma
Slide7Specific LocationBONE TUMOR
COMMONEST SITE
SBC
Proximal humerus > prox. Femur
ABC, GCT,
Osteosarcoma
Lowerend
femur > upper end tibia
Enchondroma
Metaphysis of small bones of hand & feet
Osteochondroma
Distal femur> prox. Tibia > prox. Humerus
Chondroblastoma
Proximal humerus>
prox
femur
Ewing’s
Femur > fibula > tibia
Adamantinoma
Mandible > tibia
Myeloma
Vertebra
Fibrous dysplasia
Ribs > Upper femur > Tibia > lower femur
Osteoid osteoma
Femur > tibia
Chordoma
Sacrum >
clivus
(
spheno
occipital) > anterior vertebral body
Ivory
osteoma
Frontal sinus
Chondromyxoid fibroma
Tibia > femur
Chondroblastoma
Pelvis > femur
Osteoblastoma
Posterior spine
Slide8Cysts and cyst like lesions of bone
Slide9Patterns of bone destruction:LyticScleroticB: What is the lesion doing to the bone?
PERMEATIVE
GEOGRAPHIC
MOTHEATEN
Poorly demarcated lesion imperceptibly merging with uninvolved bone
Long zone of transition
Areas of destruction with ragged borders.
Less well defined / demarcated
lesional
margin Longer zone of transition
Well-defined smooth / irregular margin
Short zone of transition
Slide10Margin between tumor and native bone is visible on the plain radiograph.Slowly progressive process is “walled-off” by native bone, producing distinct margins.Rapidly progressive process destroys bone, producing indistinct margins.
MARGIN
Slide11Radiographic MarginsMargin types 1A, 1B, 1C, 2, and 3least aggressive 1A, to most aggressive 3Aggressive lesions destroy bone.Aggressiveness increases likelihood of malignancy.BUT, not all aggressive processes are malignant.AND, not all malignant diseases are aggressive.
Slide12Margins: 1A,1B,1C
increasing aggressiveness
A well circumscribed lesion with a narrow zone of transition
Slide131A: sclerotic margin
simple cyst (UBC)
enchondroma
FD
chondroblastoma
GCT
chondrosarcoma (rare)
MFH (rare)
Slide141B: well-defined, non-sclerotic
GCT
enchondroma
chondroblastoma
myeloma, metastatsis
CMF
FD
chondrosarcoma
MFH
Slide151C: lytic, ill-defined margins
chondrosarcoma
MFH
osteosarcoma
GCT
metastasis
infection
EG
lymphoma
Slide162: “motheaten”
myeloma, metastases
infection
EG
osteosarcoma
chondrosarcoma
lymphoma
Multiple scattered holes that vary in size & seem to arise separately
Slide173: “permeative”
Ewing
EG
infection
myeloma, metastasis
lymphoma
osteosarcoma
Poorly demarcated from normal, numerous elongated holes/slots in cortex, run parallel to long axis of bone
Slide18Limited responses of bone Destruction: lysis (lucency) Reaction
: sclerosis
Remodeling
:
periosteal
reaction
Rate of growth determines bone response
slow progression, sclerosis prevails
rapid progression, destruction prevails
B. Reaction of bone to tumor
Slide19Periosteal ReactionPeriosteal reaction must mineralize to be seen on X ray ( 10 days – 3 weeks)Configuration of periosteal reactionNature of inciting processIntensity
Aggressiveness
Duration
Slide20Periosteal ReactionThick, uninterruptedlong standing process, often non-aggressivestress fracturechronic infectionosteoid
osteoma
Spiculated
,
lamellated
aggressive process
tumor likely
Slide21Slide22Codman Triangle
periosteal
reaction
tumor
advancing tumor margin
destroys
periosteal
new
bone before it ossifies
Codman
Triangle
Slide23Sunburst Appearance
Slide24C: Tumor Matrix“Matrix” is the internal tissue of the tumorMost tumor matrix is soft tissue in nature.Radiolucent (lytic) on x-rayCartilage matrix
calcified rings, arcs, dots (stippled)
enchondroma
,
chondroblastoma
,
chondrosarcoma
Ossific
matrix
osteosarcoma
Slide25Slide26Slide27Osteochondroma
Exostosis
: well defined bony
projection growing away from
physis
Cartilage maybe calcified if lesions are
large / malignant change
Slide28Osteoid osteoma
Nidus
: a tiny radiolucent area
If in
diaphysis
surrounded by dense bone and thickened cortex
Metaphysis
less cortical thickeningDouble density sign on bone scan – increased uptake in nidus and decreased uptake in reactive sclerotic zone (also seen in Brodie’s abcess)Lytic nidus
surrounded by sclerotic bone in CT
Centre of
nidus
may be calcified
Slide29Well demarcated osteolytic lesion sometimes containing flecks of calcificationLess reactive bone than osteoid osteomaBone scan - intense activity
Osteoblastoma
Slide30Cystic radiolucency on the diaphysial side of the growth plateCortex may be thinned and bone expanded with well defined thin sclerotic marginMay have pseudo-loculated appearance secondary to irregular cortical thinning and thin septal ridges
Falling fragment sign
typical and the lesion is never wider than
epiphysial
plate
Bone scan cold or minimal activity unless fractured
Simple
bone cyst
Slide31Gross honey comb lesionOften eccentrically placedDoes not extend to the joint (unlike GCT)Warm to hot on bone scan
Aneurysmal
bone cyst
Slide32Usually well defined geographic lytic lesion in the epiphysis/metaphysis extending up to the joint surface without marginal sclerosisJunction with normal bone often poorly definedCortex thinned and sometimes balloonedBone scan warm to hot
Giant cell tumor
Slide33Fibrous cortical defect
Margin well defined, sometimes scalloped and often
sclerosed
Slide34Geographic Well marginated
Multilocular
appearance
Inter cortical
osteolysis
- single or multiple bubble like areas
Non-ossifying
Fibroma
Slide35Ground glass appearance typicalShepherds crook deformity of proximal femurVariable appearance with expansion of cortex
Fibrous Dysplasia
Slide36Scalloped erosions on endosteal surfaceMay have flecks of calcificationEnchondroma
Slide37Rounded or oval rare areaUsually eccentrically placedMay cross the growth plateSharp outline and sclerotic rimScalloped margin and thin cortex
Chondromyxoid
fibroma
Slide38Well defined area of rarefaction eccentrically placed in the epiphysis or across the growth plateNo reaction in surrounding bone50% show central calcification, 50% show linear periosteal reactionBone scan increased uptake at margins
Chondroblastoma
Slide39Multiple loose bodiesSynovial Chondromatosis
Slide40Large osteolytic lesion in the midlineMay contain flecks of calcificationMarked bone destruction
Chordoma
Slide41Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton.
Brown Tumor
Slide42Characteristic honey comb appearance in diaphysisCortical thinning with expansion
Adamantinoma
Slide43Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)
Hemangioma
Slide44Mottled lytic defect usually no sclerotic rimMay destroy cortexUsually endosteal or periosteal reactionLesions in flat bones and ribs appear punched outMay appear loculated
due to sparing of large
trabeculae
Spinal lesions- collapse
(vertebra
plana
), which may heal
Eosinophillic
granuloma
Slide45Mottled or moth eaten lesion diffusely involving boneLytic destruction common, often the cortex is perforatedOnion skin appearance- layers of periosteal new bone are said to be characteristicMay form Codman’s triangle
Ewing’s sarcoma
Slide46Variable with combination of bone destruction and bone formationSun ray spicules/ sun burst appearance and Codman’s triangle may be evidentCortical breach commonAdjacent soft tissue massJoint space rarely involved25%
Lytic
35% Sclerotic
40% Mixed
Telangiectatic
type- purely
lytic
Osteosarcoma
Slide47Variable appearance with 60 - 70% have calcification and 50% have sub periosteal new boneMay be a large cystic lesion with cortical destruction and central calcification, endosteal scalloping and cortical expansion; annular, punctate or comma shaped calcification
Chondrosarcoma
Slide48Bone often mottled or moth eaten with extension into soft tissueOsteolytic lesion may be surrounded by reactive boneDestructive appearance radiologicallyUsually little periosteal reaction
Fibrorosarcoma
Slide49METASTATIC BONE DISEASEOsteolytic commonest - cortical destruction with little or no periosteal reaction; Lungs, Kidney, Adrenal, Thyroid, UterusOsteoblastic deposits – Prostate, Bladder, Testis, Breast and Bowel secondaries. Also carcinoid
lung tumors, lymphoma
Mixed- Breast, Lung, Ovary, Cervix
Lymphoma deposits may resemble prostatic deposits, i.e. sclerotic
secondaries
Lytic
,
expansile
, with soft tissue mass- RCC, thyroid
X-Ray- at least 50% loss of bone to produce lysis on X-ray, Loss of single pedicle produces a “winking owl sign”. CT scan, MRI
Slide50Slide51Osteolytic bone metastases: breast carcinoma shows multiple osteolytic
bone lesions.
Slide52Osteoblastic bone metastases
Slide53Mixed pattern bone metastases:
Slide54Early - vague mottled lucent areasDiffuse destructive lytic lesion with little periosteal reactionUsually combination of patchy sclerosis and mottled destructionHogkins disease - typical appearance of ivory vertebrae
Lymphoma
Slide55May be generalised decrease in bone densityMultiple punched out defects Little bony reaction around lesionsSolitary lesion = plasmacytoma; multilocular expanding lytic lesion in a red marrow area
Frequently cold on bone scan
Myeloma