Radiology of B one T umors - PowerPoint Presentation

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Radiology of Bone Tumors

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(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:

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A. LocationLocation and age of patient most important parameters in classifying a primary bone tumor.Simple to determine from plain radiographs.

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Location

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EPIPHYSEALChondroblastomaClear 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

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Location in Transverse PlaneCentral: EnchondromaEccentric: GCT, CMF, osteosarcomaCortical: osteoid

osteoma

, NOF

Parosteal

:

osteochondroma

,

parosteal

osteosarcoma

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Specific 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

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Cysts and cyst like lesions of bone

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Patterns 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

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Margin 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

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Radiographic 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.

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Margins: 1A,1B,1C

increasing aggressiveness

A well circumscribed lesion with a narrow zone of transition

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1A: sclerotic margin

simple cyst (UBC)

enchondroma

FD

chondroblastoma

GCT

chondrosarcoma (rare)

MFH (rare)

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1B: well-defined, non-sclerotic

GCT

enchondroma

chondroblastoma

myeloma, metastatsis

CMF

FD

chondrosarcoma

MFH

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1C: lytic, ill-defined margins

chondrosarcoma

MFH

osteosarcoma

GCT

metastasis

infection

EG

lymphoma

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2: “motheaten”

myeloma, metastases

infection

EG

osteosarcoma

chondrosarcoma

lymphoma

Multiple scattered holes that vary in size & seem to arise separately

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3: “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

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Limited 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

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Periosteal ReactionPeriosteal reaction must mineralize to be seen on X ray ( 10 days – 3 weeks)Configuration of periosteal reactionNature of inciting processIntensity

Aggressiveness

Duration

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Periosteal ReactionThick, uninterruptedlong standing process, often non-aggressivestress fracturechronic infectionosteoid

osteoma

Spiculated

,

lamellated

aggressive process

tumor likely

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Codman Triangle

periosteal

reaction

tumor

advancing tumor margin

destroys

periosteal

new

bone before it ossifies

Codman

Triangle

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Sunburst Appearance

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C: 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

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Osteochondroma

Exostosis

: well defined bony

projection growing away from

physis

Cartilage maybe calcified if lesions are

large / malignant change

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Osteoid 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

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Well demarcated osteolytic lesion sometimes containing flecks of calcificationLess reactive bone than osteoid osteomaBone scan - intense activity

Osteoblastoma

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Cystic 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

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Gross honey comb lesionOften eccentrically placedDoes not extend to the joint (unlike GCT)Warm to hot on bone scan

Aneurysmal

bone cyst

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Usually 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

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Fibrous cortical defect

Margin well defined, sometimes scalloped and often

sclerosed

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Geographic Well marginated

Multilocular

appearance

Inter cortical

osteolysis

- single or multiple bubble like areas

Non-ossifying

Fibroma

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Ground glass appearance typicalShepherds crook deformity of proximal femurVariable appearance with expansion of cortex

Fibrous Dysplasia

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Scalloped erosions on endosteal surfaceMay have flecks of calcificationEnchondroma

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Rounded or oval rare areaUsually eccentrically placedMay cross the growth plateSharp outline and sclerotic rimScalloped margin and thin cortex

Chondromyxoid

fibroma

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Well 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

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Multiple loose bodiesSynovial Chondromatosis

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Large osteolytic lesion in the midlineMay contain flecks of calcificationMarked bone destruction

Chordoma

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Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton.

Brown Tumor

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Characteristic honey comb appearance in diaphysisCortical thinning with expansion

Adamantinoma

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Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)

Hemangioma

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Mottled 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

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Mottled 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

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Variable 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

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Variable 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

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Bone often mottled or moth eaten with extension into soft tissueOsteolytic lesion may be surrounded by reactive boneDestructive appearance radiologicallyUsually little periosteal reaction

Fibrorosarcoma

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METASTATIC 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

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Osteolytic bone metastases: breast carcinoma shows multiple osteolytic

bone lesions.

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Osteoblastic bone metastases

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Mixed pattern bone metastases:

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Early - 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

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May 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