Dr Bashar Adnan Forms 02 of human tumor burden Primary malig bone tumors make 1 of all malignant tumors Most have male predominance except GCT ABC Most common malignant ID: 1033699
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1. Imaging of Bone Tumors Dr. Bashar Adnan
2. Forms 0.2% of human tumor burdenPrimary malig bone tumors make 1% of all malignant tumorsMost have male predominance except GCT, ABC.Most common malignant tumour is secondary metastatic deposits, mostly from Introduction
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4. (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:
5. A. LocationLocation and age of patient most important parameters in classifying a primary bone tumor.Simple to determine from plain radiographs.
6. Location
7. EPIPHYSEALChondroblastomaClear cell chondrosarcomaGiant cell tumorAneurysmal bone cystGeode (subchondral cyst)InfectionEosinophilic granulomaLocation in Longitudinal PlaneDIAPHYSEALAdamantinoma Leukemia, Lymphoma, Reticulum cell sarcomaEwing sarcomaMetastasis Osteoblastoma/ osteoid osteoma Nonossifying fibromaMETAPHYSEALNonossifying fibroma (close to growth plate)Chondromyxoid fibroma (abutting growth plate)Solitary bone cyst, ABC, GCTOsteochondromaBrodie abscessOsteogenic sarcoma, chondrosarcoma
8. Location in Transverse PlaneCentral: EnchondromaEccentric: GCT, CMF, osteosarcomaCortical: osteoid osteoma, NOFParosteal: osteochondroma, parosteal osteosarcoma
9. Specific LocationBONE TUMOR COMMONEST SITESBCProximal humerus > prox. FemurABC, GCT, OsteosarcomaLowerend femur > upper end tibiaEnchondromaMetaphysis of small bones of hand & feetOsteochondromaDistal femur> prox. Tibia > prox. HumerusChondroblastomaProximal humerus> prox femurEwing’sFemur > fibula > tibia AdamantinomaMandible > tibiaMyelomaVertebraFibrous dysplasiaRibs > Upper femur > Tibia > lower femurOsteoid osteomaFemur > tibiaChordomaSacrum > clivus (spheno occipital) > anterior vertebral bodyIvory osteomaFrontal sinusChondromyxoid fibromaTibia > femurChondroblastomaPelvis > femurOsteoblastomaPosterior spine
10. Cysts and cyst like lesions of bone
11. Patterns of bone destruction:LyticScleroticB: What is the lesion doing to the bone?PERMEATIVE GEOGRAPHICMOTHEATENPoorly demarcated lesion imperceptibly merging with uninvolved boneLong zone of transitionAreas of destruction with ragged borders. Less well defined / demarcated lesional margin Longer zone of transition Well-defined smooth / irregular marginShort zone of transition
12. 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
13. 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.
14. Margins: 1A,1B,1Cincreasing aggressivenessA well circumscribed lesion with a narrow zone of transition
15. 1A: sclerotic marginsimple cyst (UBC)enchondromaFD chondroblastomaGCTchondrosarcoma (rare)MFH (rare)
16. 1B: well-defined, non-scleroticGCTenchondromachondroblastomamyeloma, metastatsisCMFFDchondrosarcomaMFH
17. 1C: lytic, ill-defined marginschondrosarcomaMFHosteosarcomaGCTmetastasisinfectionEGlymphoma
18. 2: “motheaten”myeloma, metastasesinfectionEGosteosarcomachondrosarcomalymphomaMultiple scattered holes that vary in size & seem to arise separately
19. 3: “permeative”EwingEGinfectionmyeloma, metastasislymphomaosteosarcomaPoorly demarcated from normal, numerous elongated holes/slots in cortex, run parallel to long axis of bone
20. Limited responses of bone Destruction: lysis (lucency) Reaction: sclerosis Remodeling: periosteal reactionRate of growth determines bone responseslow progression, sclerosis prevailsrapid progression, destruction prevailsB. Reaction of bone to tumor
21. Periosteal ReactionPeriosteal reaction must mineralize to be seen on X ray ( 10 days – 3 weeks)Configuration of periosteal reactionNature of inciting processIntensityAggressivenessDuration
22. Periosteal ReactionThick, uninterruptedlong standing process, often non-aggressivestress fracturechronic infectionosteoid osteomaSpiculated, lamellatedaggressive processtumor likely
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24. Codman Triangleperiosteal reactiontumoradvancing tumor margin destroys periosteal new bone before it ossifiesCodmanTriangle
25. Sunburst Appearance
26. C: Tumor Matrix“Matrix” is the internal tissue of the tumorMost tumor matrix is soft tissue in nature.Radiolucent (lytic) on x-rayCartilage matrixcalcified rings, arcs, dots (stippled)enchondroma, chondroblastoma, chondrosarcomaOssific matrix osteosarcoma
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30. OsteochondromaExostosis: well defined bony projection growing away from physisCartilage maybe calcified if lesions are large / malignant change
31. Osteoid osteomaNidus: a tiny radiolucent areaIf 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 CTCentre of nidus may be calcified
32. Well demarcated osteolytic lesion sometimes containing flecks of calcificationLess reactive bone than osteoid osteomaBone scan - intense activityOsteoblastoma
33. 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 ridgesFalling fragment sign typical and the lesion is never wider than epiphysial plateBone scan cold or minimal activity unless fracturedSimple bone cyst
34. Gross honey comb lesionOften eccentrically placedDoes not extend to the joint (unlike GCT)Warm to hot on bone scanAneurysmal bone cyst
35. 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 hotGiant cell tumor
36. Fibrous cortical defectMargin well defined, sometimes scalloped and often sclerosed
37. Geographic Well marginated Multilocular appearance Inter cortical osteolysis - single or multiple bubble like areas Non-ossifying Fibroma
38. Ground glass appearance typicalShepherds crook deformity of proximal femurVariable appearance with expansion of cortexFibrous Dysplasia
39. Scalloped erosions on endosteal surfaceMay have flecks of calcificationEnchondroma
40. Rounded or oval rare areaUsually eccentrically placedMay cross the growth plateSharp outline and sclerotic rimScalloped margin and thin cortexChondromyxoid fibroma
41. 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 marginsChondroblastoma
42. Multiple loose bodiesSynovial Chondromatosis
43. Large osteolytic lesion in the midlineMay contain flecks of calcificationMarked bone destructionChordoma
44. Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton. Brown Tumor
45. Characteristic honey comb appearance in diaphysisCortical thinning with expansionAdamantinoma
46. Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)Hemangioma
47. 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 trabeculaeSpinal lesions- collapse (vertebra plana), which may healEosinophillic granuloma
48. 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 triangleEwing’s sarcoma
49. 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% MixedTelangiectatic type- purely lyticOsteosarcoma
50. 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 calcificationChondrosarcoma
51. Bone often mottled or moth eaten with extension into soft tissueOsteolytic lesion may be surrounded by reactive boneDestructive appearance radiologicallyUsually little periosteal reactionFibrorosarcoma
52. 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, lymphomaMixed- Breast, Lung, Ovary, Cervix Lymphoma deposits may resemble prostatic deposits, i.e. sclerotic secondaries Lytic, expansile, with soft tissue mass- RCC, thyroidX-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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54. Osteolytic bone metastases: breast carcinoma shows multiple osteolytic bone lesions.
55. Osteoblastic bone metastases
56. Mixed pattern bone metastases:
57. Early - vague mottled lucent areasDiffuse destructive lytic lesion with little periosteal reactionUsually combination of patchy sclerosis and mottled destructionHogkins disease - typical appearance of ivory vertebraeLymphoma
58. 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 areaFrequently cold on bone scanMyeloma
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