bone tumors: page 1 of 31 in 1 simple chart · 2018-03-12 · active osteomyelitis chronic osteo....

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info

page 1 of 31Bone Tumors:In 1 Simple Chart

©Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Tumors

In 1 Simple Chart

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NON-aggressiveBlastic

Chondroid:Enchondroma

Osseous:Osteoid OsteomaOsteoblastoma

Osseous & Chondroid:Osteochondroma

NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD

Mets/Mult MyelomaOsteomyelitis (Active)2ºOsteosarc (>60)

AGGRESSIVE

<20

20-40

>40

age

Osteosarcoma Ewing SarcomaOsteomyelitis (Active)Mets (NB <5yo)

Cortical Desmoid(Helms: “DNT”)

LymphomaChondrosarcomaFibrosarcoma/MFHOsteomyelitis (Active)

...MetsSurface OSAdamantinoma

GCTFD

“Pitts Pit”PHALANX:

Enchon, GlomusEpidermoid,FelonGCTTS,SarcoidGout,Met(lung)

Mets/MMFD

Mets/MM (“POEMS”)Osteomyelitis (Chronic)

Paget’s

“Ivory Vertebra”:Lymphoma,Paget,Met

Bone InfarctEnchondromaStress FractureOsteomyelitis (Chronic)


Overview of this PresentationWhy Bone Tumors are Intimidating

Describing Bone Tumors1) Patient’s Age

2) “Aggressive”

Zone of Transition

Periosteal Reaction

3) Matrix

4) Location

Building the Bone Tumor Chart

Underlined Text = PowerPoint Interactivity


WhyBoneTumorsare IntimidatingBone Tumors are Rare

http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdfAnnual Cancer Statistics Review, updated 5/29/09, p34

20091,500,000

New CancerCases in

USA



http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdfAnnual Cancer Statistics Review, updated 5/29/09, p34

13%Breast194,000

192,000Prostate

13%19%GI

276,000

273,000Lung/Oral

18%

15%Renal/GU221,000

180,000Other12% Bone

Tumors2,5700.17%

www.acr.org/SecondaryMainMenuCategories/SocioeconomicResearch/PracticeofRadiologyintheUS.aspx

# Radiologistsin USA =

30,0002,570

Only 1-in-12 Radiologists

will even see a Bone Tumor

per year

Bone Tumors: Many Types

30!

GREENSPAN:OrthoRad 15.24

http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdf

http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdf

http://www.acr.org/SecondaryMainMenuCategories/SocioeconomicResearch/PracticeofRadiologyintheUS.aspx







Don’t see enough to be confident

Many types of Bone Tumors

Have Confusing (similar) Names“Osteosarcoma”

“Osteochondroma”Occur in children

Essentially only 2bone malignanciesoccur in children

http://seer.cancer.gov/statfacts/html/bones.html

0%

5%

10%

15%

20%

25%

30%

<20 20-34 35-44 45-54 55-64 65-74 75-84 >85

Incidence Bone Tumors

by age

Bone Tumors: by Age

20

Bone Tumors: by Age

4020


Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors

1) Patient’s Age<20Osteogenic SarcomaEwing SarcomaEverything else benign

20-40Could be anything

>40Multiple Myeloma, Metastases



1) Patient’s Age2) “Aggressive” vs “Non-aggressive”

(NOT “Malignant” vs “Benign”)

Zone of TransitionPeriosteal Reaction

Not everything that looks aggressive is malignant(e.g. osteomyelitis)

“Aggressive” “Non-aggressive”

Describing


2 Cases: Destructive lesions distal fibulaBenign?

Malignant?

Can’t tell with radiographs…

Thus we use the term “Aggressive”

http://seer.cancer.gov/statfacts/html/bones.html




AggressiveAggressive vs Non-aggressiveZone of Transition

Periosteal Reactions


Zone of TransitionAggressive vs Non-aggressive

Grow Slowly “Narrow” “Geographic” “Well Defined”

Can Outline Lesion with Sharp Pencil

Sclerotic MarginsGrows VERY Slowly!






Asymptomatic, incidental finding














Grow Rapidly“Wide”“Permeative”“Ill Defined”“Moth Eaten”

Cannot tell where Lesion ends and

Normal Bone begins





Grow Rapidly“Wide”“Permeative”“Ill Defined”“Moth Eaten”

Cannot tell where Lesion ends and

Normal Bone begins

Aggressive vs Non-aggressiveZone of Transition

Cannot tell whereLesion ends and

Normal Bone begins

W,S 16yoF


Grows Slowly “Narrow” “Geographic” “Well Defined”


Grows Rapidly“Wide”“Permeative”“Ill Defined”“Moth Eaten”


Cannot tell whereLesion ends and

Normal Bone begins


Grows SlowlyGrows RapidlyPeriosteal Reaction

Aggressive vs Non-aggressive

TOOCOMPLI-CATED


Grows Rapidly“Interrupted”

Simplifying Periosteal ReactionAggressive vs Non-aggressive

Grows Slowly“Solid”SmoothContinuous



BoneModel

Fx


Looks like Healing Callus

F,A 2moM 1m later©Ken L Schreibman, PhD/MD 2010 schreibman.info


BoneModel


V,T 49yoM

HOAHypertrophicOsteo-Arthropathy

HPOAHypertrophicPulmonaryOsteo-Arthropathy Stable over 1y




Grows Rapidly“Interrupted”

May grow so rapidly it doesn’t

have time to ossify

(Unossified periosteum is not

radiopaque)

Aggressive vs Non-aggressiveSimplifying Periosteal Reaction


Grows Rapidly“Interrupted”LamellatedOnionskin

Grows… ossifies…Grows… ossifies…Grows… ossifies…


Courtesy of James Choi, MD


Grows Rapidly“Interrupted”LamellatedOnionskinSpiculatedHair-on-end



Grows Rapidly“Interrupted”LamellatedOnionskinSpiculatedSunburstCodman’s

Triangles(Growing so rapidly, has time to ossify only at corners)




Triangles(Growing so rapidly, has time to ossify only at corners)




Triangles



Looks like Healing Callus

S,C 15yoM

3w post Fx, ORIF=very early callus8w post Fx, ORIF

=more mature callus






Zone of TransitionPeriosteal ReactionCortical Destruction


Describing


Aggressive vs Non-aggressiveCortical Destruction

Cortex Intact =

Non-aggressive

Similar lytic lesionsBoth have well

defined, sclerotic, medullary borders

Cortex Absent =

Aggressive

IR




Zone of TransitionPeriosteal ReactionCortical DestructionSoft Tissue Extension

Radiographs

MRI


Describing


2 Cases: Aggressive lesions distal fibula

Cortical Destruction

Periosteal Reaction

Benign?

Malignant?

Can’t tell with radiographs…

Thus we use the term “Aggressive”


2 Cases: Aggressive lesions distal fibulaT2 Soft Tissue

Extension

T2

T1

H,M 13yoF


TwoYEARSlater

Active Osteomyelitis Chronic Osteo.

Aggressive vs Non-aggressive




Bone Matrix: 4 TypesChondroid“rings&arcs”

Osseous“cloud-like”“amorphous”

▓Fibrous“GroundGlass”

NonePurely LyticNotnecessarilycystic

Calcified Uterine Fibroid Myositis Ossificans

Multiple Myeloma©Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Matrix: 4 TypesChondroid“rings&arcs”

Calcified Uterine FibroidEnchondroma


Bone Matrix: 4 TypesOsseous“cloud-like”“amorphous”

Myositis OssificansF,C 8yoF

Osteogenic SarcomaH,S 15yoM


Bone Matrix: 4 Types▓Fibrous

“GroundGlass”

Fibrous DysplasiaB,C 53yoF


Bone Matrix: 4 TypesNonePurely Lytic

Not necessarily cystic

Multiple MyelomaS,N 62yoM


Bone Matrix: 4 Types

G,B 18yoF

CTNonePurely Lytic

Not necessarily cystic

T1

Intraosseous Lipoma





1) Patient’s Age2) “Aggressive”3) Matrix4) LocationWhich bone?

Some tumors have propensity for certain bonesWhich part of the bone?

MANY tumors characteristically occur at the:Epiphysis / Metaphysis / Diaphysis


AGGRESSIVE NON-aggressiveLytic


<20

20-40

>40

age

Osteosarcoma Ewing Sarcoma


Pt Age: 10-20 years(when growth spurt occurs)

Location: Metaphyseal(where growth occurs)Distal FemurProximal Tibia(where most growth occurs)

Matrix: Osseous“osteo-genic”: makes bone

Need to eval for “skip mets”MR entire length of bone

Osteogenic Sarcoma


Osteogenic Sarcoma

F,C 8yoF

Pt Age: 10-20 years

Location: Metaphyseal

Matrix: Osseous

T1

T1

T2

MRI is useful for staging the extent of the tumor…


Osteogenic Sarcoma

F,C 8yoF


Radiographs show us what we need to know to diagnose type of tumor!

Skeletally immatureAggressive lesionWide zone of trans.Sunburst periost.Osseous matrixMetaphyseal---------------------------------Osteogenic Sarcoma!


Osteogenic Sarcoma

R,T 11yoF

Sometimes osteosarc is growing SO quickly it doesn’t have time to form an osseous matrix

Patient presents with hair-on-end periosteal reaction

After 2 months of chemotherapy tumor growth has slowed enough to form osseous matrix




Ewing SarcomaPt Age: 5-25 years

Tumor of Bone MarrowLocation: Diaphyseal

Flat Bones

Matrix: PermeativeCortical DestructionAggressive

Periosteal Reaction

Soft Tissue Extension>> Bone Extent


Ewing SarcomaT2 Soft Tissue

Extension

T2

T1

H,M 13yoF

>> BoneExtent


Ewing Sarcoma common in pelvis

S,B 6yoM

Things can hide in the

pelvis

Air incolon

3 months later…

Air incolon?


Ewing Sarcoma common in pelvis

S,B 6yoM

T2fs Things can hide in the

pelvis

Unlike in the extremities where radiographs are key,

the usefulness of radiographs in the pelvis is limited.

In the pelvis,cross-sectional

imaging is crucial, preferably with MRI.




<20

20-40

>40

age



Osteomyelitis resembles Tumor!

Whenever doing a bone biopsy,

ALWAYS send samples for

BOTH surgical pathology

AND microbiology culture!

“Do Not Touch”lesions


Cortical DesmoidCortical Desmoid: Do Not Touch!

Q,M 17yoM

They all present like this:Athletic teenagerJust a little periosteal reactionMEDIAL posterior femoral condyle

Tug lesion: Adductor longus insertionMedial gastrocnemius origin




Cortical DesmoidCortical Desmoid: Do Not Touch!

Q,M 17yoM

Just a little periosteal reactionMEDIAL posterior femoral condyle

Tug lesion: Adductor longus insertionMedial gastrocnemius origin

CT

T2fs

Cross-sectional imaging doesn’t really help



ALWAYS consider Lymphoma!



<20

20-40

>40

age



Lymphoma13%

Breast194,000

192,000Prostate

13%19%GI

276,000

273,000Lung/Oral

18%

15%Renal/GU221,000

180,000Other12%

BoneTumors2,5700.17%

New Cancer Cases, USA, 2009

Lymphoma = 74,490

Lymphoma is 29x more common than all Bone Tumors combined


Lymphoma

R,H 22yoM

T1

Tumor of bone marrowCan be lytic or blastic

T1

T2fs

Resembles Ewing


Why Age is ImportantLocation: Diaphyseal

Soft tissue extension

Age: < 20Ewing Sarcoma

Age: 20-40Lymphoma

Age: > 40MetastasesMultiple Myeloma


Cartilage malignancy

Matrix: Chondroid

Location: Ends of bones

Pelvis

Soft tissues

Chondrosarcoma


Chondrosarcoma

S,B 39yoM

Chondroid“rings&arcs”

Radiographs

Cartilage malignancy

Matrix: Chondroid




ChondrosarcomaCartilage malignancy

Matrix: ChondroidChondroid

“rings&arcs”RadiographsCT

S,B 39yoM



Matrix: ChondroidChondroidMRI

T2: Bright

Gd: peripheralenhancement

Bulk of tumor doesn’t enhance

S,B 39yoM

T2fs T1fs+Gd



Matrix: Chondroid

Normal cartilage has no blood supplyInjured cartilage doesn’t regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesn’t respond to chemotherapy

Treatment: Complete tumor resection



Matrix: Chondroid

Normal cartilage has no blood supplyInjured cartilage doesn’t regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesn’t respond to chemotherapy

Treatment: Complete tumor resectionS,B 39yoM


Chondrosarcoma

W,A 30yoF

30yoF 1 year history heal pain

1 week later

other side


Chondrosarcoma

T2fs T1fs+Gd

T1







<20

20-40

>40

age



LymphomaChondrosarcomaFibrosarcoma/MFH


FibrosarcomaMalignant Fibroblastic Cells

Malignant Fibrous Histiocytoma (MFH)

Pt Age: > 20

May involve the bonesSecondarilyPrimarily


Fibrosarcoma

F,B 23yoF

T1 T2fs






<20

20-40

>40

age




...MetsSurface OS


Pt Age: 10-20 years

Location: Metaphyseal

Matrix: Osseous

4 Subtypes:1) Conventional2) TelangiectaticSurface Osteosarcomas3) PERIosteal4) PARosteal

Osteogenic Sarcoma


1) ConventionalPt Age: 10-20 yearsLocation: MetaphysealMatrix: Osseous

2) TelangiectaticHighly vascular/bloodyVery aggressiveNearly purely lyticUsually present after

pathologic fractureDiffuse metastases

Osteogenic Sarcoma




Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if

marrow not involved,can resect tumor.

If spreads to marrow,conventional OS.

3) PERIostealLooks like aggressive

periosteal reactionLocation: Long bones

Osteogenic Sarcoma Periosteal Osteosarcoma

Murphey M D et al. Radiology 2004;233:129-138

©2004 Radiological Society of North America

tibia 11yoM

AggressivePeriostealReaction

Periosteal Osteosarcoma

Murphey M D et al. Radiology 2004;233:129-138

©2004 Radiological Society of North America

tibia 34yoF

AggressivePeriostealReaction

SoftTissueExtension

SparingBoneMarrow


Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if

marrow not involved,can resect tumor

If spreads to marrow,conventional OS.

3) PERIostealLooks like aggressive

periosteal reaction4) PARosteal

Osteogenic Sarcoma


Surface Osteosarcoma4) PARosteal

Pt Age: 20-30 yearsLocation: Back of

Femoral CondylesArise from cortex,

grow outwardDo NOT contain

normal marrow(As opposed to

osteochondroma)

Osteogenic Sarcoma CT


Osteogenic Sarcoma CT

T2fs

T1 MRI: No Marrow involvement







<20

20-40

>40

age






AdamantinomaVERY RARE

0.1% Primary Bone TumorsPt Age: 30-50Matrix: PermeativeLocation: TIBIA (90%)DiaphysealAnterior CortexSoft Tissue Mass:

Likely Malignant




Likely Malignant




Likely Malignant







<20

20-40

>40

age





ABCUBC

CBFCD/NOF

EG


A) Aneurysmal Bone CystPt Age: < 20

Matrix: None (Cyst)Only tumor named for x-ray appearance

Aneurysmal & Cystic“AVM of Bone”MRI: fluid/fluid level

Location: MetaphysealPosterior SpineHandsPelvis


A) Aneurysmal Bone Cyst

Aneurysmal

Multi-septatedlooks like

soap bubbles©Ken L Schreibman, PhD/MD 2010 schreibman.info


Aneurysmal


soap bubblesN,N 15yoF

T2

fluid/fluid level

CT



T2

D,R 12yoM

Aneurysmal


soap bubbles

fluid/fluid level



Aneurysmal


soap bubbles

T2

fluid/fluid level




B) Unicameral (Simple) Bone CystUni-cameral: Latin “one” - “chamber”(in US we have bi-cameral legislature)

Pt Age:< 20Matrix: None (True Cyst)Location:Metaphyseal>50% Proximal Humerus

20-30% Proximal Femur50% - Incidental Finding50% - Pathologic Fx

“Fallen Fragment”©Ken L Schreibman, PhD/MD 2010 schreibman.info

B) Unicameral (Simple) Bone Cyst

D,C 5yoM

Normal Side



D,C 5yoM after 1 month…

Fractures tend to heal

after 3 months…

Fracture healed

Cyst?


B) Unicameral (Simple) Bone CystCysts tend to recur

6m later… 12m later… 18m later

Although UBCs arise from

metaphysis…end of bone grows away from cyst…

so cyst becomes diaphyseal


MRI shows cyst extentB) Unicameral (Simple) Bone Cyst

18m later

T1 T2fs

T1

T2fs

Simple cyst©Ken L Schreibman, PhD/MD 2010 schreibman.info


M,T 4yoM

FallenFragment

after 3 months





P,D 6yoM



H,T 18yoM

T2fs

Simple cyst withhemorrhagefluid-fluid level


C) ChondroblastomaPt Age: Skeletally immature

Location: Epiphyseal

Matrix: Chondroid(No matrix if not calcified)

Benign…Aggressive appearance!

Periosteal ReactionSurrounding EdemaBone MarrowSoft Tissues


C) ChondroblastomaPt Age: 10 – 30yo

Location: Epiphyseal

Matrix: Chondroid(No matrix if not calcified)

Benign…Aggressive appearance!

Periosteal Reaction

16yoM

Surrounding EdemaBone MarrowSoft Tissues

T2fs


C) Chondroblastoma

16yoM

Cartilage-sensitive sequence

Articular Cartilage

Cartilageunfused physis


C) Chondroblastoma

B,Q 15yoM

T1 IR Cartilage sequence

Epiphyseal mass, skeletally immatureAggressive appearanceEdema in surrounding marrow & tissues




Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect

THE most common bone lesionOccurs up to 40% ALL children

(75% occur 10 – 20 years old)Regress after skeletal maturity

Asymptomatic, incidental finding(e.g. on knee MR for ACL tear)

If >50% bone diameter Fx

Location: MetaphysisFemur & Tibia



Radiographic appearance:

Characteristic& Diagnostic If asymptomatic, no

further workup is needed

Eccentric, sub-corticalCortex thinned, expanded

Sclerotic marginScalloped

Multi-loculatedF,M 18yoF



Radiographic appearance:

Characteristic& Diagnostic If asymptomatic, no

further workup is needed

Eccentric, sub-corticalCortex thinned, expanded

Sclerotic marginScalloped

Multi-loculatedB,J 19yoM

T1IRNo aggressive characteristics



G,M 9yoF

9yo 11yo 13yo

Fx HealingCallus




E) Eosinophilic GranulomaNon-neoplastic proliferation histiocytes

Langerhans Cell HistiocytosisPt Age: typically <12yo (can occur young adult)EG (aka Histiocytosis X)Hand-Schuller-Christian (>3yo)Triad: skull lesions, exophthalmos, DI

Letterer-Siwe (<3yo, fatal)Pain, swelling, fever, ESR, eosinophiliaDiff.Dx: Osteomyelitis (Ewing, Lymph/Leuk)

Bone lesions may resolve spontaneouslyOften get Dx Bx/curettage. Steroids?


E) Eosinophilic GranulomaPt Age: < 12

Matrix: None

Location: Bone MarrowSkull (most common site)SharpPunched-out “Beveled Edge”

due to uneveninvolvement ofouter/inner table

W,J 2yoM



Matrix: None

Location: Bone MarrowSkull (most common site)Spinevertebra plana

Can regrowheight withtreatment!

R,D 5yoM



Matrix: None

Location: Bone MarrowSkull (most common site)SpinePelvissupra-acetabulum

Long bones (Femur)diaphysis



Matrix: None

Location: Bone MarrowSkull (most common site)SpinePelvissupra-acetabulum

Long bones (Femur)diaphysis

W,J 2yoM F,D 5yoM





<20

20-40

>40

age





ABCUBC

CBFCD/NOF

EGFD




Pt Age: <30 years

Location: Any bone

Matrix: Ground Glass

Monostotic (one bone)Usually asymptomatic

Polyostotic (many bones)Presents at younger ageUsually symptomaticSyndromesMcCune–Albright syndrome

F) Fibrous Dysplasia

L,I 7yoM

R


McCune–Albright syndrome

L,I 7yoM

RLRLTriadPolyostotic

Fibrous Dysplasia Unilateral

R L

Base of skull

R L

Top of skull


McCune–Albright syndromeTriadPolyostotic Fibrous Dysplasia Unilateral

Endocrine Abnormalities Precocious puberty in girls

café au lait spots “coast of Maine”

wikipedia.org


McCune–Albright syndromeTriadPolyostotic Fibrous Dysplasia Unilateral

Endocrine Abnormalities Precocious puberty in girls

café au lait spots “coast of Maine”(as opposed to

“coast of California”=Neurofibromatosis)





<20

20-40

>40

age





ABCUBC

CBFCD/NOF

EGFD

http://en.wikipedia.org/wiki/McCune%E2%80%93Albright_syndrome




ABCUBC

CBFCD/NOF

EGFD




<20

20-40

>40

age





GCT


Giant Cell TumorPt Age: Skeletally Mature(as opposed to Chondroblastoma)THE most common bone tumor

in young adults 20-40yo

Location: SubarticularArise from MetaphysisExtend across fused

Growth PlateMatrix: Purely LyticNarrow Zone of TransitionNO SCLEROTIC MARGIN


Giant Cell TumorPt Age: Skeletally Mature(as opposed to Chondroblastoma)THE most common bone tumor

in young adults 20-40yo

Location: SubarticularArise from MetaphysisExtend across fused

Growth PlateMatrix: Purely LyticNarrow Zone of TransitionNO SCLEROTIC MARGIN V,R 21yoM

BenignLocally Aggressive

T1T2fs


Giant Cell Tumor

BenignLocally Aggressive B,J 25yoM


Giant Cell Tumor

Solid & Cystic componentsHistologically, similarities GCT↔ABC B,J 25yoM

T1 T2fs T1fs+Gd


Giant Cell TumorPt Age: Skeletally Mature

Physis fused

C,A 18yoM

16yoM 18yoM




Location: SubarticularMatrix: Purely Lytic

Age:< 20 (skeletally immature)Chondroblastoma

Age:20-40 (skeletally mature)Giant Cell Tumor

Age:> 40MetastasesMultiple Myeloma

Why Age is Important

V,R 21yoM

GCT


Location: SubarticularMatrix: Purely Lytic

Age:< 20 (skeletally immature)Chondroblastoma

Age:20-40 (skeletally mature)Giant Cell Tumor

Age:> 40MetastasesMultiple Myeloma

Why Age is Important

C,G 61yoM

Met

1LungCancer


ABCUBC

CBFCD/NOF

EGFD




<20

20-40

>40

age





GCTFD

“Pitts Pit”


Herniation Pit of the Femoral Neckaka “Pitt’s Pit”Michael Pitt, et.al. AJR 1982

vol 138, 6, p 1115-1121

Round lucencyThin sclerotic rimProximal SuperiorAnterior

Incidental finding ⅓ patients

Mechanical, not neoplastic

courtesy Donna Blankenbaker, MD


ABCUBC

CBFCD/NOF

EGFD




<20

20-40

>40

age





PHALANX:Enchon, GlomusEpidermoid,FelonGCTTS,SarcoidGout,Met(lung)

GCTFD

“Pitts Pit”


Lytic Lesion: Distal PhalanxEnchondromaLytic: phalangesPathologic Fx

Glomus TumorNail bedDorsal

EpidermoidInclusion CystPunctureVolar

Giant Cell Tumor Tendon Sheath(Localized PVNS)

Felon(Fingertip infection)

Sarcoidosis

Gout

MetastasesLung




EnchondromaBenign rests of hyaline cartilageCommonOften discovered incidentally

Typically asymptomatic50% small tubular bonesMostly lyticPathologic Fracture


Glomus TumorBenign vascular tumor

(neuromyoarterial apparatus)

Subungual, erodes boneDorsal cortex distal phalanx

Age: 30 – 50 ( 3x> )

TriadSensitivity to coldLocalized tendernessSevere intermittent

painS,D 37yoF


Glomus Tumor

S,D 53yoM

Dorsal cortex distal phalanx


Epidermoid Inclusion CystImplantation of epidermal elementsAmputationPuncture (seamstress)Volar cortex distal phalanx

T2fsT1fs+GdT1fs+GdT1fs


Epidermoid Inclusion Cyst


Gout

M,B 78yoM




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD


AGGRESSIVE NON-aggressiveBlastic

<20

20-40

>40

age






Mets/MMFD

Mets/MM (“POEMS”)

GCTFD

“Pitts Pit”


POEMS syndromePolyneuropathyOrganomegalyEndocrinopathyMonoclonal gammopathySkin abnormalities(Sclerotic bone lesions)Medial ClaviclePelvis

http://www.scielo.br/scielo.php?pid=S0100-39842008000600002&script=sci_arttext&tlng=en


NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age






Mets/MMFD

Mets/MM (“POEMS”)Osteomyelitis (Chronic)Paget’s

GCTFD

“Pitts Pit”


Paget’s DiseaseBecoming less common

Three PhasesLytic: Wedge with sharp borders “Blade of grass”, “Candle flame”

Mixed: Bone destruction & formationBlastic: Cortical/Trabecular thickening

2 Osteosarcoma

B,S 83yoF


NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s



Ivory Vertebra

LymphomaPagetBlastic MetBreastProstateTreated MetChronic Osteo(Sarcoid) rare

K,K 76yoM







NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s




EnchondromaBenign rests of hyaline cartilage

CommonOften discovered incidentally

Typically asymptomaticcan be painful (40%)Pathologic Fracture

50% long tubular bonesMetaphysealChondroid matrix











50% small tubular bonesMostly lytic


ChondrosarcomaMalignant tumor of cartilage

PelvisEnds of bones

Presents with PAIN!99% Painful40% Enchondromas

Low Grade difficult todifferentiate from benign Radiologist Pathologist

30% - Low Grade


ChondrosarcomaHistopathology

1: Low Grade2: Intermediate3: High Grade

Cellularity:markedlyincreased

Nuclei Size: markedlyincreased




Chondrosarcoma

IR T1fs + Gd

Histopathology1: Low Grade2: Intermediate3: High Grade

Cellularity:markedlyincreased

Nuclei Size: markedlyincreased



1: Low Grade2: Intermediate3: High Grade

Cellularity:slightlyincreased

Nuclei Size: slightlyincreased



0.5: Borderline1: Low Grade2: Intermediate3: High Grade

Histologically:resemblesenchondroma

Radiologically:aggressive

Enchondroma


ChondrosarcomaEnchondroma

T1 T2fs

B,B 42yoF



How do you distinguish between them?Very difficult, sometimes you can’tClues:

All ChondrosarcHot on BS

Some EnchonHot on BS

All ChondrosarcPainful (never incidental)

40% EnchonPainful

This pt had painuncontrollable with

oral narcotics



B,B 42yoF

This pt had painuncontrollable with

oral narcoticsHistopathology:No malignant cells

So was this:

Enchondroma?

0.5 BorderlineChondrosarcoma?

Pt was very happy with outcome!She’s now pain freeShe’s doesn’t have cancer




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s






Osteoid Osteoma (Osteoblastoma)Pt Age: < 30Presents with PAIN!98% PainfulNight pain, Rx NSAID

Matrix: Lucent NidusLocation:DiaphysealSurrounding SclerosisIntra-capsularNo SclerosisPosterior Elements (OB)Painful Scoliosis


Osteoid Osteoma

W,N 13yoM

RadiographsCortical thickening

Bone ScanHot all 3 phases

Flow Blood Pool Delayed


Osteoid Osteoma

W,N 13yoM

RadiographsCortical thickening

MREdemaEnhancement Nidus

IR

MarrowEdema

CorticalThicken

Sub-QEdema

T2fs T1fs +Gd T1fs +Gd

PainMarker


Osteoid OsteomaCT:Gold Standard for OODiagnosisLucent NidusCentral Dot Calcium

RxCT

GuidedRFAblation

W,N 13yoM




Osteoblastoma (= Osteoid Osteoma)Term osteoblastoma used for:Larger lesions

( > ≈1cm)

Lesion in spine posterior elementsPainful scoliosis

(Typically scoliosis is painless)

S,T 16yoM


Osteoblastoma (= Osteoid Osteoma)

Bone Scan(Posterior)

SPECT(Sagittal)

S,T 16yoM

SPECT(Axial)


Osteoblastoma (= Osteoid Osteoma)CT:Gold StandardDiagnosisLucent NidusCentral Dot Calcium

S,T 16yoM


Young womanwith back painFetus is an

incidental finding

Years earlier…with back pain

Osteoblastoma




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD



<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s







OsteochondromaMost Common Benign Neoplasm of Bone“Exostosis”Pedunculated (stalk)Sessile (flat)

Cartilage Capseen only on MR

Point away from jointContinuity with

underlying boneCortex continuous with cortexMarrow continuous with marrow

BoneModel




















underlying boneCortex continuous with cortexMarrow continuous with marrow P,N 20yoF












underlying boneCortex continuous with cortexMarrow continuous with marrow K,J 11yoM


Osteochondroma

K,J 11yoM

Cortex continuous with cortexMarrow continuous with marrow

T1

T2fs

No aggressive characteristics

Cartilage Cap


OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity

(can grow during childhood)Cartilage cap > 1cm

(can be 2-3cm during childhood)


OsteochondromaMalignant Transformation to Chondrosarcoma

Funny shaped femursMHE?

Chondroid matrixAggressive appearance

Hot on BSc/w Chondrosarc


OsteochondromaMalignant Transformation to Chondrosarcoma

CT: Tissue Window CT: Bone Window

T1fs+GdT2fs




OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity

(can grow during childhood)Cartilage cap > 1cm

(can be 2-3cm during childhood)

Can cause mechanical problems


OsteochondromaCan cause mechanical problems

W,M 25yoF

Multiple miscarriagesT1

T2fs



K,T 18yoM MRA

Mass effect on right subclavian artery



H,P 11yoF T1 PDfs

T2fs

Rubbing, causingPes Anserine Bursitis


Osteochondroma T1

vs PARosteal Osteosarcoma

T1 T2fsW,K 17yoM

Cortex continuous with cortexMarrow continuous with marrow

CartilageCap

NO cortex/marrowcontinuity






NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD


AGGRESSIVE

<20

20-40

>40

age





GCTFD



Mets/MMFD


Paget’s



ABCDEF

bone tumors: page 1 of 31 in 1 simple chart · 2018-03-12 · active osteomyelitis chronic osteo....

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