Download - Xray bone-tumor
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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 / matrix
X-rays - the question need to ask:
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A. Location Location 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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EPIPHYSEAL◦ Chondroblastoma◦ Clear cell
chondrosarcoma◦ Giant cell tumor◦ Aneurysmal bone
cyst◦ Geode
(subchondral cyst)◦ Infection◦ Eosinophilic
granuloma
Location in Longitudinal Plane DIAPHYSEAL
◦ Adamantinoma ◦ Leukemia,
Lymphoma, Reticulum cell sarcoma
◦ Ewing sarcoma◦ Metastasis ◦ 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 Plane
Central: Enchondroma Eccentric: GCT, CMF,
osteosarcoma Cortical: osteoid
osteoma, NOF Parosteal:
osteochondroma, parosteal osteosarcoma
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Specific LocationBONE TUMOR COMMONEST SITESBC Proximal humerus > prox. FemurABC, GCT, Osteosarcoma Lowerend femur > upper end tibiaEnchondroma Metaphysis of small bones of hand & feetOsteochondroma Distal femur> prox. Tibia > prox. HumerusChondroblastoma Proximal humerus> prox femurEwing’s Femur > fibula > tibia Adamantinoma Mandible > tibiaMyeloma VertebraFibrous dysplasia Ribs > Upper femur > Tibia > lower femurOsteoid osteoma Femur > tibiaChordoma Sacrum > clivus (spheno occipital) > anterior
vertebral bodyIvory osteoma Frontal sinusChondromyxoid fibroma Tibia > femurChondroblastoma Pelvis > femurOsteoblastoma Posterior spine
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Cysts and cyst like lesions of bone
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Patterns of bone destruction:
Lytic
Sclerotic
B: What is the lesion doing to the bone?
• PERMEATIVE
• GEOGRAPHIC
• MOTHEATEN
Poorly 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
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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 Margins Margin types 1A, 1B, 1C, 2, and 3
◦ least aggressive 1A, to most aggressive 3 Aggressive 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 Reaction Periosteal reaction must mineralize to be
seen on X ray ( 10 days – 3 weeks) Configuration of periosteal reaction
◦ Nature of inciting process◦ Intensity◦ Aggressiveness◦ Duration
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Periosteal Reaction
Thick, uninterrupted◦ long standing process, often non-aggressive
stress fracture chronic infection osteoid 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
CodmanTriangle
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Sunburst Appearance
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C: Tumor Matrix
“Matrix” is the internal tissue of the tumor Most tumor matrix is soft tissue in nature.
◦ Radiolucent (lytic) on x-ray Cartilage matrix
◦ calcified rings, arcs, dots (stippled)◦ enchondroma, chondroblastoma, chondrosarcoma
Ossific matrix ◦ osteosarcoma
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OsteochondromaExostosis: 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 thickening Double 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 calcification
Less reactive bone than osteoid osteoma Bone scan - intense activity
Osteoblastoma
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Cystic radiolucency on the diaphysial side of the growth plate Cortex may be thinned and bone expanded with well defined thin
sclerotic margin May 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 lesion Often eccentrically placed Does 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 sclerosis
Junction with normal bone often poorly defined Cortex thinned and sometimes ballooned Bone 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 typical Shepherds crook deformity of proximal femur Variable appearance with expansion of cortex
Fibrous Dysplasia
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Scalloped erosions on endosteal surface May have flecks of calcification
Enchondroma
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Rounded or oval rare area Usually eccentrically placed May cross the growth plate Sharp outline and sclerotic rim Scalloped margin and thin cortex
Chondromyxoid fibroma
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Well defined area of rarefaction eccentrically placed in the epiphysis or across the growth plate
No reaction in surrounding bone 50% show central calcification, 50% show linear
periosteal reaction Bone scan increased uptake at margins
Chondroblatoma
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Multiple loose bodies
Synovial Chondromatosis
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Large osteolytic lesion in the midline May contain flecks of calcification Marked 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 diaphysis
Cortical 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 rim
May destroy cortex Usually endosteal or periosteal reaction Lesions in flat bones and ribs appear
punched out May 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 bone
Lytic destruction common, often the cortex is perforated
Onion skin appearance- layers of periosteal new bone are said to be characteristic
May form Codman’s triangle
Ewing’s sarcoma
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Variable with combination of bone destruction and bone formation
Sun ray spicules/ sun burst appearance and Codman’s triangle may be evident
Cortical breach common Adjacent soft tissue mass Joint space rarely involved
◦ 25% 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 bone
May 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 tissue
Osteolytic lesion may be surrounded by reactive bone
Destructive appearance radiologically Usually little periosteal reaction
Fibrorosarcoma
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METASTATIC BONE DISEASE Osteolytic commonest - cortical destruction with
little or no periosteal reaction; Lungs, Kidney, Adrenal, Thyroid, Uterus
Osteoblastic 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 areas Diffuse destructive lytic lesion with little periosteal
reaction Usually combination of patchy sclerosis and mottled
destruction Hogkins disease - typical appearance of ivory
vertebrae
Lymphoma
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May be generalised decrease in bone density Multiple punched out defects Little bony reaction around lesions Solitary lesion = plasmacytoma; multilocular expanding lytic
lesion in a red marrow area Frequently cold on bone scan
Myeloma