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Images in Rheumatology
A Black Hole in a Bone — Intraosseous Lipoma

PETER MANDL, MD, PhD; ADAM MESTER, MD, PhD; PETER V. BALINT, MD, PhD, FRCP, National Institute of Rheumatology and Physiotherapy,
25-29 Frankel Leo str., H-1023, Budapest, Hungary. Address reprint requests to Dr. Mandl; E-mail: mandlpeter@yahoo.com. J Rheumatol 2009;36:466–8;
doi:10.3899/jrheum.080731
Intraosseous lipoma is an extremely rarely diagnosed benign Laboratory tests including metabolic panel and parathyroid
bone tumor. In most cases diagnostic imaging techniques, hormone values were normal. Conventional radiographs of
namely computed tomography (CT) and magnetic reso- the right ankle and foot revealed a round, translucent, cystic
nance imaging (MRI) are sufficient to reach a diagnosis, lesion in the right calcaneal diaphysis in the trabecular bone,
which in some cases is confirmed by postsurgical or post- with areas of calcification (Figure 1a). CT scan of the lesion
mortem histological examination. We describe 2 cases of showed complete resorption of bone within the lesion, with
intraosseous lipoma that were identified by practising the remaining tissue showing a fat attenuation level (–77
rheumatologists at our rheumatology clinic. Hounsfield units; Figure 1b). The presence of fat within the
A 38-year-old man presented with pain in his right foot, lesion ruled out the diagnosis of intraosseous gouty tophus.
ankle, knee, and first metatarsophalangeal joint. His history On T1-weighted MRI scans the well delineated lesion
featured trauma-induced fractures of the left ankle and the appeared to be isointense with subcutaneous fat (Figure 1c),
right 6th rib. He did not recall any recent infection, travel, while significantly lower signal intensity was observable on
exertion, or other illness. Examination including muscu- T2-weighted images (Figure 1d).
loskeletal examination yielded no significant findings. The second patient, a 61-year-old man, had a history of
Figure 1. a. Plain radiograph. b. CT scan. c. T1-weighted MRI scan. d. T2-weighted MRI scan of the right ankle. Arrows show the lesion.
Personal non-commercial use only. The Journal of Rheumatology Copyright © 2009. All rights reserved.
434 The Journal of Rheumatology 2009; 36:2; doi:10.3899/jrheum.080731
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sport-related injuries culminating in meniscectomies carried In both of our cases plain radiographs showed round,
out on both knees. He also suffered a trimalleolar fracture of translucent, cystic lesions with sclerotic margins. A classical
the right ankle in 2002, but presented at our clinic in 2003 appearance of intraosseous lipoma of the calcaneus is the
with pain in the left hip. He reported slight difficulty walk- presence of central calcification within a well defined lytic
ing. Examination including musculoskeletal examination lesion resembling a cockade. The calcaneal lesion seen in
yielded no abnormality, but the anteroposterior radiograph Patient 1 also showed similar areas of increased radiograph-
of the pelvis revealed a round lesion in the other femoral ic density due to fat calcification. CT scans showed com-
head (diameter 30 mm; Figure 2a), where he had not complete resorption of bone within the lesions, with the remain-
plained of symptoms. Laboratory tests including metabolic ing tissue showing a fat attenuation level (–77 and –63
panel and parathyroid hormone values were normal. The Hounsfield units, respectively). A hypointense rim was
lesion resembled a “black hole” when viewed under CT observable surrounding both lesions, consistent with reac-
(Figure 2b), with a main Hounsfield unit of –63 that corre- tive sclerosis. Both lesions appeared to be isointense, with
sponded to adipose tissue. The lesion appeared to be isoin- subcutaneous fat on T1-weighted MRI scans exhibiting low
tense with subcutaneous fat on T1-weighted MRI scans and signal intensity with fat suppression on T2-weighted
exhibited low signal intensity with fat suppression on T2- images. The 2 cases correspond to stage 2 and stage 1
weighted images (Figure 2c, 2d). intraosseous lipomas, respectively, according to Milgram’s
Intraosseous lipomas are rare benign neoplasms that rep- classification.
resent proliferation of fat tissue within the marrow of normal Modern imaging techniques have proven to be reliable in
trabecular bone1. Intraosseous lipomas occur primarily in the diagnosis of intraosseous lipoma6. In some cases fatty
the long bones of the lower extremities (i.e., femur, tibia, involution of an aneurysmal bone cyst, or bone infarct, may
calcaneus), which are characterized by a scarcity of trabec- not be ruled out unequivocally7; malignant tumors and the
ular bone. They can also occur in the flat bones, pelvis, and malignant transformation of benign lesions should also be
other locations2,3. Milgram classified intraosseous lipomas considered8. In such cases a guided biopsy is required for
according to the degree of involution (necrosis, calcification, the correct diagnosis. Complete removal is indicated in
cyst formation, and reactive ossification) observable in the cases leading to potential pathological fractures. In the
lesion. Based on this classification intraosseous lipomas majority of cases lipomas run an indolent course, and can be
were categorized into 3 types — Stage 1 tumors consisting followed by a wait and scan approach9. Due to the unequiv-
of viable fat cells; Stage 2 tumors composed partly of viable ocal diagnosis based on imaging modalities and lack of clin-
fat cells also demonstrating fat necrosis and calcification; ical progression over a course of more than 5 years, our 2
and Stage 3 lesions with full range of involution: necrotic cases did not require biopsy or surgery, with followup con-
fat, calcification of necrotic fat, variable degrees of cyst for- sisting of regular scans.
mation, and reactive woven bone formation4. Typically,
plain radiographs suggest the diagnosis, which is subse- REFERENCES
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report and literature review. Skull Base 2007;17:211-4.
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Figure 2. a. Plain radiograph. b. CT scan. c. T1-weighted MRI scan. d. T2-weighted MRI scan of the right femoral head. Arrows show the lesion.
Mandl, et al: Intraosseous lipoma 435

2. MacFarlane MR, Soule SS, Hunt PJ. Intraosseous lipoma of the 6. Coquerelle P, Cotten A, Flipo RM, Chastanet P, Duquesnoy B,
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manifestations. Radiology 1988;167:155-60. 8. Kyriakos M, Hardy D. Malignant transformation of aneurysmal
5. Blacksin MF, Ende N, Benevenia J. Magnetic resonance imaging of bone cyst, with an analysis of the literature. Cancer
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Images in Rheumatology

A Black Hole in a Bone — Intraosseous Lipoma

434 The Journal of Rheumatology 2009; 36:2; doi:10.3899/jrheum.080731

Downloaded on August 24, 2020 from www.jrheum.org

Mandl, et al: Intraosseous lipoma 435

Downloaded on August 24, 2020 from www.jrheum.org

436 The Journal of Rheumatology 2009; 36:2; doi:10.3899/jrheum.080731

Downloaded on August 24, 2020 from www.jrheum.org

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