BONE TUMOR

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BONE TUMOR

Dr Elias Sabir( MD, MRT)


Bone Tumors
The majority of bone tumors are detected by
conventional radiographs.
Occasionally occult lesions may be detected using
more sensitive techniques such as CT scan and MR
imaging.
Careful analysis of the pattern of bone destruction,
periosteal reaction and matrix mineralization on
radiographs allow for characterization of many
bone tumors.
 Additional factors that should be included in
determining the likely diagnosis include the age of
the patient, location of the tumor in bone .
Introduction

Benign Criteria of Bone Tumors :


Well defined margin

Sclerotic rim

Expanding lesion

No periosteal reaction

No extraosseous soft tissue component

Narrow zone of transition


Malignant Criteria of Bone Tumors :

 ill defined margins

 Cortical destruction

 Periosteal reaction

 Extraosseous extension

 Intra-articular invasion

 Neurovascular bundle affection

 Wide zone of transition


Basics of characterization of bone tumors
1.Site in Skeleton
2.Location in the bone
3.Pattern of Bone
Destruction
4.Tumor matrix
5.Periosteal Reaction
6.The age of the
patient
1.Site in Skeleton

Most bone tumors and infections occur around the knee


and in the proximal humerus.
The majority of lesions arising in the medial third of the
clavicle in children and adolescents are osteomyelitis
Conversely, most lesions arising in the sternum are
malignant.
Chordoma characteristically arises from the clivus or
sacrum.
Although many different tumors may arise in the bony
spine, malignant lesions are found predominantly in the
anterior part of the vertebra (body), while benign
lesions, with a few exceptions, are characteristically
found in the posterior elements.
2.Location in the bone
Location Within Anatomic Regions :
a) Epiphysis :

 1-Chondroblastoma

 2-Infection

 3-Geode

 4-GCT

b) Metaphyseal :-Lesions of different causes :


neoplastic , inflammatory and metabolic
c) Epiphyseal / Metaphyseal :-GCT

d) Diaphysis :-After the 4th decade of life , most

solitary diaphyseal bone lesions involve the bone


marrow
Epiphyseal – Diaphyseal – ewing
chondroblastoma sarcoma
Subchondral – giant
cell tumor
3.Pattern of Bone Destruction
Type 1: Geographic-In
this pattern the growth
rate is sufficiently
indolent that the lesion
will appear well
marginated with a thin
zone of transition[clear
distinction b/n the
tumor and bone ].
The vast majority of
these lesions will prove
to be benign .
Type 2: Moth-eaten & Type 3:
Permeative
Moth-eaten and
permeative patterns of
bone destruction
reflect the increasingly
aggressive nature of
these tumors
compared with
geographic lesions,
most of this pattern of
destruction indicate an
aggressive / malignant
lesion.
Moth-eaten & Type 3: Permeative
 Highly aggressive nature of
these lesions does not allow
the host bone sufficient time to
react and produce a response.
 Typically, malignancies,
including metastasis, Ewing’s
sarcoma and osteosarcoma,
exhibit a moth-eaten or
permeative appearance .
 Benign tumors in general do
not show this pattern of bone
destruction.
 Exception -Acute osteomyelitis
may also give a moth eaten
pattern of bone destruction.
4.Tumor matrix;osteoid VS chondroid
Chondroid matrix
Osteoid matrix
5.Periosteal Reaction[PR]
Types
Continuous PR
Sunburst
Sun ray / sunbrust PR Codman triangle
Hair on end PR
6.Age
1.BONE FORMING TUMORS
Bone forming tumors
Benign Malignant
 Enostosis/ bone islands  Osteosarcoma
 osteoma
 Osteoid osteoma
 Osteoblastoma
Bone island / enostosis
Osteoid Osteoma
 Osteoid osteoma may
occur in virtually any
bone, although there is a
strong predilection for
the lower extremity, with
50% or more of lesions
occurring in the femur
and tibia .
Osteoid osteoma
Imaging
 The radiologic appearance of
classic cortical osteoid
osteoma arising in the shaft of
a long bone is characteristic.
 The osteoid osteoma, which
may be radiolucent or contain
a variable amount of
mineralization, is often
referred to as the “nidus,”
because it is the focus of the
underlying pathologic process
and is usually centrally
positioned within an area of
dense, fusiform, reactive
osteosclerosis
Osteoblastoma
 Osteoblastoma of the spine accounts for about one third (range
32–46%) of all osteoblastomas.
 Tree radiographic patterns have been described with
osteoblastoma
1. The first consists of a central radiolucent area (with or
without calcification) and surrounding osseous sclerosis and is
similar to the radiographic appearance of osteoid osteoma,
but the lesion is larger than 1.5 cm in diameter.
2. Expansile lesion with multiple small calcifications and a
peripheral sclerotic rim, is the most common appearance of
spinal osteoblastoma
3. The third pattern has a more aggressive appearance,
consisting of osseous expansion, bone destruction, infiltration
of surrounding soft tissue, and intermixed matrix calcification.
Bone-Forming Tumors: Malignant
(Osteosarcoma)
 They are most common in patients in the second and third
decades of life, with 75% of cases encountered in patients 15–
25 years of age.
 Conventional osteosarcoma most frequently affects long bones
(70–80% of cases), particularly about the knee (50–55%) .
 Specifically, the femur is involved in 40–45% of cases, the tibia
in 16–20%, and the humerus in 10–15% .
 Involvement of the pelvis, fibula, facial bones, and spine is
unusual.
 Metastases most commonly affect the lungs, bones, and
regional and distant lymph nodes. Ossification of pulmonary
and lymph node metastases may be apparent on radiographs.
 Skip lesions have been reported to occur in 1–25% of high-
grade intramedullary osteosarcomas .
Osteosarcoma
 At radiographic examination, This growth pattern is
the vast majority
(approximately 90%) of associated with an
osteosarcomas demonstrate a aggressive periosteal
variable amount of fluffy, reaction (Codman
cloudlike (cumulous) opacities
within the lesion, triangle, laminated,
characteristic of osteoid hair-on-end, or
matrix production sunburst patterns) and
 Conventional osteosarcoma
soft-tissue mass in 80–
tends to violate the cortex
without expanding the osseous 90% of cases .
contours, a characteristic that
reflects its aggressive
pathologic behavior.
Cartilage forming bone
tumors
Matrix mineralization
 This concept of matrix
mineralization is important to
understand, because the pattern
of mineralization can be a clue to
the type of underlying matrix and,
thus, the diagnosis.
 For example,calcification of
chondral tissue often produces
punctate, flocculent, comma
shaped, or arclike or ringlike
mineralization,indicating that the
lesion is cartilaginous,such as an
enchondroma,chondrosarcoma, or
chondroblastoma
 Bone-forming tumors have fluffy,
amorphous, cloudlike
mineralization, causing an opaque
radiographic appearance
Cartilage forming tumors
Benign Malignant
 Chondroblastoma  Chondrosarcoma
 Enchondroma
 Osteochondroma
Chondroblastoma
Chondroblastoma
DDX
 Osteomyelitis ; clinical
correlation .
Imaging ; tongue like
extension is typical for OM

 Eosinophilic granuloma
Enchondrma
DDX
Solitary bone cyst
Giant cell tumor
Aneurysmal bone
cyst
* Tumor location is
very important ; 50%
of enchondromas
occur at short tubular
bones
DDX
The differential diagnosis of an enchondroma in
the hands or feet is different from that of an
enchondroma in the more proximal tubular bones.
Chondrosarcoma is rare in the hands or feet,
regardless of the radiographic appearance. If the
lesion shows no matrix calcification, one might
also consider a diagnosis of giant cell tumor,
epidermoid inclusion cyst, aneurysmal bone cyst,
solitary bone cyst, and fibrous dysplasia.
Statistically, giant cell tumor is the second most
common neoplasm in the small tubular bones.
ENCHONDROMA vs CHONDROARCOMA
The major diagnostic
consideration at sites
other than the hands
and feet is low-grade
chondrosarcoma.
 There is considerable
histologic and
radiographic overlap
between enchondroma
and low-grade
chondrosarcoma.
Chondrosarcoma can develop de
novo or occur as malignant
transformation within an
enchondroma or other
cartilaginous tumor.
The difficulty in distinguishing
low-grade chondrosarcoma from
enchondroma
lies in the fact that these benign
and malignant lesions may be
indistinguishable
radiographically.
Multiple enchondromatosis
(ollier’s disease and maffucci’s
syndrome)
Olliers disease
The risk of
secondary
development
/malignant
transformation is
increased compared
to echondroma
Maffucci’s Disease
Maucci’s disease is a
disease with multiple
enchon-dromas and
multiple so tissue
haemangiomas.
 Patients usually have
deformities of long
bones. Secondary
development of
chondrosarcomas is
reported to be even
more frequent than in
Ollier’s disease
EXOSTOSIS (OSTEOCHONDROMA,
OSTEOCHONDRAL EXOSTOSIS
Exostoses are one of the most common benign
tumors, seen in approximately 3% of the population.
 Exostoses are the result of displaced growth plate
cartilage, which causes lateral bone growth from the
metaphyseal region.
This results in the essential feature of an exostosis:
continuity of the normal marrow, cortex, and
periosteum between the exostosis and the host bone.
An exostosis can be pedunculated (cauliflower-like or
sessile (broad-based) .
The most common locations are the distal femur,
proximal humerus, tibia, and fibula.
Exostosis  The imaging appearance of
an exostosis usually is
Pedunculated exostosis
pathognomic.
usually grows away
from the adjacent joint.
Ninety-five percent of
cases occur in the
extremities and 36% are
found around the knee.
Ninety percent are
solitary. Growth of an
exostosis normally
ceases at skeletal
maturity.
Sessile exostosis
Pedunculated osteochondroma / exostosis
Osteochondromatosis/ multiple exostosis
Osteochondromatosis
(hereditary multiple
exostosis is an autosomal
dominant inherited trait.
The rate of malignant
trans formation is
reported to be in the
range of 5–25% .
The imaging appearance
of osteochondromas in
osteochondromatosis does
not differ from that in
solitary osteochondromas.
Chondrosarcoma

Chondrosarcoma is
the most common
malignant cartilage
tumour and the third
most common
malignant bone
tumour after myeloma
and osteosarcoma.
Chondrosarcoma
Miscellaneous tumor and
Tumor-Like Lesions
Giant cell tumor / GCT
 The typical radiographic
appearance of GCT is a lytic
geographic lesion with a
narrow zone of transition with
or wit out marginal sclerosis
at the end of a long bone,
often with mild bone
expansion.
 The tumors are eccentric and
arise in the metaphysis then
enlarge.
 In the skeletally mature,
extension into the epiphysis is
a hallmark feature, with
extension typically seen to the
articular margin .
GCT
GCT
Solitary bone cyst (SBC) , simple or unicameral
bone cyst
 It is a very common non
neoplastic lesion of
childhood, most frequently
discovered in the first and
second decades of life.
 It is often found incidentally,
or presents with a
pathologic fracture. The
most common sites are the
proximal humerus (50%),
followed by the proximal
femur (20%).
 Solitary bone cyst is a
geographic lytic lesion with
sharp margins .
SBC An SBC is usually a
well-defined area of
osteolysis, located
centrally within the
metaphysis of the
proximal humerus or
proximal femur
The fallen-fragment
sign is seen in 5–
20% of SBCs . It is
thought to be
pathognomonic of an
SBC.
ANEURYSMAL BONE CYST[ABC]
 An ABC is a benign,
expansile (often extremely,
hence the term
“aneurysmal”), eccentric
bone lesion consisting of
blood-filled cystic cavities.
 It is found most frequently
in the first through third
decades of life, with 70% of
cases occurring between 5
and 20 years of age.
Aneurysmal bone cyst
is usually a geographic
lesion with a narrow
zone of transition,
often large with
extreme
(“aneurysmal”) bone
expansion, a narrow
zone of transition, and
a fine sclerotic rim.
Ewing Sarcoma
Ewing Sarcoma
Ewng’s sarcoma is a
highly malignant
neoplasm found
primarily in children.
Diaphyseas of the
tubular bones
commonly affected
Ewing sarcoma
Ewing sarcoma
MULTIPLE MYELOMA
Neoplastic proliferation
of plasma cells is the
most common primary
bone tumor.
The solitary form of this
type of proliferation is
called plasmacytoma;
the multiple form is
much more frequent.
Ninety-five percent of
patients are older than
40 years of age.
MULTIPLE MYELOMA
METASTATIC DISEASE OF BONE

Osseous metastasis
occurs in 20% to 35% of
malignancies.
Metastases to bone are
significantly more
common (in a ratio of
25:1) than primary bone
tumors.
 About 80% of bone
metastases arise from
primary tumors of the
lung, breast, prostate,
and kidney.
Reference
Green span orthopedics
RSNA
 Thank you.

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