Radiology (dra Bandong

Bone tumors

19 July 08

•Bone tumors can be divided into primary and - kidney, lungs, colon, melanoma
secondary
•purely blastic
•Secondary tumors can be further subdivided into:
- prostate and breast carcinoma
o Metastatic tumors
•mixed lytic and blastic
o Tumors resulting from contagious
spread of adjacent soft tissue - most common appearance
neoplasm
Primary bone tumors
o Tumors representing malignant
•predominant appearance in the 1st 3 decades of
transformation of the preexisting
life
benign lesion
•the most common sites include distal femur and
Metastatic disease
proximal tibia
•Most malignant tumor found in the bone
•benign tumors are more common than malignant
•Predominant in 2 age group: one

-adult over 40 yr. old and children In the 1st
decade of life
•Multifocality and predilection for hematopietic
marrow sites in axial skeleton( vertebrae, pelvis,
ribs, cranium) and the proximal long bone
•Metastases to long bones distal to elbows and
knees are unusual
Most common malignancies producing
skeletal metastases:
•the most common benign tumors are
osteochondroma, non-ossfying fibroma and
enchondroma
•among the primary malignant tumors:
- osteosarcoma and multiple myeloma
have highest incidence followed by
chondrosarcoma and Ewing’s
sarcoma
AGE 0-10

Adults Children Most common benign Most common malignant

lesion tumor
•More than 75% •neuroblastoma
originates from the •simple bone cyst •Ewing sarcoma
carcinomas of prostate, •rhabdomyosarcoma
•eosinophilic granuloma •Leukemic involvement
breast, kidney and lungs
•retinoblastoma
•Also common are •Metastatic
metastases form the neuroblastoma
thyroid and colon cancer

•melanoma

Radiologic appearance of the metastatic tumor

•purely lytic AGE 10-20

Mika maQ 1 of 15
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Most Benign lesion Most common malignant

tumor
•Non ossifying fibroma
•Osteosarcoma
•Simple bone cyst
•Ewing’s sarcoma
•Aneurysmal bone cyst
•adamantinoma
•Osteochondroma
(exostosis)

•Osteoblastoma

•Chondroblastoma

•Chondromyxiod fibroma

AGE 30 and above

Most benign lesion Most malignant tumors

•osteoma •metastatic tumor

•myeloma

•leukemic involvement

•chondrosarcoma

•osteosarcoma (Paget’s
associated)

•MFH

•Chordoma

Site of long bone Involvement: Giant Cell Tumor

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Metaphyseal intramedullary lesions

- osteosarcoma is
usually centered in the
metaphysis

-chondrosarcoma and
fibrosarcoma often
present as
metaphyseal lesions

- osteosarcoma, enchondroma, fibrous dysplasia,

simple bone cyst and aneurysmal bone cyst are
common in this location.

Osteosarcoma

Chondrosarcoma

- typical chondroid
matrix calcification

Metaphyseal lesions centered in the cortex

Radiology – GI Radiology by Dra Bandong Page 4 of 15

- Classic location on a
non-ossfying fibroma
(NOF)

Also a common site for

osteoid osteoma

Metaphyseal exostosis

- Osteochondroma
Fibrous dysplasia Multiple myeloma

Enchodroma

Diaphyseal intramedullary lesion

- favored location for Diaphyseal lesions centered in the cortex

ewing’s sarcoma,
lymphoma, myeloma. Adamantinoma, osteod
osteoma
Common fibrous dysplasia
and enchondroma
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Checklist in the analysis of bone lesion Geographic pattern

Skeletal location Cortical integrity - refers to a well

defined area of lysis.
Position within the bone Behavior of lesion
- Benign and non-
site of origin Matrix growing (or strowing
slow growing) leasions
shape Periosteal response
are well circumscribed
size Soft tissue changes
- the sclerotic rim is
margination Joint changes more commonly seen
in weight bearing
Cortical Expansion bones and represents
bone reaction to the
If lesion is growing more rapidly, it
lesion.
may still show a well demarcated
zone of bone destruction (geographic
pattern) but it will lack a sclerotic rim.
- it’s presence means that the bone has been given
sufficient time to react

- some author say’s that sclerotic rim signifies

benignancy to about 95%

BEHAVIOUR OF LESION

- osteolytic

- geographic

- moth-eaten

- permeative

- osteoblastic

- Mixed

“BUTTRESS”

- slow growing tumors provoke

focal cortical thickening ( solid
periosteal reaction, or
“buttress” )
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Generally, the more rapidly growing a lesion, the

more difficult it is seen in the plain

•“moth eaten” and permeative patterns are

CODMAN’S Triangle indicative of destruction involving medullary and
cortical bone.
•rapidly growing lesions
penetrate through the •They are seen in high grade malignant neoplasms
cortex causing separation and in osteomyelitis.
of the periosteum and
formation of laminated
new bone.

•If the periosteum elevates

to a significant degree it
can break forming an
acute angle ( codman’s
triangle)

“ HAIR-ON-END”

- response to a rapidly
growing lesion include
“onion-skinning” and
speculated types.

PERMEATIVE PATTERN

- characterized by numerous
tiny radioluscencies in
between the residual bone
trabeculae.

- due to minute size of

radioluscencies the lesion
maybe difficult to see and to
delineate the plain film.
 Radiology – GI Radiology by Dra Bandong Page 7 of 15

lobulated areas as rings or arc

of calcifications.

- best demonstrated by CT,

whatever the pattern, it only
suggest the histologic nature
of tissue (cartilage) but does
not reliably differentiate
between benign and
malignant process.

PATTERN OF MATRIX MINERALIZATION

osteoid

-malignant osteoid can be

recognized radiologically as
cloudlike or ill-defined
amorphous densities with
haphazard mineralization

- this pattern is seen in

osteosarcoma

- matured osteoid or organized bone, shows more

olderly, trabecualr pattern of ossification

- this is characteristic of the benign bone-forming

lesions such as osteoblastoma

Case 1.

•A 17 year old male presented with increasing pain

in the left upper arm of approx. 3 months duration
and recent onset of low grade fever.

•On PE. There was some local tenderness and soft

tissue swelling over the proximal and thirds of the
left humerus.

• xray shows a large ill-

CHONDROID
defined, destructive,
- radiologically, it is easier to diaphyseal
recognize cartilage as intramedullary lesion
opposed to osteoid by the with permeative
presence of focal stippled or pattern of bone
flocculent densities or in destruction and
periosteal reaction of
“hair-on-end” type.
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The lesion is •In elderly, osteosarcoma usually seen in

associated with a soft association with pre-existing bone disease, such as
tissue mass. Paget’s, radiation ostietis, or bone infarct.

Location

•The distal femur and proximal tibia ( 50% of cases)

and proximal humerus
EWING’S Sarcoma
•Within the long bone, the metaphysis is the most
•Small round blue cell tumors of children and
common site.
young adults occurring in 80% of the cases
between age 5 to 20 year old. •In elderly, osteosarcoma tends to involve the axial
skeleton and flat bone.
•They are extremely rare in patients older than
30 years old. Differential diagnosis

•Most common skeletal sites includes
diaphyses of femur, tibia, and humerus, and
also pelvias and ribs (askin tumor of the chest)
•Associated tissue mass is a common finding.
- in general, low grade osteosarcoma should be
differentiated from benign bone-producing tumors
(osteoblastoma), whereas a highgrade
osteosarcoma must be differentiated from other
sarcoma.

Case 2. Case 3.

An 11 year old male was seen in consultation for an
increasingly painful distal femoral lesion associated
with soft tissue mass.
•A 20 year old male presented with a painless, hard
subcutaneous mass in popliteal fossa
•He stated that the mass had been present for
several years and did not change in size.

- plain Xray
demonstrated a
pedunculated bony
outgrowth at the
proximal tibial
metaphysis. The lesion
had a uniform,
cartilaginous cap with
stippled calcifications.
The tibial cortex and
medulla were
continuous with those
OSTEOSARCOMA
of the lesion.
•Most common primary sarcoma of the bone.

•The peak incidence is in the second decade of life

during the period of most active skeletal growth

• Fewer than 5% of osteosarcoma occurs in the

children younger than 10 years. OSTEOCHONDROMA
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•Most common skeletal sites includes
metadiaphyses of femur and tibia at the knee
(35%), proximal femur and humerus, pelvis and
scapula.
•This tumor does not occur in bones with
membranous type of ossification.
•Solitary osteochondromas may be either primary
due to developmental anomaly of the bone or
secondary following trauma.
•Secondary lesions are often seen in the phalanges
of hands and feet and have their peak incidence in
the 3rd and 4th decade of life.
•A common, benign intramedullary bone tumor
composed of mature hyaline cartilage.
•It shows wide age distribution with peak incidence
during 3rd and 4th decade of life.
•Characteristically, it has limited growth potential
and therefore many lesions remain small and
asymptomatic.
•Pain in enchondroma is a worrisome symptom,
which indicates either a pathologic fracture or
continued growth. It is one of the criteria used to
distinguished they benign tumor from low grade
(grade 1) chondrosarcoma.

•Multiple osteochondromas represent an autosomal •Location in general, enchondroma are very rare in
dominant hereditary disorder and are associated the sites most commonly affected by
with bone deformities. chondrosarcoma.

•Most common secondary malignancy is •Rare, non-hereditary disorder characterized by

chondrosarcoma
•The earliest pathologist sign of malignant
transformation to a low grade chondrosarcoma is
increased thickness of the cartilage cap.
Case 4.
An incidental finding of a bone lesion in the distal
femur of a 38 year old female. The lesion was
completely asymptomatic.
•Plain radiograph showed
an intarmedullary zone of
stippled and ring shaped
calcifications in the distal
femoral metaphysis.
•This mineralization pattern
with radiodense stipples and
rings is a acharacteristic of
mature hyaline cartilage.
multifocal proliferation of dysplastic cartilage is
known as enchondromatosis, or ollier’s disease.
•It is usually diagnosed in children and adolescents
between 10-20 years of age. The risk of malignant
transformation, usually chondrosarcoma, is very
high (20-30%).
Enchondroma Chondrosarcoma
•Characteristically •Common in the ribs,
involves the acral pelvis and long bones.
skeleton (small bones of
•Not unusual in the
hand and feet-60%) and
scapula, spines, and
long bones, such as
craniofacial bones.
femur, fibula, tibia,
humerus, radius and
ulna).
•In long bones, the
tumor is found in the
metaphyses and
proximal/distal
diaphyses.

•Mid-shaft involvement
is rare.

•Enchondromas are very

rare pelvis, ribs, scapula
ENCHONDROMA and spine and do not
involve craniofacial
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bones A 39 yr old female gave a 2 month history of

increasing pain in the knee. There was no evidence
of joint effusion. Laboratory work-up showed normal
serum level of calcium, phosphate and alkaline
Case 5.
phosphatase.
A 22 year old male presented with intermittent dull
Plain radiograph
pain at the ankle of approximately 6 months
demonstrate a well
duration.
defined, lytic lesion
Plain film shows a well eccentrically located in
defined, expansile lytic the distal femur
lesion, which is centered at epiphysis with
the distal fibular metaphysis subchondral and
and is bordered by a metaphyseal
sclerotic rim. extension. There was
associated focal
thinning of the cortex

CHONDROMYXOID Fibroma

•A rare benign tumor with predominant occurrence
in patients younger than 40 year old.
•The peak incidence is between 20 and 30 years
old.
•It one of the the 2 neoplasms of incompletely
differentiated cartilages.
•The other is chondroblastoma.
Giant Cell Tumor of Bone (GCT)
•Is relatively common, locally aggressive neoplasm
accounting for apprx 4% of all primary tumors.
•It affect skeletally mature individuals, F > M, 20 to
50 years of age.
•It is extremely rare in children and patient older
than 60 years.

•Location: the most frequent skeletal sites are the
knee area (30%), pelvis and the small bones of the
feet. In the long bone, the tumor characteristically
involves the metaphysis or metadiaphysis and is
often seen in eccentric position.
Differential Diagnosis
•Chondroblastoma- epiphyseal location and
“chicken wire” calcifications.
•Chondrosarcoma- hyaline cartilage matrix, tumor
permeation of the sorroundinf bone and mitotic
activity.
Case 6.
•Location: most GCTs affects long bones with the
highest incidence (65%) in the distal femur,
proximal tibia and distal radius.
•In the long bones, the tumor is invariably centered
in the epiphysis.
•It can also be found in any other longbone, pelvis,
sacrum and spine (3%).
•GCTs of the hands and feet are very rare.
•Common secondary changes in the GCT are
hemorrhage and necrosis, fibrohistiocytic
(Xanthomatous change) and aneurysmal bone cyst
formation.
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•Complications include pathologic fractures and femur with “sheperd’s

malignant transformation (dedifferentiation). crook” deformity
(lateral bowing) due to
Case 7. a healed pathologic
fracture. The lesion is
A 14 year old female was seen in for consultation
partially surrounded by
for an increasingly painful left humeral lesion
sclerotic rim and has
associated with mild joint effusion.

Plain radiograph
showed an irregular,
but circumscribed, lytic
epiphyseal lesion A complex appearance with lytic areas, multiple foci
surrounded by reactive “ground glass “ density and radiopaque areas.
bone sclerosis. There
was no evidence of Fibrous Dysplasia
bone expansion, and
•A common benign fibro-osseous lesion
the cortex was intact.
The growth plates were •Which occurs sporadically during the period of
open. skeletal growth (age 10-25)

• It is a hamartoma and is characterized by the

intramedullary location.

•There are 2 forms of the disease: monostatic (80%)

Chondroblastoma
•A rare benign neoplasm occurring in 75% of the
cases in the 2nd decade of life, when the growth
plates are still open
•The other neoplasm is chondromyxoid fibroma
•Most common location are the long bones (70%
arise in the proximal humerus and at the knee), and
flat bones, including pelvis. In the long bones, the
tumor almost invariably occurs in the epiphysis.
Case 8.
A 22 year old was seen in consultation for a lesion
in the proximal femur. She complained of chronic
mild to moderate pain in her right hip and was
walking with a noticeable limp. Physical
Examination revealed hip deformity and minimal
limb length discrepancy. There were no other
abnormal findings.
Plain film showed a
large, elongated, well
defined intramedullary
lesion of the proximal
and polyostatic.
•Polyostatic involvement maybe a part of McCune-
Albert syndrome (fibrous dysplasia, patches
cutaneous pigmentation, and precocious puberty)
or Mazabraud’s syndrome (fibrous dysplastic lesions
in close proximity to soft tissue myxomas)
•Most common locations includes the long bones
(femur,tibia and humerus), the ribs, cranio-facial
bones and pelvis. In the long bones, the lesion is
found in the metaphysis and diaphysis.
•The hallmark of fibrous dysplasia is inability of the
tissue at the unaffected site to produce mature
lamellar bone. The maturation is arrested at the
level of the woven bone. The difference between
the two types of bone is best appreciated by using
polarized light.
Case 9.
An incidental finding of a bone lesion in the distal
tibial meta=diaphysis of a 13 year old male. The
lesion was totally asymptomatic.
Plain x-ray showed a sharply
demarcated, lucent, loculated,
 Radiology – GI Radiology by Dra Bandong
metadiaphyseal lesion
surrounded by rim of sclerotic
bone. The lesion
predominantly involves the
lateral portion of the bone and
produces mild cortical
expansion.
NON-OSSFYING FIBROMA.
•A common, non-neoplastic, self healing lesion
occurring in the skeletally immature individuals.
•Usually between the age of 5 and 20 years old.
•Small lesions are usually incidental radiologic
findings.
•The larger lesions occupying more than half
•Of the bone diameter may present with a
pathologic fracture.
•Location. Metaphysis or metadiaphysis of the long
bone at the knee ( distal femur, proximal tibia or
fibula) distal tibia and proximal humerus.
•A syndrome of multiple non-ossifying fibroma and
cutaneous café au lait spots known as Jaffi-
Campanacci syndrome.
•GCT may enter your differential diagnosis.
Remember, however, that it is characterized by the
epiphyseal location and occurrence in adults.
Case 10
A 14 year old female presented with a 3 months
history of increasing pain in her elbow.
Plain x-ray
showed a well
circumscribed
“punch out”
lytic,
Page 12 of 15
intrameduallry
lesions in the
distal humeral
shaft.
•There was no sclerotic rim and no periosteal
reaction.
Eosinophilic Granuloma (EG)
•Classification of the lesions of the Langerhans Cell
Histiocytosis is based on the extent of the disease
and includes the following 3 forms:
a. eosinophilic granuloma ( localized form of
the disease at single skeletal sites)
b. Hand-Schuller-Christian disease ( Extensive
multifocal, symptomatic disease with
predominantly skeletal involvement).
c. Letterrer-siwe disease ( aggressive systemic
form of the disease that involves multiple
organs and systems and leads to functional
impairment of the affected sites).
•EG commonly occurs in individuals younger than
30 years old and has the highest incidence in the
first decade of life.
•Location: skeletal sites include cranio-facial
bones, ribs, vertebra, pelvis, and major long
bones such as femur and humerus. Small bones of
the hands and feet are not affected. Extraskeletal
lesions most commonly arise in the lungs and
lymph node.
•Differential diagnoses includes osteomyelitis,
granulomatous inflammation, hodgkin’s and non-
hodgkin’s lymphoma. Identification of
morphologic features of langerhans cells and the
use of appropriate markers and/or EM help to
resolve diagnostic problems.
•Case 11
A 12 year old boy presented with a short history of
pain in his thigh.
Plain radiograph
demonstrates a well-
defined, symmetric,
 Radiology – GI Radiology by Dra Bandong Page 13 of 15

expansile, •ABC is rapidly growing, locally aggressive,

intramedullary lytic intramedullary, vascular lesion, which
lesion of the proximal characteristically produce a blowout expansion of
femur. the affected portion of the bone. It can be Primary
(de novo) or secondary:

•Secondary ABC may develop in a preexisting

benign lesions such as chondroblastoma,
chondromyxoid fibroma, giant cell tumor and
fibrous dysplasia or superimposed on a malignant
Solitary Bone Cyst (SBC) tumor (osteosarcoma)

•Solitary bone cyst is relatively common, non- •Although ABC can occur at any age, the majority of
neoplastic lesion, which typically occurs in the the patients are younger than 25 year old.
skeletal immature patients, in the first and second
decade of life (80%). Case 13

•It is usually unicameral cyst, which does not have A 45 year old female presented with an increasing
pain and swelling around the knee. She mentioned
an epithelial lining (hence not a true cyst) and is
that the symptoms had progressed over the 4
filled with serous fluid.
months period.
•Location: about 80% of the case is diagnosed in 2
•Plain film
locations: humerus and proximal femur. In the long
demonstrates a large
bone, SBC characteristically involves the
lobulated, ill-defined
metaphysis and diaphysis.
lesion centered in the
•Other skeletal sites are the ilium, talus and distal femoral
calacaneus. metaphysis.

Case12 •There is an endosteal

scalloping and
A 17 year old male presented with a slowly periosteal thickening.
enlarging, painful lesion of the right clavicle.

•Central stippled and “ring and arc” classications

are apparent and are typical of the cartilaginous
matrix.

•Small radioluscent areas are seen in the periphery

of the lesion.

Chondrosarcoma, low grade (grade 2)

•A malignant, cartilage producing tumors, which

unlike most other primary brain tumors, tends to
occur in the older age group (30-50 years) and is
extremely rare in children. When it does occur in
children, it almost always of a high grade (grade 3)

•The majority of the chondroid tumor in children

and adolescent are chondroblastic osteosarcoma,
Aneurysmal Bone Cyst (ABC) not chondrosarcoma.
 Radiology – GI Radiology by Dra Bandong
•Chondrosarcoma is the 2nd most common primary
malignant tumor after osteosarcoma.
•Location. Unlike benign cartilaginous lesions,
chondrosarcoma has a predilection for trunk bones
including the pelvis (particularly ilium), the ribs and
scapula. It is also common In the long bone such as
femur and humerus.
Case 14
A 27 year old male presented with chronic, dull pain
and some soft tissue swelling along the antero-
lateral surface of the left lower leg.
Plain film showed a large, cortically based
radioluscent lesion partially surrounded by rim of
sclerotic bone and 2 smaller lesions of similar
appearance.
The location in the cortex of the tibial shaft is a
major diagnostic clue (about 90% of this tumor are
centered in the antero-lateral cortex of the tibial
shaft).
Adamantinoma
•Rare, low-grade malignant neoplasm, which occur
almost exclusively in 2 skeletal locations: the bone
of the lower leg and the jaw.
•Tumors of the jaw are also known as
“ameloblastoma”.
•Adamantinoma of long bones
•Most patient are young adults, 20-30 years old.
Page 14 of 15
•Radiologic appearance is very typical. In about
70% of the cases the tumor involves the midshaft of
the shaft.
•In the remaining cases, it is found at the end of the
tibia, and in fibula
•Early lesions are characteristically centered in
anterolateral cortex.
•Advance tumors may involved the medullary cavity
and soft tissue.
Case 15
A 16 year old boy was seen in consultation for
increasing pain In the mid upper arm.
Characteristically, the pain intensifies at night and
subsided with aspirin.
Osteiod osteoma
•Is a common, benign, bone producing neoplasm
characterized by a small size, limited growth
potential, and a tendency to
•Cause extensive reactive changes in surrounding
tissues.
•The lesional tissue, called a “nidus”, usually
appears as a small radioluscent focus, less than 1
cm in size, either within the cortex or adjacent to it.
•Predominat occurrence in males between the age
10 and 25 years.
Location
•Most frequently (50%) arise in the femur and tibia.
 Radiology – GI Radiology by Dra Bandong Page 15 of 15

•The femoral neck is one of the most common •They are slowly and progressively growing
anatomic sites. neoplasm.

•Other skeletal location includes humerus, the small •Although any bone maybe involve, osteoblastoma
bones of hands and feet, and the spine. tend to arise in the axial skeleton, involving the
spine and the sacrum in about 40 % of the cases.
•In a long bone, the tumor is usually found in the
metaphyses or diaphyses. •The 2nde most frequent site is mandible, fallowed
by cranio-facial bone.
Case 16
•Unlike osteoid sarcoma, osteoblastoma do not
A 21 year old male with a 6 month history of dull produce prostaglandin/ prostocyclin mediated tissue
pain in the knee that was not relieved by aspirin. reaction.
A plain x-ray
•Peak incidence in the 2nd and 3rd decade of life.
showed a well,
circumscribed,
low metaphyseal,
adioluscent lesion
containing matrix
type
radiodensities.
Note the absence
of sclerotic rim.

Osteoblastoma

•Rare bone-producing neoplasm that closely

resembles osteoid sarcoma on microscopic
examination.

•However there are significant differences between

the 2.

•By definition, all osteoblastomaa are larger than

1.5 cm.