BONE TUMORS

Dr. Rosalina,SpRad

Normal Anatomy
diaphysis
cortex metaphysis

epiphysis

physis

Medullary space

Physeal scar

Childhood

Adult

Criteria to Classify Lesions

Age Location of lesion
Which bone? Location within bone

Soft tissue involvement

Less reliable

Size Pattern of bone destruction

Criteria to Classify Lesions

Zone of transition
Margin of lesion Visible tumor matrix

Polyostotic or monostotic

Malignant Bone Tumors by Age

1-30
Ewings Osteosarcoma

30-40
Fibrosarcoma and MFH Malignant Giant Cell Tumor

Reticulum Cell Sarcoma

Osteosarcoma

AGE 20 Location metaphysis Margins 3 Periosteal Reaction irregular Matrix bone Other DX osteosarcoma

Malignant Bone Tumors by Age

40+
Mets Myeloma

(Chondrosarcoma)

Location
Location and age are important parameters
Most primary tumors arise in areas of rapid growth
distal femur, proximal tibia, humerus, etc.

Metastases occur in well-vascularized red marrow

spine, iliac wings, etc.

Location
Enchondroma: phalanges
Osteosarcoma & giant cell tumor: around the knee Hemangioma: skull and spine Chordoma: sacrum and clivus Adamantinoma: mid-tibia

Location

Pattern of Bone Destruction

Geographic
Well-defined margin

Least aggressive

Pattern of Bone Destruction

Permeative
Poorly demarcated, difficult to visualize

Moth Eaten Subcategory with larger holes If mixed, work up as aggressive

Permeative
Ewing
Eosinophilic Granuloma

Infection
Myeloma, metastasis Lymphoma

Osteosarcoma

Motheaten
Myeloma, metastases
Infection Eosinophilic

Granuloma Osteosarcoma Chondrosarcoma Lymphoma

Reaction of Bone to Tumor

Margin between tumor and native bone can be 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

Zone of transition
Wide
Aggressive

Narrow
Less aggressive

Non-ossifying fibroma-Narrow Zone

Margin Sclerosis
Sclerotic margin
Generally non-aggressive

Lack of sclerotic margin

Suggests more aggressive Exceptions

Radiographic Margins
Margin types 1A, 1B, 1C, 2, and 3
Least aggressive 1A, to most aggressive 3

Margins: 1A,1B,1C

increasing aggressiveness

1A: Sclerotic margin

Simple cyst (UBC)
Enchondroma Fibrous Dysplasia

Chondroblastoma
Giant Cell Tumor Chondrosarcoma

1B: Well-defined, nonsclerotic

Giant Cell Tumor
Enchondroma Chondroblastoma

Myeloma, Metastatsis
Fibrous Dysplasia Chondrosarcoma

Giant Cell Tumor: Well-defined, Non-sclerotic

1C: Lytic, ill-defined margins

Chondrosarcoma
Osteosarcoma Giant Cell Tumor

Metastasis
Infection Eosinophilic

Granuloma Lymphoma

Periosteal Reaction
Limited usefulness
Thick, uninterrupted
Long standing process, often non-aggressive
Stress fracture, Chronic infection, Osteoid osteoma

Spiculated, lamellated
Aggressive process Tumor likely

Types of Periosteal Reaction

Malignant type reaction

Codman Triangle

Periosteal reaction Codman Triangle Advancing tumor margin destroys periosteal new bone before it ossifies Tumor

Tumor Matrix
Chondroid matrix
Calcified rings, arcs, dots (stippled)
Enchondroma, osteochondroma,

chondroblastoma, chondrosarcoma

Osteoid matrix
Dense, homogenous, cloudlike

Osteoid osteoma, bone island, osteosarcoma

Tumor Matrix
Fibrous Matrix
Diffuse uniform mineralization: ground glass
Fibrous dysplasia

Matrix

Enchondroma

AGE 56 Location metaphyseal Margins 1A Periosteal Reaction none Matrix chondroid Other DX enchondroma

Polyostotic vs. Monostotic

Benign polyostotic
Fibrous Dysplasia, Pagets, histiocytosis, multiple

exostosis, multiple enchondromatosis

Malignant polyostotic
Mets, Myeloma, Ewings with mets, Osteosarc

with mets and MFH.

Work up
Radiograph Aggresive

STOP

+ +
Bone Scan Polyostotic Will information regarding polyostotic vs. monostotic be valuable?

Chest film and CT

+
Can distinguish benign, mets, myeloma from other

+
STOP

Workup
Chest film and CT MR (Less likely CT) For site evaluation + + Plan to resect lung mets -

Biopsy

Palliative Care

Biopsy
Sample away from necrotic or aggressive area

non-

Avoid contaminating compartments

Knee- suprapatellar bursa is large Pelvis- avoid gluteal musculature which will need

for coverage

Unicameral Bone Cyst

AGE 13 Location metadiaphysis Margins 1A-1B Periosteal Reaction none Matrix none Other trabecular struts DX UBC

Aneurysmal Bone Cyst

Aneurysmal Bone Cyst

AGE Location Margins Periosteal Reaction Matrix Other DX

adult metaphysis 1B none none fx ABC

Non-ossifying fibroma

Giant Cell Tumor

Giant Cell Tumor

AGE 45 Location metaphysis Margins 1B Periosteal Reaction none Matrix none Other epi involvement DX GCT

Osteoid Osteoma

Osteoid Osteoma

AGE 45 Location diaphysis Margins 1B Periosteal Reaction thick Matrix faint Other DX osteoid osteoma

Multiple Myeloma

AGE 66 Location diaphyseal Margins 1A Periosteal Reaction minimal, thick Matrix none Other 2nd lesion DX wait..

Multiple Myeloma

AGE Location Margins Periosteal Reaction Matrix Other DX

66 diaphyseal 2 none none wait..

Multiple Myeloma

AGE Location Margins Periosteal Reaction Matrix Other DX

66 flat bone 1B none none multiple myeloma

Ewings Sarcoma

AGE Location Margins Periosteal Reaction Matrix Other DX

12 diaphysis 3 lamellated none Ewing

Ewings sarcoma

onion-skin

Osteosarcoma

Osteosarcoma

AGE 16 Location diaphysis Margins 3 Periosteal Reaction spiculated Matrix bone Other fx DX osteosarcoma

Osteomyelitis

Primary lymphoma

Primary lymphoma

Metastatic Adenocarcinoma

THANK YOU