Kenneth Buckwalter, M.D.

Indiana University
kbuckwal@iupui.edu
(317) 274-1837
Radiology of Bone Tumors
Outline
Work-up and Radiologic assessment
Approach
Normal bone anatomy
Radiographic Analysis
Location
Margins
Periosteal reaction
Matrix
Examples

Work-up
History
Age is critical.
Smoker?
Malignancy?
Physical examination
Breast mass?
Good radiographs of affected region
2 views minimum
Multiple vs. Solitary
Multiple
metastatic
congenital
fibrous dysplasia
acquired
Paget
Solitary
metastatic
primary bone tumor, malignant or benign
Multiple
50+ y/o
known malignancy?
myeloma, get SPEP
otherwise, do metastatic work-up
child to early adult
known malignancy?
EG?
polyostotic fibrous dysplasia?
otherwise, do metastatic work-up

Solitary
Aggressive radiographic appearance
bone scan to stage and verify solitary nature
metastatic work-up
baseline CXR
spiral CT for pulmonary nodules
Staging for surgery
cross-sectional imaging: CT or MR
Need tissue biopsy
Biopsy
obvious superficial mass, blind biopsy
tissue compartments must not be
contaminated
Biopsy should be done in consultation with a
tumor surgeon.
skinny needle most helpful with metastatic
disease
core best for primary tumor
Cross-sectional imaging
Pictures are pretty, but diagnosis established
at histology
MRI best for most tumors
optimal results at sites with experience
Role of CT limited
may assist in assessing tumor matrix
useful in directing biopsy
Normal Anatomy
epiphysis
metaphysis
diaphysis
physis
childhood adult
cortex
medullary
space
physeal scar
How are Bone Tumors
Like Real Estate?
Location!
Location!
Location!
Location
Location and age of patient most important
parameters in classifying a primary bone
tumor.
Simple to determine from plain radiographs.
Location
Rad Clin N Am,
Dec 1981
Reaction of bone to tumor
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

Reaction of bone to tumor
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.
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.
Margins: 1A,1B,1C
increasing aggressiveness Rad Clin N Am,
Dec 1981
1A: sclerotic margin
simple cyst (UBC)
enchondroma
FD / FX
chondroblastoma
GCT
chondrosarcoma (rare)
MFH (rare)

Rad Clin N Am,
Dec 1981
1B: well-defined, non-sclerotic
GCT
enchondroma
chondroblastoma
myeloma, metastatsis
CMF
FD
chondrosarcoma
MFH

Rad Clin N Am,
Dec 1981
1C: lytic, ill-defined margins
chondrosarcoma
MFH
osteosarcoma
GCT
metastasis
infection
EG
lymphoma
Rad Clin N Am,
Dec 1981
2: motheaten
myeloma, metastases
infection
EG
osteosarcoma
chondrosarcoma
lymphoma

Rad Clin N Am,
Dec 1981
3: permeative
Ewing
EG
infection
myeloma, metastasis
lymphoma
osteosarcoma
Rad Clin N Am,
Dec 1981
Types of
Periosteal
Reaction
Rad Clin N Am,
Dec 1981
Periosteal Reaction
Limited usefulness
Thick, uninterrupted
long standing process, often non-aggressive
stress fracture
chronic infection
osteoid osteoma
Spiculated, lamellated
aggressive process
tumor likely

Codman Triangle
periosteal reaction
tumor
advancing tumor margin
destroys periosteal new
bone before it ossifies
Codman
Triangle
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
Matrix
Rad Clin N Am,
Dec 1981
Examples
AGE 13
Location metadiaphysis
Margins 1A-1B
Periosteal Reaction none
Matrix none
Other trabecular struts
DX UBC
Example 1
Example 2
AGE adult
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other fx
DX ABC
Example 2
Example 3: 13 y/o with knee pain
AGE 13
Location epiphyseal
Margins 1B
Periosteal Reaction none
Matrix none
Other
DX chondroblastoma
Example 3
Example 4: 45 y/o with knee pain
Example 4
AGE 45
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other epi involvement
DX GCT
Example 4*, 35 y/o F, GCT
AGE 66
Location diaphyseal
Margins 1A
Periosteal Reaction minimal, thick
Matrix none
Other 2nd lesion
DX wait..
Example 5
Example 5
AGE 66
Location diaphyseal
Margins 2
Periosteal Reaction none
Matrix none
Other
DX wait..
Example 5
AGE 66
Location flat bone
Margins 1B
Periosteal Reaction none
Matrix none
Other multiple
DX myeloma
Example 6: 14 y/o with claudication
Example 6
Example 6
AGE 14
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix mature bone
Other claudicat'n
DX exostosis
Example 7: 25 y/o woman with knee pain
Example 7
AGE 25
Location metaphysis
Margins 1A
Periosteal Reaction none
Matrix ?
Other multiple
DX NOF
Example 7
Example 8: 45 y/o with thigh pain
Example 8
AGE 45
Location diaphysis
Margins 1B
Periosteal Reaction thick
Matrix faint
Other
DX osteoid osteoma
AGE 12
Location diaphysis
Margins 3
Periosteal Reaction lamellated
Matrix none
Other
DX Ewing
Example 9
Example 9
onion-skin
Example 10
AGE 16
Location diaphysis
Margins 3
Periosteal Reaction spiculated
Matrix bone
Other fx
DX osteosarcoma
Example 10
AGE 20
Location metaphysis
Margins 3
Periosteal Reaction irregular
Matrix bone
Other
DX osteosarcoma
Example 10*, osteosarcoma
AGE 56
Location metaphyseal
Margins 1A
Periosteal Reaction none
Matrix chondroid
Other
DX enchondroma
Example 11
Summary
Radiographs are essential
Aggressiveness of process dictates the
response of the bone
Most helpful information in analysis
Age
Location
Margins
Dont Touch Me
Fibrous lesions
fibrous dysplasia
NOF (non-ossifying fibroma)
enchondroma
exostosis
unicameral (simple) bone cyst
AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX
Example