AlbertLeung,HMSIII

GillianLieberman,M.D.
BIDMCRadiologyClerkship
February22,2010
Overview
y IndexPatient
y PeriostealReactions
y DifferentialDiagnosis
y PrinciplesofOsteoid Osteomas
y BoneAnatomy
y MenuofTests
y RadiologicImages
y Treatments

http://peakrunningperformance.com/webpages/images/stories/skeleton.gif
LearningObjectives
y Recognizetheclinicalpresentationofosteoid osteoma
y Understandthedifferentialdiagnosisforthisclinical
presentation
y Reviewtheprinciplesofosteoid osteoma andits
classificationwithinthecontextofboneanatomy
y Learnthemenuofappropriateradiologicimagingstudies
andtheindications
y Studytheradiologicpresentationsandrecognizeclassic
findings
y Knowhowtomedicallyandsurgicallymanageosteoid
osteomas
IndexPatient:PresentingHistory
y ChiefComplaint
y Rightwristpain
y History
y 18yroldRhanddominantmalewithpersistentRwristpainfor4
months
y Painisworseatnight,wakingpatientfromhissleep
y Painreliefwithibuprofen
y Nohistoryoftraumaorrepetitivemotionswithhand
y ReviewofSystems
y Deniesnumbness/tingling,fevers,chills,nightsweats
y Past,Family,SocialHistories
y Nonsignificant
IndexPatient:PhysicalExam
y Palpablenodule(3.5x3cm)overtheradialaspectoftheRdistal
radiuswithfocaltendernessandswelling
y Noerythema,discoloring,ecchymosis,ordrainage
y FullrangeofmotionofRshoulder,elbow,wrist,andfingers;no
strengthdeficits
y Normalsensationinalldistributions
y +2pulsesbilaterally
y Nopalpableaxillary lymphnodes
OurPatient:Radiographofcorticalosteoid
osteoma inRdistalradius APRadiograph

Ovoidscleroticlesionwith
centralradiolucency
1.1x1.3cm

Fusiform corticalthickening

Image from BIDMC PACS

OurPatient:Rdistalradiusosteoid
osteoma onCTImaging
AxialC CT

Focalareasofradiolucency surroundedbysclerotic
regionsthatoccupythecortexandinvadethemedulla

Image from BIDMC PACS

OurPatient:Periostealreactionon
CTImaging
Coronal C- CT of R distal radius

Periostealreaction:elevatedcortex
frombonyexpansion

Image from BIDMC PACS

PeriostealReaction:
NonaggressiveTypes

Rana RS, Wu JS, and Eisenberg RL. Periosteal Reaction. American Journal of Roentgenology. Oct 2009. 193(4): W259-272.
PeriostealReaction:
AggressiveTypes

Rana RS, Wu JS, and Eisenberg RL. Periosteal Reaction. American Journal of Roentgenology. Oct 2009. 193(4): W259-272.
PartialDifferentialDiagnosisfor
WristPain/BoneMass
y Masses y Inflammation
y BenignNeoplasms y Tenosynovitis
y Osteoid Osteoma y Rheumatoidarthritis
y Osteoblastoma y DegenerativeConditions
y Osteoma y Osteoarthritis
y Enostosis (boneisland) y Stressfracture
y Ganglioncyst y Neurological
y Infection y Carpaltunnelsyndrome
y Brodie abscess(subacute
osteomyelitis)
y Osteomyelitis
OurPatientsDifferentialDiagnosis

Unlikely given patients history and presentation

DistinguishingCharacteristicson
RadiologicImaging
y Masses
y BenignNeoplasms
y Osteoid Osteoma <2cm;radiolucentnidus withsurrounding
sclerosis;mayspontaneouslyregress
y Osteoblastoma large(>2cm);noregressioninsizeovertime
y Osteoma coldbonescan;absent periostealreaction&
radiolucentnidus
y Enostosis coldbonescan;thornyradiations;lowsignalonT2w
MRI
y Infection
y Brodie abscess corticaldestructionwithalinear,serpentinetract
extendingawayfromabscess
y DegenerativeConditions
y Stressfracture linearradiolucency perpendicular,ratherthan
parallel,tocortex
 Background:Osteoid Osteoma
y Demographics
y Majorityofpatientsareyoung(<35yrold)
y Males>females(23:1)
y Benign skeletalneoplasm
y Consistsofasphericalnidus ofosteoid tissue&bonytrabeculae
superimposedonhighlyvascularized connectivetissue
y Mayinitiallyappearonradiographasasmallscleroticboneisland
withinacircularlucency
y NOmalignantpotential
y Size
y Rangesfrom0.52cm(avg 1.5cm)
y Nogrowthprogression
y Mayregressspontaneouslyoveryears
Background:Osteoid Osteoma
(continued)
y Mechanism
y Unknownetiology
y Nidus consistsofhighlyvascularosteoblastic proliferation,surroundedby
asecondaryzoneofsclerosis
y ElevatedprostaglandinE2levelsinnidus responsibleforbonepain&
vasodilation
y Tumorinfarctionmaybeinvolvedduringcasesofspontaneousregression
y Locations
y Typicallyaffectstheappendicular skeleton
y Metaphysis/diaphysis oflongbones:70%
y Femur/tibia:55%
y Phalangesofhands/feet:20%
y Spine:10% Causespainful scoliosiswithconcavitytowardsthelesion
y Posteriorelements:90%
y Extremelyrareinskull&facialbones
Osteoid osteoma vs
Osteoblastoma
Osteoid osteoma
y Usually<2cmdiameter
y Presentswithintensepain,
oftensharplylocalizedand
worseatnight
y Paincharacteristicallyrelieved
byaspirin/NSAIDs
y Nonaggressivebehavior
y Variablelocations:femur,tibia,
fibula,humerus,hands/feet,
vertebrae
y Neuralstaining revealsaxons
throughoutthetumor(may
explainbonepain)
Osteoblastoma
y Usually>2cmdiameter
y Lackofintensepain
y Aggressivebehavior
y Typicallyinthevertebraeor
majorbonesofthelower
extremity
y Oftenaffectsthespongiosa
ofthebone
y Absenceofneuralaxons
uponstaining
ReviewofBoneAnatomy

tsagalis.net/bones/anatomy.jpg

tsagalis.net/bones/anatomy.jpg
ClassificationofOsteoid Osteomas
y Cortical
y Mostcommonlocation(80%)
y Radiolucentnidus seenwithinthebonecortexandsurroundedby
fusiform corticalthickening/laminatedperiostealformation
y Cancellous
y Intramedullary lesion;mildreactivesclerosis&difficulttoidentify,
significantlydelayingthediagnosis
y Commonsites:femoralneck,posteriorspine,hands&feet
y Intraarticular
y Jointeffusionorsynovitis
y Subperiosteal
y Roundmassadjacenttocortex
y Absentperiostealreaction
y Veryrare
 Osteoid Osteomas

Gitelis S,WilkinsR,andConradEU,III.BenignBoneTumors. JournalofBone&JointSurgery(Am).1995;77:17561782.

ClassicClinicalPresentation
y Focalbonepainthatworsensatnight&increaseswithactivity
y Painisrelievedbyaspirinwithin30minutes(75%ofcases)
y Localswellingandpointtenderness
y Exacerbationofpainwithalcohol

http://library.thinkquest.org/08aug/01036/Imagini/Sleep.jpg

http://paddyk.files.wordpress.com/2009/11/5-aspirin.jpg
MenuofRadiologicTests
y PlainRadiographs*
y ComputedTomography*
y MRI
y Ultrasonography
y NuclearImaging*
y Angiography

*Usuallyusedforevaluatingosteoid osteomas
PlainRadiographs
y Mainimagingtechnique
y Diagnosticin75%ofcases
y ClassicAppearance
y Welldefinedradiolucentnidus with
surroundingzoneofsclerosis
y Centralnidus istypically<1.5cmindiameter
CompanionPatient#1:Radiograph
ofLtibial osteoid osteoma
Sagittal Radiograph

21 yr old male with 4 months of

atraumatic left calf pain, worse at
night; osteoid osteoma eventually
removed by percutaneous RF
ablation

Periosteal reaction with cortical thickening in posterior tibia

Image from BIDMC PACS

CTImaging
y Bestimagingtoolforosteoid osteoma
y Studyofchoiceforlocalizingthenidus
y Goodatevaluatingcomplexanatomy(e.g. spinal
pedicles,laminae,femoralneck,hands,feet)
CompanionPatient#1:Ltibial
osteoid osteoma onCTImaging
Axial C- CT Sagittal C- CT

Mature periosteal reaction and

thickening with central radiolucency

Image from BIDMC PACS Image from BIDMC PACS

 BackToOurIndexPatient:Rdistal
radiusosteoid osteoma onCT
Sagittal C- CT

Centralradiolucentnidus
withinascleroticzone

Osteoid osteoma
eventuallyremovedby
opensurgicalcurettage

Image from BIDMC PACS

MRI
y Advantages
y Easilydetectsedemainthesofttissues&bonemarrow
y Betteratdiagnosingcancellous/intramedullary osteoid
osteomas
y Goodforevaluatingjointeffusion/synovitis for
intraarticular lesions
y Appearance
y T1w:nidus isisointense tomuscle
y T2w:radiolucentareasofnidus withintermediateto
highsignalintensity
CompanionPatient#2:Radiograph
ofLtibial osteoid osteoma
AP Radiograph

18 yr old male with nocturnal focal pain

in L proximal tibia for 2 years; relief with
NSAIDs; osteoid osteoma eventually
removed by percutaneous RF ablation
Non-aggressive thick periosteal reaction of
the L medial tibial metaphysis

Image from BIDMC PACS

CompanionPatient#2:Ltibial
osteoid osteoma onAxialCT
Axial C- CT

5 mm radiolucent nidus

Thick periosteal reaction (10 mm)

Image from BIDMC PACS

CompanionPatient#2:Ltibial
osteoid osteoma onCoronalCT
Coronal C- CT

Oval-shaped radiolucent lesion within the medial

tibial cortex
Dimensions: 4 x 4 x 18 mm

Image from BIDMC PACS

CompanionPatient#2:Ltibial
osteoid osteoma onMRISTIR
Coronal C- MRI STIR

Edema appears as high signal intensity

within the bone marrow

Image from BIDMC PACS

CompanionPatient#2:Ltibial
osteoid osteoma onMRIT1w

Low signal intensity edema in soft tissue structures surrounding the cortical lesion

Coronal C- MRI T1w Axial C- MRI T1w

Image from BIDMC PACS Image from BIDMC PACS
NuclearImaging:BoneScan
y Usestechnetium99mphosphonates
y Tumorsitedemonstratesfocalareaofintenseuptake
y Doubledensitysign:smallfocusofincreasedactivity
(nidus)surroundedbyalargerareaoflessintenseactivity
(reactivesclerosis)
y Tracerisexcretedthroughkidneysandurinarybladder
 CompanionPatient#3:Sacrococcygeal
osteoid osteoma onCTImaging
Axial C- CT
19 yr old male with 1 yr hx of
pain at coccyx, worse at night
pain & relieved with
ibuprofen; osteoid osteoma
eventually removed by
percutaneous RF ablation

Small curvilinear lucency (6 mm) with

focal sclerosis in adjacent posterior
cortex

Image from BIDMC PACS

CompanionPatient#3:CTguidedbiopsyof
asacrococcygeal osteoid osteoma
Axial C- CT

CT guided needle core biopsy of the

radiolucent nidus

Image from BIDMC PACS

CompanionPatient#3:Coronalbonescan
ofasacrococcygeal osteoid osteoma

Coronal Bone Scan

Small intense focus of tracer uptake in the coccyx

with double density sign

Image from BIDMC PACS

CompanionPatient#3:Sagittal bonescanof
asacrococcygeal osteoid osteoma
Sagittal Bone Scan

Abnormally increased focal area of intense

tracer uptake

Image from BIDMC PACS

Ultrasonography
y Maybeusedforguidanceofpercutaneous biopsies
y DopplerU/Sdetectsthehighlyvascularnidus
y Usefulfordetectingintraarticular osteoid osteomas
Angiography
y Centralnidus ishighlyvascular
y Intensecircumscribedblushthatdevelopsduringthe
earlyarterialphaseandpersistsintovenousphase is
diagnostic
y Angiographyisusefulfordistinguishingosteoid osteoma
fromaBrodie abscess
Treatments
y MedicalManagement
y NSAIDS
y SurgicalManagement
y Opensurgicalcurettage
y CTguided
y Percutaneous radiofrequency(RF)ablation,laser,ethanol,
orthermocoagulation therapy
y Anesthesia
y Generalorspinal
Summary
y Osteoid osteoma (OO)isalatentbenignbonetumorthat
classicallypresentsasfocalpainthatisworseatnightand
relievedbyNSAIDs
y Corticalosteoid osteomas areoftenassociatedwithnon
aggressiveperiostealreactions
y OOs andosteoblastomas arehistologically similarbutdifferin
size,painintensity,location,aggressiveness,andneuralstaining
patterns
y OOs areclassifiedbytheirrelativepositiontothebone:
cortical,cancellous,intraarticular,andsubperiosteal
SummaryContinued
y OOs haveaclassicappearanceonplainradiographsandCT
imaging:centralradiolucentnidus withsurroundingzoneof
sclerosis
y CTimagingisthebestimagingtoolforOOs andisthestudyof
choiceforlocalizingthenidus
y MRIisusefulfordetectingsofttissue/bonemarrowedemaand
intramedullary OOs
y Nuclearbonescansmaylocalizethetumoranddemonstrate
focalareasofintensetraceruptake;doubledensitysignis
occasionallyseen
y DopplerU/Scandetectthehighlyvascularnidus
y AngiographymaydistinguishOOs fromaBrodie abscess:
intenseblushthatpersistsintovenousphaseisdiagnosticof
OO
References
Assoun J,Richardi G,Railhac JJ,etal.Osteoid osteoma:MRimagingversusCT. Radiology1994;191(1):21723.

Bilchik T,Heyman S,SiegelA,andAlavi A.Osteoid osteoma:theroleofradionuclideboneimaging,conventional

radiographyandcomputedtomographyinitsmanagement. TheJournalofNuclearMedicine.Feb1992;33(2):269
271.

DaviesAMandWellings RM.Imagingofbonetumors. CurrentOpinioninRadiology.1992;4(6):3238.

Dorfman HDandCzerniak B.BoneTumors(1st ed).St.Louis,MO,Mosby,1998.

GilS,MarcoSF,ArenasJ,etal.Dopplerduplexcolorlocalizationofosteoid osteomas. SkeletalRadiology.Feb1999;

28(2):107110.

Gitelis S,WilkinsR,andConradEU,III.BenignBoneTumors. JournalofBone&JointSurgery(Amed).1995;77:1756

1782.

GrecoF,Tamburrelli F,Ciabattoni G.Prostaglandinsinosteoid osteoma. InternationalOrthopedics.1991;15(1):3537.

GreenspanAandRemagen W.DifferentialDiagnosisofTumorsandTumorlikeLesionsofBonesandJoints(1st ed).

Philadelphia,PA,Lippencott Williams&Wilkins,1998.

PerkinsACandHardyJG.Intraoperativenuclearmedicineinsurgicalpractice. NuclearMedicineCommunications.
Dec1996;17(12):10061015.

Rana RS,WuJS,andEisenbergRL.PeriostealReaction. AmericanJournalofRoentgenology.Oct2009.193(4):W259

272.
Acknowledgements
y Dr.GillianLieberman
y Dr.JimWu
y Dr.EricaGupta
y Dr.JayCatena
y SpecialThanksTo:
y Dr.Corrie Yablon
y Dr.Aarti Sekhar
y MariaLevantakis
y Patients