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Editors: Brant, Will iam E.; Helms, Clyde A. Title: Fu ndamentals o f Diagnostic Radio logy, 3 rd Edition Copyright ©2 00 7 Lippinco tt Williams & Wilkins
> Table of Conte nts > S ection X - Musculosk ele tal Radiolog y > Chapte r 41 - Benign Cy stic Bone Les ions

Chapter 41 Benign Cystic Bone Lesions
Clyde A. Helms A benign, bubbly, cystic les ion o f bone is on e of t he m ore com mon skeletal lesions that a radiologist enco unt ers. Th e differential diagnosis c an be quite length y and is usu ally structu red on how th e lesio n loo ks to th e ra diologist, using h is or h er experience as a guide. This m ethod, called pa ttern iden tificatio n, c ertainly has merit, but it can lead to a very long differential dia gn osis an d m any erro neous con clu sio ns if no t tempered with some lo gic. I n gen eral, if a differen tia l diagn osis will yield th e correct diagn osis 9 5% of t he t im e, mo st w ou ld consider it a usefu l differential list; h owever, it w ould n ot be a ppropriate to accept a 1 -in-2 0 miss rate for fract ures and dislocation s. In gen eral, th e sho rter th e differential diagnosis list, the m ore helpfu l it is to c linician s an d th e easier it is to rem ember. A sh orter differen tia l list will u sually h ave a lo wer accuracy rate th an a lon g list; h ow ever, man y times the lon ger lists c ontain such rare en tit ies that the accuracy does not really increase s ubstant ially. For mo st o f the entities in bo ne radiolo gy, a 95% accu rate differen tial is acceptable. If o ne w ants to be m ore accurate t han that , mo re diagno ses can simply be added to the list o f differential possibilities. Wh en the differen tial diagno sis is long, as in the differential for bubbly, cystic lesions of bo ne, it can be difficult to recall all of th e entities th at shou ld be m entioned. A mnem onic can be helpful in recalling long lists of info rm atio n and is recom mended.

FEGNOMASHIC
F EGNO MASHI C is a mnem onic t hat serves as a nice startin g point for discu ssin g po ssibilities t hat appea r a s benign, cyst ic lesion s in bone. Th is mnem onic has been in gen eral u se for man y years. By itself, it is merely a long list†”1 4 en tit ies†”an d it n eeds to be c oupled with ot her criteria to shorten the list into a m anageable form for each particu lar case. For instan ce, th e age of the patient w ill h elp add or elim in ate m any o f the possibilities. If mu ltiple lesion s are present, only h alf a dozen ent ities n eed to be discussed. Metho ds o f narrow in g t he differen tial are discussed lat er in this chapter. The firs t step in approaching a ben ign, cystic bon e lesio n is to be certa in it is really ben ign. The crit eria for differentiating ben ign les ion s fro m malignan t

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lesions are covered in Chapter 4 2. Once it is establish ed th at t he lesio n is tru ly a ben ign, cystic lesio n, F EGNO MAS HI C will enable a differen tial diagn osis th at is at least 95 % a ccurat e. Mem orization o f the 14 entities in this different ial is eas ily do ne (Table 41 .1). The next step after learning t he n ames of all of th e lesio ns is get tin g so me idea o f each lesion 's radio graph ic appearance. This is w hen experience becomes a facto r. For the medical studen t o r first-year residen t, it is difficult to go beyon d s aying that they all loo k cystic, bubbly, an d benign. Th e fourth-year resident s hould have no trou ble P.10 64 differen tiat in g between a unicameral bon e cyst a nd a gia nt cell tu mor becau se he o r she has seen examples o f each many tim es before and kn ows their a ppearance.

TABLE 41.1 Discriminators for Benign Lytic Bone Lesions—Mnemonic: FEGNOMASHIC
Letter Represents Characteristics

F

Fibrou s dyspla sia

No periosteal reactio n

E

En chon drom a

1. Calcifica tio n present (except in phalanges) 2. Painless (no periostitis)

Eo sin ophilic granu lom a

You nger than age 30

G

Gian t cell tu mor

1. E piphyses clos ed 2. Abu ts t he articular surface (in long bon es) 3. Well defined w it h a n onsclerot ic margin (in long bon es) 4. E ccen tric

N

Nono ssifyin g fibro ma

1. Youn ger than age 3 0 2. Painless (no periostitis) 3. Cortically based

O

Osteo blasto ma

M en tioned when aneu rysmal bo ne

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cyst (AB C) is ment ion ed (es pecially in the posterior elements of th e spine)

M

Metast atic disea ses and myelo ma

Older than age 40

A

An eu rysmal bo ne cyst

1. E xpan sile 2. Youn ger than age 3 0

S

So litary bone cyst

1. Central 2. Youn ger than age 3 0

H

Hyperparath yroidism (brow n t umo r)

M ust have o ther evidence of h yperpa rath yroidism

I

Infection

Alwa ys ment io n

C

Chon droblasto ma

1. Youn ger than age 3 0 2. E piphyseal

Chon drom yxo id

No calcified matrix

A fter getting a feel fo r wh at each lesio n loo ks like radio graphically and o vercom ing the frustration that builds wh en one realizes that ma ny o f them lo ok a like, on e sho uld try to lea rn ways to differentiate each lesio n fro m the others. I h ave developed a n umber of keys that I call discriminato rs, wh ich help to differen tiat e each lesion . These discrim ina tors are 90 % to 95 % u sefu l (I will m ention wh en they are mo re or less accurate, in my experience) an d are by n o m eans in tended to be absolutes or dogma . They are guidelines but have a high a ccuracy rate. Textboo ks rarely state t hat a fin din g †œalways†o r “never†o ccurs. They t emper descriptio ns w ith “virt ually alw ays,â € “in va riably,†⠀œusually,†o r “characteristically.†I have tried to pick out fin dings that c ome as close to “always†as I can , realizing that I will o nly be a pproximately 95 % accura te. That is goo d eno ugh fo r most radiologists. The fo llow in g is o nly a brief description o f ea ch en tit y; m ore com plete description s are readily available in any skelet al radiology text. What is em phasized h ere are th e point s th at are u niqu e for each entity, t hereby ena bling

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differen tiat io n fro m the others. Table 41 .1 is a syn opsis of these discriminato rs.

Fibrous Dysplasia
Fi brous dysplasia is a benign co ngenital pro cess th at can be seen in a patien t o f any age and can lo ok like alm ost any pa thologic process radiograph ically. It c an be wild looking, discretely lucent, patch y, sclerotic, expansile, mu lt iple, an d m any other descriptions. It is, th erefo re, difficult t o loo k at a bu bbly lytic lesion a nd u nequivocally sa y it is o r is not fibrous dys plasia. I t w ould be better if t he F EGNO MAS HI C differential started o n a positive no te, say, with gian t cell tum or o r chon droblasto ma, for w hich there are som e definite crit eria. How ever, becau se fibrou s dyspla sia is firs t o n t he list, w e might as well deal with it . Ho w do yo u kno w wh et her to in clu de or exclude fibrous dysplasia if it can loo k like almost anyth ing? Experience is the best guideline. In oth er words, look in a few texts an d fin d as man y different exam ples as po ssible; get a feelin g for w hat fibrou s dyspla sia lo oks like.

FIGU RE 41 .1. Fibro us Dysplasi a. Th is patient has po lyost otic fibrous dyspla sia with diffu se involvem ent of th e pelvis as well as the proximal femurs.

P.10 65 F ibrous dysplasia w ill no t h ave periostitis asso ciat ed with it; therefore, if perio stit is is present , on e m ay safely exclude fibrous dysplasia. Fibrous dysplasia

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virtu ally n ever un dergoes malign ant degen eration and sho uld no t be a painful lesion unless there is a fracture. An occu lt fractu re oft en o ccurs in lon g bon es w ith fibrou s dyspla sia; th erefore, it is n ot unu sual to ha ve it present w ith pain a nd n o obviou s fract ure seen in a lon g bo ne. P ain in a flat bon e, such as the ribs o r pelvis (non –weight-bearin g bo nes), shou ld no t o ccur with fibro us dysplasia. F ibrous dysplasia can be eith er m ono stotic (mo st comm only) or polyo stotic and h as a predilect ion for th e pelvis, proxim al fem ur, ribs, and sku ll. Wh en it is present in th e pelvis, it is in variably present in th e ipsilateral proximal femur (Figs. 4 1.1, 41 .2). I have seen o nly one case in wh ich th e pelvis w as invo lved w ith fibrou s dyspla sia, and the proximal femur w as spared. The proximal femur, h ow ever, ma y be affected alo ne, withou t involvement in t he pelvis (Fig. 4 1.3 ). F ibrous dysplasia o ften involves the ribs. I t typically h as an expansile, lytic a ppearance in th e post erio r ribs (Fig. 41 .4) an d a sclerotic appearance in the a nterior ribs. The classic descriptio n of fibrous dysplasia is t hat it has a grou nd-glass or smo ky m atrix. This descript ion co nfuses peo ple as often as it helps th em, a nd I do no t recom mend usin g †œgroun d-glass a ppearance†as a bu zz word for fibrous dysplasia . Fibrou s dysplasia is often purely lytic and becomes hazy or takes o n a grou nd-glass loo k as the matrix P.10 66 c alcifies (Fig. 41 .5). I t can go on to calcify significant ly, and t hen it present s as a sclerot ic lesion. Also, I oft en see lytic lesio ns with a pat hologic diagnosis other t han fibro us dysplasia th at h ave a distinct gro und-glass appearan ce; therefore, t he †œgrou nd-glass†qualifier can be mislea ding.

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Ovid: Fundamentals of Diagnostic Radiology Page 6 of 57 FIGU RE 41 . Fibro us Dysplasi a. the ipsilateral fem ur on the affected side is in varia bly also in volved. Th is patient has po lyost otic fibrous dyspla sia with in vo lvemen t o f the right femu r as w ell as th e supraacetabular portion of th e ilium . . When th e pelvis is in vo lved w it h fibrou s dysplasia. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20... 5/23/2011 .

5/23/2011 .3. Fibro us Dysplasi a..Ovid: Fundamentals of Diagnostic Radiology Page 7 of 57 FIGU RE 41 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. I t is n ot un usual for m ono stotic fibrou s dysplasia to involve the pro ximal femu r and spa re t he pelvis. The pelvis wa s un in vo lved. gro und-glass appearan ce in the neck of the righ t femu r. Th is patient has a w ell-defined lytic lesio n with a h azy..

5/23/2011 ..Ovid: Fundamentals of Diagnostic Radiology Page 8 of 57 FIGU RE 41 . Wh en th e an terior ribs a re involved. Note also th e involvem ent of the tho racic spine.. th e post erior ribs o ften demo nstrate a lytic expansile appeara nce. Fibro us Dysplasi a. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. th ey are most often sclerotic in appearance. When fibro us dysplasia affects the ribs.4. as in t his example.

on e may choo se n ot to in clude it in the differen tial†”a misdiagn osis w ill no t o ccur mo re than on ce or t wice in a lifetim e.Ovid: Fundamentals of Diagnostic Radiology Page 9 of 57 FIGU RE 41 . w hereas ot hers are more lytic appearing. Adamantinoma Wh en a lesio n is encou ntered in th e tibia tha t resem bles fibro us dysplasia .. It occurs almo st exclusively in the tibia a nd t he j aw (for un kn own reason s) and is rare. bu t j ust as o ften. Becau se it is rare. An adaman tin oma is a malign ant t umo r that radiographically an d histologically resembles fibrous dysplasia (Fig. an a damantino ma shou ld also be considered. Parts of th is lesion have a h azy. McCune Albrig t Syndrome P olyo stotic fibrou s dyspla sia occasion ally occu rs in asso ciat ion w it h ca fé -au -lait mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. gro und-glass appearance. Polyostot ic fibro us dysplasia is seen in th e radius in this ch ild. A h azy. 4 1. 5/23/2011 ..6 ). th e appearance ca n be purely lytic or even sclerotic. . Fibro us Dysplasi a. groun d-glass appearance is oft en present in fibrous dysplasia.

and even in the sim ple polyo stotic form.. oft en o ccur u nilat erally—th at is. The presence of m ultiple lesio ns of fibrous dysplasia in the jaw has been termed c er ism This is fro m t he ph ysical appearance o f the child with puffed-o ut c heeks having a n an gelic loo k..Ovid: Fundamentals of Diagnostic Radiology Page 10 of 57 s po ts on the skin (dark-pigm ented. Adamantino ma. This mixed lytic an d sclero tic pro cess in the m idsha ft of th e tibia is ch aracteristic for fibrou s dysplasia. This complex is called McCun e-Albright syndro me. Biopsy show ed th is to be an adam antinom a. t hro ugho ut one half of th e body. 5/23/2011 . Th is P. The j aw lesions of ch erubism regress in mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. FIGU RE 41 . The bon y lesion s in this s yn drom e.10 67 do es n ot happen oft en en ough to be o f any diagno stic use in differen tiat ing fibrou s dyspla sia from oth er lesions. An adam antinom a h as an identical appeara nce an d sh ould be considered in any tibial lesion th at resembles fibro us dysplasia. frecklelike lesion s) and precociou s puberty. .

. A lth ough th ese c riteria are helpfu l in separating an infarct from an ench ondroma.9). mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. A n in farct u sually has a w ell-defined. w hereas a bo ne infarct w ill no t.7 ). Discriminator No periosteal reaction. they are not foo lproof. wh ereas an en chon drom a does no t (Fig. Enchondroma and Eosinophilic Granuloma E nchon dromas occur in any bone fo rmed from cart ilage an d may be cent ral. An en chon drom a is t he m ost comm on ben ign cystic lesio n in the phalanges (Fig. expansile.8 ). or n onexpansile.. serpiginou s bo rder (Fig. O ften it is difficult to differen tia te betw een an ench ondroma and a bo ne infarc t. 4 1. eccen tric. They invariably cont ain calcified cho ndro id m atrix. I do n ot include encho ndro ma in my differential. except when in the ph alan ges. If a cystic lesion is presen t w ithou t calcified ch ondroid mat rix anywh ere except in th e phalanges. 5/23/2011 . A n en chon drom a o ften c auses en dosteal scallopin g. 41 . 4 1.Ovid: Fundamentals of Diagnostic Radiology Page 11 of 57 a dult hoo d. densely sclerotic.

5/23/2011 . at times. Clinical fin din gs (prim arily pain ) serve as a bet ter indicato r t han radiographic fin dings. A lytic lesio n in the phalanges is mos t co mmo nly an encho ndro ma. and in deed pain in an apparen t ench ondroma sho uld w arrant surgical investigation. if n ot im possible. I t is difficult. . Trying to differen tiate h isto lo gically an en chon drom a fro m a c hondrosarcoma is also difficult. if no t impo ssible. Periostitis sh ould n ot be seen in an ench ondroma either. M ultiple en ch ondro mas o ccur on o ccasio n. th is condition has been t ermed mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Biopsy o f an a ppa rent encho ndro ma shou ld not be perfo rmed ro utinely fo r his tologic differen tiat io n. to different iate an encho ndro ma from a c hondrosarcoma. E nc on droma.Ovid: Fundamentals of Diagnostic Radiology Page 12 of 57 FIGU RE 41 . These m ost o ften presen t w ith path ologic fractu res.. as in this example. Th is is the on ly locat io n in the skeleton w here an ench ondroma does not con tain calcified ch ondroid ma trix..

41 . 41 . infarcts are easily diagnosed. h ow ever. the different ial betw een a bon e infarct and an en chon drom a ca n be difficult on plain films. . It is not P. it do es ha ve an in creased incidence of malign ant degeneration o f the en chon drom as. h owever.10 68 P. serpigin ous borders are t ypical for bon e infa rcts. B one Inf arct. Th e presence o f mu ltiple encho ndro mas associated w it h s oft tissue heman giom as is kn own as Maffu cci syndro me (Fig. FIGU RE 41 . in t his example. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.10 69 h ereditary a nd do es no t h ave an increased rate of m alignant degenera tio n..11 ). These lytic les ion s in the dista l femu rs with calcified.10 ). 5/23/2011 .Ovid: Fundamentals of Diagnostic Radiology Page 13 of 57 O llier disease (Fig. Th is syndro me also is n ot hereditary.. Occasionally.

. E nc on droma.Ovid: Fundamentals of Diagnostic Radiology Page 14 of 57 FIGU RE 41 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. .. 5/23/2011 . punct ate calcification typical for ch ondroid mat rix seen in an ench ondroma . Th is lesion in the distal righ t femu r show s th e stippled.

1 .. 5/23/2011 . Th is is a t ypical example o f Ollier disease.. Oll ier Di sease.Ovid: Fundamentals of Diagnostic Radiology Page 15 of 57 FIGU RE 41 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. M ultiple en chon drom as are pres en t th rou ghou t t he h and.

t he o ther form s being L etterer-Siwe disease and Hand-S chü ller-Christian disease. wh en presen t. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.Ovid: Fundamentals of Diagnostic Radiology Page 16 of 57 FIGU RE 41 . it might or might no t h ave a s clero tic border. The bony manifesta tio ns of all three disorders are s imilar and are discussed in th is review simply as EG. M ust have ca lcification (except in phalanges). and it might or might no t elicit a periost eal respon se. Discriminators 1 . No periostitis o r pain. Maffu cci Syn drome. it m ay be w ell defined o r ill defined. 5/23/2011 . is typically benign in appearance (t hick. 2 . It can be lytic or s clero tic. U nfo rtu nately for radiologists. The perio stit is. uniform . mo st investigators c ategorize them separately.. Multiple encho ndro mas associated w ith ph lebolit hs are present in th e phalanges.. E osino phili c granu loma (EG) is a form of histiocytosis X. E G has man y appeara nces (1).11. Th is com bin atio n of findings invariably represen ts h emangiom as an d ench ondromas in M affucci syndrome. Alt hou gh t hese forms may be merely different phases of th e sam e disease.

E G c an be ment ion ed w ith out even loo king at the film ! E G is m ost often m ono stotic (Fig. Becau se EG can loo k like an ything. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Ho w.. I recom mend ment ion in g EG as a differential po ssibility for an y lesio n in a pat ient less th an the age of 3 0. has to be included w henever multiple lesion s are presen t in a patient yo unger tha n t he age of 3 0 years. can on e distin guis h E G from an y of th e o ther lytic lesions in th is differen tial? Rem em ber that it is diffic ult to exclu de EG from almost any differen tial of a bony lesion.1 2). FIGU RE 41 .. E G occu rs alm ost exclusively in patien ts u nder 30 years (u sually <20 years). 41 . then. E G can mimic Ewing sarco ma and present as a perm ea tive (mu ltiple small ho les) lesio n. t he pa tient 's age is th e best criterion.Ovid: Fundamentals of Diagnostic Radiology Page 17 of 57 w avy) bu t ca n be lam ellated o r amo rpho us. A well-defined lytic lesion is seen involving the midfemu r in th is 20 -year-old patient. 5/23/2011 . t hus. be it ben ign or m alignan t. so lon g as the radiograph is n ot of an arthritide o r trau ma. Eosin op il ic G ran ulo ma EG . but it can be polyo stotic (Fig. th erefo re. 4 1.13 ) a nd.1 . Biopsy sh owed th is to be E G.

10 70 it unn ecessary in mo st cases to rely on plain films alone fo r the soft tissues.Ovid: Fundamentals of Diagnostic Radiology Page 18 of 57 E G might or m igh t n ot have a soft t issu e mass associated. I kn ow of n o entity in which the presence or absence of an asso ciated soft t issue mass will w arrant inclu sio n or exclu sion o f the process from a differen tial. M ost radiologists a re inept at evaluat ing the soft t issu es because they are difficult t o see. Th e treatin g physician w ill un doubtedly w ant to kn ow wh ether the soft t issu es are in volved and t o what extent. and CT and MR h ave made P. so the presence o r a bsen ce o f a so ft tissue m ass w ill n ot help in th e different ial diagno sis.. F ortu nately. the presence or absence of a soft tissue mass will not a lter th e differential diagnosis. th is can be s atisfacto rily dem onstrated w it h MR. in most cases.. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. but th is will do little t o narrow th e differential diagnosis. It is im port ant t o note the presence of a soft tissue mass (o r its absence). 5/23/2011 .

4 1.Ovid: Fundamentals of Diagnostic Radiology Page 19 of 57 FIGU RE 41 .1 4). Clinically. lymph oma. o steom yelit is. In additio n t o th e lesio n a rou nd t he righ t h ip.. E G occ asio nally h as a bon y sequestrum (Fig. B iopsy show ed th is to be E G. and fibrosa rcom a. Giant Cell umor mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. E G. EG m ight o r m igh t n ot be asso ciat ed with pain. 5/23/2011 . Discriminator M ust be u nder age 3 0 years. a lesio n is seen a t th e right sacroiliac j oint.13. therefore. and fibro sarco ma shou ld be con sidered. an o steoid o steoma will often give an appearance o f a s equ estration w hen the nidu s is pa rtially calcified. Well-defin ed lytic lesions are presen t t hro ugho ut the pelvis in th is 24 -year-old patient. Eosin op il ic G ran ulo ma EG . On ly a few other ent ities h ave been des cribed that on o ccasio n have bon y sequestra: osteo myelitis . therefore. lympho ma.. clinic al history is no ncon tributo ry for th e m ost part. As discu ssed in Chapter 4 7. w hen a sequ est rum is identified.

B iopsy revealed this to be EG.. 4 1. t hey can met astasiz e to t he lun gs. F our classic radiographic crit eria for dia gn osing giant cell tum ors exist. Histologically. I do no t ent ertain t he diagno sis of giant cell t umo r in a patien t w it h o pen epiphyses. it is im port ant to realize that o ne is u nable to tell wh ether a giant cell t umo r is benign o r maligna nt. Wh en m alignan t. If an y of t hese crit eria are no t m et w hen lo okin g at a lesion. as do th e maj ority o f radiologists a nd pat hologists (2). E ven th en. w hich is typical for o steom yelitis o r EG. Th is well-defined lytic lesio n contains a bo ny sequ es trum (arro ). I su bscribe to th e mo st w idely u sed appro ach. a giant cell t umo r canno t be divided in to eith er a benign or a m alignan t ca tegory. 2. but th ey do so infrequ en tly.Ovid: Fundamentals of Diagnostic Radiology Page 20 of 57 G ian t cell tumor is an unco mm on. somew hat con troversial lesio n with several s choo ls of th ough t as to it s radio graphic a ppearance. The lesion m ust be epiph yseal and a bu t t he articular surface (Fig. Eosin op il ic G ran ulo ma EG . this is va lid a t least 98% to 9 9% of t he time and is extremely useful. regardless o f it s radiographic appearance.15 ). 5/23/2011 .14. F irst. gia nt cell tu mor can be eliminated fro m the differen tia l diagn osis . 1. FIGU RE 41 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Most surgeons curettage an d pack t he lesions and consider t hem benign u nless th ey recur. t hey can still be benign a nd recur a s eco nd or third time. Giant cell tumo r occurs o nly in pat ient s w ith closed epiphyses.. A bout 15 % of giant cell t umo rs a re t hou ght to be malign ant o n the basis of th eir rec urrence rate.

. Th is occurs in 98 % to 9 9% o f gian t cell tum ors. This rule does not apply in flat bo nes. if I h ave a lesion that is P.. wh ich h ave no articula r s urfaces. it sh ould be flush against the art icular surfac e of t he j oin t. When on e sees a giant cell tum or.1 . Perh aps m ore im port antly. Th e metaph ysis also h as so me o f the t umo r in it becau se th e les ion s are generally very large. 4 1. it w ill be epiphyseal. I w ill n ot in clude gian t cell tu mor in the diagno sis. except for rare cases. t herefore. These are all mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. they are epiphyseal an d a re flush again st the a rticular surface. h owever. w hen radiologists see the lesions. A w ell-defin ed lyt ic lesion with out a sclerotic m argin is seen abutting the articular surface of th e dist al femur in a pat ient wh o has clo sed epiph yses. Giant Cell T umor. 5/23/2011 . su ch as in the pelvis or in the apophyses (Fig.Ovid: Fundamentals of Diagnostic Radiology Page 21 of 57 There is disagreem en t a s to w hether giant cell t umo rs begin in th e epiphyses o r metaphyses or from th e physeal plate itself.10 71 s eparated fro m the articular surface by a defin it e margin o f normal bo ne.16 ). FIGU RE 41 .

Ovid: Fundamentals of Diagnostic Radiology Page 22 of 57 ch aracteristics of a gian t cell tum or. bu t it does n ot occur o ften eno ugh to in clu de as a discriminat or). such as n ono ssifyin g fibromas.10 72 description o f being eccentrically placed (altho ugh several lesio ns. No oth er lesion mu st alwa ys abut the articular surface... I know o f no oth er lesion that depends on whet her the epiphyses are o pen or clo sed. 41. When a bo ny lesion is quite large. such as the pelvis (Fig. including n ono ssifyin g fibroma and chon drom yxo id fibro ma. No oth er lesion in any of my lists uses a s a diagn ostic factor w hether t he zo ne of transitio n is s clero tic or n ot (m any lesio ns. bu t it is one o f the cla ssic “ru les†o f a giant cell tumo r. it can be difficult t o t ell w hether it is centra l or eccen tric.1 7) a nd t he calcaneu s. I do no t fin d th is to be a terribly u seful description . 5/23/2011 . I t is im po rtan t t o realize that the fo ur criteria fo r a giant cell tumo r apply o nly to giant cell tum ors and not to an y oth er lesion. will usually have a s clero tic ma rgin . This is a very helpful finding in gian t cell tu mor. are eccen tric m ost of th e t im e). The only places this does no t apply is in flat bones. The lesion m ust have a sharply defin ed zo ne o f tra nsit io n (border) that is n ot sclerotic. as o pposed t o being centra lly placed in the m edullary cavity. For instan ce. Giant cell tumo rs are said to be eccent rically located in th e bon e. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. 4. 3. and no o ther lesio n h as t he classic P.

Giant Cell T umor. 5/23/2011 . Biopsy sh owed this t o be a giant cell tumo r.. The apo physes have the same differen tial diagno sis as lesions in t he epiphyses.1 .. w hich m akes giant cell t umo r a strong possibility in t his example.Ovid: Fundamentals of Diagnostic Radiology Page 23 of 57 FIGU RE 41 . Th is well-defined lytic lesio n t hat does n ot have a sclerotic m argin completely in vo lves t he greater tro chant er. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.

A large.1 . wh ich th is pro ved to be at bio psy.Ovid: Fundamentals of Diagnostic Radiology Page 24 of 57 FIGU RE 41 . The u sual rules for giant cell tu mors su ch as presen ce o f a n onsclero tic margin do no t apply in flat bo nes... A well-defined lytic lesion is seen in the medial metaphysis o f this tibia (arro s). The pelvis is a go od lo catio n for giant cell tum or. w hich is typical for a fibro us co rtical defect.1 . w hich does co ntain a sclero tic margin an d does not appear to abut an y art icular surfac e. Fibrous Co rtical Def ect. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Giant Cell T umor. well-defined lytic lesio n in the iliac wing is seen . FIGU RE 41 . 5/23/2011 .

mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Th e examination w as o bt ain ed for a sprain ed an kle an d no t for th is asympto matic lesio n.. is seen in the distal tibia in this you ng pat ient .. This is a characteristic appearance of a n ono ssifying fibro ma.Ovid: Fundamentals of Diagnostic Radiology Page 25 of 57 FIGU RE 41 . w hich is slightly expansile with scalloped sclerotic m argins. Non ossifyin g Fibroma. w ell-defin ed lyt ic lesion. A large. 5/23/2011 .1 .

. O nce one of the criteria is violated. expan sile lytic lesio n in the dist al fibula is noted in th is asympto matic patient. th ey do not apply at a ll for an y oth er lesions. 5/23/2011 . . giant cell tumo r can be exclu ded. For instance.Ovid: Fundamentals of Diagnostic Radiology Page 26 of 57 FIGU RE 41 . or mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. wh ich is ch aracteristic for a no nossifying fibro ma.. There is no need to check further to see wheth er it is eccentric. Non ossifyin g Fibroma. wh ether it ha s a non sclerotic m argin. Residents have a ten den cy to apply these criteria t o every lytic lesio n encou ntered fo r the simple reason th at th ey have learned th e fou r criteria. A well-defined. A lt hough th ese four criteria apply well fo r gian t cell tu mor. if a lytic lesion is fou nd in the middiaphysis o f a bo ne. the remainder do no t even have to be used t o eliminate a giant cell t umo r.

it seems a ppropriate to refer to them all as NOFs rat her than to su bdivide them by th eir s ize. Th ese pa thologists may be correct. Must be eccen tric. Discriminators 1 . 2.19 ). 41 . bo th radiograph ically and histologically. bu t t hey are no t in the mainstream of wh at m ost peo ple use for giant cell tumo r criteria.. fo r inst ance. I t sh ould be not ed tha t th ese criteria only apply to giant c ell tu mors o f lo ng bo nes. these lesions are iden tica l. in the pelvis o r the c alcan eus. M ust be w ell defin ed w ith a non sclerotic m argin. hence. E piph yses must be clo sed.Ovid: Fundamentals of Diagnostic Radiology Page 27 of 57 w heth er t he epiphyses are closed. in my experience.1 8) an d an NOF being larger than 2 c m (Fig. Histo lo gically. an oth er pat hologist sh ould review th e s lides. “Fibrou s co rtical defect †is a c omm on syn onym . 5/23/2011 . A gain . I f one or tw o ca ses a re fou nd t hat do n ot fit the criteria. 4 1. t hey ha ve gian t cell tum ors th at do n ot obey any of th e criteria. onossifying Fibroma on ossifyin g fibroma (NO F) is pro bably the m ost com mon bon e lesio n en coun tered by radiologists. P. with a fibrou s co rtical defect being smaller th an 2 cm in len gth (Fig. so as to be seen on ly rarely after the age o f 3 0.10 73 M any pa thologists refer to an eurysma l bone cys ts as gian t cell tu mors. Th ey wou ld not w ork. 3 . t wo lo cations wh ere giant cell tum ors often occur. Mu st abu t t he articula r surface. I t reportedly occ urs in u p to 2 0% of ch ildren and u sually sponta neously regresses. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. th erefo re. th ese ru les will be greater t han 95 % effect ive an d.. altho ugh some people differen tiat e th e tw o lesions on the basis of size. c lose to 99 % effective. 4.

A well-defined. sclerotic bo rder tha t is sca lloped an d sligh tly expan sile (Fig. These lesion s are so characteristic t hat no differential diagnosis sh ould be mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. 1. Non ossifyin g Fibroma. A CT exam in atio n show ed apparen t co rtical destru ction (arro ). They do no t h ave to have expansion o r a scalloped or sc lero tic border and a re n ot limited t o t he m etaphyses. Bot h CT an d MR will o ft en sh ow apparen t co rtical destruction. that is . lytic lesio n t hat is m in im ally expansile is seen in th e distal tibia in th is child wh o was examined for a sprained ankle. 41 .. this is a gen eral description tha t probably applies to o nly 75 % of the lesion s an d co uld equ ally apply to mo st o f the lesion s in FEGNO MAS HI C. B. They classically h ave a thin. Biopsy sho wed this to be a n ono ssifying fibro ma. eman atin g from th e co rtex. th e radiolo gist's diagno sis shou ld be th e fin al wo rd and t hereby su pplan t a bio psy. It is important to reco gniz e th ese lesion s becau se t hey are w hat I call †œdo n’ t touc h†lesion s (see Chapter 4 6). Then h ow are they best reco gnized? The best w ay is to familiarize o neself with their gen eral appearance by lo okin g at examples in t extbo oks. NOF s are benign. 5/23/2011 . asym ptom atic lesion s th at typically occur in the metaphysis o f a long bone..Ovid: Fundamentals of Diagnostic Radiology Page 28 of 57 FIGU RE 41 .20 ). A. wh ich is m erely co rtical replacement by benign fibro us tissu e. That c an be done in 1 5 minutes. h owever. wh ich w as believed to be suggestive of an aggres sive lesio n.

.. which can be misinterpreted as cortica l destruct io n (Fig. alt hou gh a few en tities can indeed occasionally simulate t hem. th ere will o ften appear to be interru pt io n o f t he co rtex. Th is is a typical appearance of a disappearing or healin g no nossifying fibro ma. Th is m erely repres en ts co rtical replacemen t by ben ign fibrous tissue an d sh ould n ot w arrant fu rth er investigation. this lesio n will m elt into th e no rm al bone and essen tially disappea r.10 74 FIGU RE 41 . is seen in th e proxim al h umerus in this child who is asym pt omat ic. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.Ovid: Fundamentals of Diagnostic Radiology Page 29 of 57 en tertained. P. which is minimally expan sile an d w ell defin ed. With time. 41 .. A predo minantly sclero tic lesio n.21 ). I f a CT o r MR is obtained o f an NO F. Healin g No nossifyi ng Fibro ma. 5/23/2011 .

. 3. it has sclerotic m argins and does no t abu t t he articula r surface. This large. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. It has a very t ypical appearance for a gian t cell tu mor. 5/23/2011 . The lesion un derwen t biopsy a nd w as foun d to be a n ono ssifying fibro ma. how ever.Ovid: Fundamentals of Diagnostic Radiology Page 30 of 57 FIGU RE 41 .. well-defined lytic lesio n w ith fain t sclero tic ma rgins is seen in the distal femu r. Non ossifyin g Fibroma.

Discriminators 1 . NOFs must be as ym ptomat ic and exh ibit n o perio stitis. I t h as intact co rtices an d con tains s ome calcified m atrix. Osteobl asto ma. No perio stitis or pain. A lytic expan sile lesio n invo lvin g th e right T12 pedicle (arro ) and tran sverse process is seen o n this an teropo sterior plain film. These lesio ns can occasionally get qu it e large (Fig. u nless th ere is an antecedent history of t raum a. 2. 41 . so o steobla stoma rem ain s. O steoblastom as h ave two appearances: (1 ) They look like large o steoid o steomas a nd are o ften called ian t o steoid ost eomas Becau se ost eo id osteo mas are mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. usually aro und the ages of 20 to 3 0 years. Wh y.22 ). 5/23/2011 . Du ring th is healin g period. th erefo re. NO F sh ould n ot be included in the differen tial diagno sis. Co rtically ba sed. th en . include them? Th e m nemon ic FEGNOMA SHIC w ou ld not have nearly t he sa me rin g w ith out the extra vo wel. m ultiple NOF s are seen about th e knee.. M ust be you nger than age 30 years. They rou tin ely †œhealâ € with s clero sis and even tually disappear (Fig. they can appear h ot on a radionu clide bon e s can becau se th ere is osteoblastic act ivit y. They are mo st co mmo nly seen about th e knee bu t can o ccur in an y lon g bon e. B.. Oc casio nally. grow th or cha nge in siz e sho uld no t alter th e diagno sis. 4.Ovid: Fundamentals of Diagnostic Radiology Page 31 of 57 FIGU RE 41 . This is a classic example of an o steoblastom a o f the spin e. A. steoblastoma steoblasto mas are rare lesions tha t co uld ju stifia bly be excluded from this differen tial withou t t he fear of m issing a diagnos is more th an once in a lifet im e. Th e lesion is seen on CT t o extend in to the vertebral body. each o f which is c haract eristic in appearance.23 ).10 75 I f the patien t is older th an 30 years of age. 41 . 3 . P.

24 ).2 5). w hich in clu des osteo blasto ma. 4 1. (2) They simu late a neurysm al bone cysts (ABCs). A classic radiology differential is t hat of an expansile lytic lesio n of t he po sterior elem ents of th e spine. In fact. th is is no t th e type o f o steoblastom a w e are con cerned with in t his differential. 41. m etastases can have an y radiographic appearance. 5/23/2011 . u nles s trauma or arthritis is the primary conc ern. O steoblastoma s com mon ly occur in the posterior elements of t he vertebral bodies. “Becau se th is lesion looks benign . a ny bon e lesio n in a patien t o lder tha n t he age of 4 0 shou ld have m et astatic disease a s a considerat ion . and t ubercu los is. a nd abo ut half of th e cases demon strate speckled ca lcifications (Fig. so it is not valid t o s ay.. often having a †œso apbu bble†appearance. I f an ABC is bein g con sidered. but a sign ifican t n umber o f metastases appear ben ign. so sho uld an o steoblastom a. therefore. Metastatic Disease and Myeloma M etastatic disease sho uld be co nsidered for an y lytic lesion†”ben ign or a ggressive in appearan ce—in a patient over 40 years of age. it shou ld not be a metas tasis.. Discriminator M entioned wh en A BC is mentioned (especially in the posterior elements of t he s pine).†Most m etastatic disease has an a ggressive appearance and will n ot be in the F EGNO MAS HI C differential. ABC. They are expansile.Ovid: Fundamentals of Diagnostic Radiology Page 32 of 57 s clero tic lesio ns a nd do no t resemble bubbly lyt ic lesions. Metastatic disease c an a ppear perfectly benign radiograph ically (Fig. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.

. m etastatic diseases wou ld have to be mention ed in every sin gle c ase of a lyt ic lesion . F or statistical purposes. I will be correct m ore tha n 9 9% of the t im e using 40 as a cu toff a ge. it can present as either a solit ary lesio n (Fig. I a m n ot cla iming that met astatic disease does no t o ccur in pat ient s youn ger than a ge 40 —on ly t hat I c onsider it acceptable to miss it (u nless given a history of a kn own prima ry n eo plasm ). 41.Ovid: Fundamentals of Diagnostic Radiology Page 33 of 57 FIGU RE 41 . lytic bo ne lesions of m yelom a are mo re mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.2 6). B ubbly.. as in this example. B iopsy show ed th is to be a ren al metastasis. A well-defined lytic lesio n is seen in th e pro xim al fem ur in th is 50 -year-old patient wh o had pain associated with th is lesion . I do no t m ention metasta tic disease in a patient yo unger t han age 4 0. 5/23/2011 .2 7) o r as m ultiple lytic lesio ns. Myeloma A lt hough m yelom a mo st comm only presen ts as a diffu se perm eative process in t he skeleton (Fig. . Oth erwise. A significan t n umber of m etastatic lesions can have a com pletely benign appea rance. 4 1. Metastatic Disease. and I prefer t o limit th e list of differen tial possibilities.

Discriminator M ust be o lder tha n age 40 years. FIGU RE 41 . V irtually any m etastatic process can present as a lytic. 4 1. in to one grou p an d using greater th an a ge 40 as the limiting facto r. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.. In gen eral. th ere is no harm in lumping all m etastatic disease. w hich a re w ell defin ed. 5/23/2011 . B . A diffu se permeative pattern is pres en t t hro ugho ut the femu r in th is patien t w it h m ultiple m yelom a.Ovid: Fundamentals of Diagnostic Radiology Page 34 of 57 c orrectly called p asmac to mas I m ention plas macytom a separately fro m m etastatic disease becau se it can occur in a sligh tly youn ger po pula tio n (age greater than 3 5 years is my cu toff) and can precede c linical or hem atologic evidence o f myelo ma by 3 to 5 yea rs.10 76 t ry t o gu ess th e sou rce of th e metast atic disea se from its appearance. t herefore. lytic expan sile m etastatic diseases tend t o co me from thyro id and renal t umo rs (Fig. benign-appearin g lesio n. .2 8). it serves no purpose t o P. Mul tiple Myeloma. The o nly metast atic lesion t hat is said to always be lytic is renal cell carcino ma. inc luding myelo ma. In gen eral. A. A lateral sku ll film sho ws a typical present atio n of mu lt iple myeloma in t he skull with mu lt iple sma ll h oles throu gh out th e calvaria..

mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. plasm acyt omas often h ave a co mpletely ben ign appearan ce. L ike m etastases. 5/23/2011 . lasmacytoma. A large. w ell-defin ed lytic lesion is seen in th e left ilium (arro s) in this patient with mu ltiple myelo ma.. Th is is a co mmo n locat io n for a pla smacytom a.Ovid: Fundamentals of Diagnostic Radiology Page 35 of 57 FIGU RE 41 . ..

30 ). They often h ave flu id†“flu id levels on CT o r MR (Fig. . alth ough th is is a non specific mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. altho ugh occasion ally o ne w ill be encou ntered in o lder patients.. P. 41 . an ABC will present before it is expan sile.10 77 neurysmal one Cyst n eu rysmal bon e cysts (AB Cs) are the only lesion s I kno w of that are na med for th eir radio graphic a ppearance. Metastatic Disease. Th ey are virtually alw ays an eu rysmal o r expansile (Figs. I use bo ny expansion and age o f less than 3 0 years as fairly rigid gu idelin es and seldo m miss th e diagnosis o f ABC. Aneu rysmal bo ne cysts occu r prim arily in patients wh o are yo unger tha n a ge 30 . 41 . bu t t hat is un usual en ough no t t o w orry abo ut.. 41 . Ra rely.31 ). An expansile lesion with a soap- bubble appearance is present in t he proxim al radius in a patient with renal cell carcino ma.Ovid: Fundamentals of Diagnostic Radiology Page 36 of 57 FIGU RE 41 . An expan sile lytic lesio n is a co mmo n findin g w ith renal or th yroid m etastatic disease. 5/23/2011 .29.

as man y oth er lesions can have fluid–fluid levels.Ovid: Fundamentals of Diagnostic Radiology Page 37 of 57 findin g. An expan sile lytic lesion is present in the distal femu r in th is 24 -year-old patient who presents with pain . A lso . bu t t his is m ere speculation . There are apparently t wo types o f ABCs: a primary type an d a secondary type. A BCs a re. An eu rysmal B one Cyst. osteo sarco mas. The secondary type o ccurs in conj unction w ith an other lesio n or from trauma . As to occurring after traum a. I suspect that AB Cs an d t raum a a re also coincidental. This is a fairly typical appearance for an an eu rysmal bo ne cyst . so mewh at co ntroversial.. Secon da ry A BCs h ave been s aid to occur w it h giant cell tum ors.10 78 w ere once tho ught to occu r after traum a because of th e frequen t asso ciat io n o f a h ist ory of ant ec eden t traum a w ith m alignan t bo ne tu mors. m alignant tu mors P. FIGU RE 41 . I h ave seen do zens of AB Cs an d have seen o nly a few in asso ciat io n w it h a noth er lesion. 5/23/2011 .. This is not seriou sly c onsidered t oday an d is th ough t t o be coinciden tal. like gian t cell tu mors. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. . I do not un derstan d w hy th ey wo uld be agelimited if trau ma were causat ive. w hereas a prim ary A BC h as n o kn own cau se o r associatio n with oth er lesio ns. and almo st a ny ot her lesion .

This is a ch aracteristic appea rance fo r an aneurysm al bon e cyst.3 . A w ell-defin ed expansile lesion is seen in t he m idsh aft of th e ulna in a child w ho presented with pain in this region .. An eu rysmal B one Cyst. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. 5/23/2011 .Ovid: Fundamentals of Diagnostic Radiology Page 38 of 57 FIGU RE 41 ..

31.. a nd t here is no location tha t w ould m ake them m ore highly ran ked in th e differen tial diagno sis. As with osteo blasto ma. Th is is a typical a ppearance for an aneu rysmal bo ne cyst. 5/23/2011 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.Ovid: Fundamentals of Diagnostic Radiology Page 39 of 57 FIGU RE 41 . An axial T2WI th rou gh a th oracic vertebral body sh ow s an expansile lesion involving the posterior elements th at h as severa l fluid–fluid levels (arro s). they o ften o ccur in th e po sterior element s of the s pine.. They can o ccur an yw here in th e skeleto n. A BCs t ypically present because o f pain . An eu rysmal B one Cyst.

mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. are characteristic for a solitary bon e cyst. as well as t he age of th e patient. A piece o f cortical bone h as broken o ff an d descended through the sero us fluid con tained w ith in th e lesio n and ca n be seen in the depen dent portion o f the lesion (arro ) as a fallen fragment sign. A fallen fragment sign is said to be path ogno mon ic fo r a unicam eral bon e cyst. A w ell-defined lytic lesion is present in th e pro xim al hum erus in t his child wh o suffered a fract ure through th e lesio n.. Soli tary Bo ne Cyst.. 5/23/2011 .Ovid: Fundamentals of Diagnostic Radiology Page 40 of 57 FIGU RE 41 . Th e location and central appearan ce.3 .

ho wever.3 2) an d pro xima l femu r (Fig. 4 1. w hich is a c omm on occurren ce.3 3). Even wh en path ologic fractu res occur. Mu st be yo unger th an age 30 years. This occu rs wh en a piece of co rtex breaks off a fter a fracture in a so litary bone cyst. 4 1. S olita ry bon e cysts are usually asympto matic u nless fractu red. th ey rarely fo rm perio stit is.32 ). mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. M ust be expansile. olitary one Cyst one c st s or nicamera one c st s olitary bon e cysts are a lso called sim p e They are not necessarily un icam eral (one com partm en t).. Many of th e ot her lesions may be central. rather than a lesio n filled w ith m atrix. Th is is the o nly lesion in FEGNOMA SHIC th at is alw ays cent ral in lo catio n. A classic radiograph ic finding for a solitary bo ne c yst is th e fallen fra gm ent sign (see Fig.. an d th e piec e of co rtical bon e sinks t o t he gravity-depen den t po rtion of t he lesio n. Applica tio n o f this rule alon e is n ot that h elpful. It is o ne of the few lesio ns that does not occu r most com mon ly arou nd the kn ees. o r one third to one fo urt h o f lesion s w ould be missed. 5/23/2011 . Th is has not been P. 2.Ovid: Fundamentals of Diagnostic Radiology Page 41 of 57 Discriminators 1 .10 79 described in an y oth er lesion and in dicates a fluid-filled cyst ic lesion . 4 1. Two t hirds t o three fo urt hs o f these lesions occu r in th e pro xima l hum erus (Fig. but a solitary bon e cyst can be excluded if it is no t.

is seen in th e pro ximal femu r in th is child. Th is is ch aracteristic for a solitary bo ne cyst . A w ell-defined lytic lesion.. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.33. 5/23/2011 . Soli tary Bo ne Cyst. wh ich is cent ral in lo cation.Ovid: Fundamentals of Diagnostic Radiology Page 42 of 57 FIGU RE 41 ..

. which is typica l in location and appearance for a solit ary bo ne cyst. A w ell-defined lytic lesion is seen in th e calcaneus abut tin g th e inferio r surface. Soli tary Bo ne Cyst. A solitary bon e cyst in th e calcaneus o ccurs almost exclu sively in th is lo cation and is not su bj ect t o pat hologic fractu re as readily as when o ne o ccurs in t he proxim al fem ur and hu meru s. 5/23/2011 .Ovid: Fundamentals of Diagnostic Radiology Page 43 of 57 FIGU RE 41 .34.. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.

3 . th erefo re. O steoporosis o r osteosclero sis might suggest that ren al osteodystrophy with s eco ndary HPT is presen t. Su bperio steal bo ne resorptio n is pathogn omo nic for HPT an d sh ould be P. th e bro wn tum or un dergoes sclerosis an d w ill even tually disappear. 2 . They begin at the ph yseal plate in lon g bon es an d grow in to the shaft o f the bone. ow ing to t he effect of paratho rmo ne. ragged appearance. Gen erally. 3. M ust be cent ral. or brow n t umo r can be safely excluded fro m t he different ial. M ust be youn ger than age 3 0 yea rs. solitary bon e cysts have been described in almo st every bo ne in the body. w here they have a characteristic location adja cen t t o the inferior surfa ce of t he c alcan eus (Fig.10 80 s earched fo r in the phalanges (part icu larly in th e radial aspect of th e m iddle ph alan ges) (Fig. but th is is un usual. addit io nal ra diographic fin din gs of HP T shou ld be seen. I f the physes are open . interrupted cortex. medial aspect of th e proximal tibias. they are n ot epiphyseal lesion s. bu t su bperiosteal res orption m ust be present . w hen the pa tient 's HP T is trea ted. If a bro wn tum or is going to be co nsidered in the differen tial diagno sis. distal clavicles (resorptio n). A lt hough lon g bon es are mo st co mmo nly involved. 4 1. how ever. Discriminators 1 .3 5). as in ricket s. 5/23/2011 . Bro n T umor. an d a second. B.34 ).3 5) to a sclerotic process. Th is makes t he diagnosis of hyperparathyroidism with mu ltiple bro wn tum ors mo st likely. best seen in th e radial a spect of the m iddle phalanges (arro s) as in distinct. A. fro m a pu rely lytic lesion (Fig. 41 . and sacro iliac jo in ts. No periost itis. An expan sile lytic lesion is seen in the fifth metaca rpal (arro s)..Ovid: Fundamentals of Diagnostic Radiology Page 44 of 57 FIGU RE 41 . This pa tien t is n oted to h ave subperiosteal bo ne resorptio n. extend up int o an epiphysis after the plate clo ses. S olita ry bon e cysts occur a lmo st exclusively in yo ung patients (un der age 30 ). mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. th ey shou ld have a fra yed. 4 1.. They can. yperparathyroidism ro n umors ro n tumors of hyperparathyroidism (HPT) can ha ve alm ost any a ppearance. smaller lytic lesion is seen in the proxim al port io n o f the fo urt h proxim al phalanx. A fairly comm on location is in the calcan eus.

A. 5/23/2011 . mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Osteomyeliti s. if th e articu lar su rface is abu tted. T2 WI o f the hum erus sho ws the lesion to have h igh signal an d an asso ciated joint effusion . S oft tissue findin gs su ch as o bliteration of adjacent fat planes are noto riously u nreliable a nd even misleading.. th ere is n o reliable w ay radiographically to exclu de a fo cus of o steom yelit is. w hich likely represents a drainin g abscess. A plain film o f the proximal h umerus in th is child with sho ulder pain reveals a well-defined lytic lesion in the medial m et aphysis.Ovid: Fundamentals of Diagnostic Radiology Page 45 of 57 FIGU RE 41 . It has a protean radiographic appeara nce an d can o ccur at any loca tio n a nd in a pat ient of any age. It migh t o r might not be expansile. Discriminator M ust have o ther eviden ce of HPT. a n effu sio n (Fig. w hich is a ccept able. infection will be in almo st every differential diagn osis o f a lytic lesion . more brow n t umo rs are seen in patien ts w it h seco ndary rath er than primary HPT. because t umo rs and EG can do the same thing. Wh en osteom yelit is occurs n ear a j oint. as it is one of th e m ost comm on lesion s enco unt ered. This is a large focu s o f osteom yelitis or B rodie abscess. o r have ass ocia ted periostitis (3). invariably th e jo in t w ill be involved and sho w cartila ge loss.3 . M ost auth orities believe t hat brow n tum ors occu r most com mon ly in primary HP T.. Infection Infection U nfo rtu nately. The probable site o f con nectio n to the joint can be seen (arro ). Therefore. B. h owever. because we see so many more patients with secon dary HPT. have a s clero tic or n onsclero tic border. Aspiration o f the joint fluid revealed pu s.

5/23/2011 . EG. Discriminator No ne. 4 1.38) (a h andful of cases ha ve been reported in th e m et aphyses. o r bo th. This finding is no t particula rly helpful. Th e fin ding of a s equ estrum in osteo myelitis can be significant for trea tment in t hat it usu ally requires surgical rem oval ra ther than an tibiotics alo ne becau se a sequestru m is a focu s o f devitalized bone that does no t h ave a bloo d supply an d w ill not be effect ively treated with parent eral medication. but it is occasion ally u seful in ru ling out ost eo myelitis w hen no effu sio n is present and the lesion abut s th e articu lar su rface. As mention ed previously.Ovid: Fundamentals of Diagnostic Radiology Page 46 of 57 4 1.10 81 o f calcificat io n is helpful. as an y lesion can cau se a n effu sio n. lym ph oma . with o steoid o steoma som etim es m imickin g a sequestrum.3 6). but th is is rare) and t hey oc cur alm ost exclus ively in patients youn ger th an the age of 30 years. Chondroblastoma Ch ondro blastomas are rare les ion s bu t are am ong the easiest lesion s for radiolo gists to deal w ith because they occur o nly in th e epiphyses (Fig. th e on ly lesions described th at dem onst rate sequ estra are in fection . bo th of wh ich can oc cur in th e epiphyses. 41 . Presen ce P. CT is ro utinely recom mended w hen osteo myelitis is co nsidered.. For t his reaso n. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. B etween 40 % and 60% demo nstrate calcification. so the absence o f calcificat ion is not helpfu l. I f a bo ny sequest rum is present. as long as o ne is certain that it is n ot detritus or s equ estra from infect ion o r EG.. osteom yelit is shou ld be strongly co nsidered (Fig.37 ). and fibro sarco ma.

w hich has some associated perio stit is lat erally.. Osteomyeliti s. CT scan th rou gh th is area reveals a lytic lesio n that con tain s a calcific density w ith in (arro ).Ovid: Fundamentals of Diagnostic Radiology Page 47 of 57 FIGU RE 41 . w hich is a bo ny sequestrum. 5/23/2011 . This is an area o f osteom yelitis with a bony sequestration. B .. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.3 . A lytic lesio n is present in t he proxim al h umerus. A.

or an u nnecessary bio psy of a geode migh t be perform ed o n the basis of th e differential o f an epiphyseal lesio n. w hich o nly occu r adjacent to articu lar s urfaces. and osteo phytes).Ovid: Fundamentals of Diagnostic Radiology Page 48 of 57 FIGU RE 41 . The clinician must be certain n o joint patho lo gy that might indica te on e o f these processes is present. the t arsal bo nes. Biopsy sh owed this t o be a ch ondroblastom a. and (4) avascu lar n ecrosis. classic different ial an d probably en compasses 98 % of epiph ys eal lesions. so it can usu ally be defin it ely ruled ou t o r in ).3 .. (3 ) calcium pyro phosph ate dihydra te crysta l dispo sition disease or pseu dogout . The carpal bo nes. 4 1. C on dro blastoma. s clero sis. A plain film in this yo ung patien t show s a well-defined lytic lesio n in the greater tu berosity o f the hum erus. with the exception o f geo des. A pophyses are identical to epiphyses as far as the differential diagnosis o f lytic lesions. 5/23/2011 . (2) ch ondroblastom a.. The differential diagnosis o f a lytic lesio n in the epiphysis o f a pat ient un der 30 years o f age is simple: (1 ) infection (m ost comm on). Th is is an old. an d (3) giant cell tum or (w hich has its ow n diagno stic criteria. A caveat on epiph yseal lesions is to always consider the possibility of a s ubchon dral cyst or geode (Fig.3 9). a nd t he patella ha ve mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. wh ich h as been described in fou r disease processes: (1) degenerat ive j oin t disease (mu st h ave jo int space narrow in g. (2) rh eumat oid arthritis.

FIGU RE 41 .Ovid: Fundamentals of Diagnostic Radiology Page 49 of 57 P. ho wever. t he biopsy c ould h ave been avoided. chon drom yxoid fibrom as resem ble NOFs. Ch ondromyxoid fibromas often ext end mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. is such a rare lesion th at failure t o mention it is probably no t go in g to resu lt in m issing mo re t han one in a lifetime. Basically. t hey can be s een in a patient of an y age. Mu st be epiphyseal. well-defined lytic lesio n in the proximal h umerus is present. a lyt ic lesion in t hese areas h as a similar differential diagnos is as an epiphyseal lesion . A biopsy was perfo rm ed. M ust be you nger than age 30. Why include it. U nlike NOFs. or subch ondral cyst. wh ich is asso ciat ed with marked degenerative disease o f the gleno hum eral jo in t.. ho wever. like osteoblastom a. but it is part o f the c lassic FE GNO MASHI C differential.. 5/23/2011 . Chondromy oid Fibroma Ch ondro my oi d fibroma. A large. 2. Discriminator 1 . the lytic lesio n shou ld be co nsidered to be a geode. Geo de. If it is mention ed. at least kno w what it loo ks like. then? I recom mend not including it. Therefo re.3 . Wh en defin ite degenerative jo in t disease is pres en t an d asso ciat ed with a lytic lesio n.10 82 a tenden cy to behave like epiphyses in th eir differential diagnosis of lesion s. wh ich co nfirm ed th is to be a geode.

as in this exam ple. whereas NOFs rarely do. Th ey have been repo rted to progress fro m a benign pro cess to an aggressive an d even m alignan t lesio n. ho wever. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. Discriminator 1 . t his un derwen t biopsy a nd w as fou nd t o be a ch ondromyxoid fibroma. but this is extremely rare. 5/23/2011 .4 .Ovid: Fundamentals of Diagnostic Radiology Page 50 of 57 int o t he epiphyses (Fig. 41 . wh ich w ill no t o ccur with an NOF.. C on dro my o id Fibroma.40 ). Chon drom yxo id fibro mas o ft en extend in to the epiphysis.. M ention wh en an NOF is m en tioned. FIGU RE 41 . Altho ugh cho ndro myxo id fibro mas are cartila gino us lesions. A well-defined lytic lesio n in the distal tibia th at extends slightly into th e epiphysis is no ted o n t his an teropo sterior plain film. No calcified mat rix. 2. c alcified cartilage matrix is virt ually n ever seen radiographically. A lso . A non ossifyin g fibroma cou ld certainly ha ve this appearance. th ey can present w ith pa in. whereas n ono ssifying fibro mas usually do not .

is the differen tial diagno sis for a ben ign cystic lesio n o f bone. 5/23/2011 . I f there is a favorit e lesion th at is not on th is list. Lesions in atients ears of Age ounger T an E osin ophilic granu lo ma An eurysm al bone cyst Non ossifyin g fibroma Cho ndro blast oma So litary bon e cyst mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. by all means add it.. w hich is good enou gh for m ost radiologists.. I am un able to make it much simpler t han that an d still be reaso nably accurate. I t is probably 9 8% accurate. an d th e wh ole pro cess w ould beco me t oo confusing fo r most radiolo gists to learn and P.Ovid: Fundamentals of Diagnostic Radiology Page 51 of 57 S MMA Tha t. it wou ld be necessary to add many unco mmo n o r rare lesion s. in essence. forget abou t o steoblastoma and c hondrom yxoid fibrom a. if th e list is already too cum bersom e. L ikew ise.10 83 a pply. To increase th e accu racy t o 99% . TABLE 41.

. o ssifying fibro ma. pseu dotum or of h emoph ilia. but are best left to t he pat hologist—no t t he radio lo gist†”for th e diagnosis. If th e patient is over 30 years of a ge. glomu s tu mor. other lesio ns such as fibrou s dysplasia a nd infection must also be men tio ned. and s chwan nom a. mus t be mention ed ro utinely. n eu ro fibrom a. There are a few lytic lesion s th at h ave no go od discriminato rs oth er t han age a nd. plasma cell granu lo ma..3).2 ). it sim ply m eans these en tities shou ld not be m entioned in older pa tient s. For instan ce. Infectio n a nd E G mu st be mention ed for t hose younger th an age 3 0. be sure to co nsider E G c o ndro asto ma NO F so itar one c st. whereas m et astatic disease an d infect io n m ust be included in an y differential in a patient older t han age 4 0 (Table 41 . I call t hese lesio ns â €œauto matics†because one shou ld auto matically m ention them rega rdless of t he locat io n o r appearance of th e lesio n. TABLE 41. These lesions have a pro tean radiograph ic appearan ce an d sho uld be m entioned not o nly in t he ben ign cystic differential but also fo r an a ggressive lesion. †Automatics†You nger than age 30 Infection Eos ino philic granulom a Older than age 40 Infection Metast atic disease and myelo ma S ome of th e lesio ns I h ave purpo sefu lly om itt ed are intra osseous ganglio n. O thers cou ld be added t o t his list.4 Lesions T at Ha e No eriostitis ain or mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. hem angioendot heliom a.Ovid: Fundamentals of Diagnostic Radiology Page 52 of 57 TABLE 41. t herefore. There are several features th at are so mewh at usefu l in separatin g th e variou s lesions in FE GNOM ASHIC. of co urse. if the patien t is yo unger th an the a ge of 3 0 years. an d A C (Table 41. int raosseo us lipoma. Fo r those youn ger t han age 3 0. 5/23/2011 . tho se five lesions can be excluded. Not e th at th is is no t a differential diagnosis for lesions in patients u nder age 3 0.

In fection Epip yseal Lesions Giant cell t umo r Cho ndro blast oma Geode I f periostitis or pain is present (assuming no trauma. 4 1.4 ). add m etastatic disease an d m e om a an d remove c ondro astom a from t he epiphyseal list. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20.. and t he pat ella. yo u can exclude fi ro s d sp as ia so itar on e c st NO F. a unicameral bo ne cyst sho uld also be con sidered and has a ch aract erist ic appearan ce and loca tio n (see Fig.3 4).. wh ereas a pophyses serve as ligamento us attachm ents. The differen ce between an epiph ysis and an a pophysis is th at epiphyses co ntribut e to th e length of a bone. an d en c on drom a (Table 41. 5/23/2011 . The epiph yseal differen tial tends t o apply also to the tarsal bones (especially th e c alcan eus). If th e patient is over 40 years of age. wh ich can be a foolhardy a ssumption ). If th e lesio n is epiphyseal.5 ).Ovid: Fundamentals of Diagnostic Radiology Page 53 of 57 Fibro us dysplasia E ncho ndro ma Non ossifyin g fibroma So litary bon e cyst TABLE 41. the carpal bo nes. Apo physes are †œepiphyseal equivalentsâ € and h ave t he sa me different ial as epiph ys es. In th e calcaneu s. th e differential is infection ian t ce t m or c o ndro ast oma (an d do no t forget eodes) (Table 4 1.

Ch ondroblastom as an d ost eoblast omas dem onst rate calcified m atrix abo ut half the tim e. M = m et astatic diseases an d m e oma. and size of th e lesio n. or s equ estration s in osteom yelitis can mimic ch ondroid or o steoid calcification and be misleading. in w hich F = fi ro s d sp asia. TABLE 41. B e c arefu l of th is.10 84 o r the chon droid series of lesio ns. Differential for ib Lesions Fibro us dysplasia An eurysm al bone cyst M et astatic disease an d m yeloma E ncho ndro ma and eo sin ophilic granu lo ma TABLE 41. Very few radio lo gists can reliably different iate chon droid from o steoid m atrix. 5/23/2011 . it is tempting t o n arrow the differen tial to eith er t he o steoid series P.7). det ritus. an d I infect ion (Table 41 . cys tic rib lesio ns is the mnem onic F AME. Rou tin e calcificatio n of a lesion or debris. F EEM HI is a useful m nemon ic of th e lesio ns in FEGNOM ASHIC that can be m ultiple: F = fi ro s d sp a sia. presence o r absence o f bony stru ts o r c ompartment s in the lesion.. a nd E enc ondroma and EG (Table 41 . M = metast atic disease a nd m e om a. Multiple Lesions FEEMHI mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. H perparat roidism (bro wn tum or). I f calc ified matrix is ident ified in a lesion . sclerotic or non sclerotic bo rder (except it mu st be n onsc lero tic in giant cell tum or).. E E G.6). A = A C.Ovid: Fundamentals of Diagnostic Radiology Page 54 of 57 A classic different ial for benign. Th e o nly lesion tha t m ust exh ibit ca lcified m atrix is th e en chon drom a (except in t he ph alan ges). an d cho ndro myxoid fibromas n ever h ave radiographically demo nstrable calcified m atrix. depen ding on th e character of t he m atrix. A few findings that just do no t seem to narro w the differen tial diagno sis are presence o r absence o f a s oft tissue mass. If m ultiple lytic lesion s are presen t. expan sio n o f the bone (except it must be present in an A BC). E en c on drom a.

4 1. in ciden tal finding. the P. 4 1.41 ).Ovid: Fundamentals of Diagnostic Radiology Page 55 of 57 Fibro us dysplasia E osin ophilic granu lo ma E ncho ndro ma M et astatic disease an d m yeloma Hyperparathyro idism (bro wn tu mors) In fection DIFFE ENTIAL DIAGNOSIS OF A SCLE OTIC LESION M any lytic lesio ns spo ntan eously regress an d are no t u sually seen in patients o ver 3 0 yea rs of age. osteoid osteom a. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20... Several ot her lesion s sho uld be included that can also a ppear sclero tic: fibrou s dysplasia. especially if it is an a sym ptoma tic. bro wn tum or (h ealing).10 85 following lesions sho uld be c onsidered: NOF (Fig. they o ften fill in with new bo ne and h ave a sclerotic o r blastic a ppearance. aneurysm al bone c yst. Th erefo re. solitary bo ne cyst. Wh en t hese lesio ns regress. the nu mber one possibilit y sho uld be metast atic disease. and cho ndro blasto ma. 5/23/2011 . when a sclerotic focu s is identified in a 20. EG. an d perh aps a gian t bo ne island (Fig.t o 4 0-year-o ld patien t. infection.4 2). I n any patient older than th e age o f 40 years.

A plain film of th e knee in th is 25 -year-old patient reveals a sclerotic lesio n in th e pro ximal tibia. w hich is a h ea ling or reso lvin g n ono ssifying fibro ma.Ovid: Fundamentals of Diagnostic Radiology Page 56 of 57 FIGU RE 41 .. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. 5/23/2011 . Healin g No nossifyi ng Fibro ma..41.

Radio lo gic featu res o f eosinoph ilic granu lo ma of bon e.4 . and scin tigraphy. CT. A JR A m J Ro entgeno l 19 91.. The slightly feat hered margins of th e trabeculae.1 53 : 102 1†“1 02 6. Go ld R. which represen ts a giant bone is land.Ovid: Fundamentals of Diagnostic Radiology Page 57 of 57 FIGU RE 41 . AJR Am J Roentgen ol 1 989 .15 7:365 –37 0. et al. Kum ar R. Katz R.. and t he lon g axis of t he lesion being in t he direction of prim ary weigh t bearin g are cha racteristic for a bon e islan d. 2. Giant Bon e Island. Dah lin D. Bacterial o steomyelitis: findings o n plain radiograph y. David R. Pictorial essay. Gian t cell tum or of bo ne: highligh ts o f 40 7 cases. mk:@MSITStore:M:\medicalheaven_radiology2\Fundamentals%20of%20Diagnostic%20. A large sclerotic lesion is presen t in th e right supraacetabular region of t he iliu m (arro ).14 4:955 –96 0. AJR Am J Ro entgeno l 19 85. w hich blend in with the no rmal bo ne. 5/23/2011 . EFE ENCES 1. 3. MR. O ria R. Pictorial ess ay. Hawkins R.