Key points in the evaluation of focal bone lesions: from plain

film to multidetector CT

Poster No.: C-2060

Congress: ECR 2011
Type: Educational Exhibit
Authors: I. Rubio Marco, M. Arraiza Sarasa, H. Gómez Herrero, A. De Blas
Mendive, I. García de Eulate, C. De Arriba Villamor, A. Ovelar
Ferrero, M. Tirapu Tapiz; Pamplona/ES
Keywords: Diagnostic procedure, Plain radiographic studies, CT,
Musculoskeletal bone
DOI: 10.1594/ecr2011/C-2060

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Learning objectives

• To review the features that should be evaluated to radiographically

differenciate aggressive from non-aggressive focal bone lesions and try to
characterize them with plain film and multidetector CT.
• To identify the main advantages and limits of each technique.
• To ilustrate this review with some cases studied in our institution.

Background

Radiologists play a key role in the detection and characterization of focal bone lesions.
Bone tumors are relatively uncommon in general radiological practice and they show
varied appearances, so it is crucial to evaluate the images in a systematic manner to lead
to a short differential diagnosis list, guiding the further management of these patients.

Conventional radiography is the first-line imaging technique in the evaluation of patients

with bone tumors. In the 1960s, Dr. Gwilym Lodwick, professor of radiology, introduced a
systematic approach to the radiological diagnosis of bone tumors that is still used today
with some more recent contributions, as we will see later.

A lot has been said and written about the analysis of focal bone lesions with conventional
radiography but not too much with computed tomography (CT).

In this exhibit we will review the fundamental radiographic principles in bone tumor
diagnosis and the correlation between plain film and CT images, emphasizing on the
aditional information provided by the last one.

Imaging findings OR Procedure details

The diagnostic approach to focal bone lesion should include:

1. Clinical information

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 2. Number of lesions (solitary or multiple)
3. Location
4. Morphologic features

1. Clinical information:

The age of the patient is the most important piece of clinical information because the
majority of bone lesions show predilection for a specific age range: <20, 20-40 and >40
years old.

Fig.: Group age predilection of bone lesions

References: Miller T. Radiology 2008; 246:662-674

Page 3 of 32
Most primary bone tumors develop in childhood, late adolescence or early adulthood,
coinciding with the growth spurt and the time of maximal metabolic activity of bone.

Some other parameters that should be evaluated are family history (eg, hereditary
multiple osteochondromatosis, neurofibromatosis), past history (eg, evaluation of
metastatic disease) and history of presenting complaint (eg, swelling, characteristics
of pain...).

Laboratory data (eg, alkaline and acid phosphatases, PSA levels, neutrophilia...) may
also provide useful information.

2. Number of lesions:

Benign and malignant lesions can be multiple. Benign multiple tumors include polyostotic
fibrous dysplasia, enchondromatosis, multiple osteochondral exostoses, Langerhans
cells granulomatosis and some more. When malignant multiple bone lesions, they are
commonly caused by metastases, multiple myeloma or lymphoma.

3. Location:

Certain tumors have predilection for specific bones or specific locations within bones.

Page 4 of 32
Fig.: Preferential localization of bone tumors in the skeleton
References: Differential Diagnosis of Tumors and Tumor-like lesions of Bones and
Joints. Adam Greenspan, Wolfgang Remagen

Page 5 of 32
Fig.: Specific sites of selected tumors
References: Bone Tumors and Tumorlike Conditions: Analysis with Conventional
Radiography. Miller T. Radiology 2008; 246:662-674. Differential Diagnosis of Tumors
and Tumors-like lesions of Bones and Joints. Adam Greenspan, Wolfgang Remagen

Within long bones, the radiologist must determine the location in the longitudinal
(epiphysis*, metaphysis and diaphysis) and axial (intramedullary, intracortical and
surface or juxtacortical -the last ones include parosteal and periosteal lesions-)
planes. However, in short or thin tubular bones, such us the metacarpals or phalanges,
the entire diametre of the bone can be involved, sometimes making it difficult to determine
in which part of the bone the lesion started.

*An apophysis is equivalent to an epiphysis because both of them are growth centers
(the first one does not contribute to the length of a bone and the second one does).

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Most primary bone lesions are metaphyseal and intramedulary, probably because the
metaphysis is the most metabolically active and most vascular area in a growing long
bone.

Fig.: Common location of tumors and tumorlike bone lesions. Based on the diagram
published by Miller, AJR 2009 Vol 246 Num 3
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

4. Morphologic features:

a. Patterns of bone destruction:

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They reflect the growth rate rather than the malignant potential of the lesion. The patterns
may range from a discrete well-defined abnormality to an ill-defined infiltrative process.

Fig.: Patterns of bone destruction.

References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

• geographic destruction (type I): bony destruction is confined to one area

within which all bone is destroyed. These are slow-growing lesions. Based
on their aggressiveness they are subclassified in three groups:

- type Ia (sharp margins with thick sclerotic rim), usually benign.

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Fig.: Type 1a geographic bone lesion.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

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Fig.: Type 1a geographic lesion.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

- type Ib (sharp margins without sclerotic rim), usually benign.

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Fig.: Type 1b geographic lesion.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

Page 11 of 32
Fig.: Type 1b geographic bone lesion.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

- type Ic (ill-defined margins), usually malignant

• moth-eaten destruction (type II): multiple clustered foci of bone destruction,

each one 2-5 mm size. This pattern reflects a lesion that grows rapidly
through the medula of the bone but leaves small islands of tissue intact.

• permeative (type III): multiple ill-defined destructive foci, usually smaller

than 1 mm in diameter. This pattern reflects fast-growing lesions.

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Fig.: Type 3 permeated lytic lesion.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

• combination and changing pattern: characterised by a combination of type-

I, type II and type III in a single lytic lesion and suggests more aggressive
local growth. This pattern is usually seen in some benign lesions when they
become active, undergo malignant change or fracture.

However, while a non-aggressive appearance suggests a benign lesion and an

aggressive appearance suggests a malignant one, it is not always the case

b. Periosteal reaction:

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Periosteal reaction results when cortical bone reacts to one of many possible insults
(trauma, congenital disease, arthritis, metabolic disorders, infection, tumors...). It is
another indicator of the biological activity of the lesion as its appearance is determined
by the intensity, aggressiveness and duration of the underlying insult. Thus, intense,
rapid-acting processes usually result in aggressive periosteal reaction, whereas slower,
indolent result in a non-aggressive appearance, regardless of being benign or malignant.

One has to bear in mind that the periosteum in children is more active and less adherent
to the cortex than in adults, so periosteal reaction can occur earlier and appear more
aggressive.

The terminology used to describe periosteal reactions is confusing because many terms
have been used. In 1965 Lodwick described two "proliferative responses": encapsulated
and mottled. In 1966 Edeiken coined the term "periosteal reaction" and described
continuous and interrupted forms. To summarize, we can consider two major groups:
aggressive and non-aggressive.

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Fig.: Types of non-aggressive and aggressive periosteal reaction. (Based on AJR:193,
October 2009)
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

The major goal in evaluating periosteal reaction is to recognize its presence rather than
the specific subtype because there is significant overlap in the disease entities that result
in aggressive and non-aggressive forms.

Sometimes the subtype of periosteal reaction can suggest a certain process:

- Solid periosteal reaction (thin or thick): It is radiographically seen as a focal area of

cortical thickening. It is a non-aggressive form associated to benign slow processes
(healed fracture, osteoid osteoma and osteomyelitis)

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Fig.: Solid periosteal reaction (osteoid osteoma)
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

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Fig.: Solid periosteal reaction (osteomyelitis).
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

- Single lamella: It is radiographically seen as a dense line 1-2 mm from the outer surface
of the bone. If this space fills with new bone, it will result in a solid periosteal reaction.
Suggests slow-growing lesion.

- Laminated periosteal reaction (onionskin) consists in multiple layers of new bone. It is

seen in a variety of lesions (osteomyelitis, sarcomas, chondroblastomas…)

- Spiculated periosteal reaction: It is an aggressive form that appears when linear spicules
of new bone form along newly form vascular chanels and fibrous bands. It includes:

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- perpendicular/hair-on-end subtype, in which spicules of bone form perpendicular to
the periosteal surface. It is highly suggestive of Ewing´s sarcoma. It may coexist with a
lamellated pattern

- sunburst pattern, with spicules radiating in a divergent pattern. It is often associated

with conventional osteosarcomas.

Fig.: Aggressive periosteal reaction (prostate cancer metastases).

References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

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Fig.: Aggressive periosteal reaction (lung cancer metastases)
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

- Codman triangle: It is an aggressive form that develops when a portion of periosteum is

lifted off the cortex by a mass at the leading point. It is commonly seen in osteosarcomas
and occasionally with infection, metastases or hemangiomas.

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Fig.: Codman triangle in osteosarcoma.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

Considering the unilaterality or bilaterality of the periosteal reaction may be helpful in

guiding the diagnosis:

- If unilateral it is more likely to be caused by a localized process (trauma, infection or

tumor).

- If bilateral, one has to consider systemic processes (arthritis, metabolic, congenital,

genetic, drug-related and vascular entities). In this setting, the age of presentation of the
periosteal reaction can often narrow the diagnosis:

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- < 6 months: physiologic periostitis of the newborn, Caffey disease (also known as
infantile cortical hyperostosis) and periostitis related to prostaglandine use.

- > 6 months: hypertrophic osteoarthropathy, juvenile idiopathic arthritis, hypervitaminosis

A and venous stasis.

(In the appropiate clinical setting, it is essential to consider nonaccidental trauma as the
underlying cause of multiple healing fractures).

c. Mineralization of tumor matrix:

Recognition of several types of matrix mineralization is helpful in distinguishing different

histologic types of primary bone tumors.

The term matrix refers to the type of tissue of the tumor (osteoid, chondral, fibrous or
adipose), all of which are radiolucent, and mineralization refers to calcification of the
matrix. The pattern of mineralization can be a clue to the type of underlying matrix.

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Fig.: Types of tumor matrix.
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

- Osteoid matrix shows an opaque radiographic appearance: mature ossification

typically shows greatest density peripherally, but inmature ossification may be difficult to
distinguish from calcification because its appearance is like an ill-defined, homogeneus,
cloud-like increased density.

A bone-forming tumor is frequently indistinguishable from the bone apposition secondary

to bone destruction in the setting of a fracture or reactive sclerosis, but the identification of
irregular osteoid incompletely mineralized matrix within or adjacent to a bone destruction
region is highly suggestive of osteosarcoma. In the same way, cloudlike densities within
medular cavity represent tumoral bone.

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- Chondroid matrix shows punctate, flocculent, arclike or ringlike calcifications. Malignant
transformation within a chondral lesion may produce focal destruction of the chondral
calcifications.

Fig.: Chondral mineralization.

References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

It can be difficult to distinguish between osteoid and chondroid matrix: the first one usually
shows an amorphous appearance and the second one presents in a organized fashion
(trabeculated).

- Fibrous matrix shows ground-glass density. Punctate calcification may also be present.

Page 23 of 32
Fig.: Fibrous matrix tumor
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

Faint mineralization in a lession is best assesed using CT, which is mores sensitive than
radiographs for differences in attenuation.

d. Size

The likelihood of malignancy increases with the size of bony lesions. For example, a 1-2
cm chondral lesion in a long bone is most likely to be an enchondroma, while the risk of
being a low-grade chondrosarcoma increases if it is greater than 4 or 5 cm.

Page 24 of 32
The size of a lesion can also be a clue to its diagnosis. For example, the nidus of the
osteoid osteoma is less than 1,5 cm in diameter, while the osteoblastoma is larger than
1,5 cm.

e. Cortical response:

The cortex may be affected by processes that originate in the medullary canal,
periosteum, surrounding soft tissue or within the cortex.

As a medullary lesion expands, it may cause erosion of the inner surface of the cortex,
called endosteal scalloping. It commonly suggests a chondral or fibrous tumor.

Fig.: Cortical response (I).

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References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

Fig.: Cortical response (IV).

References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

If the medullary lesion is so aggressive that it erodes the inner aspect of the cortex
without giving the periosteum time to lay down new bone, the cortex will eventually
be destroyed. The most aggressive malignant lesions can penetrate the cortex before
cortical destruction is radiographically visible, so apparent preservation of the cortex does
not preclude its involvement.

Page 26 of 32
Fig.: Cortical response (III).
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

On the other hand, cortical expansion implies that endosteal bone removal due to the
lesion is occurring at a similar speed to periosteal bone production. Depending on the
aggressiveness of the lesion, the ballooned cortex may have normal thickness or be thin.

Page 27 of 32
Fig.: Cortical response (II).
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

A process that arises either in the periosteum or adjacent soft tissue may erode the outer
surface of the cortex. This feature called saucerization or scalloping of the bone´s outer
surface can reveal the presence of a soft tissue extraosseus mass otherwise not visible.

f. Soft tissue component:

The presence of soft tissue mass with a bone lesion suggests a malignant process.
Exceptions are giant cell tumor, aneurysmal bone cyst, desmoplastic fibroma and
eosinophilic granuloma.

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Inflamatory processes may also show soft tissue mass or swelling, but in these cases
the mass is not well-defined and fat planes are affected.

Fig.: Soft tissue mass (giant cell tumor).

References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

Page 29 of 32
Fig.: Soft tissue mass (bone metastases secondary to breast cancer).
References: I. Rubio Marco; Radiología, Hospital Virgen del Camino, Pamplona,
SPAIN

However, the first question should be: is it a bone tumor with extension to soft tissue
planes or is it a soft tissue mass that invades the adjacent bone? Some features may
help to answer this question:

- the size of the bone lesion: if it is a small bone lesion with large soft tissue component
associate, it is more likely to be a primary soft tissue tumor. Ewing´s sarcoma may be an
exception, because it may show a large peritumoral mass.

- the presence of periosteal reaction: it is usually associated to bone tumors.

Page 30 of 32
- the location of the epicenter of the lesion within the bone.

To finish, we well summarize the advantages of CT on the field of focal bone lesions:

• CT remains superior to plain radiography in demonstrating tumor matrix

mineralization.

- In osteoid osteoma, CT is more sensitive than MR imaging in detecting the nidus,

periosteal reaction and cortical thickening.

- In osteomyelitis, sequestra and air within regions affected are more readly identificable
by CT.

- CT is also highly sensitive in the detection of fluid-fluid levels, which are seen
most commonly in aneurysmal bone cyst and also in various rarer lesions, including
telangiectatic osteosarcoma.

- CT aids in the detection of calcium and fat in a soft tissue mass, which are characteristic
in certain tumors, such us synovial chondromatosis, myositis ossificans and well-
differenciated liposarcoma.

• CT serves as guidance for biopsy and, in some cases, for treatment. For
example, radio frequency (RF) and treatment of osteoid osteoma.

Conclusion

The radiologist is essential in the diagnosis of a focal lesion in bone. Plain film is still the
starting point in the evaluation of these lesions but new techniques add useful information
for the management of these patients.

By paying attention to the age of the patient and the location and radiological features
of the lesion, the radiologist will lead to a short differential diagnosis list, if not to the
correct one.

A team work among radiologists, surgeons and pathologists is mandatory for correct
diagnosis and proper management and follow-up of the patient.

Page 31 of 32
Personal Information

References

1. The Evolution of Musculoskeletal Tumor Imaging. Sinchun Hwang, David M.

Panicek. Radiol Clin N Am 47 (2009) 435-453.
2. Periosteal Reaction. Rana, Wu and Eisenberg. AJR 2009; 193:259-272.
3. Evaluation of focal bone lesions: basic principles and clinical scenarios. P O
´Donnell. Imaging 15 (2003), 298-323.
4. Bone Tumors and Tumorlike Conditions: Analysis with Conventional
Radiography. Miller, T. Radiology 2008; Vol 245: Number 3.
5. Malignant and Benign Bone Tumors. Miller, S and Hoffer, F. Radiol Clin
North Am 2001; Vol 39: Num 4.
6. Differential Diagnosis of Tumors and Tumors-like lesions of Bones and
Joints. Adam Greenspan, Wolfgang Remagen.
7. CT-guided needle biopsies of bone and soft tissue tumors a pathologist's
perspective. Mc Carthy, E. Skeletal Radiol 2007; 36:181-182.

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