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Imaging of Musculoskeletal Neoplams

Part I
Osteoblastic Tumors

Timothy G. Sanders, M.D.
Benign Osteoblastic Tumors
• Osteoma
• Enostosis (Bone Island)
• Osteoid Osteoma
• Osteoblastoma

Osteoma -Benign Tumor
-Cortical dense lamellar bone
-Arises on outer surface of bone
-Facial/ skull region (typical)
-Single
-Multiple (Gardner’s Syndrome)
-Colonic polyps, desmoids
Bone Island
-Asymptomatic
-Radiography
-Round/oval osteosclerosis
-Margins blurred/ spiculated/
brush-like appearance
-CT - Uniform, no destruction
-MRI -Low signal T1/T2; no
edema
-Nuc Med- warm/ not hot
-DDX: sclerotic met/ osteosarcoma/
osteopatha striata/ osteopoikilosis
Osteopoikilosis
-Closely related to osteomas and bone islands
-Multiple bone islands clustered at ends of bones/ metaphysis
-Symmetric distribution is characteristic
-Lamellar bone
-Identical to bone
islands
Melorheostosis
-Usually incidental
-Can present with
bone pain
-Decreased ROM/
joint pain
-Overlying skin
thickening
-Cortical hyperostosis
in a dermatomal
distribution
-Diaphyseal; can
cross joints-
contractures
Osteopatha Striata
-Incidental radiographic
finding
-Usually asymptomatic
-Longitudinal striations
-Metaphyseal
Osteoid Osteoma
• Age: 5-25 y.o.
• Male 3/1
• Location
– Long bones of lower extremities
– bones about the elbow
– Posterior elements of spine
• Night pain – relieved by aspirin
• Spine – painful scoliosis
– Concave toward the lesion
• Fibrovascular nidus
– Surrounded by extensive sclerotic reactive bone
– Nidus <1 cm/ may calcify

Osteoid Osteoma
Radiographic Appearance
-Well demarcated lucent nidus
-Nidus < 1cm
-Wide zone of surrounding
sclerosis
18 y.o. male collegiate swimmer from the University of
Hawaii with thigh pain
Osteoid Osteoma
-Sclerosis often absent in lesion of
small bones of hands and feet or
intra-articular lesions

-Intra-articular lesion can mimic
other lesions such as geode or
intraosseous ganglion

-Diagnosis often delayed
Osteoid Osteoma
-Sclerosis absent
-Mimic intraosseous ganglion
-Bone scan “double density
sign”
Osteoid Osteoma
- Sclerosis absent
- “Double density sign” on bone scan
Osteoid Osteoma
-CT -excellent for localization
of nidus
Forearm
Focal nidus on CT scan with surrounding sclerosis
Tibia
Osteoid Osteoma
-Treatment
-Percutaneous radio-frequency
ablation
Focal enhancement of nidus on MR imaging
T1
T2
T1
GAD
Osteoblastoma
• Histologically similar to osteoid osteoma
– Fibrovascualr stroma
• Larger (1.5 – 2.0 cm)
• Lacks nocturnal pain
• Age: 2
nd
decade
• Location:
– posterior elements of spine- expansile (DDX: ABC,
GCT)
– Less common long bones LE- bone producing (DDX:
Osteoid osteoma, osteosarcoma)

Osteoblastoma
-Nidus >1.5 cm
-Expansile in spine
-Less sclerosis
-Secondary ABC common
Long bone- osteoid production
Bone scan- intense uptake
MRI- intense enhancement
DDX: OS, Osteoid Osteoma, ABC
Osteoblastoma
Osteoblastoma
Osteoblastoma
Fibrovascular nidus-
usually > 2cm
Osteoblastoma
Malignant Osteoid Producing
Tumors
• Intramedullary osteosarcoma
• Secondary osteosarcoma
• Parosteal osteosarcoma
• Periosteal osteosarcoma
• Multifocal osteosarcoma
Osteosarcoma
• Most common primary malignant bone
tumor (>20%) excluding MM
• Produces osteoid or immature bone
• Ages:
– 1
st
peak 10 – 20 y.o.
• Location: distal femur/ proximal tibia/ proximal
humerus
– 2nd peak > 50 y.o.
• Location: axial skeleton- pelvis, skull
Osteosarcoma
• Radiography- varies greatly
– Sclerotic
• Matrix: cloud like (can be very dense)
• Asymmetric involvement of bone
• Soft tissue component common
– Lytic
– Aggressive periosteal reaction
• Sunburst/ Codman’s triangle/ “onion skin”
Osteosarcoma
-Osteoid matrix “cloud like”
-Mixed lytic/ sclerotic lesion
-MR shows extent of lesion
Osteosarcoma:
High Grade intramedullary
Osteosarcoma:
High Grade intramedullary
Osteosarcoma:
High Grade intramedullary
Osteosarcoma
DDX: fracture callous/
osteomyelitis/ osteoblastoma/
Chondrosarcoma/ MFH/ GCT
-Radiation induced osteosarcoma
in a patient with history of fibrous
dysplasia

-2
nd
peak >50 y.o. (axial skeleton)
-Predisposing factors
-Paget’s
-Enchondroma/osteochondroma
-Chronic osteomyelitis
-Fibrous dysplasia
-Infarcts
24y.o. male with pathologic fracture
Telangiectatic Osteosarcoma
• Age: 10 – 20 y.o.
• Osteoid producing malignant tumor
• Pain; swelling; femur/tibia/humerus
• Imaging:
– OS: lytic destructive with aggressive periostitis
– Telangiectatic: cystic blood filled spaces with
malignant cell in septae; expansile, purely lytic
– DDX ABC/ UBC
Osteosarcoma:
Telangectatic
Resected
Specimen
Parosteal versus Periosteal Osteosarcoma
Parosteal Sarcoma
-Well-differentiated bone forming tumor Age: 2-5 decades
-Arises from outer surface of bone (slow growth; better prognosis)
-Metaphysis (80% distal posterior femur) other long bones
X-ray- stuck on appearance- dense centrally
Parosteal Osteosarcoma: stuck on appearance
-Stuck on appearance- dense centrally
-Can involve the medullary space
Myositis Ossificans Traumatica
Juxtaposed to bone
-Dense peripherally
Osteochondral Exostosis (OCE)
Cortex and medullary
space continuous with
host bone
Osteosarcoma:
Periosteal Osteosarcoma
• Rare lesion, second decade,
female>male
• Almost always diaphyseal lesion of
tibia or femur
• Radiograph shows sunburst lesion
resting in saucerized cortical
depression
• Histology is generally chondroblastic
and lesion is intermediate to high grade
Osteosarcoma:
Periosteal Osteosarcoma
-Arisess on surface of bone- elevated spiculated periosteal reaction
Recurrent Osteosarcoma
Multifocal Osteosarcoma
-Rare lesion (0.1% of all OS) Synchronous- simultaneous lesions
symmetric in size/distribution- metaphyseal osteosclerotic
-Children- poor prognosis- metachronous- ? bone mets (10-20%)
Metachronous lesions in adults- sites of XRT/ Paget’s