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Imaging of

Musculoskeletal Tumors
57 kg
Neurofibromatosis involving
the whole R
lower
extremity

The objectives of radiologic


evaluation
detection of suspected lesion: +/-,
soft tissue or bone tumor
establishment of a diagnosis or
formulation of an appropriate
differential diagnosis, and
radiologic staging of the lesion*
*not discussed

Challenges in Diagnosis
Rare (< 1% from all malignant neoplasm)
Treatment choice can be drastic (amputation)
Radiograph interpretation have its limitation in
differentiating between malignant and benign
lesion: ABC can looked malignant, intraosseous
sarcoma can be seen as benign.
Kilpatrick S, Renner JB, Diagnostic Musculoskeletal Surgical Pathology, 1-4, 2004, Saunders

Tripple diagnosis Multidisciplinary


approach

FNA

Clinical Info

Imaging

Plain
Radiograph

Ultrasound

Scintigraphy

MRI

CT Scan

Despite all of the imaging advances: CT,


MRI, Scintigraphy .

Radiograph remains the most


reliable predictor of the
histologic nature of a given
lesion

Sundaram M, McDonald DJ (1989) The Solitary tumor or tumor like lesion of bone. Topics Magn Reson
Imaging 1(4):17-29

Growth Rate/ Activity


+
Periosteal reaction
Age
Location
Matrix calcification

Growth Rate/ Activity:


1.
2.
3.
4.
5.

Pattern of destruction
Lesion Margin
Geographic, moth-eaten, permeative
Cortex Penetration
Presence of a sclerotic rim
Presence and extent of expanded
cortical shell
Lodwick et al. Radiology 134:577-583,1980

Permeative

Geographic

Pola Destruksi tulang

Dari Jenis
BATAS lesi
3 Jenis
Destruksi
tulang

Destruksi:

What do you see?

What do you see?

Destruksi: geografik (+ sklerotik)

Moth eaten

Moth Eaten: Small areas of destruction


Multiple Myeloma

Non-aggressive

Aggressive

Periosteal reaction

Uninterupted

Interupted

Interupted

Prof. Enneking:
Tell me the age Ill tell you the pathology

Location
What bone?
Epi/Met/Dia?
Cortex/Med/
par-ost/para-ost?
Multiple/single?

Brown tumor - Hyperparathyroidism

Calcification
Chondroblastic vs.
Osteoblastic

Calcification
Chondroblastic vs.
Osteoblastic

Role of CT scan
Examine the present
or absence of nidus
Demonstrating lesion
in flat bones
Confirming any
cortical break in
lesion with thin cortex
Help characterized
type of matrix
calcification
Guide to Biopsy

MRI: 44 yrs M, malignant


degeneration of osteochondroma?

Examples:
MRI of
Bone tumor

Soft tissue sarcoma with blood vessel encasement &


extra-compartmental infiltrationstaging

Soft Tissue Tumors


And Tumor-like Lesions

SOFT TISSUE MALIGNANT TUMORS

RELATION OF AGE TO INCIDENCE OF SARCOMA

Soft tissue
tumors
Plain Film

MRI
Lipoma

Probable
hemangioma/

Other

IM lipoma

Doppler US

Biopsy

Arteriography/ MR

angio

Plain Radiography
To exclude a palpable
lesion caused by an
underlying skeletal
deformity:
* Exuberant callus
* Bony exostosis
* Bone tumor with
soft tissue mass.

Plain Radiography
Soft tissue calsification
characteristic of a specific
diagnosis:
* Phleboliths
* Synovial
osteochondromatosis.
* Myositis ossificans.

Routine chest-xray screening for


metastasis

CT scan has been replaced


by MRI

Soft tissue mass on the chest wall

Spesific Diagnosis
in MRI
Lipomatous lesions
Angiomatous lesions

Tumorlike lesions
Peripheral nerve lesions
Fibrous lesions
Synovial lesions

Lipoma

Hemangioma

Sign of Malignant lesion

Larger
Deeper
More heterogenous
Bone & neurovascular
involvement

Infiltration to adjacent
compartment

Neurofibroma

Variable signal intensity

Ultrasound + Doppler
Doppler and high resolution
ultrasonography challenges the role
of MRI.
It has a few advantages compare to
MRI; low cost, real time scanning
and more available examination.

Spesific Diagnosis(Soft tissue masses


with pathognomonic ultrasound appearance)

Angiomatous lesions
Lipomatous lesions
Neurogenic tumors
cystic masses

Hemangioma

Phleboliths of hemangioma

Lipoma

Hypoechoic
Homogenous
Well defined margin
Oval
Long axis parallel to skin
Compressible

Neurogenic tumors

Big Bursitis

Huge
Bakers Cyst

A case study:

Triple
Diagnosis
Clinical
Findings

Radiology

Pathology

Thank You

DIAGNOSIS FINAL, harus melalui


serangkaian analisis yang melibatkan:

Agresifitas
+
Umur
Lokasi
Jenis kalsifikasi

AGRESIF GANAS
NON AGRESIF JINAK

Benign non aggresive vs.


Ganas - aggresive

1. Batas Lesi

2. Jenis reaksi
periosteal
3. Besarnya
massa
jaringan
lunak

Batas Lesi
3 Jenis margin
3 Jenis Destruksi

Benign/
Malignant

Periosteal
reactions: