Imaging Diagnosis

of Bone Tumors:
Beyond Pattern
Recognition

Susan V. Kattapuram, M.D.

Massachusetts General
Hospital
Harvard Medical School

PATTERN RECOGNITION

If my own Aunt Minnie

walked into the room
would you ask how I
knew her?
Variably attributed to Ben
Felson and E.B.D. Neuhauser

Aunt
Minnie

Aunt Minnies

Aunt

Aunt Minnies

2 KEYS TO DIAGNOSIS
Grade and Tissue Type
GRADE

Local aggressiveness (margins)

Differentiation (maturity of matrix)
Metabolic activity
Size

TISSUE TYPES:
Bone
Cartilage
Round cells

BONE MARGINS

TYPE I:

TYPE II:

TYPE III:

GEOGRAPHIC

MOTH-EATEN

PERMEATED

MARGINS
TYPE I
Geographic

TYPE II
Moth-eaten

TYPE III
Permeated

MARGINS
TYPE I
Geographic

TYPE II
Moth-eaten

TYPE III
Permeated

SCLEROTIC MARGINS

WALL

INFLAMMATORY

INVOLUTING

Sclerotic Margins

CYST

N.O.F.

F.D.

ABSCESS

SCLEROTIC MARGINS
INVOLUTING

INFLAMMATORY

Fibrous Dysplasia

Osteoid osteoma

Non-ossifying
fibroma

Chondroblastoma

Eosinophilic
granuloma

Abscess/Eosinophilic
granuloma

MATRIX:
BONE

MICROSCOPIC
Cloud-like
Fluffy

MACROSCOPIC
Spicules
Cortex

DENSITY

Does not
exceed cortex

BONE LESION GRADE

LOW :
Small lesion
Densely mineralized
Rare

HIGH:
Sparsely mineralized
Invasive

OSTEOMA

ADULTS
SLOW GROWTH
SYMPTOMS (if any) DUE TO MASS
MEDULLARY- Bone island
PERIOSTEUM

SKULL Button osteoma, Sinuses >> LONG

BONES Ivory exostosis

Bone Islands
(osteopoikilosis
)

Uniform, mature
bone
Oval, long axis
parallel to stress
lines
Serrated, irregular
outlines

OSTEOMA

BONE ISLAND

BUTTON OSTEOMA

Multiple Osteomas

(Idiopathic, Gardners Syndrome,

Tuberous sclerosis, osteopoikilosis)

OSTEOID OSTEOMA

CHILDREN, YOUNG ADULTS,

NO GROWTH
MALE>>FEMALE
PAINFUL
CORTEX = PERIOSTEUM, >
MEDULLARY
LONG BONES >> FLAT BONES

OSTEOID OSTEOMA

cortica

periosteal

medullary

OSTEOBLASTOMA

CHILDREN, YOUNG ADULTS

PROGRESSIVE
PAINFUL
MEDULLARY > PERIOSTEAL
SPINE (blastic) > LONG BONES (lytic)
TRANSITION LESION

AGGRESSIVE, PSEUDOMALIGNANT
FORMS

OSTEOBLASTOMA

6 mths later

OSTEOBLASTO
MA

Aggressive
osteoblastoma

Aggressive
osteoblastoma vs OSA
17 male
Osteoblastom
a
curettaged,
packed
? recurrence

Osteosarcoma

OSTEOSARCOMA:

a malignant tumor which

forms bone

CHILDREN, YOUNG ADULTS BUT

LONG TAIL
MOST FREQUENT 1
MALIGNANT BONE TUMOR
PAINFUL
MEDULLARY > PERIOSTEAL >
SOFT TISSUE > CORTEX
LONG BONES > SPINE

OSTEOSARCOMA
TYPES:
Location in Bone

MEDULLARY most common

INTRACORTICAL least common
SURFACE conventional, parosteal,
periosteal
SOFT TISSUE
SPECIAL SITES:
MANDIBLE, SPINE
OLDER, SOMEWHAT BETTER
PROGNOSIS

OSTEOSARCOMA
Intramedullary

PAROSTEAL OSA
LOW GRADE,
WELL DIFFERENTIATED BONE

PAROSTEAL
OSTEOSARCOMA:
Marrow invasion

SURFACE OSA:
(conventional)

Intracortical
Osteosarcoma

OSTEOSARCOMA
TYPES:

ETIOLOGY
PRIMARY
SECONDARY

GeneticLi Fraumeni syndrome

Familial retinoblastoma

Pre-existing lesions
Paget sarcoma
Fibrous dysplasia
Dedifferentiation

Radiation

SECONDARY
SARCOMA

Initial

9 mths

SECONDARY
SARCOMA

Ax

Cor T2

T1
postgado

OSTEOSARCOMA TYPES:

HISTOLOGY
OSTEOBLASTIC
CHONDROBLASTIC
FIBROBLASTIC
TELANGECTATIC

Summary #4: Many lesions contain more than one cel

OSTEOSARCOMA:
Osteobla
stic

Chondroblastic

Telangiect
atic

OSTEOSARCOMA:
Imaging longitudinal extent

Longitudinal and soft tissue

extent best seen on MR
images

Attenuation differences >

20 HU are abnormal

OSTEOSARCOMA:
Special anatomical
situations

CARTILAGE MATRIX:

WATER CONTENT
LOW ATTENUATION
HIGH T2 SIGNAL

NODULES (HYALINE TYPE)

CALCIFICATION
AMORPHOUS (dense!)
ENDOCHONDRAL BONE FORMATION

AVASCULAR

CARTILAGE TUMORS:
GRADE

LOW:

HIGH

NODULES
MINERALIZATION THROUGHOUT
UNCOMMON
DEGENERATED vs. DEDIFFERENTIATED

ALL:

INVASIVE IN BONE, PUSHING IN SOFT

TISSUES

CHONDROMA

ADULTS
MEDULLARY (enchondroma) >>
PERIOSTEAL SOFT TISSUE>> CORTICAL
SYMPTOMS

Medullary - none
Periosteal, Cortical - PAIN

SLOW OSSIFICATION
MULTIPLE LESIONS:

Olliers Disease
Maffuccis Disease

ENCHONDROMA

ENCHONDROMA

OSTEOCHONDROMA:
A GROWTH DISTURBANCE

CHILDREN, YOUNG ADULTS

SYMPTOMS (if any) DUE TO MASS OR

COMPLICATION:

Growth ceases at skeletal maturity

May (rarely) regress

Fracture
Bursitis
Malignant degeneration

LONG BONES >> FLAT BONES

SUBTYPES

Radiation
Trauma
Multiple hereditary

OSTEOCHONDROMA

OSTEOCHONDROMA

OSTEOCHONDROMA

Cartilage cap

OSTEOCHONDROMA
Cartilage cap

Medullary continuity

Soft tissue mass

OSTEOCHONDROMA
Points
wrong

PERIOSTEAL
CHONDROMA

PERIOSTEAL
CHONDROMA

CHONDROBLASTOMA

CHILDREN, YOUNG ADULTS

LONG BONE EPIPHYSIS (humerus,
femur)>> FLAT BONES
PAINFUL (prostaglandin)
GROWTH USUALLY LIMITED

CHONDROBLASTOMA

CHONDROBLASTOM
A

CHONDR
OMYXOID
FIBROMA

Usually resembles
non-ossifying
fibroma
Not usually
calcified

CHONDROSARCOMA

Third most common primary

malignant bone tumor
Older adults
Some pain
Long bones >> Flat bones
Mostly low, intermediate grade

CHONDROSARCOMA
SUBTYPES BASED ON
LOCATION

MEDULLARY (CENTRAL) most

common
INTRACORTICAL least common
SURFACE (PERIPHERAL)
SOFT TISSUE (rare)

CHONDROSARCOMA

SUBTYPES BASED UPON ETIOLOGY:

Primary
Secondary: DEGENERATION of chondroma

SUBTYPES BASED UPON

HISTOLOGY

HYALINE
MYXOID
DEDIFFERENTIATED
MESENCHYMAL (soft tissues)
CLEAR CELL (epiphyseal, slow)

CHONDROSARCOMA:
borderline lesion

CHONDROSARCOMA:
Longitudinal growth

CHONDROSARCOMA
nodular growth

CHONDROSARCOMA:
Arising from osteochondroma

CHONDROSARCOMA:
surface lesion

CHONDROSARCOMA:
Soft Tissue

CHONDROSARCOMA:
Mesenchymal

CHONDROSARCOMA:
High grade

CHONDROSARCOMA:
Dedifferentiation

CHONDROSARCOMA:
Dedifferentiation

ROUND CELL TUMORS

Ewing

Family

There is no mature tissue of origin

Histochemistry: 95% express p30/32 MIC2 antigen

Cytogenetics: 85% contain a specific translocation t(11;22)
(Q24;Q12).

Lymphoma
Metastases

EWING TUMOR

Second most common 1 bone tumor

80% < age 20
Males > females
Survival
before chemotherapy 5-10%
current 70%

Neural origin same as PNET and

ASKIN tumor

EWING / PNET:
Permeated margins

Subperiosteal
spread

Ewing Tumor

ROUND CELL TUMOR:

RAPID GROWTH AFTER
PATHOLOGICAL FRACTURE

2 mths later

ROUND CELL TUMOR:

RAPID GROWTH AFTER PATHOLOGICAL

FRACTURE

EWING TUMOR:
PROGNOSIS

GOOD PROGNOSTIC FEATURES:

Distal location
Rib
Good response to chemo (>90%
histological necrosis)*

BAD PROGNOSTIC FEATURES:

Large (>8-10 cm or 100 ml)
Central (especially pelvic tumors)

* Wunder, Jay S.; Paulian, Gabe; Huvos, Andrew G.; Heller, Glenn; Meyers, Paul A., and Healey, John
H. The histological response to chemotherapy as a predictor of the oncological outcome of operative
treatment of Ewing Sarcom. Journal of Bone and Joint Surgery. 1998 Jul; 80-A(7):1020-1033

EWING FAMILY

LYMPHOMA

MEDULLARY > SURFACE OR S.T.

MEDULLARY > ST

DIA = METAPHYSIS

DIA = METAPHYSIS

LONG BONES > SPINE

TRUNK > LONG BONES

AGE 5-30
PAINFUL, OFTEN SYSTEMIC
SYMPTOMS

T(11;22) TRANSLOCATION

AGE 20-60
OFTEN NOT VERY SICK

EWING / PNET:
Soft tissue primary
Before Chemotherapy: 4/26/00