ABCDEF approach to

Radiographic Analysis of
Bone Tumors
Age- Child, adolescent,30 to 50 , 50 to 70
Bone-Which bone is involved? Axial ,spine ,flat
bones, Long bones etc.…
Characteristics of the lesion? Sclerotic, lytic,
Blastic , solitary, multiple, skip
Dynamics-What lesion does to bone and what
bone doing in response?
Erosion- Characteristics of erosion /destruction
Filled with?? Is the lesion making matrix? What
kind of matrix is being made?
•Benign
– Latent, Active ,
Aggressive

•Malignant
– Mesenchymal ,
Myeloproliferative ,
Metastatic
 B for
Bone
Where
is the
lesion ?

Central or
eccentric
• Symptomatic metastatic tumors are usually found
proximal to the knees and elbows

• The metastatic lesion found distal to knees and elbows

are usually from lung cancer, renal cell cancer and
melanoma

• The phalanges are a common site for enchondromas

• Aggressive and malignant primary bone tumors sites

include the metaphyses of the distal femur, proximal tibia,
proximal femur, proximal humerus

• Chondrosarcoma is more frequently found in the proximal

skeleton (pelvis, scapula, proximal humerus and femur)

• Chordoma is most commonly found in the sacrum and at

the base of skull
The Affected Portion of the Bone
• Epiphyseal
– These lesions in adults may extend across the
growth plate
– This is typical of a chondroblastoma

• Epiphyseal-metaphyseal
– This is a classic location for locally aggressive tumors
such as giant cell tumor of bone to

• Metaphyseal or metaphyseal-diaphyseal
Lesions that do not cross the growth plate and tend
grow away
– enchondroma, unicameral bone cyst
– Bone abscesses (Brodie's abscess)
– The metaphysis is the most common site for
primary mesenchymal malignancies (osteosarcoma,
chondrosarcoma)
• Diaphyseal
This is a relatively uncommon location for bone
tumors
–Infections and fractures may cause tumor-like
changes
–Ewing's sarcoma, eosinophilic granuloma, osteoid
osteoma, and metastases

• Peri-articular
Changes are present on both sides of the joint
– Infectious, Inflamatory, Metabolic (Gout) joint
– vascular tumor, such as disappearing bone disease
(Gorham's disease- angioma or lymphangioma of
bone) or angiosarcoma of bone
• Central
– Enchondroma
– Fibrous Dysplasia

• Eccentric
– Non-ossifying Fibroma
– Chondromyxoid
Fibroma

• Juxtacortical
– Osteochondroma
– Parosteal
Osteosarcoma

• Cortical
– Osteoid Osteoma
 C for Characteristics of the lesion-How large is the
lesion ?
• In general, the larger the lesion, the more likely it is to
be aggressive or malignant

• Conversely, smaller lesions, such as an osteoid osteoma,

are usually benign. This is not universally true
 How extensive are the abnormalities
seen
• The assessmenton Radiographs?
begins with local radiographs

• Xrays of other sites or a bone scan may be needed

• In metastatic bone disease and multiple myeloma,

other lesions may be seen in the same Xray

• endocrine conditions, congenital diseases (familial

osteochondromatosis), or developmental skeletal
dysplasia (Ollier's disease, Maffucci's disease) may
become obvious when the skeleton surrounding
the primary lesion is examined
D for Dynamics-What lesion does to bone and what
bone doing in response?
• Bone tumors have a limited number of potential
effects on the skeleton

• The most common is to produce bone lysis

• The pattern of lysis and the extent of the host

response to lysis provide major clues as to
whether the lesion is latent, active, aggressive,
or malignant

• Margin or interface is present between the host

bone and the lesion
• The margin of the lesion and
the zone of transition in Margin
between lesion and adjacent
bone are key factors in
determining if a lesion is
aggressive or nonaggressive.

• A lesion with sharp margins

and a narrow transition zone –
nonaggressive

• Illdefined margin and wide

zone transition –
aggressive
 E for Erosion- Characteristics of erosion
/destruction
Pattern of Bone Destruction
• Geographic - Focal discrete
lesion +/- sclerosis
(Lodwick pattern I)

• Moth-eaten (Lodwick pattern

II)

• Permeative (Lodwick pattern

III)
Type 1a : geographic lesion - well-defined lucency
with sclerotic rim

Eg. Non ossifying

Fibroma
Type 1b : geographic lesion-well-defined lucent
lesion without sclerotic rim

Eg. Aneurysmal bone

cyst
Type 2 : moth-eaten lesion- patchy lysis
of
medullary cavity

Eg.
metastasis
Type 3 : permeated lytic lesion - small patchy lucencies
in
medullary cavity

Eg. Ewing’s
Sarcoma
 Pattern Of Destruction

Geographic Moth-eaten Permeative

Non agressive Agressive

 What is the bone doing in response?
• Often, the bone responds by making new
bone, which can be seen in either the
medullary bone or in the cortex and
periosteum

• The pattern of bone response, especially

combined with the pattern of lytic destruction,
is very useful in determining whether the
lesions is latent, active, aggressive or
malignant
 Periosteal Reaction
• Periosteum is an envelope of highly
vascular tissue consisting of an outer
fibrous layer and an inner cellular
(cambium) layer that possesses
osteoblastic potential

• It may be elevated from its location

adjacent to the underlying cortex by
dilated periosteal vessels or edema
from passive hyperemia or it may be
elevated directly by tumour, pus, or
haemorrhage
• The presence and appearance of periosteal reaction
are features that help characterize a bone lesion

• Solid & unilamellated- slow growing ,

nonaggressive lesion eg. Osteoid osteoma.

• Multilamellated or onion skin appearance -

intermediate aggressive process eg. Ewing’s
sarcoma or acute osteomyelitis

• Interruption of uni or multilamellated periosteal

reaction – aggressive process eg. osteosarcoma
Types of Periosteal Reaction

Lamellated (single layer)

Unilamellated periosteal
reaction Diagram shows single
layer of reactive periosteum
(arrow)

Lamellated (multiple layers)

Multilamellated periosteal
reaction
Diagram shows
multilamellated, or onionskin,
periosteal reaction (arrow)
Solid periosteal reaction

Spiculated periosteal reaction /

Perpendicular (hair on end)

Perpendicular periosteal reaction

Diagram shows spiculated, or hair-on-
end,
periosteal reaction (arrow)

Sunburst

Diagram shows radial, or sunburst,

periosteal reaction (arrow)
Codman’s triangle : Diagram shows elevated
periosteum forming an angle with the cortex
 Periosteal Reaction

Solid Lamellated Sunburst Codman’s

Non agressive Agressive

 F for Filled with?? What kind of matrix is being
made
• This question is fundamental to the diagnosis of
primary mesenchymal tumors, especially
benign and malignant bone and cartilage
forming tumors

• It may be difficult to differentiate calcified

cartilage from ossification in tumor matrix

• Calcium deposition in cartilage is typically less

well organized than bone
 Matrix and minerlisation
• Matrix : refers to the type of tissue of the tumor -
such as osteoid, chondral, fibrous, or adipose, all of
which are radiolucent

• Mineralization : refers to calcification of the matrix

• Tumors may be lytic, sclerotic, or mixed

• For example, simple bone cysts and giant cell

tumors are lytic, bone islands are sclerotic, and
adamantinomas are often mixed
• Pattern of mineralization can be a clue to the type
of
underlying matrix and, thus, the diagnosis

• Chondral tissue often produces punctate, flocculent,

comma shaped, or arclike or ringlike mineralization
– enchondroma,chondrosarcoma, or
chondroblastoma

• Bone-forming tumors have fluffy, amorphous,

cloudlike mineralization, causing an opaque
radiographic appearance
– osteosarcoma
 Chondral mineralization
Diagram shows patterns
and of mineralization of
cartilaginous tumor matrix:
stippled (left), flocculent
(middle), and ring and arc
(right)
• Diagram shows patterns of
mineralization of osseous
matrix with solid (left),
cloudlike (middle), and
ivory- like (right) opacity
 Is the cortex eroded ?
• Cortical erosion is the hallmark of the active,
aggressive or malignant tumor

• The pattern of cortical erosion may be highly

correlated with the histology of the lesion

• In chondrosarcoma, (unicameral bone cyst, non-

ossifying fibroma) may cause cortical erosion with
minimal periosteal response

• The erosion of the endosteum caused by

chondrosarcoma is often accompanied by well
ordered periosteal bone formation on the bone's
surface, leading to a pattern of endosteal
expansion
Radiologic characteristics of benign
and malignant bone tumors
Benign Malignant
Well defined Sclerotic border Destructive poorly defined,
permeative
Less aggressive periosteal reaction
Infiltrative border
Absence of soft
tissue mass More aggressive periosteal
reaction
Slow growth Metastasis rare
Soft tissue
mass or extension

Rapid growth Metastasis common