Download - Bone Tumors and Tumor-like Conditions
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Prof. Mamoun KremliAlMaarefa College
Bone Tumors andTumor-like Conditions
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ObjectivesBone tumors:
Primary:Benign – Malignant
Secondaries in bone
Tumor-like conditionsBone cysts
How to read x-ray of a bone lesion
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Classification – predominant tissueTissue of Origin Benign MalignantBone forming Osteoma
Osteoid OsteomaOsteoblastoma
Osteosarcoma
Cartilage forming ChondromaOsteochondromaChondroblastoma
Chondrosarcoma
Fibrous tissue Fibroma FibrosarcomaGiant-cell tumor Benign
OsteoclastomaMalignant Osteoclastoma
Marrow tumors Ewing’s SarcomaMyeloma
Vascular Haemangioma HaemangiosarcomaOther connective tissue
Fibrous histocytomaLipoma
Malignant fibrous histocytomaLiposarcoma
Other tumors Neurofibroma Adamantoma
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Clinical presentation - historyProlonged history:
In most benign lesionsSome malignant: slow growing / in pelvis (expandable)
Age:Childhood and adolescence
Most benign, and some malignant (e.g. Ewings sarcoma)4th – 5th decade:
Chondrosarcoma and fibrosarcomaSixth decade:
Myeloma (the commonest primary malignant bone tumor)Over 70 yrs:
Metastatic lesions are the commonest
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Clinical presentation - historyPain:
In both malignant and benign May be caused by:
Rapid expansion – stretching of tissuesCentral hemorrhage or degenerationInsipient pathological fractureTense encapsulation in bone (e.g. osteoid osteoma)
Swelling
H/O Trauma
Neurological symptoms Pressure on nerve / stretching the nerve
Pathological fracture
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Clinical examinationA mass (lump)
LocationDiscrete or ill-definedTendernessWarmPulsatileMobility….etc
Range of motion
LN, pelvis, abdomen, chest, spine
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Imaging – x-raysWhich bone, and which site in bone?
Solitary or multiple?
Bone forming or bone eating?
Margins: well-defined or ill-defined?
Calcifications in the lesion?
Is cortex eroded or destroyed?
Is there periosteal new bone formation?
Soft tissue extension?
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Location
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Radiographic features
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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The Border
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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The Matrix
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Type of Bone Destruction
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Type of Periosteal Reaction
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Soft Tissue Extension
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Benign Vs. malignant
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Other imagingBone scan (Tc99):
Shows the site of lesion / and skip lesions
CT: Intraosseous and extraosseous structure and extensionGood in deep bones (pelvis, spine)
MRI:Tumor spread
Within bone, into joints, into soft tissueRelation to vesselsSoft tissue and cartilage tumors
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Lab, investigationsLook for infection
Look fro metabolic disease (brown tumor)
Anemia, raised ESR
S. Alkaline phosphatase
Bence Jones protein in urine: myeloma
S. Acid phosphatase: prostatic carcinoma
Raised s Calcium in metastasis
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BiopsyDiagnostic
Needle biopsy:CT- guided In the line of further surgical incisionRepresentative sample
? frozen section confirmation of a good sample
Open biopsy:After all imaging techniques completedMore reliable – significant morbiditySite considering further surgeryFrom boundariesExcision biopsy for almost certainly benign tumors
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Differential diagnosis Soft tissue hamartomas
Myositis ossificans
Stress fracture: Histopath. may be confused with osteosarcoma?
Tendon avulsion injuries Near hip and knee (e.g. Osgood-Schlatter)
Infection
Gout: Large gouty typhus
Other bone lesions: Cortical defects, bone infarcts, “bone islands”
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StagingHow does the tumor behave?
Aggressiveness
How far has it spread?Extent
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Staging – benign tumorsType
(Staging))Description
Latent Well-defined marginGrows slowly and then stopsRemains static / heals spontaneously(e.g. Osteoid osteoma)
Active Progressive growth limited by natural barriersNot self-limiting. Tendency to recur(e.g. Aneurysmal bone cyst)
Aggressive Growth not limited by natural barriers(e.g. Giant cell tumor)
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Staging – malignant tumorsStage I Low-grade sarcomasStage II Histologically high-grade lesionsStage III Distant Metastasis
Site DiscriptionIntracompartmental Confined within an enclosed tissue
space (e.g. a bone, a joint, a muscle group within the fascial coverage
Extracompartmenta;
No natural barrierExtends across interfascial planes
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Tumor ExcisionIntracpsular
Marginal
Wide local
Radical
Amputation
Apley’s System of Orthop. And Fractures
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Benign bone lesionsNon-ossifying fibroma
Fibrous dysplasia
Osteoid osteoma / osteoblastoma
Chondroma / chondroblastoma
Osteochondroma
Simple bone Cyst
Aneurysmal bone cyst
Giant cell tumor
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Non-ossifying fibromaAnother name:
Fibrous cortical defect
The commonest benign lesion of bone
Asymptomatic Incidentally discovered
Children: Disappears later
Common site: Metaphysis of long bones
Treatment: Observation Surgery if v large
Apley’s System of Orthop. And Fractures
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Non-ossifying fibroma
Non-ossifying fibroma ……..………Fibrous cortical defect
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Fibrous DysplasiaDevelopmental disorder
Trabecular bone replaced by fibrous tissue
Types:MonstaticMonomelicPolystatic
Site:Prox. Femur:
Shepherd’s crookTibia, humerus. Ribs, cranio-facial
Deformity of bone
Apley’s System of Orthop. And Fractures
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Polystotic Fibrous Dysplasia
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteoid osteomaSmall tumor (<1 cm)
Young adults
Pain, pain, pain Relieved by Salicylates
Sites: Femur, tibia, spine
X-ray: Small radiolucent “nidus” Surrounded by sclerotic bone
CT: Shows “nidus” better
Tc scan: hot
Treatment: surgical excision, or thermal ablation
Apley’s System of Orthop. And Fractures
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Osteoid osteomaSmall tumor (<1 cm)
Young adults
Pain, pain, pain Relieved by Salicylates
Sites: Femur, tibia, spine
X-ray: Small radiolucent “nidus” Surrounded by sclerotic bone
CT: Shows “nidus” better
Tc scan: hot
Treatment: surgical excision, or thermal ablation
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteoid Osteoma7 year old boy
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Osteoid Osteoma
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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OsteoblastomaA giant ostoid osteoma
Spine and flat bones
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Chondroma (Enchondroma)Incidentally discovered
Young age
Tubular bones of hands and feet
X-ray:Well-defined, central lesionAt junction of metaphysis with diaphysisFlake of calcification are characteristic
Malignant transformationRare in solitary30% in multiple (Ollier’s disease)
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Chondroma (Enchondroma)Incidentally discovered
Young age
Tubular bones of hands and feet
X-ray:Well-defined, central lesionAt junction of metaphysis with diaphysisFlake of calcification are characteristic
Malignant transformationRare in solitary30% in multiple (Ollier’s disease)
Slide Atlas of Orthop Pathology, P Bullough. Gower Med P
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Chondroma (Enchondroma)
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Enchondromatosis (Ollier’s)Many lesions
Malignant transformation: 30%
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Enchondromatosis (Ollier’s)Many lesions
Malignant transformation: 30%
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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ChondroblastomaIn epiphysis
Proximal humerus, femur, tibia
Apley’s System of Orthop. And Fractures
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteochndroma (Exostosis)A common lesion
Ends of long bone
Bony overgrowthAway from epiph. LateCovered by cartilage
Growth:Stops when epiphysis closeIf continues later:
? Malignant transformationOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteochndroma (Exostosis)
Apley’s System of Orthop. And Fractures
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Multiple ExostosisMany lesions
Causes growth disturbance
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Simple bone cystSolitary – unicameral
Children
MetaphysisProx. Humerus and Femur
Not a tumorNot seen in adultsHeals spontaneously
Pathological fracture / incidental
Aspirate is clear straw-coloredOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Simple bone cystSolitary – unicameral
Children
MetaphysisProx. Humerus and Femur
Not a tumorNot seen in adultsHeals spontaneously
Pathological fracture / incidental
Aspirate is clear straw-coloredOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Simple bone cystTreatment:
Small, reducing: leave aloneIncreasing in size, active
Multiple bone marrow injectionsPathological fracture
Treat fractureCyst might heal
Recurrent / injection failed:Surgical curettage and bone grafting
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Aneurysmal bone cystYoung adults
Metaph. of long bone
X-ray:Well-defined cystTrabeculatedEccentrically placedBallooning
Bloody content
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Giant-Cell TumorUnknown origin
Giant cells abundant
Behavior:One third benignOne third locally aggressiveOne third (less) with distant metastasis
Young adults
Common sites:Around kneeProximal humerusDistal radius
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Giant-Cell TumorUnknown origin
Giant cells abundant
Behavior:One third benignOne third locally aggressiveOne third (less) with distant metastasis
Young adults
Common sites:Around kneeProximal humerusDistal radius
Apley’s System of Orthop. And Fractures
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Giant-Cell TumorEccentric lesion
RadiolucentSoap bubbleAbuts against the jointThin cortex
Margins may be clear / unclearDepends on aggressiveness
TreatmentCurettage & bone graftingMore wide excision in recurrent and aggressive lesions
Apley’s System of Orthop. And Fractures
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Giant-Cell Tumor
Apley’s System of Orthop. And Fractures
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Giant-Cell Tumor
Apley’s System of Orthop. And Fractures
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Giant-Cell Tumor
Apley’s System of Orthop. And Fractures
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Cyst-like lesions in bone
Apley’s System of Orthop. And Fractures
Simple bone cyst Aneurysmal bone cyst Giant-cell tumor
• Fills medullary cavity• Does not expand bone
• At metaphyseal side of physis
• Expansile
• After fusion of physis• Extend to sub-
articular
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Cyst-like Lesions
Apley’s System of Orthop. And Fractures
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Primary malignant bone tumorsChondrosarcoma
Osteosarcoma
Ewings sarcoma
Multiple myeloma
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ChondrosarcomaMales: 4th – 5th decade
Slow growing
Common sites:Metaphysis of long bonePelvic girdle
Types:Central: in medullaPeripheral: out from cortex
In pre-existing osteochondromaChange in pain / size
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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ChondrosarcomaX-rays:
ExpandedSomewhat radiolucentFlakes of calcification
More fluffiness: more aggressive
Treatment:Surgical wide excision / radicalNot sensitive to:
chemotherapy, nor radiotherapyWhy?
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Chondrosarcoma
Apley’s System of Orthop. And Fractures
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Chondrosarcoma
Apley’s System of Orthop. And Fractures
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Chondrosarcoma
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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OsteosarcomaUsually highly malignant
(10% already lung metastasis)
Children - adolescents
Presentation:PainMass
Sight:Metaphysis of long bones
PathologyBone forming: osteoblasticWith chondroblastic areas
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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OsteosarcomaUsually highly malignant
(10% already lung metastasis)
Children - adolescents
Presentation:Pain – mass
Sight:Metaphysis of long bones
PathologyBone forming: osteoblasticWith chondroblastic areas
Apley’s System of Orthop. And Fractures
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OsteosarcomaX-ray:
Radiolucency and sclerosisPoorly defined marginsExtends into soft tissuePeriosteal reaction:
Sunburst (sun-ray) appearanceCodman’s triangle
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteosarcoma
Slide Atlas of Orthop Pathology, P Bullough. Gower Med P
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OsteosarcomaTypes:
Medullary: usualParostealPeriostealPaget’s sarcoma
old age
Apley’s System of Orthop. And Fractures
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OsteosarcomaTreatment:
Look for metastasisBiopsy a must
Well planned incisionChemotherapySurgery:
Wide resectionAmputation
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Osteosarcoma - case
Apley’s System of Orthop. And Fractures
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Osteosarcoma - case
Apley’s System of Orthop. And Fractures
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Osteosarcoma - case
Apley’s System of Orthop. And Fractures
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Ewing’s SarcomaFrom bone marrow cells
A round-cell tumor
Age: 10-20 yrs.
Tubular boneTibia, fibula, clavicle
Presentation:Throbbing painSwellingTendernessHotnessESR raised
Osteomyelitis ?
Apley’s System of Orthop. And Fractures
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Ewing’s SarcomaX-ray:
DiaphysealBone destructionNew bone formation
Along the bone“Onion-peel” layers? “Sunray”? Codman’s triangle
Secondaries – in skeleton Apley’s System of Orthop. And Fractures
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Ewing’s SarcomaX-ray:
DiaphysealBone destructionNew bone formation
Along the bone“Onion-peel” layers? “Sunray”? Codman’s triangle
Secondaries – in skeleton
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
![Page 73: Bone Tumors and Tumor-like Conditions](https://reader035.vdocuments.us/reader035/viewer/2022081417/568166af550346895ddaa839/html5/thumbnails/73.jpg)
Ewing’s SarcomaTreatment
Poor prognosis – a killing tumorRadiotherapyChemotherapy – multiple drugs
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Multiple MyelomaB-Cells of bone marrow
Plasma cells mainly
Age: 45-65 yrs
Bone pains
Increases s. Calcium
Bence Jones protein in urine
Apley’s System of Orthop. And Fractures
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Multiple MyelomaX-ray:
OsteoporosisVertebral compression fracture
If both present in a male >45: ? MyelomaMultiple punched-out lesionsCommon sites:Skull, Prox. Femur, vertebrae
Bone marrow biopsy
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Multiple Myeloma
Apley’s System of Orthop. And Fractures
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Multiple Myeloma
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Metastatic bone diseaseCommon in skeleton
In patients >50 yrs.:metastasis more common than all primary
tumors together
Primary from:Prostate, Kidney, Lung, Thyroid, Bladder,
GIT
Common sites:Vertebrae, pelvis, Proximal femur and
humerusOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Metastatic bone diseaseClinical features:
Age 50-70 yrs.Pain – may be silentH.O CarcinomaHypercalcaemia
X-ray:Osteolytic, moth-eatenOsteoblastic in ca prostate
Bone scan
Anemia, raised ESR
Antigen markers of tumorsOrthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Metastatic - Prostate
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Metastatic bone disease
Apley’s System of Orthop. And Fractures
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Which lesion?
Orthopedic Radiolgy. A Greenspan. Lippincott-Raven
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Which lesion?
http://www.radiologyassistant.nl/
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SummaryBone is a common site of tumors
Primary bone tumors:Benign tumorsTumor-like: CystsMalignant
Secondary metastatic
Features, bone, site, age, and X-ray shape characteristic for each tumor
Keep an open mind