Dr. Rosalina,SpRad

Normal Anatomy

epiphysis

metaphysisdiaphysis

physis

Childhood Adult

cortex

Medullary spaceMedullary space

Physeal scarPhyseal scar

Criteria to Classify Lesions Age Location of lesion

Which bone? Location within bone

Soft tissue involvement Less reliable

Size Pattern of bone destruction

Criteria to Classify Lesions Zone of transition

Margin of lesion

Visible tumor matrix

Polyostotic or monostotic

Malignant Bone Tumors by Age 1-30

Ewing’s Osteosarcoma

30-40 Fibrosarcoma and MFH Malignant Giant Cell Tumor Reticulum Cell Sarcoma

AGE 20Location metaphysisMargins 3

Periosteal Reaction irregularMatrix boneOther

DX osteosarcoma

Osteosarcoma

Malignant Bone Tumors by Age

40+ Mets

Myeloma

(Chondrosarcoma)

Location

Location and age are important parameters Most primary tumors arise in areas of rapid

growth distal femur, proximal tibia, humerus, etc.

Metastases occur in well-vascularized red marrow spine, iliac wings, etc.

Location

Enchondroma: phalanges

Osteosarcoma & giant cell tumor: around the knee

Hemangioma: skull and spine

Chordoma: sacrum and clivus

Adamantinoma: mid-tibia

Location

Pattern of Bone Destruction Geographic

Well-defined margin

Least aggressive

Pattern of Bone Destruction Permeative

Poorly demarcated, difficult to visualize

“Moth Eaten” Subcategory with larger holes

If mixed, work up as aggressive

“Permeative”

Ewing Eosinophilic

Granuloma Infection Myeloma,

metastasis Lymphoma Osteosarcoma

“Motheaten”

Myeloma, metastases

Infection Eosinophilic

Granuloma Osteosarcoma Chondrosarcoma Lymphoma

Reaction of Bone to Tumor Margin between tumor and native bone

can be visible on the plain radiograph

Slowly progressive process is “walled-off” by native bone, producing distinct margins

Rapidly progressive process destroys bone, producing indistinct margins

Zone of transition

Wide Aggressive

Narrow Less aggressive

Non-ossifying fibroma-Narrow Zone

Margin Sclerosis

Sclerotic margin Generally non-aggressive

Lack of sclerotic margin Suggests more aggressive Exceptions

Radiographic Margins

Margin types 1A, 1B, 1C, 2, and 3 Least aggressive 1A, to most aggressive

3

Margins: 1A,1B,1C

increasing aggressiveness

1A: Sclerotic margin

Simple cyst (UBC) Enchondroma Fibrous Dysplasia Chondroblastoma Giant Cell Tumor Chondrosarcoma

1B: Well-defined, non-sclerotic

Giant Cell Tumor Enchondroma Chondroblastoma Myeloma,

Metastatsis Fibrous Dysplasia Chondrosarcoma

Giant Cell Tumor:Well-defined, Non-sclerotic

1C: Lytic, ill-defined margins

Chondrosarcoma Osteosarcoma Giant Cell Tumor Metastasis Infection Eosinophilic

Granuloma Lymphoma

Periosteal Reaction

Limited usefulness

Thick, uninterrupted Long standing process, often non-aggressive

Stress fracture, Chronic infection, Osteoid osteoma

Spiculated, lamellated Aggressive process Tumor likely

Types of PeriostealReaction

Malignant type reaction

Codman Triangle

Periosteal reaction

Tumor

Advancing tumor margin destroys periosteal new bone before it ossifies

CodmanTriangle

Tumor Matrix

Chondroid matrix Calcified rings, arcs, dots (stippled) Enchondroma, osteochondroma,

chondroblastoma, chondrosarcoma

Osteoid matrix Dense, homogenous, cloudlike Osteoid osteoma, bone island,

osteosarcoma

Tumor Matrix

Fibrous Matrix

Diffuse uniform mineralization: ground glass

Fibrous dysplasia

Matrix

AGE 56Location metaphysealMargins 1A

Periosteal Reaction noneMatrix chondroidOther

DX enchondroma

Enchondroma

Polyostotic vs. Monostotic Benign polyostotic

Fibrous Dysplasia, Paget’s, histiocytosis, multiple exostosis, multiple enchondromatosis

Malignant polyostotic Mets, Myeloma, Ewing’s with mets,

Osteosarc with mets and MFH.

Work up

Radiograph Aggresive STOP

+

-

Will information regarding polyostoticvs. monostotic be valuable?

Bone Scan Polyostotic - Chest film and CT

Can distinguish benign, mets, myeloma from other

-

+

+

-+

STOP

Workup

Chest film and CT-

+MR (Less likely CT)For site evaluation

Plan to resect lung mets

Biopsy

+

Palliative Care

-

Biopsy

Sample away from necrotic or non-aggressive area

Avoid contaminating compartments Knee- suprapatellar bursa is large Pelvis- avoid gluteal musculature which

will need for coverage

AGE 13Location metadiaphysisMargins 1A-1B

Periosteal Reaction noneMatrix noneOther trabecular struts

DX UBC

Unicameral Bone Cyst

Aneurysmal Bone Cyst

AGE adultLocation metaphysisMargins 1B

Periosteal Reaction noneMatrix noneOther fx

DX ABC

Aneurysmal Bone Cyst

Non-ossifying fibroma

Giant Cell Tumor

Giant Cell Tumor

AGE 45Location metaphysisMargins 1B

Periosteal Reaction noneMatrix noneOther epi involvement

DX GCT

Osteoid Osteoma

Osteoid Osteoma

AGE 45Location diaphysisMargins 1B

Periosteal Reaction thickMatrix faintOther

DX osteoid osteoma

AGE 66Location diaphysealMargins 1A

Periosteal Reaction minimal, thickMatrix noneOther 2nd lesion

DX wait…..

Multiple Myeloma

AGE 66Location diaphysealMargins 2

Periosteal Reaction noneMatrix noneOther

DX wait…..

Multiple Myeloma

Multiple Myeloma

AGE 66Location flat boneMargins 1B

Periosteal Reaction noneMatrix noneOther multiple

DX myeloma

AGE 12Location diaphysisMargins 3

Periosteal Reaction lamellatedMatrix noneOther

DX Ewing

Ewing’s Sarcoma

Ewing’s sarcoma

“onion-skin”

Osteosarcoma

AGE 16Location diaphysisMargins 3

Periosteal Reaction spiculatedMatrix boneOther fx

DX osteosarcoma

Osteosarcoma

Osteomyelitis

Primary lymphoma

Primary lymphoma

Metastatic Adenocarcinoma

THANK YOU