Bone Tumors Clues and Cues William Herring, M.D. © 2002

William Herring, M.D. © 2002
Bone Tumors
Clues and Cues
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Clues by Appearance
of Lesion
Patterns of Bone Destruction
O
Geographic
O
Moth-eaten
O
Permeative
Geographic Bone Destruction
O
O
O
Destructive lesion with sharply
defined border
Implies a less-aggressive, more
slow-growing, benign process
Narrow transition zone
Patterns of Bone Destruction
O
Geographic
O
Moth-eaten
O
Permeative
© R3, 2000
Non-ossifying fibroma
Geographic Lesions
Examples
O
Non-ossifying fibroma
O
Chondromyxoid fibroma
O
Eosinophilic granuloma
Moth-eaten Appearance
O
O
Areas of destruction with ragged
borders
Implies more rapid growth
Q
Probably a malignancy
Patterns of Bone Destruction
O
Geographic
O
Moth-eaten
O
Permeative
© R3, 2000
Multiple Myeloma
Moth-eaten Appearance
Examples
O
Myeloma
O
Metastases
O
Lymphoma
O
Ewing’s sarcoma
Permeative Pattern
O
Ill-defined lesion with multiple “wormholes”
O
Spreads through marrow space
O
Wide transition zone
O
Implies an aggressive malignancy
Q
Round-cell lesions
Patterns of Bone Destruction
O
Geographic
O
Moth-eaten
O
Permeative
Leukemia
Permeative Pattern
Round cell lesions
O Lymphoma, leukemia
O Ewing’s Sarcoma
O Myeloma
O Osteomyelitis
O Neuroblastoma
Patterns of Destruction
Geographic
Less malignant
Moth-eaten
Permeative
More malignant
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
More aggressive or malignant
Q
Lamellated or onion-skinning
Q
Sunburst
Q
Codman’s triangle
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
Aggressive/malignant
Q
Onion-skinning
Q
Sunburst
Q
Codman’s triangle
© R3, 2000
Non-ossifying fibroma
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
Aggressive/malignant
Q
Onion-skinning
Q
Sunburst
Q
Codman’s triangle
© R3, 2000
Chronic osteomyelitis
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
Aggressive/malignant
Q
Onion-skinning
Q
Sunburst
Q
Codman’s triangle
© Greenspan, 2000
Ewing’s sarcoma
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
Aggressive/malignant
Q
Onion-skinning
Q
Sunburst
Q
Codman’s triangle
© Greenspan, 2000
Osteosarcoma
Periosteal Reactions
O
O
Benign
Q
None
Q
Solid
Aggressive/malignant
Q
Onion-skinning
Q
Sunburst
Q
Codman’s triangle
© R3, 2000
Ewing’s-Codman’s
triangle
Periosteal Reactions
Solid
Less malignant
Lamellated
Sunburst
Codman’s
More malignant
Tumor Matrix
O
Osteoblastic
Q
Fluffy, cotton-like or cloud-like densities
V Osteosarcoma
O
Cartilaginous
Q
Comma-shaped, punctate, annular, popcornlike
V
Enchondroma, chondrosarcoma, chondromyxoid
fibroma
Tumor matrix
O
Osteoblastic
O
Cartilaginous
© R3, 2000
Osteosarcoma
Tumor matrix
O
Osteoblastic
O
Cartilaginous
© R3, 2000
Chondrosarcoma
Expansile Lesions of Bone
O
Multiple myeloma
O
Brown tumor
O
Mets
O
Enchondroma
O
Aneurysmal bone cyst
O
Lymphoma
O
Fibrous dysplasia
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
Multiple Myeloma
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
Renal Cell Carcinoma
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
Aneurysmal Bone Cyst
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
Fibrous Dysplasia
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
© R3, 2000
Brown Tumor
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
Lymphoma
© R3, 2000
Enchondroma
Expansile lesions
O
Multiple myeloma
O
Mets
O
Aneurysmal bone cyst
O
Fibrous dysplasia
O
Brown tumor
O
Enchondroma
O
© R3, 2000
Lymphoma
Lymphoma
Clues by Location
of Lesion
In the Transverse Plane
O
Central
Q
O
Eccentric
Q
O
GCT, osteosarcoma, chondromyxoid fibroma
Cortical
Q
O
Enchondroma
Non-ossifying fibroma, osteoid osteoma
Parosteal
Q
Parosteal osteosarcoma, osteochondroma
Osteosarcoma
Parosteal sarcoma
Osteochondroma
© Greenspan, Lippincott, 2000
In The Transverse Plane
In the Longitudinal Plane
O
Epiphyseal
Q
O
Metaphyseal
Q
O
GCT, chondroblastoma
Osteomyelitis, osteo- and chondrosarcoma
Diaphyseal
Q
Round cell lesions, ABC, enchondroma
Tumor Types
Characteristic Locations
O
Simple bone cyst
Q
O
Chondroblastoma
Q
O
Proximal humerus
Epiphyses
Giant Cell tumor
Q
Epiphyses
Characteristic locations
O
Simple bone cyst
Q
O
Chondroblastoma
Q
O
Proximal humerus
Epiphyses
Giant Cell tumor
Q
Epiphyses
© R3, 2000
Characteristic locations
O
Simple bone cyst
Q
O
Chondroblastoma
Q
O
Proximal humerus
Epiphyses
Giant Cell tumor
Q
Epiphyses
© R3, 2000
Chondroblastoma
Characteristic locations
O
Simple bone cyst
Q
O
Chondroblastoma
Q
O
Proximal humerus
Epiphyses
Giant Cell tumor
Q
Epiphyses
© R3, 2000
Giant Cell Tumor
Tumor Types
Characteristic Locations
O
Adamantinoma
Q
O
Chordoma
Q
O
Tibia
Sacrum, clivus
Osteoblastoma
Q
Spine, posterior
Characteristic locations
O
Adamantinoma
Q
O
Chordoma
Q
O
Tibia
Sacrum, clivus
Osteoblastoma
Q
Spine, posterior
© R3, 2000
Adamantinoma
Characteristic locations
O
Adamantinoma
Q
O
Chordoma
Q
O
Tibia
Sacrum, clivus
Osteoblastoma
Q
Spine, posterior
© R3, 2000
Chordoma
Characteristic locations
O
Adamantinoma
Q
O
Chordoma
Q
O
Tibia
Sacrum, clivus
Osteoblastoma
Q
Spine, posterior
© R3, 2000
Osteoblastoma
Tumor Types
Characteristic Locations
O
Parosteal sarcoma
Q
O
Distal femur
Periosteal sarcoma
Q
Tibia
Characteristic locations
O
Parosteal sarcoma
Q
O
Distal femur
Periosteal sarcoma
Q
Tibia
Parosteal sarcoma
Characteristic locations
O
Parosteal sarcoma
Q
O
Distal femur
Periosteal sarcoma
Q
Tibia
© R3, 2000
Characteristic Tumors
By Body Site
Pelvic Lesions
O
Chondrosarcoma
O
Solitary plasmacytoma
O
Chordoma
Pelvic lesions
O
O
O
Chondrosarcoma
Solitary
plasmacytoma
Chordoma
Pelvic lesions
O
O
O
Chondrosarcoma
Solitary
plasmacytoma
Chordoma
Plasmacytoma
Pelvic lesions
O
O
O
Chondrosarcoma
Solitary
plasmacytoma
Chordoma
© R3, 2000
Chordoma
Expansile Rib Lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic
granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic
granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
Thyroid Carcinoma
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic
granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
© R3, 2000
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
O
O
Eosinophilic
granuloma
Neurofibromatosis
Fibrous dysplasia
© R3, 2000
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic
granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
© R3, 2000
Expansile rib lesions
O
Plasmacytoma
O
Metastases
O
Chondrosarcoma
O
Eosinophilic
granuloma
O
Neurofibromatosis
O
Fibrous dysplasia
© R3, 2000
Lesions of the Spine
O
Osteoblastoma
Q
Expansile, with punctate densities
within
O
Chordoma
O
ABC
O
Metastatic disease
Spine lesions
O
Osteoblastoma
O
Chordoma
O
ABC
O
Metastatic
disease
© R3, 2000
Osteoblastoma
Spine lesions
O
Osteoblastoma
O
Chordoma
O
ABC
O
Metastatic
disease
© R3, 2000
Chordoma
Spine lesions
O
Osteoblastoma
O
Chordoma
O
ABC
O
Metastatic
disease
Aneurysmal bone cyst
Spine lesions
O
Osteoblastoma
O
Chordoma
O
ABC
O
Metastatic
disease
© R3, 2000
Metastatic Breast Carcinoma
Clues by Density
Of Lesion
Sclerotic Cortical Lesions
O
Osteoid osteoma
O
Brodie’s abscess
O
Stress fracture
Sclerotic cortical lesions
O
Osteoid osteoma
O
Brodie’s abscess
O
Stress fracture
Osteoid Osteoma
Sclerotic cortical lesions
O
Osteoid osteoma
O
Brodie’s abscess
O
Stress fracture
© R3, 2000
Brodie’s abscess
Sclerotic cortical lesions
O
Osteoid osteoma
O
Brodie’s abscess
O
Stress fracture
Healing Stress Fracture
Sclerotic Cortical Lesions
Osteoid Osteoma
Brodie’s abscess
Healing Stress
Fracture
Lytic Lesions in Children
O
Eosinophilic granuloma
O
Neuroblastoma
O
Leukemia
Lytic Lesions in Children
O
Eosinophilic
granuloma
O
Neuroblastoma
O
Leukemia
© R3, 2000
Eosinophilic granuloma
Lytic Lesions in Children
O
Eosinophilic
granuloma
O
Neuroblastoma
O
Leukemia
© R3, 2000
Neuroblastoma
Lytic Lesions in Children
O
Eosinophilic
granuloma
O
Neuroblastoma
O
Leukemia
© R3, 2000
Leukemia
Lytic Lesions in Adults
O
Metastatic lesions
Q
Lung
Q
Renal
Q
Thyroid
O
Multiple myeloma
O
Primary bone tumor
Lytic Lesions in Adults
O
Mets
O
Myeloma
O
Primary bone
tumor
Met from Thyroid Carcinoma
Lytic Lesions in Adults
O
Mets
O
Myeloma
O
Primary bone
tumor
Multiple myeloma
Lytic Lesions in Adults
O
Mets
O
Myeloma
O
Primary bone
tumor
Chondrosarcoma
Blastic Lesions in Children
O
Medulloblastoma
O
Lymphoma
Blastic Lesions in Children
O
Medulloblastoma
O
Lymphoma
© R3, 2000
Medulloblastoma
Blastic Lesions in Children
O
Medulloblastoma
O
Lymphoma
Lymphoma
Blastic Lesions in Adults
O
Metastatic disease
Q
Breast – female
Q
Prostate – male
O
Lymphoma
O
Paget’s disease
O
Etcetera-mastocytosis, fluorosis
Blastic Lesions in Adults
O
Mets
O
Lymphoma
O
Paget’s
Prostate Mets
Blastic Lesions in Adults
O
Mets
O
Lymphoma
O
Paget’s
Breast Mets
Blastic Lesions in Adults
O
Mets
O
Lymphoma
O
Paget’s
Lymphoma
Blastic Lesions in Adults
O
Mets
O
Lymphoma
O
Paget’s
Paget’s of Spine
Other Clues
Benign Lesions
Without Sclerotic Boarders
O
Giant Cell tumor
O
Brown tumor
O
Osteolytic phase of Paget’s Disease
Benign Lesions without Sclerotic
Borders
O
Giant cell tumor
O
Brown tumor
O
Osteolytic Paget’s
© R3, 2000
Giant Cell Tumor
Benign Lesions without Sclerotic
Borders
O
Giant cell tumor
O
Brown tumor
O
Osteolytic Paget’s
© R3, 2000
Brown Tumor
Benign Lesions without Sclerotic
Borders
O
Giant cell tumor
O
Brown tumor
O
Osteolytic Paget’s
© R3, 2000
Osteolytic Paget’s
Soft Tissue Extension
O
Usually implies malignancy
Q
O
More likely to form discrete soft tissue mass
Benign conditions with soft tissue
extension
Q
Osteomyelitis
V
Usually infiltration of fat
© R3, 2000
Osteosarcoma
Multiple Lesions
O
More often benign
O
Malignancies with multiple lesions
Q
Metastatic disease
Q
Multiple myeloma
Q
Lymphoma
Q
Ewing’s sarcoma (rarely)
Q
Osteosarcoma (rarely)
Multiple lesions
O
Metastatic
O
Multiple myeloma
O
Lymphoma
© R3, 2000
Mets from Ca of Prostate
Multiple lesions
O
Metastatic
O
Multiple myeloma
O
Lymphoma
© R3, 2000
Multiple Myeloma
Multiple lesions
O
Metastatic
O
Multiple myeloma
O
Lymphoma
© R3, 2000
Lymphoma
Multiple lesions
O
Metastatic
O
Multiple myeloma
O
Lymphoma
O
Osteosarcomatosis
© R3, 2000
Osteosarcomatosis
Benign vs. Malignant
© Greenspan, Lippincott, 2000
The End