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TOPIC OUTLINE

I.
II.

Bone Tumors
A. Modalities
B. Diagnostic Criteria
Summary

Transers Note: Dr. Galsim didnt give us a copy of his PPT so we used the pictures
from the 2016 buddy CD files and from the internet. Happy studying! :)

Parts of a long bone


o Epiphysis one end of the long bone
o Metaphysis growth plate region
o Diaphysis shaft
o Others: epiphyseal plate, apophysis, articular cartilage
Epiphysis

Legend:
From PPT
Mentioned by lecturer

I. BONE TUMORS
Seldom encountered by clinicians
Important to recognize them in future clinical practice
A. MODALITIES
Radiographic findings may not allow precise diagnosis
Provide reliable information on aggressiveness or rate of growth of
bone tumors
Aggressive malignant; non-aggressive benign; except:
o Aneurysmal bone cyst & osteomyelitis aggressive but benign
o Ameloblastoma non-aggressive but malignant
X-RAY
Conventional 2D imaging modality
Sensitive technique
Assesses the aggressiveness of the lesion, based on certain criteria
given (ex. non-aggressive lesions are benign)
Cannot provide a histological diagnosis
50% of bone matrix must be destroyed to be observed

Metaphysis

Diaphysis

Four most common conditions:


Chondroblastoma (with calcification in matrix)
child
Giant cell tumors adult
Osteomyelitis fungus, TB
Aneurysmal bone cysts/ABC
Characterized by high vascularity and metabolic
activity, so most bone lesions (including infections)
occur in this region
Most benign and malignant bone tumors such as
Osteochondroma (benign)
Osteosarcoma (malignant)
Chondrosarcoma (malignant)
Composed of yellow or red marrow
Apart from cortical lesions, there are lesions of marrow
origin
Round cell tumors such as Ewings sarcoma,
reticulum cell sarcoma (lymphoma of bone), and
multiple myeloma (plasma cell origin)

Table 2. Long bone locations and associated bone lesions.

ULTRASOUND
Used for joint diseases (ex. effusion, edema)
Not very useful unless with total destruction of the bone cortex
Often used in MSK for assessment of muscles, tendons, & soft
tissue
CT
Used for cortical lesions
Determine calcified lesions (appear hyperdense)
Useful for determining the extent of the tumor, for its staging, and for
detecting metastasis (contiguous or distal)
MRI
Used for marrow, medullary cavity lesions, & soft tissue
Gives superior soft tissue resolution
Like CT, useful for determining tumor extent, staging, and metastasis

Figure 1. Frequent sites of bone tumors.

BONE SCAN
Assesses bone metastasis
Unlike plain radiographs, bone marrow destruction can be as low as 5
to 20% to be detected
Determines level of metabolic activity
Very sensitive but non-specific
o False positive: degenerative, superimposed inflammatory process, or
from previous thoracotomy
PET
Able to assess functionality
Expensive, but when combined with CT/MRI, extent or status of the
lesion becomes easily defined
B. DIAGNOSTIC CRITERIA
AGE
Jack Edeiken
o Bone radiologist
o Evaluated 4000 malignant bone tumors, which could be diagnosed
correctly 80% of the time just by using the patients age
Infant
1st to 2nd decade
2nd to 3rd decade
40 years old and above

Figure 2. Epiphyseal tumor with metaphyseal involvement. Pointed


structure is a giant cell tumor (GCT) in the upper right tibia (left). Other
examples of GCT (upper and lower right).

Metastatic neuroblastoma
Ewings tumor
Osteosarcoma
Metastatic carcinoma, multiple
myeloma, and chondrosarcoma

Table 1. Most common bone tumors based on age groups.


LOCATION IN LONG BONE

Avie & Yanyan

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Lec 09: Musculoskeletal Radiology


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Figure 3. Metaphyseal tumor (but extends to the diaphysis, so more of


metadiaphyseal involvement). Pointed structures are osteosarcomas,
examples of cloudy, amorphous matrices.

Figure 6. Geographic lytic lesion in the metadiaphysis of the humerus


(leftmost). Moth eaten appearance of multiple myeloma (middle).
Permeative bone destruction (rightmost).

Figure 4. Diaphyseal
involvement. Ewings sarcoma
young patient, then multiple myeloma older patients (left).
Enchondroma with pathologic fracture (right).

in

TUMOR MARGINS
Pattern of bone destruction/zone of transition
Most reliable plain film indicator for aggressive vs. non-aggressive
lesions
Zone of transition (ZOT) border of lesion with normal bone
o Narrow ZOT well-defined; mostly non-aggressive
o Wide ZOT ill-defined or imperceptible margin; mostly aggressive
Pattern of bone destruction Types of margins:
1. Geographic
Well-defined or narrow ZOT
Sometimes with sclerotic margin
If bone has time to form sclerosis, this is indicative of
its non-aggressiveness!
Least aggressive, and with most benign bone tumors
2. Moth eaten
Less well-defined
Multiple small lucencies, with tendencies to coalesce if
numerous
More aggressive, and mostly malignant
Ex. multiple myeloma
3. Permeative
Poorly defined or wide ZOT
Imperceptibly merge with normal bone
True size larger than seen on radiograph
Ex. Ewings sarcoma

Figure 7. Geographic bone destruction.

Figure 8. Moth-eaten skull. Similar appearance in hyperparathyroidism


wherein bone resorption is promoted, resulting in osteopenia (left).
Moth-eaten lesions seen in multiple myeloma (right).

Figure 5. Different patterns of bone destruction.

Avie & Yanyan

Figure 9. Permeative bone lesion with a wide ZOT. Lower zone appears
more lucent than upper.
PERIOSTEAL NEW BONE FORMATION

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When there is a tumor or infection, the endosteum and periosteum react
and try to contain the lesion.

Figure 10. Types of periosteal reaction from left to right: (1) Lamellar, (2)
Laminated/Layered, (3) Sunburst, and (4) Codmans Triangle.
1.

Lamellar
Most common form of bone formation
With single layer of new bone formation
Uniform thickness (>1mm) and density
Hallmark of a benign lesion (no surgical intervention necessary)
o Ex. Non-ossifying fibroma benign, should not be touched
o Ex. Chronic osteomyelitis thats healed
o However, osteoid osteoma is a benign lesion, but requires
intervention/enucleation because it causes the patient pain.

Figure 13. Osteosarcoma. With typical sunburst pattern.


4.

Codmans triangle
Non-specific findings seen in both tumors and infections
Three sides are observed:
o Bone
o Periosteal reaction
o Tumor
Can be mistaken for inflammatory exudates infiltrating the
cortex, appearing as an abscess at the bottom

Figure 11. Lamellar periosteal reaction.


2.

Laminated or layered
Multiple layers of periosteal reaction almost parallel to long axis
of bone
Onion skin appearance
o Result of alternating tumor growth and attempt of bone to
control tumor growth
o Periosteal reaction is not enough to contain the process
Aggressive lesions
Figure 14. Codmans Triangle (purple arrow). Sunburst (red arrow).
TUMOR MATRIX FORMATION
When the tumor advances, soft tissue pathology can be seen.
With calcifications osteoid or chondroid
Without calcification long spectrum of sarcomas & malignancies
We should know how to differentiate between osteoid and chondroid.
1.

Chondroid
Punctate, popcorn-like, flecks, rings, or arcs of calcific density
Examples:
o Chondrosarcoma recurrence in bony pelvis
o Intramedullary chondrosarcoma in the distal femur
o Popcorn-like inferior pubic rim

Figure 12. Laminated/layered periosteal reaction.


3.

Sunburst or hair-on-end
Periosteal reaction almost perpendicular to long axis of bone
Aggressive lesions
o Tumor is too fast periosteal reaction cant catch up!
Sharpeys fiber
o Bones failed attempt to contain the growing lesion
o Formation is pulled and grows outward with the tumor
Example: osteosarcoma, Ewings
sarcoma

Avie & Yanyan

Figure 15. Chondroid matrix. High grade chondrosarcoma of the left iliac
bone. Soft tissue extension seen on axial T2-weighted MRI.

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Lec 09: Musculoskeletal Radiology


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GREETINGS!
Avie:
Thank you for taking pictures, Trish!
Hello, Block 8! Lets eat more of these please :Q

Figure 16. Chondroid matrix.


2.

Osteoid
Cloudlike or amorphous (chalk-like appearance)
No particular shape
May also present with calcifications

Yanyan:
Hey Block 8! Hurrah for our very first block bonding activity last Friday!
Also, lets all attend the TRP practices! TWTh at Calderon Hall and
Student Lounge! Kamon mamooon! LETS WIN IT THIS YEAR!!! \:D/

Figure 17. Osteoid matrix in osteosarcoma (left). Osteoid osteoma (right).

Figure 18. Intramedullary osteosarcoma of distal femur with large soft


tissue mass exhibiting classic osteoid matrix.
II. SUMMARY
Knowledge of the radiologic diagnostic criteria for bone tumors would
enable a physician to accurately characterize the lesion, determine its
aggressiveness, and come up with a short list of differential
diagnoses.
What determines how the lesions appear?
When cells are activated, it can be either:
o Blastic osteoblasts form more bone (ex. osteosarcoma)
o Lytic osteoclasts stimulated
Matrix of tumor
END OF TRANSCRIPTION

Avie & Yanyan

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