Journal Reading :

BONE TUMOR AND TUMOR LIKE CONDITION :

WITH CONVENTIONAL RADIOGRAPHY

ANALYSIS

(Theodore T Miller, MD) Radiology : Volume 246: Number 3 March 2008

Presented by : dr. Febria Rahayuni Supervised by : dr. Paulus Rahardjo SpRad(K)

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Tujuan penulis :
Membantu pembaca untuk mengorganisir pemahaman tentang kelaianan tumor tulang atau kondisi mirip tumor tulang, sesuai :
- Kelompok umur - Predileksi LOKASI - Gambaran Radiologi yang spesifik Hal ini lebih baik daripada memperbanyak daftar ingatan kita tentang jenis kelainan dengan gambaran radiologinya

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Terminologi Bone Tumor

Katagori yang Luas
Benign
Malignant

Kelaianan fokal reaktif Kelainan Metabolik

Miscellanous tumor like condition

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Kesatuan DiagnosisRadiologi
A n a l i s i s Powerpoint Templates

Umur

Lokasi

Diagnosis Tajam

spesific Radiographic pattern

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Klinis Tumor Tulang

UMUR

L O K A S I

Spesifik RO Pattern

DX TUNGGAL

Langkah Diagnosis penyaringan DD

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Patient Age
Tumor Tulang mempunyai

predileksi spesifik pada kelompok umur

Umur hal terpenting

dalam informasi klinis
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Patient Age..
Simple Bone cyst/ Chondroblastoma--skeletally immature people Lytic lesion

E.g.
Giant Cell Tumor--Skeletally matur people

Ewing Sarcoma

Conventional Osteosarcoma

Pagetic/previously irradiated Bone

Primary Bone Lesion

Malignant Bone Lesion

40 th MM, Metastasis

younger Powerpoint Templates

Elder Page 7

< 20
Skeletaly immatur
Skeletaly matur UMUR

20-40

> 40

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Peak Age Predilection of Bone Lesions

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LOCATION

Most Bone Tumor occur in characteristic location

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Some Tumor have Predilection

Sites of rapid bone e.g. Osteosarcoma growth (Metaphysial)

Follow the distribution of red marrow

e.g. Ewing Tumor Langerhans Cell Histiocytosis (young : Diaphysis Old :flat bones)

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LOKASI
MEDULLA

FLAT BONE

TRANSVERSAL

CORTEX JUXTACORTEX

LONG BONE
LONGITUDINAL

DIAFISIS
METAFISIS

(APOFISIS; PATELLA; WRIST; HINDFOOT; Powerpoint Templates MIDFOOT; Subarticular Portion of flat bone)

EPIFISIS/ Growth center End of-bone

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e.g.
medullar
Simple bone cyste

Cortical

Metaphysial lesion

(centrally)
Aneurysmal bone cyste

Nonossifying fibroma

(Eccentrically)

In short /thin tubular bones the entire diameter can be involved Templates Page 13 difficultPowerpoint to determined

e.g. Lytic lesion in end-of-bone VS Patient Age

Adolescent
Chondroblastome

Young Adult

Giant Cell Tumor

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Diagram shows common locations of tumors and tumorlike conditions in transverse and longitudinal dimensions of a long bone.

Miller T T Radiology 2008;246:662-674

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2008 by Radiological Society of North America

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Typical Locations of Bone Lesions

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Specific Sites of Selected Tumors

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Spesific Radiographic pattern

Margin

TransisionalZone Periosteal Reaction Mineralization

Size and number

Soft Tissue Component

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Margin+Transition Zone Agressiveness

Geographic Lesion

Moth eathen

Permeated

More Agressive
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Margin+Transition Zone Agressiveness

TYPE
a Well defined with sclerotic rim Narrow transition zone Type I (Geographic) b Well defined without sclerotic rim c II (Moth-eaten) III (Permeated) Infiltrative Broad Transitional Zone; ill defined; with bone destruction Moth-eatean small; patchy; lytic bone destruction

Focal Lytic ; ill defined border

Most Innocuous/ Benign

Except : GCT (local aggressive)

Except : Osteomyelitis Local

Langerhans cell Powerpoint Templates hystiocytosis Page 20 Small round blue cell group

Most aggressive/ malignant

Type 1a geographic lesion. (a) Diagram

shows well-defined lucency with sclerotic rim. (Adapted and reprinted, with permission, from reference 1.) (b) Lateral radiograph shows intraosseous lipoma of the calcaneus, with a sclerotic rim (arrows). Powerpoint Templates Page 21

Type 1b geographic lesion. (a) Diagram shows welldefined lucent lesion without sclerotic rim. (Adapted and reprinted, with permission, from reference 1.) (b) Anteroposterior radiograph of femur shows well-defined geographic lytic focus of myeloma without a sclerotic rim. Notice the endosteal scalloping (arrows). Powerpoint Templates Page 22

Type 1c geographic lesion. (a) Diagram shows ill-defined

lytic lesion. (Adapted and reprinted, with permission, from reference 1.) (b) Lateral radiograph of femur in patient with osteosarcoma shows large ill-defined lytic lesion (large black arrows). Note Codman triangles (large white arrows), periosteal interruption Powerpoint Templates (small white arrow), and tumor-induced new bone production (small black arrow). The Page 23 diaphyseal location is unusual for osteosarcoma.

Type 2 moth-eaten lesion. (a) Diagram shows patchy

lysis of medullary cavity. (Adapted and reprinted, with permission, from reference 1.) (b) Anteroposterior radiograph of osteosarcoma shows ill-defined patchy lytic lesion involving medullary cavity (long solid arrows) and cortex Powerpoint periosteal Templatesreaction (short solid arrows). (open arrow). Also note multilamellated Page 24

Type 3 permeated lytic lesion. (a) Diagram shows small

patchy lucencies in medullary cavity. (Adapted and reprinted, with permission, from reference 1.) (b) Anteroposterior radiograph shows fine permeated pattern involving cortex and medullary space of diametaphysis of proximal portion of tibia (arrows) in a patient with Ewing sarcoma. (Image courtesy of Marcia Blacksin, MD, University of Medicine and Dentistry of New Jersey, Newark, Powerpoint Templates Page 25 NJ.)

.Tumors with a Permeated or Moth-eaten Appearance, by Age

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Periosteal Reaction
Solid/Unilamelated -Slow Growing - Bone have the chance to wall the lesion of Onion Skin/ Multilamelatidb Bone continually trying to wall off but cannot Codman Triangle Aggressive proccess that lifts the periosteum and bone with angle form (Beningn : Infection; subperiostelal hematome) Hair on end/ Sunburst Pattern Bone try to wall the lesion but interupted/Broken periosteum

Most Innocuous/ Benign

Sometimes periosteal reaction is a result of pathologic fracture trough a bone tumor. Not because of the tumor itself. E.g : Symple bone cyst Powerpoint Templates

Most aggressive/ malignant

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Unilamellated periosteal reaction.

(a) Diagram shows single layer of reactive periosteum (arrow). (Adapted and reprinted, with permission, from reference 2.) (b) Anteroposterior radiograph of the knee in patient with hypertrophic osteoarthropathy Powerpoint Templates shows thick unilamellated periosteal reaction (arrows). Page 28

Multilamellated periosteal reaction. (a) Diagram shows

multilamellated, or onionskin, periosteal reaction (arrow). (Adapted and reprinted, with permission, from reference 2.) (b) Anteroposterior radiograph in a patient with osteosarcoma shows multilamellated periosteal reaction (arrow) in proximal portion of femur. Note also large surrounding soft-tissue mass. See Powerpoint Templates also Figure 6b. Page 29

Codman triangle. (a) Diagram shows elevated periosteum

(arrow) forming an angle with the cortex. (b) Lateral radiograph in patient with osteosarcoma shows the elevated periosteum forming Codman triangle (long arrow). Notice the tumor-induced new bone formation (short arrows.) See also Figure 5b.
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Perpendicular periosteal reaction. (a) Diagram shows

spiculated, or hair-on-end, periosteal reaction (arrow). (b) Diagram shows radial, or sunburst, periosteal reaction (arrow). (Fig 10a, 10b adapted and reprinted, with permission, from reference 2.) (c) Anteroposterior radiograph in patient with osteosarcoma shows marked perpendicular periosteal reaction in Powerpoint Templates Page 31 proximal portion of femur.

Buttress periosteal reaction. (a) Diagram shows beaklike

solid periosteal buttress formation (arrow). (Adapted and reprinted, with permission, from reference 2.) (b) Anteroposterior radiograph of humerus in a patient with periosteal chondrosarcoma shows periosteal buttress (short white arrow). Note well-defined saucerization of humeral shaft Powerpoint Templates Page 32 (black arrows) and faint mineralization of the matrix (long white arrow).

Typical Opacity

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Typical Opacity

SBC GCT

Bone Island

Adaman tinoma

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OPACITY
Radiographic Opacity of a lesion can be affeected by :

sequestrum
Trabecular Pattern

mineralization

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Sequestrum
Neoplasms lucency// Sclerotik Stimulation of OSTEOCLAST//OSTEOBLAST
Destructive
sometime

SEQUESTERED within the LYTIC Region

BenignPowerpoint Malignant Templates
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Lesions That May Contain a Sequestrum

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Trabecular Pattern Diagnosis Clue

E X A M P L E
Honeycomb appearance : ABC, Desmoplastic Fibrome Coarsened Trabeculae : Paget Disese Sunburst/Spoke-and-wheel trabecular pattern : Hemangioma in long bone
Vertically oriented Coarsened Corduroy : Hemengioma in vertebral body

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Aneurysmal bone cysts. (a) Anteroposterior radiograph of the

pelvis shows expansile lytic lesion of right acetabulum with thinning of the cortex (arrow) and honeycomb trabeculation. Flat bones are a common location for aneurysmal bone cysts. (b) Anteroposterior radiograph of proximal portion of tibia and fibula shows expansile lytic lesion in proximal fibular metaphysis, with mild honeycombing (black arrows). Eccentric origin of the lesion is hard to appreciate in thin bones such as the fibula; both cortices are ballooned, with focal loss laterally (white arrow). (c) Anteroposterior radiograph of distal forearm and wrist shows more typical eccentric location of aneurysmal bone cyst in distal metaphysis of the Powerpoint radius, although this particular lesion lacks a Templates Page 39 honeycomb appearance. Cortex on radial side is very thin (arrows).

Mineralization of Tumor Matrix

Matrix/type of tissue of tumor (Osteoid/chondral/fibrous/adipose) R. Lucent

Mineralization Calcification
Clue to Underlying matrix Diagnosis

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Mineralization of Tumor Matrix

Chondral Tissue
Punctate/Flocculent/Comma shaped/ring like
e.g. enchondroma; chondrosarcome; Chondroblatome Vary in frequency

Difficult to distinc/ Some non mineralized

Bone Forming

Fluffy Amorphous Cloudlike Opaque radiographic Appearance

Faint mineralization Best assesed by CT Powerpoint Templates

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Chondral mineralization.
(a) Diagram shows patterns and of mineralization of cartilaginous tumor matrix: stippled (left), flocculent (middle), and ring and arc (right). (Adapted and reprinted, with permission, from reference 3.) (b) Lateral radiograph of proximal portion of tibia shows enchondroma with punctate and arclike mineralization (arrows).

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Diagram shows patterns of mineralization

of

osseous matrix with solid (left), cloudlike (middle),

and ivory-like (right) opacity. See also Figures 5b, 11b, and 16.
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Mineralization of Osseus Matrix

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Size & Number

Diagnosis Clue Some entities have size/number criteria
Histologically similar lesion Differ in size/number

Different name

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Si
1.5cm < Osteoid Osteoma :

ze
>1.5 cm : Osteoblastome

Nidus Well defined lytic lesion in the cortex of long bone

< 3 cm Fibrous Cortical defect/ Fibroxantoma

>3 cm Nonossifying Fibroma/ Fibroxantoma

1-2 cm Enchondroma

4-5 cm Chondral Low Grade Lesion Powerpoint Templates Chondrosarcoma

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Size & Number

Multiple sclerotic lesion
Similar in size No
Osteopoikilositosis (multiple bone island)

e.g.

Metastatic Disease

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Multiple lucencies > 40-year

Benign

Multiple bone Tumor

Metastatic Ca MM Metastatic Hodkin

Malignant

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Multiple Bone Lesions

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Cortical involvement
ORIGIN PROCESS

Medulla Periosteum Surrounding Soft Tissue

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Corticalinvolvementmedulla
Endosteal Scallopping : Lesi Medulla yang meluas Erosi permukaan dalam Cortex

Lesi menembus dan merusak cortex : Lesi sangat Agressif erosi inner cortex tanpa kesempatan periosteum untuk mbx tulang baru

Balloning cortex (lytic axpansile and soap bubble appearance) : Lesi agresif erosi inner cortex dengan kesempatan pembentukan periosteum baru di permukaan luarnya Powerpoint Templates Page 51

Lytic Expansile Soap Bubble Appearance

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Corticalinvolvementouter cortex
Saucerization : Erosi permukaan luar cortex

Butressed appearance : Saucerization + periosteal reaction

Note : Butressed app. dapat juga terjadi ketika slowly growing intramedullary process menjadi lebih agresif dan akhirnya Powerpoint menembus area periosteal Templates reaction yang solid

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Soft Tissue Component

+
T U M O R
Destruksi kortex Menyebar lewat canalis Havers

Malignant

Soft Tissue sekitar

Perubahan Fat planes di sekitarnya

Powerpoint Templates e.g. : Osteosarcome; Ewing Sarcoma; Lymphoma Page 54

Lateral radiograph of distal portion of femur shows osteosarcoma with amorphous tumor-induced new bone formation (black arrows). Note the large

soft-tissue mass
(white arrows) that displaces adjacent fat.

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Advance Imaging

~ Radiograph terbaru
Kelebihan MR //CT dari radiograph :

Tomographic nature Kemampuan multiplanar Kontras soft tissue

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Advance Imaging
CT
Evaluasi mineralisasi halus pada lesi litic pada gambaran destruksi tulang di radiograph memperjelas adanya nidus lusen pada osteoid osteoma di tengah area sklerotic reactiv yang luas

MRI

Staging Standar Menilai respon chemoterapi

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KESIMPULAN
DISAMPING KEMAMPUAN METODE ADVANCE IMAGING (CT/MR) DIAGNOSIS TUMOR/KONDISI MIRIP TUMOR TULANG MASIH SANGAT BERGANTUNG PADA RADIOGRAFI KONVENSIONAL DENGAN MEMPERHATIKAN UMUR, LOKASI LESI DAN GAMBARAN RADIOGRAFI SPESIFIK KITA DAPAT MEBUAT DD LEBIH SEMPIT JIKA TIDAK MUNGKIN MEMBUAT DIAGNOSIS TUNGGAL YANG TEPAT Powerpoint Templates

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KESIMPULAN
Klinis Tumor Tulang
L O K A S I

UMUR

RONTGEN SIGN

DX TUNGGAL

Langkah Diagnosis penyaringan DD

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Hatur Nuhun

Hatur Nuhun Malikan Beach, Jember, East Java Indonesia

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matrix

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Figure 16.34 Chondroid matrix . The matrix of

Figure 16.33 Osteoblastic matrix . The matrix

the typical cartilaginous tumor is characterized by punctate, annular, and popcorn-like calcifications within the radiolucent lesion. (A) (B) Chondrosarcoma.

of a typical osteoblastic lesion, in this case an

osteosarcoma, is characterized by the presence of fluffy, cotton-like densities within the medullary cavity of the distal femur.

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