BONE TUMORS AND TUMORLIKE

CONDITIONS: ANALYSIS WITH

CONVENTIONAL RADIOGRAPHY

Semarang 24 Feb 2018 Atta Kuntara

 Metastatic bone tumors : Primary Quasi- Tumor –like Processes :

BONE TUMORS
•General considerations
Malignant bone tumor :
•Paget’s Disease
•Neuroblastoma Giant Cell Tumor •Fibrous Dysplasia
•Neurofibromatosis
Primary benign bone (Ollier’s disease)
Primary •Extraosseous
tumors : •Maffucci’s
malignant bone Osteosarcoma
Syndrome
tumors : •Chondrosarcoma
•Solitary •Periosteal
•Ewing’s sarcoma
osteochondroma Chondroma
•Multiple •Fibrosarcoma
•Hereditary Multiple •Chondroblastoma
Myeloma •Chordoma
Exostosis •Chondromyxoid
•Solitary •Non-Hodgkin’s
•Hemangioma Fibroma
Plasmacytoma Lymphoma of
•Osteoma •Fibrous Xanthoma
•Central Bone
•Gardner’s Syndrome of Bone: Non-
Osteosarcoma •Hodgkin’s
•Bone Island ossifying Fibroma
•Multicentric Lymphoma of
•Osteoid Osteoma •Fibrous Xanthoma
Osteosarcoma Bone
•Osteoblastoma of Bone : Fibrous
•Parosteal •Synovial
•Solitary Cortical Defects
Osteosarcoma Sarcoma
Enchondroma •Simple Bone Cyst
•Secondary •Adamantinoma
•Multiple •Intraosseous Lipoma
Osteosarcoma
Enchondromatosis
BONE TUMORS
The majority of tumors involving bone
are secondary (or metastatic):
- secondary (metastases) (95%)
- primary (5%)
Osteosarcoma is the most common primary
malignant tumor of bone (35%), followed by
chondrosarcoma (25%) and Ewing sarcoma
(16%).
BONE TUMORS
DIAGNOSIS
BONE TUMORS
PATIENT AGE
LOCATION
LOCATION
MATRIX

Opacity

Matrix : Type of tissue of the tumor

(osteoid, chondral, fibrous / adipose.

Mineralization : Calcification of the

matrix
TUMOR AGGRESSIVENESS
Specific Radiographics Appearance

•Margin
•Periosteal Reaction

•Opacity and Mineralization

•Size and Number

•Cortical Involvement

•Soft – Tissue Component

MARGIN

Lesion
MARGIN
 A focal discrete lesion is called “geographic.”
 Geographic lesions are classified as type 1 :
 Type 1a (well-defined border with sclerotic rim)
 Type 1b (well-defined border but without sclerotic rim)

 Type 1c (focal lytic lesion with ill-defined border)

MARGIN
MARGIN
MARGIN
 An infiltrative lesion :

 “moth-eaten” (type 2) : a confluence of small lytic areas

 “permeated” (type 3) : small, patchy, ill-defined areas of lytic bone
destruction.
MARGIN
MARGIN
PERIOSTEAL REACTION
PERIOSTEAL REACTION

Solid / unilamellated

 Non-aggressive
appearance 
The underlying lesion is
slow growing and is
giving the bone a chance
to wall the lesion off.
PERIOSTEAL REACTION

Multilamellated / “onion skin”

 Intermediate
aggressive process
PERIOSTEAL REACTION

Spiculated / “hair-on-end” / sunburst pattern

 The most aggressive

appearance and is highly
suggestive of malignancy.
PERIOSTEAL REACTION

Codman triangle
PERIOSTEAL REACTION
PERIOSTEAL REACTION
OPACITY AND MINERALIZATION

 Lucency & sclerosis  stimulation of osteoclasts / osteoblasts by

the tumor.
 Destructive process will cause a fragment of bone to become
sequestered within the lytic region  benign and malignant
processes.
OPACITY AND MINERALIZATION

Opacity

Matrix : Type of tissue of the tumor

(osteoid, chondral, fibrous / adipose.

Mineralization : Calcification of the

matrix
OPACITY AND MINERALIZATION
BONE FORMING

Bone-forming
Fluffy, amorphous, cloudlike
mineralization
OPACITY AND MINERALIZATION
CHONDRAL MINERALIZATION

Chondral tissue
Punctate, flocculent, comma
shaped, arclike / ringlike
Enchondroma, Chondrosarcoma,
Chondroblastoma
SIZE AND NUMBER

Benign < 6 cm
Malignant > 6 cm

Primary tumor > 6 cm

Secondary tumor < 6 cm
SIZE AND NUMBER

1Osteoid
– 2 cm Chondral
osteoma: lesion
< 1.5 incmlong bone : Enchondroma
>Osteoblastoma
4 – 5 cm : Low-grade
: > 1.5chondrosarcoma
cm

< 3 cm Fibrous cortical

defect
Well defined lytic
lession in the cortex
of a long bone with
a sclerotic rim
> 3 cm Nonossifying fibroma
CORTICAL INVOLVEMENT
Processes in the medullary canal / the periosteum /
surrounding soft tissue

Cortex
Erosion of the inner surface of the cortex  endosteal
scalloping
Completely destroyed and breached by the lesion.
Ballooning of the cortex (normal thickness/thin)
CORTICAL INVOLVEMENT
Processes in the medullary canal / the periosteum /
surrounding soft tissue

Erode the outer surface of the cortex  “Saucerization”

“Buttressed appearance” :
 Periosteum reaction at the site adjacent to the

saucerization
 Slowly growing intramedullary process  aggressive &
break through an area of solid periosteal reaction
SOFT-TISSUE COMPONENT
 Bone lesion + Soft tissue component  MALIGNANT process
1. The tumor destroyed the cortex as it expanded, or
2. Permeated through the haversian canals of the cortex to reach the
surrounding tissue.

 The soft-tissue component may displace adjacent fat planes

SOFT-TISSUE COMPONENT
 Osteosarcoma
 Ewing Sarcoma
 Lymphoma
ADVANCED IMAGING
1 Aneurysmal Bone Cyst
2 Enchondroma
3 4
OFD
5 Chondroblastoma
6 Parosteal Osteosarcoma
7 Aneurysmal Bone Cyst
7 8 Osteo Sarcoma
9
9
10 Chronic Osteomyelitis
10 Chondroblastoma
 10

Osteoid
Brodie’s Abcess
Osteoma
10

Paget’s D
10
10
Age : 13
Location : Metadiaphysis
Margin : 1A – 1B
PX : None
Matrix : None
DX : UBC
ABC

Adult
Metaphysis
Margin 1B
Px None
Matrix None
Age : 66 th
Location : Diaphyseal
Margin : 1A
Px : Minimal , thick
Matrix : None
Dx : WAIT
Age : 66 th
Location : Diaphyseal
Margin : 1A
Px : None
Matrix : None
Dx : WAIT
Age : 66 th
Location :
Diaphyseal
Margin : 1A
Px : None
Matrix : None

DX : MYELOMA
CONCLUSION
 Despite the availability of advanced imaging methods such as CT and
MR imaging, the diagnosis of a tumor or tumorlike lesion of bone still
depends on the conventional radiograph.

 By paying attention to the age of the patient, the location of the

lesion, and the radiographic features of the lesion, the interpreter will
be led to a short differential.
HATUR NUHUN