William Herring, M.D.

2002

Bone Tumors Clues and Cues

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Clues by Appearance of Lesion

Geographic Bone Destruction

Destructive lesion with sharply defined border
l

Implies a less-aggressive, more slow-growing, benign process

l l

Narrow transitional zone

Patterns of Bone Destruction

Geographic
Moth-eaten Permeative

R3, 2000

Non-ossifying fibroma

Geographic Lesions
Examples

Non-ossifying fibroma = NOF Eosinophilic granuloma = EG

Chondromyxoid fibroma = CMF

Moth-eaten Appearance

Areas of destruction with ragged borders

l l

Implies more rapid growth

n

Probably a malignancy

Patterns of Bone Destruction

Geographic
Moth-eaten Permeative

R3, 2000

Multiple Myeloma

Moth-eaten Appearance
Examples

Lymphoma

Ewings sarcoma
Myeloma Metastases

Permeative Pattern
Ill-defined lesion with multiple wormholes
l l

Spreads through marrow space

Wide transition zone Implies an aggressive malignancy
n

Round-cell lesions

Patterns of Bone Destruction

Geographic
Moth-eaten Permeative

Leukemia

Permeative Pattern
Round cell lesions (MOLEN)

l Myeloma
l Osteomyelitis

l Lymphoma, leukemia
l Ewings Sarcoma

l Neuroblastoma

Patterns of Destruction

Geographic
Less malignant

Moth-eaten

Permeative
More malignant

Periosteal Reactions
l

Benign
n n

None
Solid

More aggressive or malignant

n
n n

Lamellated or onion-skinning
Sunburst Codmans triangle

Periosteal Reactions
l

Benign
n n

None

Solid

Aggressive/malignant
n n n

Onion-skinning

Sunburst
Codmans triangle
R3, 2000

Non-ossifying fibroma

Periosteal Reactions
l

Benign
n n

None

Solid

Aggressive/malignant
n n n

Onion-skinning

Sunburst
Codmans triangle
R3, 2000

Chronic osteomyelitis

Periosteal Reactions
l

Benign
n n

None

Solid

Aggressive/malignant
n n n

Onion-skinning

Sunburst
Codmans triangle
Greenspan, 2000

Ewings sarcoma

Periosteal Reactions
l

Benign
n n

None

Solid

Aggressive/malignant
n n n

Onion-skinning

Sunburst
Codmans triangle
Greenspan, 2000

Osteosarcoma

Periosteal Reactions
l

Benign
n n

None

Solid

Aggressive/malignant
n n n

Onion-skinning

Sunburst
Codmans triangle
R3, 2000

Ewings-Codmans triangle

Periosteal Reactions

Solid
Less malignant

Lamellated

Sunburst

Codmans
More malignant

Tumor Matrix
l

Osteoblastic
n

Fluffy, cotton-like or cloud-like densities

sOsteosarcoma

Cartilaginous
Comma-shaped, punctate, annular, popcornlike
n

Enchondroma, chondrosarcoma, chondromyxoid fibroma

s

Tumor matrix
Osteoblastic

Cartilaginous

R3, 2000

Osteosarcoma

Tumor matrix
Osteoblastic

Cartilaginous

R3, 2000

Chondrosarcoma

Expansile Lesions of Bone

Multiple myeloma Mets Aneurysmal bone cyst Fibrous dysplasia

Brown tumor Enchondroma Lymphoma

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Multiple Myeloma

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Renal Cell Carcinoma

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Aneurysmal Bone Cyst

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Fibrous Dysplasia

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
R3, 2000

Brown Tumor

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
R3, 2000

Enchondroma

Expansile lesions
l

Multiple myeloma
Mets Aneurysmal bone cyst

Fibrous dysplasia
Brown tumor Enchondroma Lymphoma
Lymphoma
R3, 2000

Clues by Location

of Lesion

In the Transverse Plane

l

Central
n

Enchondroma

Eccentric
n

GCT, osteosarcoma, chondromyxoid fibroma

Cortical
n

Non-ossifying fibroma, osteoid osteoma

Parosteal
n

Parosteal osteosarcoma, osteochondroma

Osteosarcoma

Parosteal sarcoma Osteochondroma

Greenspan, Lippincott, 2000

In The Transverse Plane

In the Longitudinal Plane

l

Epiphyseal
n

GCT, chondroblastoma

Metaphyseal
n

Osteomyelitis, osteo- and chondrosarcoma

Diaphyseal
n

Round cell lesions, ABC, enchondroma

Tumor Types
Characteristic Locations

Simple bone cyst

n

Proximal humerus

Chondroblastoma
n

Epiphyses

Giant Cell tumor

n

Epiphyses

Characteristic locations
l

Simple bone cyst

n

Proximal humerus

Chondroblastoma
n

Epiphyses

Giant Cell tumor

n

Epiphyses
R3, 2000

Characteristic locations
l

Simple bone cyst

n

Proximal humerus

Chondroblastoma
n

Epiphyses

Giant Cell tumor

n

Epiphyses
R3, 2000

Chondroblastoma

Characteristic locations
l

Simple bone cyst

n

Proximal humerus

Chondroblastoma
n

Epiphyses

Giant Cell tumor

n

Epiphyses
R3, 2000

Giant Cell Tumor

Tumor Types
Characteristic Locations
Adamantinoma
n

Tibia

Chordoma
n

Sacrum, clivus

Osteoblastoma
n

Spine, posterior

Characteristic locations
l

Adamantinoma
n

Tibia

Chordoma
n

Sacrum, clivus

Osteoblastoma
n

Spine, posterior
R3, 2000

Adamantinoma

Characteristic locations
l

Adamantinoma
n

Tibia

Chordoma
n

Sacrum, clivus

Osteoblastoma
n

Spine, posterior
R3, 2000

Chordoma

Characteristic locations
l

Adamantinoma
n

Tibia

Chordoma
n

Sacrum, clivus

Osteoblastoma
n

Spine, posterior
R3, 2000

Osteoblastoma

Tumor Types
Characteristic Locations

Parosteal sarcoma
n

Distal femur

Periosteal sarcoma
n

Tibia

Characteristic locations

Parosteal sarcoma
n

Distal femur

Periosteal sarcoma
n

Tibia

Parosteal sarcoma

Characteristic locations

Parosteal sarcoma
n

Distal femur

Periosteal sarcoma
n

Tibia

R3, 2000

Characteristic Tumors
By Body Site

Pelvic Lesions

Chondrosarcoma Solitary plasmacytoma

Chordoma

Pelvic lesions
Chondrosarcoma

Solitary plasmacytoma
Chordoma

Pelvic lesions
Chondrosarcoma

Solitary plasmacytoma
Chordoma

Plasmacytoma

Pelvic lesions
Chondrosarcoma

Solitary plasmacytoma
Chordoma

l
R3, 2000

Chordoma

Expansile Rib Lesions

l

Plasmacytoma Metastases Chondrosarcoma

Eosinophilic granuloma
Neurofibromatosis Fibrous dysplasia

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
Thyroid Carcinoma

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
R3, 2000

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
R3, 2000

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
R3, 2000

Expansile rib lesions

l

Plasmacytoma Metastases

Chondrosarcoma
Eosinophilic granuloma Neurofibromatosis Fibrous dysplasia
R3, 2000

Lesions of the Spine

l

Osteoblastoma
n

Expansile, with punctate densities within

Chordoma
ABC

Metastatic disease

Spine lesions

Osteoblastoma Chordoma ABC

Metastatic disease
R3, 2000

Osteoblastoma

Spine lesions

Osteoblastoma Chordoma ABC

Metastatic disease
R3, 2000

Chordoma

Spine lesions

Osteoblastoma Chordoma ABC

Metastatic disease
Aneurysmal bone cyst

Spine lesions

Osteoblastoma Chordoma ABC

Metastatic disease
Metastatic Breast Carcinoma

R3, 2000

Clues by Density

Of Lesion

Sclerotic Cortical Lesions

Osteoid osteoma Brodies abscess

Stress fracture

Sclerotic cortical lesions Osteoid osteoma

Brodies abscess
Stress fracture

Osteoid Osteoma

Sclerotic cortical lesions Osteoid osteoma

Brodies abscess
Stress fracture

R3, 2000

Brodies abscess

Sclerotic cortical lesions Osteoid osteoma

Brodies abscess
Stress fracture

Healing Stress Fracture

Sclerotic Cortical Lesions

Osteoid Osteoma

Brodies abscess

Healing Stress Fracture

Lytic Lesions in Children

Eosinophilic granuloma Neuroblastoma Leukemia

Lytic Lesions in Children

Eosinophilic granuloma Neuroblastoma Leukemia

R3, 2000

Eosinophilic granuloma

Lytic Lesions in Children

Eosinophilic granuloma Neuroblastoma Leukemia

R3, 2000

Neuroblastoma

Lytic Lesions in Children

Eosinophilic granuloma Neuroblastoma Leukemia

R3, 2000

Leukemia

Lytic Lesions in Adults

l

Metastatic lesions
n

Lung Renal

Thyroid

Multiple myeloma Primary bone tumor

Lytic Lesions in Adults

Mets

Myeloma
Primary bone tumor

Met from Thyroid Carcinoma

Lytic Lesions in Adults

Mets

Myeloma
Primary bone tumor

Multiple myeloma

Lytic Lesions in Adults

Mets

Myeloma
Primary bone tumor

Chondrosarcoma

Blastic Lesions in Children

Medulloblastoma Lymphoma

Blastic Lesions in Children

Medulloblastoma

Lymphoma

R3, 2000

Medulloblastoma

Blastic Lesions in Children

Medulloblastoma

Lymphoma

Lymphoma

Blastic Lesions in Adults

l

Metastatic disease
n

Breast female Prostate male

Lymphoma

Pagets disease
Etcetera-mastocytosis, fluorosis

Blastic Lesions in Adults

Mets

Lymphoma
Pagets

Prostate Mets

Blastic Lesions in Adults

Mets

Lymphoma
Pagets

Breast Mets

Blastic Lesions in Adults

Mets

Lymphoma
Pagets

Lymphoma

Other Clues

Benign Lesions
Without Sclerotic Boarders

Giant Cell tumor Brown tumor

Osteolytic phase of Pagets Disease

Benign Lesions
Without Sclerotic Boarders

Giant Cell tumor Brown tumor

Osteolytic phase of Pagets Disease

Benign Lesions without Sclerotic Borders

Giant cell tumor Brown tumor Osteolytic Pagets

R3, 2000

Brown Tumor

Benign Lesions without Sclerotic Borders

Giant cell tumor Brown tumor Osteolytic Pagets

R3, 2000

Osteolytic Pagets

Soft Tissue Extension

l

Usually implies malignancy

n

More likely to form discrete soft tissue mass

Benign conditions with soft tissue extension

n

Osteomyelitis
s

Usually infiltration of fat

 R3, 2000

Osteosarcoma

Multiple Lesions
l

More often benign

Malignancies with multiple lesions

n

Metastatic disease Multiple myeloma Lymphoma Ewings sarcoma (rarely)

Osteosarcoma (rarely)

Multiple lesions

Metastatic Multiple myeloma Lymphoma

R3, 2000

Mets from Ca of Prostate

Multiple lesions

Metastatic Multiple myeloma Lymphoma

R3, 2000

Multiple Myeloma

Multiple lesions

Metastatic Multiple myeloma Lymphoma

R3, 2000

Lymphoma

Multiple lesions

Metastatic Multiple myeloma Lymphoma Osteosarcomatosis

l
R3, 2000

Osteosarcomatosis

Benign vs. Malignant

Greenspan, Lippincott, 2000

The End