Syartis library_JUNE 2015 Radiology UNAIR

Adopted from Green span and other literature

Bone LESION / lesion like bone tumor

Type of bone destruction

Type of periosteal reaction

Borders of the lesion, zone of transtition

Geographic type of bone destruction

Matrix calcification of tumor

Benign vs malignant lesion

 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Lytic lesion
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
BENIGN OSTEOBLASTIC LESION

OSTEOMA is a slow growing bone tumor; 30 50 0f age; M=F; common site

in calvaria and mandibula, less common in long bone; the lesion grows on the
bone surface and has the radiographic appearance of a dense, ivory-like
sclerotic mass attached to the cortex with sharply demarcated border; clinically
not pain
DIFFERENTIAL DIAGNOSIS :
Parosteal osteosarcoma ( is the most important entity that needs to be
excluded,,, both lesion appear as ivory-like masses attached to the bone
surface; the key to recognize is osteoma are usually exquisitely smooth
borders and well-circumcribed, intensely homogeneous sclerotic
appearance)
Sessile osteochondroma juxtacortical myositis ossificans ( the cortex
and medulla of the lesion is uniterrupted from the host bone )
Periosteal osteoblastoma ( round or ovoid heterogeneous in density
mass, attached to cortex )
Ossified parosteal lipoma ( lobulated mass containing irregular
ossifications and radioluscent area of fat; hyperostosis of adjascent cortex
occasionally present )
Focus of melorheostosis ( cortical thickening resembling wax dripping
down one side of a candle )

Parosteal OS

Sessile 0C Myositis Ossificans

Periosteal Osteblastoma
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Medullary osteoma OSTEOID OSTEOMA most important clinal syptoms is pain severe at night
Cortical but is dramatically relieved by analgetik; 10 30 of age; M=F 2:1; sites of
osteoma There is sclerosis nidus predilection are the long bones, particularly the femur and tibia; characteristic of
surrounded by a halo lesion there is a nidus of osteoid tissue, which may be purely radioluscent or
of radioluscent osteoid have a sclerotic centre. The nidus has limited growth potential and usually
tissue
measures less than 1 cm in diameter; The lesion can be classified as cortical,
medullary (cancellous), or subperiosteal; subclassified as an exracapsular or
intracapsular

DIFFERENTIAL DIAGNOSIS :
Osteoid osteoma (cortical)
There is intense reactive sclerosis 1. Stress fracture (radioluscent line perpendicular to or angle to cortex)
surrounding the nidus 2. Cortical bone abscess (radioluscent usually elongated focus with a
linear, serpentine tract)
3. Intracortical OS (radioluscent focus surrounded by zone of sclerosis;
cortex thickened or bulged)
Osteoid osteoma (medullary)
1. Brodie abscess (lesion close to growth plate, serpentine tract)
2. Bone island ( brush borders )
3. Osteoblastoma (lesion larger than 2 cm, reactive sclerosis not striking,
prominent periosteal reaction)
Subperiosteal osteoma TREATMENT : En bloc resection

Intracapsular osteoma Stress fracture Cortical abscess Brodie abscess

Radioluscent nidus with minimal

reactive sclerosis
Radioluscent
lesion with
serpentine
tract
Perpendicular direction of
the radioluescent to the
long axis of the tibial cortex A serpentine tract extebds from an
abscess cavity toward the growth late

BoneIsland Osteoblastoma

Brush border
The lesion is larger and there is a more
pronounced periosteal reaction in the
medial and lateral humerus cortices. The
extent of reactive bone surrounding the
radioluscent nidus is less than that usually
seen in osteoid osteoma
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

OSTEOBLASTOMA, 3% of all benign bone tumors; similar to osteoid

osteoma but characterized by a larger size (usually more than 2 cm); 10 35
of age; M=F 2:1; long bones frequently involved, vertebral column is
predilection; clinically asymptomatic or pain not relieved by analgetic; Has a
four distinctive radiographic presentations: 1). A giant osteoid osteoma, the
lesion usually more than 2 cm in diameter and exhibits less reactive sclerosis
and a possibly more prominent periosteal reponse than does osteoid osteoma;
2). A blow-out expansion similar to an aneurysmal bone cyst with small
radiopacities in the center (particularly common in lesion involving the spine); Lumbosacral spine AP: Osteoblastoma show
an expansive lesion in the left pedicle and
3). An agressive lesion simulating a malignant tumor; 4). Periosteal lesion that
lamina of VL5
lack perifocal bone sclerosis but exhibits a thin shell of newly formed periosteal
bone
An AGGRESSIVE OSTEOBLASTOMA : should be differentiated from
osteosarcoma

DIFFERENTIAL DIAGNOSIS :
Osteoid osteoma ( osteoid osteoma has a radioluscent nidus <1,5 cm,
occasionally with a sclerotic center )
Bone abscess ( bone abscess usually marked by serpentine track or it is
seen to cross the growth plate,,, THIS PHENOMENA ALMOST NEVER
SEEN IN OSTEOBLASTOMA)
Aneurysmal bone cyst ( similar appearance to osteoblastoma, there is Osteoblastoma: Radioluscent focus in the
blow out, expansive lesion BUT with central opacities ) scapula surrounded by a sclerotic area,
Enchondroma ( enchondroma will usually display a calcified matrix accompanied by shaggy periosteal reaction
at the axillary border
assuming the form of dots, rings, and arcs. And enchondroma unless
there has been a pathologic fracture, )
Osteosarcoma ( OS has permeative or moth-eaten bone destruction;
wide zone transtiton; tumor bone in form of cloud-like opacities;
aggressive periosteal reaction; soft tissue mass ) A serpentine tract
extebds from an
abscess cavity toward
the growth late

Osteoid
An aggressive osteomadestruction
osteoblastoma:
of the entire fourth metacarpal with
massive bone formation, particularly in
distal portion. Although very similar in
apperance to OS, the lesion still appears to
be contained by a shell of periosteal new
bone formation

Radiographs show enchondroma-like

osteoblastoma. Note the periosteal
reaction (arrow) and lack of matrix that is
typical enchondroma. Small radiopacities in
the centre of the lesion represent bone
formation, a characteristic feature of
osteoblastoma

There is radioluscent nidus with a

sclerotic border
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
BENIGN CHONDROBLASTIC LESION
Diagnosis of a bone lesion as originating from cartilage is usually a simple task for the
radiologist. The lesions radioluscent matrix, scalloped margins, and annular, comma-
shaped or punctate calcifications usually suffice to establish its chondrogenic nature.

ENCHONDROMA (Chondroma), is the 2nd most common benign of Enchondroma

tumor bone; 10% of all benign bone tumor; most common predilection in short
tubuler bones of the hand but may also in long tubular bone, characterized by
the formation of the mature hyalin cartilage; it is called as Enchondroma when
located centrally in the bone; if it is extracortical (periosteal) named Chondroma
(periosteal or juxtacortical); 15 40 of age; M:F 1:1; clinically asymptomatic
and phatologic fracture may present as a complication. Radiographically : in
short bones, the lesion is entirely radioluscent, in long bones may display
calcificaions. If the calcification is extensive, enchondromas are called
calcifying. The lesions can also be recognized by shallow scalloping of the
inner (endosteal) cortical margins, because the cartilage in general grows in a
lobular pattern) Radioluscent lesion in the medullary portion
of proksimal femur with eroding the inner
aspect of the lateral cortex. Note scalloped
DIFFERENTIAL DIAGNOSIS : borders and matrix clcifications
The radiographic features helpful in DD/ are the lobulation of the inner
cortical margins in enchondroma, the annular, punctate, and comma-
shaped calcifications in the matrix and the lack of sclerotic rim that is
usually seen in bone infarcts

The most difficult DD/ is a large solitary enchondroma from a slowly

growing low-grade chondrosarcoma. Chondrosarcoma in the early stage
is localized thickening of the cortex. Lesion longer than 4 cm are
suggestive malignancy. In more adveanced tumor, destruction of the
cortex and the presence of a soft tissue mass are the hallmark of
malignancy
TREATMENT : Curetage
A typical enchodroma : purely radioluscent
at the base of the proximal phalanx , may
with pathologic fracture in large
enchondroma

Periosteal chondroma at distal femur

shows a lesion arising from the posterior
cortex that resembles an osteochondroma.
After ct scan, demonstrate lack of
Calcifying enchondroma, communication between the medullary
lobular appearance of the portion of the femur and the lesion, So the
lesion and the scalloping osteochondroma was excluded
of the endocortex

Periosteal chondroma at medial humerus,

DD/ osteochondroma (sessile type). Note
the periosteal reaction and separation of
the tumor from the medullary cavity by a
cortex
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

ENCHONDROMATOSIS (OLLIER DISEASE), is a condition marked

by multiple enchondromas, generally in the region of the metaphyses and Ollier disease: large,
diaphysis. The term Ollier disease is applied when the skeleton is extensively lobulation
affected, with predominantly unilateral distribution. Clinical manifestation as cartilaginous
masses markedly
unilateral, knobby swellings of the digits or gross disparity in the length of the
deform the bones
forearms or legs, are frequently recognized in childhood and adolescent; 10 of the hand
30 of age; M;F 1:1; common predilection site proksimal and distal tibia and
femur, proksimal humerus, pelvic, distal radius, and manus. Radiographic
pattern : interferences of the lesion with the growth plate causes foreshortening
of the limbs. Deformtiy of the bones is marked by radioluscent mass of
cartilage, often in the hand and foot, containing focci of calcification

Complications : the most frequent and severe complication of ollier

disease is malignant transformation to chondrosarcoma

Classic features of Ollier disease are exhibited in extensive involvement of multiple bones. In
Pelvic shows crescent shaped and ring-like calcifications in tongues of cartilage extending from
the iliac crests and proximal femora. In legs shows growth stunting and deformities of the tibia
and fibula
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

OSTEOCHONDROMA (also known as osteocartilagenous

exostoses) : 10 35 of age, has its own grown plate, usually
stops growing at skeletal maturity; M:F = 2:1; most common
benign bone lesion, involvement are metaphyses of the long
bones (common sites in proksimal humerus and tibia, distal
femur; less common sites in distal tibia, femoral neck,
proksimal ulna and scapula); Radiographically : as a bone
exostosis which is uninterrupted merging of the cortex and
medulla from the host bone. @typical pedunculated : with a
slender pedicle usually directed away from the neighboring
growth plate, @ typical sessile : with a broad base attached
to the cortex
DIFFERENTIAL DIAGNOSIS :
Myositis ossificans : lesion with dense periphery and
luscent centre, cleft separating lesion from cortex
Juxtacortical Osteosarcoma : lesion with luscent
periphery and dense centre, no cleft
Soft tissue osteosarcoma : lesion with smudgy
densities in centre, more luscent at periphery
Juxtacortical osteoma : homogeneously dense (ivory
lesion), no cleft
Periosteal chondroma : solid buttres os periosteal
reaction, calcification in centre of lesion
COMPLICATIONS :
Pressure on the adjascent bone with occasional fracture,
pressure nerves and or blood vessels

Periosteal chondroma: show

lytic mass appears confined to
the cortex and site within a
cup formed by buttresses of
reactive bone

Juxtacortical (parosteal)
osteosarcoma : typically
at the posterior aspect of
the distal femur

Myositis ossificans : zonal

phenomenon; radioluscent
area in center of lesion and
dense zone of mature
ossification at periphery;
frequently thin radioluscent
cleft separates ossific mass
from adjascent cortex

Juxtacortical (parosteal)
osteoma : atypical ivory-
like mass is seen attached
to the cortex

Soft-tissue osteosarcoma : is
an uncommon malignant tumor
of mesenchymal origin,
Malignant transformation of osteochondroma : enlargement of the accounting 4% of all OS, mean
age about 54 years; As a slowly
lesion, marked thickening of the cartilaginous cap of the lesion, growing mass, may or may not
dispersion of calcification into the cartilaginous cap, development of be accompanied by pain.
a soft tissue mass, increased isotop uptake by the lesion after Radiographically : Soft tissue
mass with scattered amorphous
skeletal maturity calcification and ossifications
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

CHONDROBLASTOMA also known as Codman tumor,

<1% of all primary bone tumors, is a benign lesion occuring Chondroblastoma
before skeletal maturity, characteristically presenting in the in the proximal
epiphysis of long bones such as the humerus, tibia, and epiphysis of tibia,
femur, metaphyseal and diaphyseal is exceedingly rare. centrally located
Common site in small bones of the hands and feet. Usually lesion, with
located eccentrically, shows a sclerotic border, and often sclerotic border
and central
demonstrated scattered calcifications of the matrix; 5-25 of
calcification
age; M > F
TREATMENT : curretage and bone grafting
DIFFERENTIAL DIAGNOSIS: Osteomyelitis

CHONDROMYXOID FIBROMA is a rare tumor of

cartilaginous derivation, characterized by the production of
chondroid, fibrous, and myxoid tissue in variable
proporstions; 0,5% of all bone tumor; 2% of all benign bone
tumors. 10 30 of age; M:F 2:1; Common site predilection
in the proximal tibia and distal femur; Clinically swelling and
pain caused by pressure on adjascent neurovascular
structures by peripherally located mass. Radiographic
pattern : an eccentrically located radioluscent lesion in the
bone, with a sclerotic scalloped margin often eroding or
Chondroblastoma in the proximal epiphysis
balloning out the cortex; the lesion mayy range from 1 10
of tibia; radiolucent lesion eccentrically
cm in size located lesion witih a thin, sclerotic margin,
TREATMENT : curretage and bone graft scattered calcification in the centre of lesion
DIFFERENTIAL DIAGNOSIS:
Aneurysmal bone cyst
Giant Cell tumor
Simple bone cyst

Aneurysmal bone cyst of the left

proximal tibia show in diaphysis,
eccentric location, expansive
character, and buttress of solid
periosteal reaction

Chondromyxoid fibroma shows

a radioluscent lesion extending
from the metaphyses into the
diaphysis of the tibia, with a
geographic type of bone
destruction and a sclerotic
scalloped border

Giant cell tumor of the knee,

shows purelyy lityc lesion in the
distal end of the femur,
eccentric location, abscense of
reactive sclerosis, and the
extension of the lesion into the
articular end of the bone

Ostemyelitis, area luscent in proximal

tibia, centrally location, no sclerotic
margin, no periosteal reaction
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
FIBROUS, FIBROOSSEUS, AND FIBROHISTIOCYTIC LESIONS

Fibrous Cortical Defect and Non Ossifying Fibroma

Are the most common fibrous lesion of bone and are predominantly seen in children and adolescents;
2-20 of age; M > F; Predilection site in long bones, particularly femur and tibia; Fibrous cortical defect
(metaphyseal cortical defect) is asymptomatic; Radiographic patterns is radioluscent lesion is elliptical
and confined to the cortex of a long bone near the growth plate, demarcated by a thin margin of
sclerotic. Non Ossifying Fibroma named if the lesion encroach on the medullary region, with continued
growth, these lesion which are typically located eccentrically in the bone, display a characteristic
scalloped sclerotic border.

COMPLICATIONS : Photologic fracture

TREATMENT : Curetage and bone grafting

DIFFERENTIAL DIAGNOSIS :
- Fibrous cortical defect
- Aneurysmal bone cyst
- Chondromyxoid fibroma
- Fibrous dysplacia

FIBROUS DYSPLASIA ,intramedullary in origin, may be entirely intracompartmental or they may

expand and deform the bone without cortical destruction, well circumcribed lesions, no perisoteal
reaction; 1st 2nd decade of life; Subtypes monostotic form (involving only one bone, most common in
rib, proximal femur) and polyostotic form(most common in femur, tibia, pelvis and foot)

DIFFERENTIAL DIAGNOSIS :
- Low-grade Osteosarcoma ( shows cortical destruction with or without soft tissue mass, findings
which are not present in fibrous dysplacia )
- Non ossifying fibroma
- Simple bone cyst
- GCT
- Enchondromatosis

NOF with complication;

pathologic fracture. Lesion
extending halfway or farther into
the medullary region of a bone

NOF (fibrous
cortical defect
encroaches on the
medullary cavity),
Fibrous cortical eccentrically Fibrous dysplacia shows an
defectFibrous
affecting located in the expansive, ground glass density,
medial cortex of bone and has a dyaphiseal lesion. The cortex is
the femur sclerotic border thinned but not disrupted
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
Miscellaneus lesions

SIMPLE BONE CYST Also called a unicamelar bone cyst, is

unknown cause. M > F; more common < 20 yo, but can also
> 20 yo; Predilection site most common in the proximal
diaphysis of the humerus and femur, but in older patient
incidence of simple bone cyst are located in the calcaneus,
talus, and ilium. Radiographically as a radioluscent,
centrally located, well-circumcribed lesion with sclerotic
margin, no periosteal reaction, but if there is pathologic
fracture, periosteal reaction may be present.
SBC in the calcaneus and talus, typically
DIFFERENTIAL DIAGNOSIS : bone cyst occuring at this site are located in
the anterolateral aspect of the bone
Bone abscess
Intraosseus lipoma ( shows sharply marginated
radioluscent lesion with central calcification )
SBC shows location in meta-
diaphisis of the proximal
TREATMENT : Curetage, followed grafting humerus, the radioluscent
lesion is centrally located and
shows pseudosepta, geographic
type of bone destruction,
narrow zone of transtition.
Slight thinning of the cortex,
no periosteal reaction, nor
matrix calcification

Intraosseus lipoma; shows

sharply marginated
radioluscent lesion with
central calcification
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

ANEURYSMAL BONE CYST , are benign expansile tumour-like

bone lesions of uncertain aetiology, composed of numerous blood
filled channels, and mostly diagnosed in children and adolescents;
insidence < 20 yo; Clinically pain, which may be of insidious onset or
abrupt due to pathological fracture, with a palpable lump or with
restricted movement; Location typically eccentrically located in
the metaphysis of long bones, adjacent to an unfused growth plate.
Although they have been described in most bones, the most common
locations are; Radiographs demonstrate sharply defined, expansile
osteolytic lesions, with thin sclerotic margins

DIFFERENTIAL DIAGNOSIS :
- Giant cell tumour (GCT)
- Chondroblastoma, (are seen as well defined lucent lesions, with
either smooth or lobulated margins and a thin sclerotic rim,
arising eccentrically in the epiphysis of long tubular bone such
as the femur, humerus, or tibia or apophysis such as greater an expansile, lucency in metaphysis. No
trochanter, greater tuberosity, calcaneus or talus. Internal fracture although the posterior cortex
calcifications can be seen in 40-60% of cases. A joint effusion is appears deficient. The lesion does not
seen in one-third of patients. They range in size from 1-10 cm, transgress the growth plate
with most being 3-4 cm at diagnosis)
- Fibrous dysplasia,( ground-glass matrix, may be completely
lucent (cystic) or sclerotic, well circumscribed lesions, no
periosteal reaction, rind sign)
- Osteosarcoma (especially telangiectatic osteosarcoma)
TREATMENT : Curetage, followed grafting

ABC; an expansive radioluscent

lesion in the metaphysis of the
distal tibia, extending into the
diaphysis. Note its eccentric
location in the bone and the
buttress of periosteal response at
the proximal aspect of the lesion
Chondroblastoma

GCT; expansile lytic lesion in a

sub-articular in the distal radius

Telangiectatic OS: an expansile

heterogeneous diaphysial mass lesion
with wide transtitional zone and
extensive periosteal reaction in mid
femur associated with soft tissue
swelling
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

GIANT CELL TUMOR (also known osteoclastoma) : 20 50 of

age; F:M = 2:1; usually in long bone (60% : proximal tibia and humerus,
distal femur and radius), almost are extending to the articular end of the
bone; As an purely lytic lesion, eccentric location, narrow transtitional
zone, geographic bone destruction, sclerotic margin, cortical destruction,
soap bubble appearance and soft tissue bulging may also present, and
usually no periosteal reaction nor matrix calcification

TREATMENT : Wide local excision (curretage) and application if

bone chips

DIFFERENTIAL DIAGNOSIS:
- Aneurysmal bone cyst (ABC): younger age group, but may co-exist
GCT; purely osteolytic lesion in the with GCT; fluid-fluid levels
distal end of femur, eccentric location, - Non-ossifying fibroma: usually younger age group
the absence of reactive sclerosis, and - Brown tumour: in the setting of hyperparathyroidism
the extension of the lesion into the - Enchondroma: only really a consideration in lesions of small bones
articular end of the bone
of the hand and foot
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

OSTEOSARCOMA : Hallmark : produce osteoid tissue or bone in

the lesion; 10 20 yo; destruction of the medullary portion of the bone
or cortex; an agressive periosteal reaction (sunburst, lamellar, or
codman traingle); presence of a soft tissue mass
Parosteal osteosarcoma : posterior aspect of the distal femur
(common lesion, less in third medial humerus and femur); usually
seen attached to the cortex, without invasion of the medullary
cavity
Periosteal osteosarcoma = like parosteal osteosarcoma, is a
Parosteal OS; typical surface lesion, very rare tumor, usually at the midshaft; there is
presentation at the inhomogeneous tumor matrix with calcified spiculations
posterior aspect of the interspersed with areas of radiolucency representing uncalcified
distal femur
matrix; occasional periosteal reaction in the form of a Codman
triangle, thickening of the periosteal surface of the cortex at the
base of the lesion, with sparing of the endosteal surface; extension
of the tumor into the soft tissues; and sparing of the medullary
cavity
Telangiectatic osteosarcoma : osteolytic destructive lesion with
an almost complete absence of sclerotic changes, soft tissue mass
may also present
Low-grade central osteosarcoma : lytic lesion with geographic
bone destruction, narrow zone of transtition (DD: FD)
Soft tissue OS (extrasceletal OS): characterized by a soft-tissue
mass with scattered amorphous calcifications and ossifications

Low grade OS;

AP, a lytic lesion with geographic
pattern of bone destruction and
narrow zone of transition Telangiectatic OS; a urely
Lateral, a lytic lesion with well-defined destructive lesion at the
borders and geographic type bone diaphysis of the femur with
destruction the velvet type of perisoteal
reaction.

Periosteal OS; surface

lesion affecting the medial
cortex, associated with a
codman triangle of
periosteal reaction and a
large soft tissue mass

Soft tissue OS; a large soft

tissue mass, sharply
outlined in its distal extent
but porly delineated at the
proximal end. Calcifications
and ossifications are
present throughout the
tumor
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Primary CHONDROSARCOMA (also know as central or medullary

chondrosarcoma) : 30 60 of age; common predilection in pelvic and long
bones, rib less common site; As an expansile, destructive lytic lesion in
medulla with thickening of the cortex and characteristic endosteal scalloping;
Pop corn-like, annular or comma shaped (chondorid matrix calcification) in
the medullary portion of the bone; A soft tissue may be present
DIFFERENTIAL DIAGNOSIS :
Enchondroma : (chondrosarcoma, all centrally located cartilage
tumor in long bones, particularly in adult patients)
GCT (because some chondrosarcoma may extend into the
articular end of bone and particularly without calcification)

Central Chondrosarcoma; Plain radiographs of the right tibia showed destruction of the
destructive lesion in the anterior cortex of the distal tibia, extending to the articular
medullary portion of the surface, and associated with a chondroid-type calcified
bone are annular and softtissue mass that protruded anteriorly. Periosteal new bone
comma-shaped calcification was observed along the anterior tibial cortex. PERIOSTEAL
CHONDROSARCOMA

Chondrosarcoma; tumor arising from

the proximal ulna. Note the huge
soft tissue mass containing
chondroid calcifications
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
Miscellaneus TUMOR
EWING SARCOMA is a highly malignant neoplasm predominantly affecting children and adolescents, with
decisive male predominance, is representative of the so-called round cell tumors, originates fromone marrow
cells, very similar to the so-called primitive neuroectodermal tumor (PNET) ; 5-25 of age, M > F; common
predilection in diaphysis of the long bones, as well as the ribs and flat bones such as the scapula and pelvis;
Clinically, it may present as a localized painful mass or with systemic symptoms such as fever, malaise, weight
loss, and an increased erythrocyte sedimentation rate; the lesion is poorly defined; Radiographically marked by
a permeative or moth-eaten type of bone destruction, and associated with an aggressive periosteal response that
has an onionskin (or onion peel) or, less commonly, a sunburst appearance, and a large soft-tissue mass
and occasionally, the bone lesion itself is almost imperceptible, with the soft-tissue mass being the only
prominent radiographic finding
DIFFERENTIAL DIAGNOSIS :
Metastatic neuroblastoma : (the latter usually occur in the first 3 years, Ewing sarcoma is
uncommon in the first 5 years)
Lymphoma (usually the absence of a soft tissue mass and occurs in older age group)
PNET (the distinction cannot be made by radiographic)
Osteomyelitis (present of the bone destruction, but no permeative lesion)

TREATMENT : Preoperative course and chemoteraphy and or combined with radiation

Ewing sarcoma in the fibula; Poorly

defined lesion exhibits permeative
bone destruction associated with an
aggressive periosteal reaction

Ewing sarcoma in distal femur, there is

permeative type of bone destruction in the
metaphysis and diaphysis associated with a large
soft-tissue mass
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

MALIGNANT LYMPHOMA a group of neoplasms that are composed of lymphoid or histiocytic cells of
different subtypes in various stages of maturation. Once called reticulum cell sarcoma, non-Hodgkin
lymphoma, lymphosarcoma, or osteolymphoma, bone lymphoma is now known as large cell or histiocytic
lymphoma. Primary bone lymphoma is a rare tumor that accounts for less than 5% of all primary bone tumors;
45-75 of age, M > F; common predilection in diaphysis of the long bones, as well as the ribs and flat bones such
as the scapula and pelvis; Clinically, with local symptoms, such as pain and swelling, or with systemic
symptoms, such as fever and weight loss; Radiographically produces a permeative or moth-eaten pattern of
bone destruction or is a purely osteolytic lesion with or more commonly without a periosteal reaction, The
affected bone can also present with an ivory appearance, as is often the case in lesions of the vertebrae or flat
bones. Because lymphoma usually does not evoke significant periosteal new bone formation, this is an
important feature in differentiating it from Ewing sarcoma
DIFFERENTIAL DIAGNOSIS :
Ewing sarcoma: (particularly in younger patient, there is periosteal new bone formation and
usually with soft tissue mass)
Paget disease (if the articular end of bone is involved and thee is a mixed sclerotic and
osteolytic pattern)

TREATMENT : Chemoteraphy and or combined with radiation

Lymphoma at the proximal femur; Lymphoma at the right knee was diagnosed with
there is destructive lesion of tje Paget disease; show a destructive lesion of the
diaphysis to the growth plate, with proximal tibia extending into the articular end of
lamellated type of periosteal the bone. The mixed sclerotic and osteolytic
reaction character of this lesion may resemble the coarse
trabecular pattern of Paget disease; however
there is a lack of cortical thickening. There is a
pathologic fracture, but only minimal periosteal
respon is evident. Biopsy is HISTOCYTIC
LYMPHOMA
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

MYELOMA also known as multiple myeloma or plasma cell myeloma, is a tumor originating in the bone
marrow and is the most common primary malignant bone tumor; 50 of age, M > F; The axial skeleton (skull,
spine, ribs, and pelvis) are the most commonly affected sites, but no bone is exempt from involvement;;
Radiographically Multiple myeloma may present in a variety of radiographic patterns, Particularly in the spine,
it may be seen only as diffuse osteoporosis with no clearly identifiable lesion; multiple compression fractures of
the vertebral bodies may also be evident. More commonly, it exhibits multiple lytic lesions scattered throughout
the skeleton. In the skull, characteristic punched-out areas of bone destruction, usually of uniform size, are
noted, whereas the ribs may contain lace-like areas of bone destruction and small osteolytic lesions, sometimes
accompanied by adjacent soft-tissue masses. Areas of medullary bone destruction are noted in the flat and long
bones, and if these appear about the cortex, they are accompanied by scalloping of the inner cortical margin.
Ordinarily, there is no evidence of sclerosis and no periosteal reaction.
An interesting variant of sclerosing myeloma is the so-called POEMS syndrome. It consists of polyneuropathy (P),
organomegaly (O), particularly of the liver and the spleen, endocrine disturbances (E) such as amenorrhea and
gynecomastia, monoclonal gammopathy (M), and skin changes (S) such as hyperpigmentation and hirsutism
DIFFERENTIAL DIAGNOSIS :
Metastatic carcinoma: (in the early stages of myeloma, the pedicle (which does not contain as much
red marrow as the vertebral body) is not involved, whereas even in an early stage of metastatic cancer
the pedicle and vertebral body are both affected. In the late stages of multiple myeloma, however, both
the pedicle and vertebral body may be destroyed)

TREATMENT : Chemoteraphy and or combined with radiation

COMPLICATION : Pathologic fracture

Multiple myeloma of the scull, note the

characteristic punched out lytic lesion, most of
which uniform in size and lack sclerotic borders.

Multiple myeloma of the distal femur show

endosteal scalloping of the cortex typical of diffuse
myelomatosis
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

SCELETAL METASTASE are the most frequent malignant bone tumors and consequently should always
be considered in the differential diagnosis of malignant lesions, particularly in older patients; Most metastatic
lesions involve the axial skeletonthe skull, spine, and pelvisas well as the proximal segments of the long
bones; These lesions result from the hematogenous spread of a malignancy, the usual mechanism by
which a primary neoplasm erodes regional blood vessels, seeding malignant cells to the capillary beds
of the lung and liver; Radiographically Metastasis to bone can be solitary or multiple and can be further
divided into purely lytic, purely blastic, and mixed lesions; A few characteristic features of metastatic lesions
may be helpful in making the distinction: (a) metastatic lesions usually present without or with only a small
adjacent soft-tissue mass and (b) they usually lack a periosteal reaction unless they have broken through the
cortex. The primary tumors that give rise to purely osteolytic metastases are usually those of the kidney, lung,
breast, thyroid, and gastrointestinal tract. For purely osteoblastic metastases are generally those of the prostate
gland
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Cortical metastase at the distal femur, show sharply

marginated osteolytic areas of bone destruction,
predominantly affecting the cortical bone. There is no
evidence of periosteal reaction. Note the characteristic
cookie bite appearance of the lesion on the lateral
radiograph
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

CASES

Foto Genu Kiri AP / Lateral :

- Tampak mixed lesi litik blastik di metafisis distal os femur kiri, tipe destruksi permeative, zona transisional
luas, periosteal reaction codman triangle, matrix calcification mixed chondroid osteoid, soft tissue mass
(+) di regio distal cruris kiri
- Trabekulasi tulang di luar lesi tampak baik

Kesimpulan : Menyokong gambaran primary malignant bone tumor distal os femur kiri (most likely Osteosarcoma)
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Cruris Kanan AP / Lateral :

- Tampak soft tissue mass regio cruris kanan yang mengerosi cortex sisi posteromedial os tibia kanan
- Trabekulasi tulang setinggi 1/3 tengah os tibia kanan tampak menurun, trabekulasi tulang di luar lesi
tampak baik
- Celah dan permukaan sendi tampak baik

Kesimpulan : Menyokong gambaran malignant soft tissue mass regio cruris kanan
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Thorax dan shoulder kanan AP :

- Tampak lesi litik tipe permeative di 1/3 lateral os clavicula kanan, zona transisional luas, periosteal reaction
(+) tipe lamellar, matrix calcification (-), dengan bulging soft tissue mass yang cukup besar
- Trabekulasi tulang di luar lesi tampak baik
- Celah dan permukaan sendi di luar lesi tampak baik

Kesimpulan :
Menyokong gambaran malignant bone tumor pada 1/3 lateral os clavicula kanan most likely Ewing Sarcoma, DD/
Malignant lymphoma
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Cruris kanan AP / Lateral :

- Tampak lesi litik intramedlar ke posterior medial cortex disertai balloning lesion, permeative type, zona
transisional luas di diaphysis distal medial os fibula kanan. Sementara ini periosteal reaction uninterrupted,
matrix calcification (+)
- Trabekulasi tulang di luar lesi tampak baik
- Celah dan permukaan sendi di luar lesi tampak baik
- Tak tampak jelas soft tissue mass / swelling

Kesimpulan :
Dari foto ini lebih mengarah ke primary bone tumor di os fibula distal dengan DD/ :
1. Berdasarkan usia dan lokasi lesi : Ewing Sarcoma
2. Berdasarkan balloning dan luscency lesi : Fibrous displacia
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Genu kanan AP / Lateral :

- Tampak blastik di epi-metafisis proksimal os tibia kanan, tipe destruksi permeative, zona transisional luas,
periosteal reacion tipe codman triangle, matrix calcification tipe osteoid, disertai soft tissue mass yang
besar
- Tampak pula lesi litik pada os patella kanan dan condylus medial et lateral os femur kanan
- Lesi tampak meluas ke intraarticular (femuropatellar dan femurotibial joint kanan yang menyebabkan
pelebaran femuropatellar joint kanan dan penyempitan femurotibial joint kanan

Kesimpulan :
Menyokong gambaran primary malignant bone tumor (most likely Osteosarcoma) yang meluas ke intraarticular, os
patella kanan dan condylus medial et lateral os femur kanan
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Thorax PA :
- Cor : besar dan bentuk normal
- Pulmo : tak tampak infiltrat / nodul
- Sinus phrenicocostalis kanan kiri tajam
- Tampak multiple bone eksostosis, dengan korteks dan medulla yang contiguous dengan tulang host, base
tak tampak jelas pada scapula kanan yang tampak mendesak costae 3-8 posterior dan di sisi posterior os
scapula kanan
- Tampak multiple bone eksostosis , dengan korteks dan medulla yang contiguous dengan tulang host di
costa 3-5 kanan anterior yang tak tampak jelas basednya

Kesimpulan :
Osteochondromatosis scapula kanan dan costa 3-5 kanan
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Femur kanan AP / Lateral :

- Tampak bone eksostosis di metaphysis distal os femur kanan, dengan korteks dan medulla yang contiguous
dengan tulang host, narrow based di distal femur kiri, dengan soft tissue bulging di sekitarnya, periosteal
reaction (-), matrix kalsifikasi (+)chondroid type
- Trabekulasi tulang di luar lesi tampak baik

Kesimpulan :
Osteochondromatosis pedunculated type distal os femur kiri
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Cruris kanan AP / Lateral :

- Tampak lesi lytic permeative type di 1/3 proksimal os tibia kanan, bone destruction geographic type, zona
transisional luas, periosteal resction tipe sunburst dan codman triangle, matrix kalsifikasi (+) osteoid type,
dengan soft tissue bulging di sekitarnya
- Trabekulasi tulang di luar lesi tampak menurun

Kesimpulan :
Menyokong gambaran aggressive primary bone tumor most likely Osteosarcoma
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Cruris kanan AP / Lateral :

- Tampak bone eksostosis di metaphysis proksimal os tibia et os fibula kanan kiri, metaphysis distal os femur
kanan kiri dengan medulla dan cortex yang masih contiguous dengan host bone, narrow based tak tampak
jelas, periosteal reaction (-), matrix kalsifikasi (-), soft tissue swelling (-)
- Trabekulasi tulang di luar lesi tampak baik
- Celah dan permukaan sendi tampak baik
Kesimpulan :
Osteochondromatosis sessile type distal femur bilateral dan proksimal tibia et fibula bilateral
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Antebrachii kiri AP / Lateral :

- Tampak ekspansile lytic lesion tipe mouth eaten di epi-meta-diaphysis distal os ulna kiri, tipe destruksi
geographic, zone transisional sempit, yang mendestruksi cortex disertai soft tissue bulging disekitarnya,
matrix kalsifikasi (-), periosteal reaction (-)
- Trabekulasi tulang di luar lesi tampak baik
- Celah dan permukaan sendi tampak baik
Kesimpulan :
Deskripsi di atas mengarah ke primary bone tumor ( most likely GCT, kemungkinan malignant masih belum dapat
disingkirkan)
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Scull AP / Lateral :

- Tampak multiple lesi blastik dengan penebalan calvaria disertai gambaran salt and papper
- Trabekulasi tulang di luar lesi tampak baik
- Bentuk dan ukuran sella turcica normal
- Tak tampak tanda tanda peningkatan TIK
- Tak tampak soft tissue mass / swelling
Kesimpulan :
Multiple lesi blastik dengan penebalan calvaria disertai gambaran salt and papper dapat merupakan metabolik
disease (mengarah ke hyperparathyroidism?)
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature

Foto Bone survey :

- Tampak uniform unched out lytic lesion multiple dan diffuse pada os calvaria, corpus VL 1-5, ramus
superior et inferior os pubis kanan kiri, 1/3 tengah hingga distal os femur kiri, 1/3 tengah hingga distal os
humerus kiri dan 1/3 distal os radius kiri
- Alignment baik
- Celah dan permukaan sendi tampak baik
- Tak tampak soft tissue mass / swelling

Kesimpulan :
Adanya uniform unched out lytic lesion multiple dan diffuse pada os calvaria, corpus VL 1-5, ramus superior et
inferior os pubis kanan kiri, 1/3 tengah hingga distal os femur kiri, 1/3 tengah hingga distal os humerus kiri dan 1/3
distal os radius kiri menyokong gambaran multiple myeloma
 Syartis library_JUNE 2015 Radiology UNAIR
Adopted from Green span and other literature