Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)
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Transcript of Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)
Kenneth Buckwalter, M.D.
Indiana University
(317) 274-1837
Radiology of Bone Tumors
Outline
• Work-up and Radiologic assessment
• Approach
– Normal bone anatomy
– Radiographic Analysis
• Location
• Margins
• Periosteal reaction
• Matrix
• Examples
Work-up
• History
– Age is critical.
– Smoker?
– Malignancy?
• Physical examination
– Breast mass?
• Good radiographs of affected region
– 2 views minimum
Multiple vs. Solitary
• Multiple
– metastatic
– congenital
• fibrous dysplasia
– acquired
• Paget
• Solitary
– metastatic
– primary bone tumor, malignant or benign
Multiple
• 50+ y/o
– known malignancy?
– myeloma, get SPEP
– otherwise, do metastatic work-up
• child to early adult
– known malignancy?
– EG?
– polyostotic fibrous dysplasia?
– otherwise, do metastatic work-up
Solitary
• Aggressive radiographic appearance
– bone scan to stage and verify solitary nature
– metastatic work-up
• baseline CXR
• spiral CT for pulmonary nodules
• Staging for surgery
– cross-sectional imaging: CT or MR
• Need tissue biopsy
Biopsy
• obvious superficial mass, blind biopsy
• tissue compartments must not be contaminated
– Biopsy should be done in consultation with a tumor surgeon.
• skinny needle most helpful with metastatic disease
• core best for primary tumor
Cross-sectional imaging
• Pictures are pretty, but diagnosis established
at histology
• MRI best for most tumors
– optimal results at sites with experience
• Role of CT limited
– may assist in assessing tumor matrix
– useful in directing biopsy
Normal Anatomy
epiphysis
metaphysis diaphysis
physis
childhood adult
cortex
medullary
space
physeal scar
How are Bone Tumors
Like Real Estate?
Location!
Location!
Location!
Location
• Location and age of patient most important
parameters in classifying a primary bone
tumor.
• Simple to determine from plain radiographs.
Location
Rad Clin N Am,
Dec 1981
Reaction of bone to tumor
• Limited responses of bone
destruction: lysis (lucency)
reaction: sclerosis
remodeling: periosteal reaction
• Rate of growth determines bone response
– slow progression, sclerosis prevails
– rapid progression, destruction prevails
Reaction of bone to tumor
• Margin between tumor and native bone is
visible on the plain radiograph.
• Slowly progressive process is “walled-off” by
native bone, producing distinct margins.
• Rapidly progressive process destroys bone,
producing indistinct margins.
Radiographic Margins
• Margin types 1A, 1B, 1C, 2, and 3
– least aggressive 1A, to most aggressive 3
• Aggressive lesions destroy bone.
• Aggressiveness increases likelihood of
malignancy.
– BUT, not all aggressive processes are malignant.
– AND, not all malignant diseases are aggressive.
Margins: 1A,1B,1C
increasing aggressiveness Rad Clin N Am,
Dec 1981
1A: sclerotic margin
• simple cyst (UBC)
• enchondroma
• FD / FX
• chondroblastoma
• GCT
• chondrosarcoma (rare)
• MFH (rare)
Rad Clin N Am,
Dec 1981
1B: well-defined, non-sclerotic
• GCT
• enchondroma
• chondroblastoma
• myeloma, metastatsis
• CMF
• FD
• chondrosarcoma
• MFH
Rad Clin N Am,
Dec 1981
1C: lytic, ill-defined margins
• chondrosarcoma
• MFH
• osteosarcoma
• GCT
• metastasis
• infection
• EG
• lymphoma
Rad Clin N Am,
Dec 1981
2: “motheaten”
• myeloma, metastases
• infection
• EG
• osteosarcoma
• chondrosarcoma
• lymphoma
Rad Clin N Am,
Dec 1981
3: “permeative”
• Ewing
• EG
• infection
• myeloma, metastasis
• lymphoma
• osteosarcoma
Rad Clin N Am,
Dec 1981
Types of
Periosteal
Reaction
Rad Clin N Am,
Dec 1981
Periosteal Reaction
• Limited usefulness
• Thick, uninterrupted
– long standing process, often non-aggressive
• stress fracture
• chronic infection
• osteoid osteoma
• Spiculated, lamellated
– aggressive process
– tumor likely
Codman Triangle
periosteal reaction
tumor
advancing tumor margin
destroys periosteal new
bone before it ossifies
Codman
Triangle
Tumor Matrix
• “Matrix” is the internal tissue of the tumor
• Most tumor matrix is soft tissue in nature.
– Radiolucent (lytic) on x-ray
• Cartilage matrix
– calcified rings, arcs, dots (stippled)
– enchondroma, chondroblastoma, chondrosarcoma
• Ossific matrix
– osteosarcoma
Matrix
Rad Clin N Am,
Dec 1981
Examples
AGE 13
Location metadiaphysis
Margins 1A-1B
Periosteal Reaction none
Matrix none
Other trabecular struts
DX UBC
Example 1
Example 2
AGE adult
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other fx
DX ABC
Example 2
Example 3: 13 y/o with knee pain
AGE 13
Location epiphyseal
Margins 1B
Periosteal Reaction none
Matrix none
Other
DX chondroblastoma
Example 3
Example 4: 45 y/o with knee pain
Example 4
AGE 45
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other epi involvement
DX GCT
Example 4*, 35 y/o F, GCT
AGE 66
Location diaphyseal
Margins 1A
Periosteal Reaction minimal, thick
Matrix none
Other 2nd lesion
DX wait…..
Example 5
Example 5
AGE 66
Location diaphyseal
Margins 2
Periosteal Reaction none
Matrix none
Other
DX wait…..
Example 5
AGE 66
Location flat bone
Margins 1B
Periosteal Reaction none
Matrix none
Other multiple
DX myeloma
Example 6: 14 y/o with claudication
Example 6
Example 6
AGE 14
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix mature bone
Other claudicat'n
DX exostosis
Example 7: 25 y/o woman with knee pain
Example 7
AGE 25
Location metaphysis
Margins 1A
Periosteal Reaction none
Matrix ?
Other multiple
DX NOF
Example 7
Example 8: 45 y/o with thigh pain
Example 8
AGE 45
Location diaphysis
Margins 1B
Periosteal Reaction thick
Matrix faint
Other
DX osteoid osteoma
AGE 12
Location diaphysis
Margins 3
Periosteal Reaction lamellated
Matrix none
Other
DX Ewing
Example 9
Example 9
“onion-skin”
Example 10
AGE 16
Location diaphysis
Margins 3
Periosteal Reaction spiculated
Matrix bone
Other fx
DX osteosarcoma
Example 10
AGE 20
Location metaphysis
Margins 3
Periosteal Reaction irregular
Matrix bone
Other
DX osteosarcoma
Example 10*, osteosarcoma
AGE 56
Location metaphyseal
Margins 1A
Periosteal Reaction none
Matrix chondroid
Other
DX enchondroma
Example 11
Summary
• Radiographs are essential
• Aggressiveness of process dictates the
response of the bone
• Most helpful information in analysis
– Age
– Location
– Margins
“Don’t Touch Me”
• Fibrous lesions
– fibrous dysplasia
– NOF (non-ossifying fibroma)
• enchondroma
• exostosis
• unicameral (simple) bone cyst
AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX
Example