Normal Anatomy
epiphysis
metaphysisdiaphysis
physis
Childhood Adult
cortex
Medullary spaceMedullary space
Physeal scarPhyseal scar
Criteria to Classify Lesions Age Location of lesion
Which bone? Location within bone
Soft tissue involvement Less reliable
Size Pattern of bone destruction
Criteria to Classify Lesions Zone of transition
Margin of lesion
Visible tumor matrix
Polyostotic or monostotic
Malignant Bone Tumors by Age 1-30
Ewing’s Osteosarcoma
30-40 Fibrosarcoma and MFH Malignant Giant Cell Tumor Reticulum Cell Sarcoma
AGE 20Location metaphysisMargins 3
Periosteal Reaction irregularMatrix boneOther
DX osteosarcoma
Osteosarcoma
Location
Location and age are important parameters Most primary tumors arise in areas of rapid
growth distal femur, proximal tibia, humerus, etc.
Metastases occur in well-vascularized red marrow spine, iliac wings, etc.
Location
Enchondroma: phalanges
Osteosarcoma & giant cell tumor: around the knee
Hemangioma: skull and spine
Chordoma: sacrum and clivus
Adamantinoma: mid-tibia
Pattern of Bone Destruction Permeative
Poorly demarcated, difficult to visualize
“Moth Eaten” Subcategory with larger holes
If mixed, work up as aggressive
“Motheaten”
Myeloma, metastases
Infection Eosinophilic
Granuloma Osteosarcoma Chondrosarcoma Lymphoma
Reaction of Bone to Tumor Margin between tumor and native bone
can be 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
Margin Sclerosis
Sclerotic margin Generally non-aggressive
Lack of sclerotic margin Suggests more aggressive Exceptions
1A: Sclerotic margin
Simple cyst (UBC) Enchondroma Fibrous Dysplasia Chondroblastoma Giant Cell Tumor Chondrosarcoma
1B: Well-defined, non-sclerotic
Giant Cell Tumor Enchondroma Chondroblastoma Myeloma,
Metastatsis Fibrous Dysplasia Chondrosarcoma
1C: Lytic, ill-defined margins
Chondrosarcoma Osteosarcoma Giant Cell Tumor Metastasis Infection Eosinophilic
Granuloma Lymphoma
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
CodmanTriangle
Tumor Matrix
Chondroid matrix Calcified rings, arcs, dots (stippled) Enchondroma, osteochondroma,
chondroblastoma, chondrosarcoma
Osteoid matrix Dense, homogenous, cloudlike Osteoid osteoma, bone island,
osteosarcoma
AGE 56Location metaphysealMargins 1A
Periosteal Reaction noneMatrix chondroidOther
DX enchondroma
Enchondroma
Polyostotic vs. Monostotic Benign polyostotic
Fibrous Dysplasia, Paget’s, histiocytosis, multiple exostosis, multiple enchondromatosis
Malignant polyostotic Mets, Myeloma, Ewing’s with mets,
Osteosarc with mets and MFH.
Work up
Radiograph Aggresive STOP
+
-
Will information regarding polyostoticvs. monostotic be valuable?
Bone Scan Polyostotic - Chest film and CT
Can distinguish benign, mets, myeloma from other
-
+
+
-+
STOP
Workup
Chest film and CT-
+MR (Less likely CT)For site evaluation
Plan to resect lung mets
Biopsy
+
Palliative Care
-
Biopsy
Sample away from necrotic or non-aggressive area
Avoid contaminating compartments Knee- suprapatellar bursa is large Pelvis- avoid gluteal musculature which
will need for coverage
AGE 13Location metadiaphysisMargins 1A-1B
Periosteal Reaction noneMatrix noneOther trabecular struts
DX UBC
Unicameral Bone Cyst
AGE adultLocation metaphysisMargins 1B
Periosteal Reaction noneMatrix noneOther fx
DX ABC
Aneurysmal Bone Cyst
Giant Cell Tumor
AGE 45Location metaphysisMargins 1B
Periosteal Reaction noneMatrix noneOther epi involvement
DX GCT
Osteoid Osteoma
AGE 45Location diaphysisMargins 1B
Periosteal Reaction thickMatrix faintOther
DX osteoid osteoma
AGE 66Location diaphysealMargins 1A
Periosteal Reaction minimal, thickMatrix noneOther 2nd lesion
DX wait…..
Multiple Myeloma
AGE 66Location diaphysealMargins 2
Periosteal Reaction noneMatrix noneOther
DX wait…..
Multiple Myeloma
Multiple Myeloma
AGE 66Location flat boneMargins 1B
Periosteal Reaction noneMatrix noneOther multiple
DX myeloma
AGE 12Location diaphysisMargins 3
Periosteal Reaction lamellatedMatrix noneOther
DX Ewing
Ewing’s Sarcoma
AGE 16Location diaphysisMargins 3
Periosteal Reaction spiculatedMatrix boneOther fx
DX osteosarcoma
Osteosarcoma
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