Bone Imaging. Scopes. Objective. Part 1 : bone tumor. Important Factors in Diagnosis of Bone tumor. Part 2 : infection and joint disease

Transcription

1 Scopes Bone Imaging Part 1 : bone tumor Part 2 : infection and joint disease Jitsupa Wongsripuemtet, M.D. Radiology Department Siriraj Hospital Mahidol University Objective ให น กศ กษาแพทย สามารถแปลผลภาพทางร งส ของภาวะหร อโรคกระด กและข อท พบบ อยและให การ ว น จฉ ยแยกโรคได ด งน Common bone tumor Benign : Malignant Infection Osteomyelitis spondylodiscitis Joint disease Degenerative joint disease Rheumatoid arthritis Gouty arthritis Septic arthritis Part 1 : bone tumor Important Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Periosteal reaction 5. Border of lesion 6. Tumor matrix 7. Shape of lesion 8. Soft tissue extension Decade Simple bone cyst Ewing s s sarcoma Chondroblastoma ossifying fibroma Osteochondroma Osteoblastoma Osteosarcoma Non-ossifying ossifying fibroma Aneurysmal bone cyst Osteoid osteoma Chondromyxoid fibroma Giant cell tumor Chondroma Fibrosarcoma & MFH Osteoma Parosteal osteosarcoma Lymphoma of bone Hemangioma Chondrosarcoma Myeloma Chordoma 1 st 2 nd 3 rd 4 th 5 th 6 th 7 th

2 Important Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Border of lesion 5. Periosteal reaction 6. Tumor matrix 7. Shape of lesion 8. Soft tissue extension Normal Anatomy Longitudinal Epiphysis Metaphysis Diaphysis Transverse Cortex Medullary cavity Normal Anatomy Central Eccentric Cortical Parosteal Periarticular Important Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Border of lesion 5. Periosteal reaction 6. Tumor matrix 7. Shape of lesion 8. Soft tissue extension Patterns of Bony Destruction Lodwick s classification Geographic 80% benign, 20% malignant Moth eaten 80% malignant, 20% benign Permeative Almost always malignant

3 Geographic Bony Destruction Moth Eaten Bony Destruction Permeative Bony Destruction Important Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Border of lesion 5. Periosteal reaction 6. Tumor matrix 7. Shape of lesion 8. Soft tissue extension Border of the Lesion Sclerotic border slow growth benign lesion No sclerotic border rapid growth malignant lesion Sclerotic Border No Sclerotic Border

4 Practice IA IB IC II III Important Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Border of lesion 5. Tumor matrix 6. Periosteal reaction 7. Shape of lesion 8. Soft tissue extension Tumor Matrix Osteoid Matrix Osteoid matrix ivory like or cloudlike Chondroid matrix stippling, ring, arcs punctate flocculent popcorn like Chondroid Matrix Impotant Factors in Diagnosis of Bone tumor 1. Age of the patient 2. Location of lesion 3. Pattern of bony destruction 4. Border of lesion 5. Tumor matrix 6. Periosteal reaction 7. Shape of lesion 8. Soft tissue extension

5 Periosteal Reaction Solid Periosteal Reaction Edeikin s classification Solid type : almost always benign Interrupted type Sunray Codman s triangle Lamellation Sunray Periosteal Reaction Lamellated Periosteal Reaction Onion peel Codman s Triangle Periosteal Reaction Shape of the Lesion Expansion nonaggressive lesion No expansion aggressive lesion

6 Expansile Lesion Non Expansile Lesion Imaging tools in musculoskeletal tumor Osseous neoplasm Differential diagnosis of primary skeleton tumor is best determined by radiograph But CT and/or MRI are vital for delineating and staging osseous neoplasms prior to surgery Soft tissue neoplasm Radiographs only occasionally helpful CT and more often MRI can be tissue specific But MRI and/or CT are vital for definite extent, staging, and preoperative evaluation BENIGN BONE LESION Osteoma Common in PNS (frontoethmoidal sinus ~ 75% and sphenoid sinuss ~ 1 4%) and calvarium Harmatoma of the bone Characterized by abnormal bone proliferation on an osseous surface Sharply defined, homogeneous, bone mass arising from surface of bone projection from bone surface no soft tissue involvement Osteoma

7 Osteoid Osteoma (OO) Osteoid Osteoma Composed of osteoid and woven bone with interconntected trabeculae Rim of highly vascularized fibrous CNT Location neck femur diaphysis femur diaphysis tibia posterior element of spine Typical clinical presentation aching pain and worse at night relieved by aspirin Osteolytic lesion (nidus) with dense fusiform sclerosis 90% of nidus less than 1 cm CT localization is most helpful in treatment Nidus Fibrous Dysplasia Developmental anomaly of bone formation Osteoblasts fail to develop Fibrous tissue replace bone marrow Usually diagnose at age < 30 YO but > 2 YO Location Medullary diaphyseal of long bone rib geographic bony destruction expansile centric lesion ground glass appearance thick sclerotic border May cause skeletal deformity fracture, bowing (Shepard s crook) and growth disturbance Simple Bone Cyst Common in 1 st and 2 nd decades. Location is a KEY Central proximal metaphyseal humerus (50%) proximal femur (20%) expansile, geographic bony destruction. central location. fine sclerotic border pathologic fracture : minimal periosteal reaction, fallen fragment sign Simple Bone Cyst

8 Chondroblastoma Skeletal immature patients Children and young adult 5 25 YO Location is a key!!! epiphysis or apophysis (40%) Epiphysis and metaphysis (55%) Metaphysis (4%) Common location : proximal femur (23%) distal femur (20%) proximal tibia (17%) proximal humerus (17%) hand and feet (10%) Radiologic Findings geographic bony destruction sclerotic margin cartilage matrix (50%) Minimal periosteal reaction (30 60%) Eccentric > central, rarely expansile Chondroblastoma Most common tumor in phalanx!!! Peak incidence YO Location Hand and feet (40 65%) Long tubular bones (25%) Phalanges and metacarpals mc locations Enchondroma geographic bony destruction expansile lesion central metaphyseal location sclerotic border most have chondroid matrix Enchondroma MC benign neoplasm of bone (biopsy) Young patient <20 YO (75%) Pathology medullary and cortical continuity with underlying bone, cartilaginous cap Location Femur (30%), tibia (20%), humerus 20%, hand and feet (10%) Osteochondroma marrow, cortex and periostea lextending from the underlying bone Metaphyseal, growth away from epiphysis cartilaginous cap chondroid matrix CT and MRI : cardilageneous cap > 1 cm, suspicious of malignant transformation Osteochondroma

9 Most common occur in years of age. Almost always occur after epiphyseal fusion Location Site of origin is metaphysis; usually extends to subarticular region. Location : long bone 75 90% Giant Cell Tumor 2. Malignancy 1. Primary 2. Secondary (Metastasis) MALIGNANCY BONE TUMOR Osteosarcoma Chondrosarcoma Ewing s sarcoma Multiple myeloma Plasmacytoma Primary Osteosarcoma (OGS) The 2 nd MC primary malignant bone tumor Conventional OGS most common type in yrs or older than 60 YO M:F = 4:1 Location 80% around knees 90% metaphyseal origin 75% extend to epiphysis

10 Osteosarcoma Clinical findings highly aggressive painful mass childhood and adolescents male Radiographic findings Usually mixed sclerosis and lytic (moth eaten or permeative bone destruction) No definite border cortical breakthrough with soft issue mass osteoid matrix : fluffy/clound like Interrupted eriosteal reaction : Codman triangle, perpendicular (sunburst or hairon end), lamination (rare) Extend across epiphyseal plate (75 90%) MR/CT for preoperative planning : NV, intraarticular Osteosarcoma Ewing s Sarcoma Most common primary malinant bone tumor in the 1 st decade of live Location Tubular bone in children Flat and axial bone in adolescences and adult. Central and diaphyseal /metadiaphyseal. Clinical findings painful mass childhood (1 10 yrs) M : F = 1:1 Ewing Sarcoma Ewing s Sarcoma moth eaten and permeative bony destructions with soft tissue mass reactive sclerosis within the bone interrupted periosteal reaction lamellation > 2 layers sunray appearance Codman s triangle

11 Ewing s Sarcoma Differential diagnosis 1. OGS 2. Osteomyelitis 3. Lymphoma and leukemia Chondrosarcoma Peak age > 40 years M:F = 1:1 Location Most common: flat bones (scapula, pelvic bone) Tubular bone (femur) Geographic to permeative bony destruction Cortical thickening and periosteal reaction Expansile remodeling destroyed cortex chondroid matrix Chondosarcoma Multiple Myeloma (MM) Most common primary malignant bone tumor in adult Proliferation of malignant plasma cells Solitary lesion call Plasmacytoma Peak age: > 60 yrs (rare in patient < 40) Most common location: vertebra, ribs, pelvis, or skull Usually not involve mandible and pedicle. DDx. Metastasis lytic type

12 Multiple Myeloma (MM) multiple small discrete lytic bony destructions no reactive sclerosis generalized osteopenia Secondary Bone metastasis 1. Blastic type 2. Lytic type History of malignancy Peak age: > 40 yrs Most common site : skull, spine and long bones Ostelytic Type : lytic bone lesion without sclerosis border involving multiple bones DDx: MM One eyed pedicle sign (Winking owl sign)

13 Most common in CA prostate breast thyroid kidney lung Blastic Type นม ไท ไต ล ง หมาก : blastic bone lesion with extensive sclerosis involving multiple bones Spinal metastasis (Blastic type) Conclusion Diagnosis of bone tumor is pattern recognition Check lists for describe the findings 1.Age 2.Location : Which bone Epiphysis, metaphysis, diaphysis Central VS eccentric 3.Type of destruction Geographic (lytic) Moth eathen Permeative 4.Sclerotic border? 5.Periosteal reaction Solid Interrupted (sun ray, Codman s triangle, lamellation ) 6.New bone / matrix formation Osteoid Chondroid 7.Associated findings Soft tissue formation Part 2 : infection and joint disease Common MSK infection INFECTION OF BONE Osteomyelitis : Organism : bacterial S.aureus (80 90%), H.influenza, Strep, GNB, pseudomonas, Acute Chronic Spinal infection

14 Routes of infection Hematogeneous Contiguous spread Direct implantation/post surgery Hematogeneous vascular supply tubular bone Age dependent Infant : vessels penetrate growth plate Child : vessels do not extend across plate Adult : vessels cross closed growth plate Immature growth plate Acute Ostomyelitis : Radiographic findings Radiographic evidence after 1 2 wks (early diagnosis: bone scan & MRI) Deep soft tissue swelling ( within 3 days) Moth eaten type of bony destruction with poorly marginated or lytic bone destruction (7 14 days) Periosteal reaction occurs by 2 wks Usually solid type Most common site: Metadiaphysis Epiphyseal involvement common in adult and children under 1 year old Child 1 16 YO

15 Subacute Osteomyelitis Adult : Bordie abscess (circumscribed lytic area surrounded by sclerotic bone), most common in tibia usually in children Chronic Osteomyelitis Spinal infection Findings mixed osteosclerosis & osteolysis cortical thickening sequestrum (necrotic bone) involucrum (thickened new bone surrounding cloaca Active infection? : new bone destruction sequestrum aggressive periosteal reaction on radiograph Routes of contamination Hematogeneous Arterial Venous : Batson plexus Contiguous source Direct implantation / post operative Spondylodiscitis Bacterial : most common pathology S. aureus L > T > C/S Pathology Localizes to anterior subchondral bone Rapidly extends into disc (1 3 weeks) Can extend to paravertebral soft tissue Spinal infection Radiographic findings Initially normal or subtle subchondral destruction Usually seen radiologically after disc involved Rapid disc narrowing with irregular endplate destruction Later osteosclerosis Spinal infection

16 Tuberculous Spondylodiscitis Most common location: T L spine Hematogeneous, pulmonary changes 50% Subchondral vertebral body (2 5 months) : anterior 80%, posterior 20% Less common involvement posterior element Subligamentous spreading (gouge defect) late involvement of disc & adjacent vertebra kyphosis (gibbus deformity) paravertebral abscess & soft tissue mass Joint disease VS bone disease Definition of joint disease Disease that affects bone on both Narrows the space between them JOINT DISEASE DJD AVN Type of arthritis Infection : Hallmark destruction of articular cortex Hypertrophic : Hallmark bone production, sclerosis OA Charcot joint Erosive : Hallmark bone erosion RA Gout, pseudogout SNSA hemophilia

17 Infection : septic arthritis Cause hematogeneous, contiguous spread direct implantation/post surgical Organism : H. influenza </=2 YO, S.aureus, Strep, GNB Pathology Synovial inflammation/hyperemia Fibrin deposit, inhibit cartilage nutrition Attract WBC s release enzyme Pannus formaion Cartilage destruction/bone Infection : septic arthritis Clinical findings painful and swelling joint one joint, unilateral involvement Soft tissue swelling/joint effusion Periarticular osteopenia narrowing joint space Erosive arthritis Inflammatory arthropathies General Synovial proliferation (pannus formation) Inflammation Erosions seen in small joints (hands), better than large (hip, knee) Destroy portion of cortex Erosive arthritis Rheumatoid arthritis Spondyloarthropathies Ankylosing spondylitis Enteropathic arthritis : UC, crohn disease Psoriasis arthritis Rieter s arthritis Gout Connective tissue disease : scleroderma, SLE Rheumatoid Arthritis General Bilatateral symmetrical Earliest change : MCP, PIP, ulnar syloid, 5th MTP Radiocarpal joint MC narrowed MC in female Clinical findings painful and swelling joints Rheumatoid Arthritis multiple joints bilateral involvement symmetrical involvement early stage: periarthricular fusiform soft tissue swelling Juxtaarticular osteoporosis joint space narrowing Marginal erosion

18 Radiologic finding (late stage) arthrosis and deformities secondary OA Subchondral cyst formation Subluxation Ulnar deviation of MCP Boutonierre and swan neck deformities Rheumatoid Arthritis Gout General Long latent period between onset of symptoms and bone change Asymmetric and monoarticular More common in male Most common at 1 st MTP Tophi rarely calcify Olecranon bursitis is common Radiographic juxta articular erosion Sharply marginated with sclerotic rims Overhanging edge (ratbites) No joint space narrowing until later Little or no osteoporosis Soft tissue swelling Tophi not calcified Gout Osteoarthritis (OA) Clinical findings painful at weight bearing joints (knees and hip joints) several used joint (DIP joints of hands) bilateral involvement symmetrical involvement. Osteoarthritis (OA) weight bearing or heavily used joints (knees, hips and hand=dip joints) bilateral involvement symmetrical involvement narrowing of joint space marginal spurs subchondral bone sclerosis and cyst soft tissue swelling around joint Charcot s Joint (Neuroarthropathy) Disturbance in sensation leads to multiple microfractures Cause Shoulder : syrinx, spinal tumor Hips : tertiary syphilis, diabetes Feet : diabetes

19 Charcot s joint Radiographic Fragmentation Soft tissue swelling Destruction of joint Sclerosis Osteophytosis No osteoporosis ***Destruction, debris diabetes*** Conclusion Common route of bone and joint infectious is hematogenoue spreading Osteomyelitis Acute, subacute, chronic stage Joint disease Hypertrophy : RA, Gout Erosive OA, Charcot joint Septic arthritis : location ofn involvement depend on maturity of grow plate