Bone Tumors: In 1 Simple Chart

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1 Bone Tumors with PowerPoint Interactivity Download this entire slideshow from When running this on your own computer you can jump from slide to slide using these buttons at bottom of each slide: Last slide viewed Overview slide The Chart p 1 of 31 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Chondroid: Osseous: Osteoid Osteoma Osteoblastoma Osseous & Chondroid: Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age 2) Aggressive Zone of Transition Periosteal Reaction 3) Matrix 4) Location Building the Bone Tumor Chart Underlined Text = PowerPoint Interactivity WhyBoneTumorsare Intimidating Bone Tumors are Rare ,500,000 New Cancer Cases in USA Annual Cancer Statistics Review, updated 5/29/09, p34 WhyBoneTumorsare Intimidating Bone Tumors are Rare 15% Renal/GU 180,000 Other 12% 221, ,000 Lung/Oral 18% 13% Breast 194, ,000 Prostate 13% 19% GI 276,000 Bone Tumors 2, % # Radiologists in USA = 30,000 2,570 Only 1-in-12 Radiologists will even see a Bone Tumor per year Bone Tumors: Many Types 30! Annual Cancer Statistics Review, updated 5/29/09, p Categories/SocioeconomicResearc h/practiceofradiologyintheus.aspx GREENSPAN: OrthoRad Ken L Schreibman, PhD/MD 01/10/10 www.

2 WhyBoneTumorsare Intimidating Bone Tumors are Rare Don t see enough to be confident Many types of Bone Tumors Have Confusing (similar) Names 30% Incidence Bone Tumors 25% by 20% 15% Occur in children 10% Essentially only 2 5% bone malignancies 0% >85 occur in children Bone Tumors: by Age p 2 of Bone Tumors: by Age Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age Osteogenic Sarcoma Everything else benign Could be anything Multiple Myeloma, Metastases Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age 2) Aggressive vs Non-aggressive (NOT Malignant vs Benign ) Zone of Transition Periosteal Reaction Not everything that looks aggressive is malignant (e.g. osteomyelitis) 2 Cases: Destructive lesions distal fibula Benign? Malignant? Can t tell with radiographs Thus we use the term Aggressive Ken L Schreibman, PhD/MD 01/10/10 www.

3 Zone of Transition Periosteal Reactions p 3 of 31 Zone of Transition Grow Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil Sclerotic Margins Grows VERY Slowly! Zone of Transition Grow Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil Sclerotic Margins Grows VERY Slowly! Zone of Transition Grow Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil Sclerotic Margins Grows VERY Slowly! Asymptomatic, incidental finding Zone of Transition Grow Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil Zone of Transition Grow Rapidly Wide Permeative Ill Defined Moth Eaten Cannot tell where Lesion ends and Normal Bone begins Grow Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil Sclerotic Margins Grows VERY Slowly! Ken L Schreibman, PhD/MD 01/10/10 www.

4 Zone of Transition Grow Rapidly Wide Permeative Ill Defined Moth Eaten Cannot tell where Lesion ends and Normal Bone begins Grows Rapidly Wide Permeative Ill Defined Moth Eaten p 4 of 31 Zone of Transition Cannot tell where Lesion ends and Normal Bone begins Grows Slowly Narrow Geographic Well Defined Can Outline Lesion with Sharp Pencil W,S 16yoF Periosteal Reaction Grows Rapidly Grows Slowly TOO COMPLI- CATED Simplifying Periosteal Reaction Grows Rapidly Interrupted Grows Slowly Solid Smooth Continuous Simplifying Periosteal Reaction Grows Slowly Solid Smooth Continuous Looks like Healing Callus Bone Model Fx F,A 2moM 1m later Simplifying Periosteal Reaction Grows Slowly Solid Smooth Continuous Bone Model HOA HPOA Hypertrophic Osteo- Pulmonary Arthropathy Osteo- Arthropathy V,T 49yoM Stable over 1y Ken L Schreibman, PhD/MD 01/10/10 www.

5 Simplifying Periosteal Reaction Grows Rapidly Interrupted May grow so rapidly it doesn t have time to ossify (Unossified periosteum is not radiopaque) p 5 of 31 Simplifying Periosteal Reaction Grows Rapidly Interrupted Lamellated Onionskin Grows ossifies Grows ossifies Grows ossifies Courtesy of James Choi, MD Simplifying Periosteal Reaction Grows Rapidly Interrupted Lamellated Onionskin Spiculated Hair-on-end Simplifying Periosteal Reaction Grows Rapidly Interrupted Lamellated Onionskin Spiculated Sunburst Codman s Triangles (Growing so rapidly, has time to ossify only at corners) Simplifying Periosteal Reaction Grows Rapidly Interrupted Lamellated Onionskin Spiculated Sunburst Codman s Triangles (Growing so rapidly, has time to ossify only at corners) Simplifying Periosteal Reaction Grows Rapidly Grows Slowly Interrupted Solid Lamellated Smooth Onionskin Continuous Spiculated Looks like Sunburst Healing Callus Codman s Triangles 8w post Fx, ORIF =more mature callus 3w post Fx, ORIF =very early callus S,C 15yoM Ken L Schreibman, PhD/MD 01/10/10 www.

6 Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age 2) Aggressive vs Non-aggressive Zone of Transition Periosteal Reaction Cortical Destruction p 6 of 31 Cortical Destruction Cortex Absent = Aggressive Similar lytic lesions Both have well defined, sclerotic, medullary borders IR Cortex Intact = Non-aggressive Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age 2) Aggressive vs Non-aggressive Zone of Transition Periosteal Reaction Radiographs Cortical Destruction MRI Soft Tissue Extension 2 Cases: Aggressive lesions distal fibula Benign? Malignant? Can t tell with radiographs Thus we use the term Aggressive Periosteal Reaction Cortical Destruction 2 Cases: Aggressive lesions distal fibula T2 Soft Tissue Extension Active Osteomyelitis Chronic Osteo. T2 Two YEARS later H,M 13yoF Ken L Schreibman, PhD/MD 01/10/10 www.

7 Bone Matrix: 4 Types Chondroid rings&arcs Osseous cloud-like amorphous Bone Matrix: 4 Types Chondroid rings&arcs p 7 of 31 Calcified Uterine Fibroid Fibrous Ground Glass Myositis Ossificans None Purely Not necessarily cystic Multiple Myeloma Calcified Uterine Fibroid Bone Matrix: 4 Types Osseous cloud-like amorphous Bone Matrix: 4 Types Fibrous Ground Glass F,C 8yoF Osteogenic Sarcoma Myositis Ossificans H,S 15yoM Fibrous Dysplasia B,C 53yoF Bone Matrix: 4 Types None Purely Bone Matrix: 4 Types None Purely CT Not necessarily cystic S,N 62yoM Multiple Myeloma Not necessarily cystic Intraosseous Lipoma G,B 18yoF Ken L Schreibman, PhD/MD 01/10/10 www.

8 Overview of this Presentation Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient s Age 2) Aggressive 3) Matrix 4) Location Which bone? Some tumors have propensity for certain bones Which part of the bone? MANY tumors characteristically occur at the: Epiphysis / Metaphysis / Diaphysis p 8 of 31 Osteogenic Sarcoma Pt Age: years (when growth spurt occurs) Location: Metaphyseal (where growth occurs) Distal Femur Proximal Tibia (where most growth occurs) Matrix: Osseous osteo-genic : makes bone Need to eval for skip mets MR entire length of bone Osteogenic Sarcoma Pt Age: years Location: Metaphyseal Matrix: Osseous F,C 8yoF MRI is useful for staging the extent of the tumor T2 Osteogenic Sarcoma F,C 8yoF MRI is useful for staging the extent of the tumor Radiographs show us what we need to know to diagnose type of tumor! Skeletally immature Aggressive lesion Wide zone of trans. Sunburst periost. Osseous matrix Metaphyseal Osteogenic Sarcoma! Osteogenic Sarcoma Sometimes osteosarc is growing SO quickly it doesn t have time to form an osseous matrix R,T 11yoF Patient presents with hair-on-end periosteal reaction After 2 months of chemotherapy tumor growth has slowed enough to form osseous matrix Ken L Schreibman, PhD/MD 01/10/10 www.

9 Pt Age: 5-25 years Tumor of Bone Marrow Location: Diaphyseal Flat Bones Matrix: Permeative Cortical Destruction Aggressive Periosteal Reaction Soft Tissue Extension >> Bone Extent H,M 13yoF p 9 of 31 T2 Soft Tissue Extension T2 >> Bone Extent common in pelvis Air in colon Things can hide in the pelvis S,B 6yoM Air in colon? 3 months later common in pelvis T2fs Things can hide in the pelvis S,B 6yoM Unlike in the extremities where radiographs are key, the usefulness of radiographs in the pelvis is limited. In the pelvis, cross-sectional imaging is crucial, preferably with MRI. Osteomyelitis resembles Tumor! Whenever doing a bone biopsy, ALWAYS send samples for BOTH surgical pathology AND microbiology culture! Do Not Touch lesions : Do Not Touch! They all present like this: Athletic teenr Just a little periosteal reaction MEDIAL posterior femoral condyle Tug lesion: Adductor longus insertion Q,M 17yoM Medial gastrocnemius origin Ken L Schreibman, PhD/MD 01/10/10 www.

10 : Do Not Touch! CT Just a little periosteal reaction MEDIAL posterior femoral condyle Tug lesion: Adductor longus insertion Q,M 17yoM Cross-sectional imaging doesn t really help T2fs Medial gastrocnemius origin p 10 of 31 ALWAYS consider! is 29x more common than all Bone Tumors combined = 74, ,000 Other 12% 15% Renal/GU 221, ,000 Lung/Oral 18% 13% Breast 194, ,000 Prostate 13% 19% GI 276,000 New Cancer Cases, USA, 2009 Bone Tumors 2, % Tumor of bone marrow Can be lytic or blastic R,H 22yoM Resembles Ewing T2fs Why Age is Important Location: Diaphyseal Soft tissue extension Age: < 20 Age: Age: > 40 Metastases Multiple Myeloma Cartil malignancy Matrix: Chondroid Location: Ends of bones Pelvis Soft tissues Cartil malignancy Matrix: Chondroid Chondroid rings&arcs Radiographs S,B 39yoM Ken L Schreibman, PhD/MD 01/10/10 www.

11 Cartil malignancy Matrix: Chondroid Chondroid rings&arcs Radiographs CT Cartil malignancy Matrix: Chondroid T2fs p 11 of 31 fs +Gd Chondroid MRI T2: Bright Gd: peripheral enhancement Bulk of tumor doesn t enhance S,B 39yoM S,B 39yoM Cartil malignancy Matrix: Chondroid Normal cartil has no blood supply Injured cartil doesn t regrow : poor blood supply Shows very little Gd enhancement Doesn t respond to chemotherapy Treatment: Complete tumor resection Cartil malignancy Matrix: Chondroid Normal cartil has no blood supply Injured cartil doesn t regrow : poor blood supply Shows very little Gd enhancement Doesn t respond to chemotherapy Treatment: Complete tumor resection S,B 39yoM 30yoF 1 year history heal pain other side 1 week later T2fs fs +Gd W,A 30yoF Ken L Schreibman, PhD/MD 01/10/10 www.

12 p 12 of 31 Fibrosarcoma Malignant Fibroblastic Cells Malignant Fibrous Histiocytoma (MFH) Pt Age: > 20 May involve the bones Secondarily Primarily Fibrosarcoma MRI is useful for staging the extent of the tumor T2fs F,B 23yoF Osteogenic Sarcoma Pt Age: years Location: Metaphyseal Matrix: Osseous 4 Subtypes: 1) Conventional 2) Telangiectatic Surface s 3) PERIosteal 4) PARosteal Osteogenic Sarcoma 1) Conventional Pt Age: years Location: Metaphyseal Matrix: Osseous 2) Telangiectatic Highly vascular/bloody Very aggressive Nearly purely lytic Usually present after pathologic fracture Diffuse metastases Ken L Schreibman, PhD/MD 01/10/10 www.

13 Osteogenic Sarcoma Surface Pt Age: years Good prognosis if marrow not involved, can resect tumor. If spreads to marrow, conventional OS. 3) PERIosteal Looks like aggressive periosteal reaction Location: Long bones p 13 of 31 Periosteal Aggressive Periosteal Reaction tibia 11yoM 2004 Radiological Society of North America Murphey M D et al. Radiology 2004; 233: Periosteal Aggressive Periosteal Reaction tibia 34yoF 2004 Radiological Society of North America Soft Tissue Extension Sparing Bone Marrow Murphey M D et al. Radiology 2004; 233: Osteogenic Sarcoma Surface Pt Age: years Good prognosis if marrow not involved, can resect tumor If spreads to marrow, conventional OS. 3) PERIosteal Looks like aggressive periosteal reaction 4) PARosteal Osteogenic Sarcoma Surface 4) PARosteal Pt Age: years Location: Back of Femoral Condyles Arise from cortex, grow outward Do NOT contain normal marrow (As opposed to osteochondroma) CT Osteogenic Sarcoma T2fs MRI: No Marrow involvement CT Ken L Schreibman, PhD/MD 01/10/10 www.

14 VERY RARE 0.1% Primary Bone Tumors Pt Age: Matrix: Permeative Location: TIBIA (90%) Diaphyseal Anterior Cortex Soft Tissue Mass: Likely Malignant p 14 of 31 VERY RARE 0.1% Primary Bone Tumors Pt Age: Matrix: Permeative Location: TIBIA (90%) Diaphyseal Anterior Cortex Soft Tissue Mass: Likely Malignant VERY RARE 0.1% Primary Bone Tumors Pt Age: Matrix: Permeative Location: TIBIA (90%) Diaphyseal Anterior Cortex Soft Tissue Mass: Likely Malignant Ken L Schreibman, PhD/MD 01/10/10 www.

15 ABC UBC CB FCD/NOF EG p 15 of 31 A) Aneurysmal Bone Cyst Pt Age: < 20 Matrix: None (Cyst) Only tumor named for x-ray appearance Aneurysmal & Cystic AVM of Bone MRI: fluid/fluid level Location: Metaphyseal Posterior Spine Hands Pelvis A) Aneurysmal Bone Cyst A) Aneurysmal Bone Cyst CT Aneurysmal Multi-septated looks like soap bubbles N,N 15yoF T2 fluid/fluid level Aneurysmal Multi-septated looks like soap bubbles A) Aneurysmal Bone Cyst A) Aneurysmal Bone Cyst T2 fluid/fluid level fluid/fluid level D,R 12yoM Aneurysmal Multi-septated looks like soap bubbles T2 Aneurysmal Multi-septated looks like soap bubbles Ken L Schreibman, PhD/MD 01/10/10 www.

16 B) Unicameral (Simple) Bone Cyst Uni-cameral: Latin one - chamber (in US we have bi-cameral legislature) Pt Age:< 20 Matrix: None (True Cyst) Location:Metaphyseal >50% Proximal Humerus 20-30% Proximal Femur 50% - Incidental Finding 50% - Pathologic Fx Fallen Fragment p 16 of 31 B) Unicameral (Simple) Bone Cyst Normal Side D,C 5yoM B) Unicameral (Simple) Bone Cyst Fractures tend to heal Fracture healed B) Unicameral (Simple) Bone Cyst Cysts tend to recur Although UBCs arise from metaphysis end of bone grows away from cyst Cyst? so cyst becomes diaphyseal D,C 5yoM after 1 month after 3 months 6m later 12m later 18m later B) Unicameral (Simple) Bone Cyst MRI shows cyst extent T2fs B) Unicameral (Simple) Bone Cyst T2fs 18m later Simple cyst M,T 4yoM Fallen Fragment after 3 months Ken L Schreibman, PhD/MD 01/10/10 www.

17 B) Unicameral (Simple) Bone Cyst p 17 of 31 B) Unicameral (Simple) Bone Cyst T2fs Simple cyst with hemorrh fluid-fluid level P,D 6yoM H,T 18yoM C) Chondroblastoma Pt Age: Skeletally immature Location: Epiphyseal Matrix: Chondroid (No matrix if not calcified) Benign Aggressive appearance! Periosteal Reaction Surrounding Edema Bone Marrow Soft Tissues C) Chondroblastoma T2fs Pt Age: 10 30yo Location: Epiphyseal Matrix: Chondroid (No matrix if not calcified) Benign Aggressive appearance! Periosteal Reaction Surrounding Edema Bone Marrow Soft Tissues 16yoM C) Chondroblastoma Cartil-sensitive sequence C) Chondroblastoma Epiphyseal mass, skeletally immature Aggressive appearance Edema in surrounding marrow & tissues IR Cartil sequence Cartil unfused physis Articular Cartil 16yoM B,Q 15yoM Ken L Schreibman, PhD/MD 01/10/10 www.

18 D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) THE most common bone lesion Occurs up to 40% ALL children (75% occur years old) Regress after skeletal maturity Asymptomatic, incidental finding (e.g. on knee MR for ACL tear) If >50% bone diameter Fx Location: Metaphysis Femur & Tibia p 18 of 31 D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) Radiographic appearance: Characteristic& Diagnostic If asymptomatic, no further workup is needed Eccentric, sub-cortical Cortex thinned, expanded Sclerotic margin Scalloped Multi-loculated F,M 18yoF D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) Radiographic appearance: IR No aggressive characteristics Characteristic& Diagnostic If asymptomatic, no further workup is needed Eccentric, sub-cortical Cortex thinned, expanded Sclerotic margin Scalloped Multi-loculated B,J 19yoM D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) 9yo 11yo 13yo G,M 9yoF Fx Healing Callus Ken L Schreibman, PhD/MD 01/10/10 www.

19 E) Eosinophilic Granuloma Non-neoplastic proliferation histiocytes Langerhans Cell Histiocytosis Pt Age: typically <12yo (can occur young adult) EG (aka Histiocytosis X) Hand-Schuller-Christian (>3yo) Triad: skull lesions, exophthalmos, DI Letterer-Siwe (<3yo, fatal) Pain, swelling, fever, ESR, eosinophilia Diff.Dx: Osteomyelitis (Ewing, Lymph/Leuk) Bone lesions may resolve spontaneously Often get Dx Bx/curett. Steroids? p 19 of 31 E) Eosinophilic Granuloma Pt Age: < 12 Matrix: None Location: Bone Marrow Skull (most common site) Sharp Punched-out Beveled Edge due to uneven involvement of outer/inner table W,J 2yoM E) Eosinophilic Granuloma Pt Age: < 12 Matrix: None Location: Bone Marrow Skull (most common site) Spine vertebra plana Can regrow height with treatment! E) Eosinophilic Granuloma Pt Age: < 12 Matrix: None Location: Bone Marrow Skull (most common site) Spine Pelvis supra-acetabulum Long bones (Femur) diaphysis R,D 5yoM E) Eosinophilic Granuloma Pt Age: < 12 Matrix: None Location: Bone Marrow Skull (most common site) Spine Pelvis supra-acetabulum Long bones (Femur) diaphysis W,J 2yoM F,D 5yoM ABC UBC CB FCD/NOF EG Ken L Schreibman, PhD/MD 01/10/10 www.

20 F) Fibrous Dysplasia Pt Age: <30 years Location: Any bone Matrix: Ground Glass Monostotic (one bone) Usually asymptomatic Polyostotic (many bones) Presents at younger Usually symptomatic Syndromes McCune Albright syndrome R L,I 7yoM Base of skull Top of skull p 20 of 31 McCune Albright syndrome Triad Polyostotic Fibrous Dysplasia Unilateral R L R L R L L R L,I 7yoM McCune Albright syndrome Triad Polyostotic Fibrous Dysplasia Unilateral Endocrine Abnormalities Precocious puberty in girls café au lait spots coast of Maine McCune Albright syndrome Triad Polyostotic Fibrous Dysplasia Unilateral Endocrine Abnormalities Precocious puberty in girls café au lait spots coast of Maine (as opposed to coast of California =Neurofibromatosis) wikipedia.org ABC UBC CB FCD/NOF EG Ken L Schreibman, PhD/MD 01/10/10 www.

21 ABC UBC CB FCD/NOF EG GCT Giant Cell Tumor Pt Age: Skeletally Mature (as opposed to Chondroblastoma) THE most common bone tumor in young adults yo Location: Subarticular Arise from Metaphysis Extend across fused Growth Plate Matrix: Purely Narrow Zone of Transition NO SCLEROTIC MARGIN p 21 of 31 Giant Cell Tumor Pt Age: Skeletally T2fs Mature (as opposed to Chondroblastoma) THE most common bone tumor in young adults yo Location: Subarticular Arise from Metaphysis Extend across fused Growth Plate Matrix: Purely Narrow BenignZone of Transition NO Locally SCLEROTIC Aggressive MARGIN V,R 21yoM Giant Cell Tumor Benign Locally Aggressive B,J 25yoM Giant Cell Tumor T2fs fs+gd Giant Cell Tumor Pt Age: Skeletally Mature Physis fused 16yoM 18yoM Solid & Cystic components Histologically, similarities GCT ABC B,J 25yoM C,A 18yoM Ken L Schreibman, PhD/MD 01/10/10 www.

22 Why Age is Important Location: Subarticular Matrix: Purely Age:< 20 (skeletally immature) Chondroblastoma Age: (skeletally mature) Giant Cell Tumor Age:> 40 Metastases Multiple Myeloma GCT V,R 21yoM Why Age is Important Location: Subarticular Matrix: Purely Age:< 20 (skeletally immature) Chondroblastoma 1 Age: Lung (skeletally mature) Cancer Giant Cell Tumor Age:> 40 Metastases Multiple Myeloma p 22 of 31 Met C,G 61yoM ABC UBC CB FCD/NOF EG GCT Pitts Pit Herniation Pit of the Femoral Neck aka Pitt s Pit Michael Pitt, et.al. AJR 1982 vol 138, 6, p Round lucency Thin sclerotic rim Proximal Superior Anterior courtesy Donna Blankenbaker, MD Incidental finding ⅓ patients Mechanical, not neoplastic ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Lesion: Distal Phalanx Giant Cell Tumor : phalanges Tendon Sheath Pathologic Fx (Localized PVNS) Glomus Tumor Felon Nail bed (Fingertip infection) Dorsal Sarcoidosis Epidermoid Inclusion Cyst Gout Puncture Metastases Volar Lung Ken L Schreibman, PhD/MD 01/10/10 www.

23 Benign rests of hyaline cartil Common Often discovered incidentally Typically asymptomatic 50% small tubular bones Mostly lytic Pathologic Fracture p 23 of 31 Glomus Tumor Benign vascular tumor (neuromyoarterial apparatus) Subungual, erodes bone Dorsal cortex distal phalanx Age: ( 3x> ) Triad Sensitivity to cold Localized tenderness Severe intermittent pain S,D 37yoF Glomus Tumor Dorsal cortex distal phalanx Epidermoid Inclusion Cyst Implantation of epidermal elements Amputation Puncture (seamstress) Volar cortex distal phalanx S,D 53yoM fs fs+gd fs+gd T2fs Epidermoid Inclusion Cyst Gout M,B 78yoM Ken L Schreibman, PhD/MD 01/10/10 www.

24 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Mets/MM ( POEMS ) POEMS syndrome Polyneuropathy Organomegaly Endocrinopathy Monoclonal gammopathy Skin abnormalities (Sclerotic bone lesions) Medial Clavicle Pelvis p 24 of 31 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s Pt s Disease Becoming less common Three Phases : Wedge with sharp borders Blade of grass, Candle flame Mixed: Bone destruction & formation : Cortical/Trabecular thickening 2 B,S 83yoF ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s Ivory Vertebra Pt Met Breast Prostate Treated Met Chronic Osteo (Sarcoid) rare K,K 76yoM Ken L Schreibman, PhD/MD 01/10/10 www.

25 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s p 25 of 31 Benign rests of hyaline cartil Common Often discovered incidentally Typically asymptomatic can be painful (40%) Pathologic Fracture 50% long tubular bones Metaphyseal Chondroid matrix Benign rests of hyaline cartil Common Often discovered incidentally Typically asymptomatic can be painful (40%) Pathologic Fracture 50% long tubular bones Metaphyseal Chondroid matrix Benign rests of hyaline cartil Common Often discovered incidentally Typically asymptomatic can be painful (40%) Pathologic Fracture 50% long tubular bones Metaphyseal Chondroid matrix 50% small tubular bones Mostly lytic Malignant tumor of cartil Pelvis Ends of bones Presents with PAIN! 99% Painful 40% s Low Grade difficult to differentiate from benign Radiologist Pathologist 30% - Low Grade Histopathology 1: Low Grade 2: Intermediate 3: High Grade Cellularity: markedly increased Nuclei Size: markedly increased Ken L Schreibman, PhD/MD 01/10/10 www.

26 IR Histopathology 1: Low Grade 2: Intermediate 3: High Grade Cellularity: markedly increased Nuclei Size: markedly increased fs + Gd p 26 of 31 Histopathology 1: Low Grade 2: Intermediate 3: High Grade Cellularity: slightly increased Nuclei Size: slightly increased Histopathology 0.5: Borderline 1: Low Grade 2: Intermediate 3: High Grade Histologically: resembles enchondroma Radiologically: aggressive B,B 42yoF T2fs How do you distinguish between them? Very difficult, sometimes you can t Clues: Some Enchon All Chondrosarc Hot on BS Hot on BS Pt was very happy with outcome! She s now pain free She s doesn t have cancer 40% Enchon Painful This pt had pain uncontrollable with oral narcotics All Chondrosarc Painful (never incidental) B,B 42yoF This pt had pain uncontrollable with oral narcotics Histopathology: No malignant cells So was this:? 0.5 Borderline? Ken L Schreibman, PhD/MD 01/10/10 www.

27 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s p 27 of 31 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Chondroid: Osseous: Osteoid Osteoma Osteoblastoma Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s Osteoid Osteoma (Osteoblastoma) Pt Age: < 30 Presents with PAIN! 98% Painful Night pain, Rx NSAID Matrix: Lucent Nidus Location: Diaphyseal Surrounding Sclerosis Intra-capsular No Sclerosis Posterior Elements (OB) Painful Scoliosis Osteoid Osteoma Radiographs Cortical thickening Bone Scan Hot all 3 phases Flow Blood Pool Delayed W,N 13yoM Osteoid Osteoma Radiographs Cortical thickening MR Edema Enhancement Nidus Pain Marker Marrow Edema Cortical Thicken Sub-Q Edema Osteoid Osteoma CT: Gold Standard for OO Diagnosis Lucent Nidus Central Dot Calcium Rx CT Guided RF Ablation T2fs fs +Gd fs IR +Gd W,N 13yoM W,N 13yoM Ken L Schreibman, PhD/MD 01/10/10 www.

28 Osteoblastoma (= Osteoid Osteoma) Term osteoblastoma used for: Larger lesions ( > 1cm) Lesion in spine posterior elements Painful scoliosis (Typically scoliosis is painless) S,T 16yoM p 28 of 31 Osteoblastoma (= Osteoid Osteoma) Bone Scan (Posterior) SPECT (Sagittal) SPECT (Axial) S,T 16yoM Osteoblastoma (= Osteoid Osteoma) CT: Gold Standard Diagnosis Lucent Nidus Central Dot Calcium Osteoblastoma Young woman with back pain Fetus is an incidental finding Years earlier with back pain S,T 16yoM Ken L Schreibman, PhD/MD 01/10/10 www.

29 ABC UBC CB FCD/NOF EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Chondroid: Osseous: Osteoid Osteoma Osteoblastoma Osseous & Chondroid: Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s p 29 of 31 Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow Bone Model Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow P,N 20yoF Ken L Schreibman, PhD/MD 01/10/10 www.

30 Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow p 30 of 31 Most Common Benign Neoplasm of Bone Exostosis Pedunculated (stalk) Sessile (flat) Cartil Cap seen only on MR Point away from joint Continuity with underlying bone Cortex continuous with cortex Marrow continuous with marrow K,J 11yoM T2fs Cartil Cap No aggressive characteristics Cortex continuous with cortex Marrow continuous with marrow K,J 11yoM Most Common Benign Neoplasm of Bone Malignant Transformation to Solitary: 1% Multiple Hereditary Exostoses (MHE): 10-30% Signs of malignant transformation: Growth of lesion after skeletal maturity (can grow during childhood) Cartil cap > 1cm (can be 2-3cm during childhood) Malignant Transformation to Malignant Transformation to Chondroid matrix Aggressive appearance T2fs CT: Tissue Window fs+gd CT: Bone Window Hot on BS c/w Chondrosarc Funny shaped femurs MHE? Ken L Schreibman, PhD/MD 01/10/10 www.

31 Most Common Benign Neoplasm of Bone Malignant Transformation to Solitary: 1% Multiple Hereditary Exostoses (MHE): 10-30% Signs of malignant transformation: Growth of lesion after skeletal maturity (can grow during childhood) Cartil cap > 1cm (can be 2-3cm during childhood) Can cause mechanical problems p 31 of 31 Can cause mechanical problems Multiple miscarris T2fs W,M 25yoF Can cause mechanical problems Can cause mechanical problems Mass effect on right subclavian artery Rubbing, causing Pes Anserine Bursitis T2fs K,T 18yoM MRA H,P 11yoF PDfs vs PARosteal Cortex continuous with cortex Marrow continuous with marrow Cartil Cap W,K 17yoM T2fs NO cortex/marrow continuity ABC UBCB CB FCD/NO EG GCT Pitts Pit PHALANX: Enchon, Glomus Epidermoid,Felon GCTTS,Sarcoid Gout,Met(lung) Mets/MM Chondroid: Osseous: Osteoid Osteoma Osteoblastoma Osseous & Chondroid: Bone Infarct Stress Fracture Osteomyelitis (Chronic) Ivory Vertebra :,Pt,Met Mets/MM ( POEMS ) Osteomyelitis (Chronic) Pt s Ken L Schreibman, PhD/MD 01/10/10 www.