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Imaging Findings of Various Calvarial Bone Lesions with a Focus on Osteolytic Lesions 다양한 두개골 병변의 영상소견: 골용해성 병변을 중심으로

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Imaging Findings of Various Calvarial Bone Lesions with a Focus on Osteolytic Lesions 다양한 두개골 병변의 영상소견: 골용해성 병변을 중심으로 Pictorial Essay pISSN 1738-2637 / eISSN 2288-2928 J Korean Soc Radiol 2016;74(1):43-54 http://dx.doi.org/10.3348/jksr.2016.74.1.43 Imaging Findings of Various Calvarial Bone Lesions with a Focus on Osteolytic Lesions 다양한 두개골 병변의 영상소견: 골용해성 병변을 중심으로 Younghee Yim, MD1, Won-Jin Moon, MD1*, Hyeong Su An, MD1, Joon Cho, MD2, Myung Ho Rho, MD3 Departments of 1Radiology, 2Neurosurgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea 3Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea In this review, we present computed tomography (CT) and magnetic resonance im- aging (MRI) findings of various calvarial lesions on the basis of their imaging pat- Received April 14, 2015 terns and list the differential diagnoses of the lesions. We retrospectively reviewed Revised June 16, 2015 Accepted July 19, 2015 256 cases of calvarial lesion (122 malignant neoplasms, 115 benign neoplasms, and *Corresponding author: Won-Jin Moon, MD 19 non-neoplastic lesions) seen in our institutions, and classified them into six cat- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, egories based on the following imaging features: generalized skull thickening, focal 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea. skull thickening, generalized skull thinning, focal skull thinning, single lytic lesion, Tel. 82-2-2030-5544 Fax. 82-2-2030-5549 and multiple lytic lesions. Although bony lesions of the calvarium are easily identi- E-mail: [email protected] fied on CT, bone marrow lesions are better visualized on MRI including diffusion- This is an Open Access article distributed under the terms weighted imaging or fat-suppressed T2-weighted imaging. Careful interpretation of of the Creative Commons Attribution Non-Commercial calvarial lesions based on pattern recognition can effectively narrow a range of License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distri- possible diagnoses. bution, and reproduction in any medium, provided the original work is properly cited. Index terms Skull Neoplasms Magnetic Resonance Imaging Tomography, X-Ray Computed Diagnosis, Differential Retrospective Studies Bone Disease Bone Marrow Disease INTRODUCTION tastases are the most common malignant lesions, multiple my- eloma is more common in our database because of errors in In this article, we reviewed our institutional database and ra- coding and also because our institution is renowned for treating diology department database of images taken from 2005 to hematologic malignancies. We retrospectively reviewed the im- 2013 and retrieved the records of 256 patients who underwent aging findings of CT and MRI for these calvarial lesions, and, brain CT or MRI and were later diagnosed with tumorous or using a categorical imaging approach, we briefly described and nontumorous calvarial lesions (122 malignant neoplasms, 115 illustrated the imaging findings of representative osteolytic cal- benign neoplasms, 19 non-neoplastic lesions). The majority of varial lesions. The Institutional Review Board approved this patients either had multiple myelomas (n = 108, 42.2%) or be- retrospective review, and the requirement of informed consent nign osteomas (n = 99, 38.7%) (Table 1). Though calvarial me- was waived. Copyrights © 2016 The Korean Society of Radiology 43 Imaging Findings of Various Calvarial Bone Lesions with a Focus on Osteolytic Lesions Table 1. Calvarial Lesions from Our Institution Database (n = 256) Table 2. Categories and Pathologies Based on Involvement Pattern of Calvarial Lesions No. of Cases (%) Calvarial Lesions Malignant neoplasm 122 (47.7) Category Lesions Multiple myeloma 108 Lytic Metastasis 7 Single Histiocytosis-X, osseous hemangioma, epidermoid and Lymphoma 3 demoid cyst, desmoplastic fibroma, aretic meningocele, Rhabdomyosarcoma 1 gorham disease, osteosarcoma/chondrosarcoma, Mesenchymal chondrosarcoma 1 osteomyelitis, arachnoid granulation, intraosseous Langerhans cell histiocytosis 2 meningioma, fibrous dysplasia, neurofibromatosis Benign neoplasm 115 (44.9) type 1, burr-hole Osteoma 99 Multiple Multiple myeloma, metastasis, lymphoma Fibrous dysplasia 5 Thickening Meningioma 4 Diffuse Acromegaly, shunted hydrocephalus, phenytoin induced Osseous hemangioma 2 hyperostosis, Paget's disease, chronic hemolytic anemia Plexiform neurofibroma 1 Focal Metastasis, osteoma, fibrous dysplasia, meningioma, Desmoplastic fibroma 1 chronic calcified hematoma, hyperostosis frontalis Inflammatory myofibroblastic tumor 1 interna Lipoma 1 Thinning Chordoid tumor 1 Generalized Prominent convolutional marking, craniosynostosis, Non-neoplastic lesion 19 (7.4) lacunar skull, long-stnding hydrocephalus, normal Epidermoid/dermoid cyst 3 parietal thinning Cephalhematoma 3 Focal Secondary thinning due to benign tumor, Parry Romberg Skull thinning due to arachnoid cyst 2 syndrome Benign parietal thinning 2 Parry Romberg syndrome 1 ingly, we can simplify the classification system into six categories Atertic meningocephalocele 1 Interparietal foramina 1 based on three main features. We suggest that calvarial lesions Gorham disease 1 are classified into calvarial thickening, thinning, and lytic lesion. Phenytoin induced hyperostosis 1 When the calvarial lesions fall into the ‘thickening’ or ‘thinning’ Depressed fracture 1 categories, they can be further subdivided into focal or general- Acromegaly 1 ized lesions. The lytic category can be subdivided into either sin- Exostosis 1 Peripheral low-flow vascular malformation 1 gle or multiple lesions. Furthermore, we can expect to get addi- Data are presented as numbers of patients with percentages in parentheses. tional information about matrix characteristics with contrast enhancement and diverse advanced MR sequences such as dif- CATEGORICAL APPROACH TO IMAGING fusion-weighted imaging (DWI) (3), perfusion-weighted imag- DIAGNOSIS ing, and MR spectroscopy. A flowchart for a systematic approach to imaging diagnosis of calvarial lesions is provided in Table 2. With increasing frequency, CT and MRI have been incorpo- rated into the basic imaging tools for evaluating calvarial le- Single or Multiple Osteolytic Lesions sions. Therefore, it is useful to categorize diagnostic features of images taken not by conventional radiography but by CT and Multiple Myeloma MRI (1, 2). It is possible to categorize 8 different types of cal- Multiple myeloma is characterized as multiple osteolytic le- varial lesions based on 4 key features: thickening or thinning of sions due to the malignant proliferation of osteoclast-activating calvarial bone, sclerosis or lysis of bone, focal or generalized le- factors triggered by myeloma. Plain radiography of multiple sions, and, finally, singularity or multiplicity of lesions. On CT myeloma patients is characterized by a subcortical circular or and MRI, sclerotic lesions appear as thickening of calvarial bone elliptical radiolucent shadow, and the axial skeleton is the pre- (either the inner/outer tables, or bone marrow, or both). Accord- dominant site of the abnormality. CT shows punched-out le- 44 J Korean Soc Radiol 2016;74(1):43-54 jksronline.org Younghee Yim, et al sions with soft tissue masses and fractures. On MRI, multiple or sometimes as diffusely destructive on bone algorithm CT (2). myeloma presents with low-to-intermediate signal intensity on Hypointense infiltrating foci are seen on T1-weighted images as T1-weighted images, high signal intensity on T2-weighted im- metastases replace hyperintense normal yellow marrow. Most ages, and high signal intensity on DWI (4). The lesions enhance skull metastases are hyperintense compared to bone marrow on strongly following contrast administration. Four different imag- T2-weighted images and appear clearly on fat-saturated con- ing patterns may appear: normal-looking marrow, a micro nodu- trast-enhanced T1-weighted images (Fig. 2). DWI is helpful for lar pattern (also described as variegated or salt and pepper le- the detection of bone marrow involvement of the calvarium (3). sions), a focal pattern, or a diffuse pattern (Fig. 1) (1, 2). Langerhans Cell Histiocytosis Osteolytic Metastases Langerhans cell histiocytosis (LCH) is an uncontrolled mono- Metastases take various forms; they can be seen as either os- clonal proliferation of abnormal Langerhans cells involving any teoblastic or osteolytic lesions on plain radiograph. When ap- organ. When LCH involves the skull, it manifests as a small soft pearing as single or multiple lytic lesions, metasteses are usually tissue calvarial mass with lytic defect and beveled edge more on seen as one or more relatively circumscribed intraosseous lesions the inner table than the outer table on plain radiograph and CT A B Fig. 1. A 70-year-old male with multiple myeloma. On lateral skull radiograph (A) and axial CT (B), multiple punch-out osteolytic lesions in the skull (salt and pepper) are seen, a pathognomonic finding of multiple myeloma. A B C Fig. 2. A 70-year-old female with renal cell carcinoma. A. On contrast-enhanced CT, two huge osteolytic soft tissue masses with extreme enhancement in right parietooccipital and left frontotemporal bone are seen (arrows). B. On lateral skull radiograph, two huge osteolytic lesions (arrows) are seen. C. On MRI, huge soft tissue metastatic tumors show heterogeneous signal intensity on diffusion-weighted imaging (arrows). jksronline.org J Korean Soc Radiol 2016;74(1):43-54 45 Imaging Findings of Various Calvarial
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