Bone Tumors: in 1 Simple Chart

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Bone Tumors: page 1 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Osteosarcoma ABC Chondroid: Ewing Sarcoma UBC Enchondroma Bone Tumors Osseous: <20 Osteomyelitis (Active) CB Osteoid Osteoma Mets (NB <5yo) FCD/NOF Osteoblastoma Cortical Desmoid EG Osseous & Chondroid: In 1 Simple Chart (Helms: “DNT”) FD Osteochondroma Lymphoma GCT Bone Infarct Chondrosarcoma Enchondroma Download this entire slideshow from Fibrosarcoma/MFH FD Stress Fracture 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) When running this on your own computer PHALANX: ...Mets Enchon, Glomus you can jump from slide to slide using Epidermoid,Felon with Surface OS GCTTS,Sarcoid “Ivory Vertebra”: these buttons at bottom of each slide: Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met PowerPoint Last slide Interactivity viewed Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) Overview The >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) slide Chart 2ºOsteosarc (>60) Paget’s ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Overview of this Presentation WhyBoneTumorsareIntimidating Why Bone Tumors are Intimidating Bone Tumors are Rare Describing Bone Tumors 2009 1) Patient’s Age Building the 2) “Aggressive” Bone Tumor Chart 1,500,000 Zone of Transition New Cancer Periosteal Reaction Cases in 3) Matrix Underlined Text = USA PowerPoint Interactivity 4) Location Annual Cancer Statistics Review, updated 5/29/09, p34 http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdf ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

WhyBoneTumorsareIntimidating Bone Tumors: Many Types Bone Tumors are Rare # Radiologists in USA = 180,000 30,000 Other 12% 2,570 15% 13% Bone Renal/GU Breast Tumors Only 1-in-12 221,000 194,000 2,570 Radiologists 273,000 192,000 0.17% will even see a 30! Lung/Oral Prostate Bone Tumor 18% 19% 13% per year GI 276,000

www.acr.org/SecondaryMainMenu Annual Cancer Statistics Review, updated 5/29/09, p34 Categories/SocioeconomicResearc http://seer.cancer.gov/csr/1975_2006/results_merged/sect_01_overview.pdf h/PracticeofRadiologyintheUS.aspx GREENSPAN: ©Ken L Schreibman, PhD/MD 2010 schreibman.info OrthoRad 15.24

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 2 of 31 In 1 Simple Chart WhyBoneTumorsareIntimidating Bone Tumors: by Age Bone Tumors are Rare  20 Don’t see enough to be confident  Many types of Bone Tumors  Have Confusing (similar) Names 30% Incidence Bone Tumors “Osteosarcoma” 25%  by age “Osteochondroma” 20% Occur in children 15%  10% Essentially only 2  5% bone malignancies 0% <20 20-34 35-44 45-54 55-64 65-74 75-84 >85 occur in children http://seer.cancer.gov/statfacts/html/bones.html ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Tumors: by Age Overview of this Presentation 20 40 Why Bone Tumors are Intimidating Describing Bone Tumors 1) Patient’s Age <20 Osteogenic Sarcoma Ewing Sarcoma Everything else benign 20-40 Could be anything >40 Multiple Myeloma, Metastases ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Overview of this Presentation 2 Cases: Destructive lesions distal fibula Why Bone Tumors are Intimidating Benign? Describing Bone Tumors Malignant? Describing Can’t tell with radiographs… 1) Patient’s Age Thus we use the term 2) “Aggressive” vs “Non-aggressive” “Aggressive” (NOT “Malignant” vs “Benign”)  Zone of Transition  Periosteal Reaction Not everything that looks aggressive is malignant (e.g. osteomyelitis)

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 3 of 31 In 1 Simple Chart Aggressive vs Non-aggressive Aggressive vs Non-aggressive Zone of Transition Zone of Transition Periosteal Reactions Grow Slowly  “Narrow”  “Geographic”  “Well Defined” Can Outline Lesion with Sharp Pencil Sclerotic Margins Grows VERY Slowly!

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Zone of Transition Zone of Transition Grow Slowly Grow Slowly  “Narrow”  “Narrow”  “Geographic”  “Geographic”  “Well Defined”  “Well Defined” Can Outline Lesion Can Outline Lesion with Sharp Pencil with Sharp Pencil Sclerotic Margins Sclerotic Margins Grows VERY Slowly! Grows VERY Slowly!

Asymptomatic, incidental finding ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Zone of Transition Zone of Transition Grow Slowly Grow Rapidly Grow Slowly  “Narrow” “Wide”  “Narrow”  “Geographic” “Permeative”  “Geographic”  “Well Defined” “Ill Defined”  “Well Defined” Can Outline Lesion “Moth Eaten” with Sharp Pencil Cannot tell where Can Outline Lesion Lesion ends and with Sharp Pencil Normal Bone begins Sclerotic Margins Grows VERY Slowly! ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 4 of 31 In 1 Simple Chart Aggressive vs Non-aggressive Aggressive vs Non-aggressive Zone of Transition Zone of Transition Grow Rapidly Grows Rapidly Grows Slowly “Wide” “Wide”  “Narrow” “Permeative” “Permeative”  “Geographic” “Ill Defined” “Ill Defined”  “Well Defined” “Moth Eaten” “Moth Eaten” Cannot tell where Cannot tell where Can Outline Lesion Lesion ends and Lesion ends and with Sharp Pencil Normal Bone begins Normal Bone begins

W,S 16yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Periosteal Reaction Simplifying Periosteal Reaction Grows Rapidly Grows Slowly Grows Rapidly Grows Slowly “Interrupted” “Solid” Smooth TOO Continuous COMPLI- CATED

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Simplifying Periosteal Reaction Simplifying Periosteal Reaction Grows Slowly Grows Slowly “Solid” “Solid” Smooth Smooth Continuous Continuous Looks like Healing Callus HOAHPOA Hypertrophic OPulmonarysteo- Bone Fx Bone AOrthropathysteo- Model Model Arthropathy Stable over 1y F,A 2moM 1m later V,T 49yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 5 of 31 In 1 Simple Chart Aggressive vs Non-aggressive Aggressive vs Non-aggressive Simplifying Periosteal Reaction Simplifying Periosteal Reaction Grows Rapidly Grows Rapidly “Interrupted” “Interrupted” May grow so Lamellated rapidly it doesn’t Onionskin have time to Grows… ossifies… ossify Grows… ossifies… (Unossified Grows… ossifies… periosteum is not radiopaque) Courtesy of James Choi, MD ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Simplifying Periosteal Reaction Simplifying Periosteal Reaction Grows Rapidly Grows Rapidly “Interrupted” “Interrupted” Lamellated Lamellated Onionskin Onionskin Spiculated Spiculated Hair-on-end Sunburst Codman’s Triangles (Growing so rapidly, has time to ossify only at corners) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Aggressive vs Non-aggressive Aggressive vs Non-aggressive Simplifying Periosteal Reaction Simplifying Periosteal Reaction Grows Rapidly Grows Rapidly Grows Slowly “Interrupted” “Interrupted” “Solid” Lamellated Lamellated Smooth Onionskin Onionskin Continuous Spiculated Spiculated Looks like Sunburst Sunburst Healing Callus Codman’s Codman’s Triangles Triangles (Growing so rapidly, 3w post Fx, ORIF has time to ossify 8w post Fx, ORIF =very early callus =more mature callus only at corners) S,C 15yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 6 of 31 In 1 Simple Chart Overview of this Presentation Aggressive vs Non-aggressive Why Bone Tumors are Intimidating Cortical Destruction Describing Bone Tumors Similar lytic lesions Both have well 1) Patient’s Age defined, sclerotic, 2) “Aggressive” vs “Non-aggressive” medullary borders  Zone of Transition IR  Periosteal Reaction  Cortical Destruction Cortex Absent = Cortex Intact = Aggressive Non-aggressive

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Overview of this Presentation 2 Cases: Aggressive lesions distal fibula Why Bone Tumors are Intimidating Benign? Describing Bone Tumors Malignant? Can’t tell with radiographs… Periosteal 1) Patient’s Age Thus we use the term Reaction 2) “Aggressive” vs “Non-aggressive” “Aggressive”  Zone of Transition Cortical  Periosteal Reaction Radiographs Destruction  Cortical Destruction MRI  Soft Tissue Extension

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

2 Cases: Aggressive lesions distal fibula Active Osteomyelitis Chronic Osteo. T2 Soft Tissue Extension Aggressive vs Non-aggressive T1

Two YEARS T2 later 

H,M 13yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 7 of 31 In 1 Simple Chart Bone Matrix: 4 Types Bone Matrix: 4 Types Chondroid Osseous Chondroid “rings&arcs” “cloud-like” “rings&arcs” “amorphous”

Calcified Uterine Fibroid Myositis Ossificans ▓Fibrous None “Ground Purely Lytic Glass” Not necessarily cystic Multiple Myeloma Enchondroma Calcified Uterine Fibroid ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Matrix: 4 Types Bone Matrix: 4 Types Osseous ▓Fibrous “cloud-like” “Ground “amorphous” Glass”

Osteogenic Sarcoma Myositis Ossificans Fibrous Dysplasia F,C 8yoF H,S 15yoM B,C 53yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Matrix: 4 Types Bone Matrix: 4 Types None None CT Purely Lytic Purely Lytic

Not necessarily cystic Not necessarily cystic Intraosseous Lipoma S,N 62yoM Multiple Myeloma G,B 18yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 8 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive Overview of this Presentation age Lytic Blastic Why Bone Tumors are Intimidating Osteosarcoma Ewing Sarcoma Describing Bone Tumors <20 1) Patient’s Age 2) “Aggressive” 3) Matrix

4) Location 20-40 Which bone? Some tumors have propensity for certain bones Which part of the bone? MANY tumors characteristically occur at the: >40 Epiphysis / Metaphysis / Diaphysis ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteogenic Sarcoma Osteogenic Sarcoma MRI is useful for staging Pt Age: 10-20 years Pt Age: 10-20 years the extent of the tumor… (when growth spurt occurs) Location: Metaphyseal Location: Metaphyseal (where growth occurs) Matrix: Osseous Distal Femur T1 Proximal Tibia (where most growth occurs) Matrix: Osseous “osteo-genic”: makes bone Need to eval for “skip mets” MR entire length of bone F,C 8yoF T1 T2 ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteogenic Sarcoma Osteogenic Sarcoma MRI is useful for staging the extent of the tumor… Sometimes osteosarc is Radiographs show us growing SO quickly it what we need to know to doesn’t have time to diagnose type of tumor! form an osseous matrix Skeletally immature Aggressive lesion Patient presents Wide zone of trans. with hair-on-end Sunburst periost. periosteal reaction Osseous matrix After 2 months of  Metaphyseal chemotherapy ------tumor growth has Osteogenic Sarcoma! slowed enough to form osseous matrix F,C 8yoF R,T 11yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 9 of 31 In 1 Simple Chart Ewing Sarcoma Ewing Sarcoma Pt Age: 5-25 years T2 Soft Tissue >> Bone Tumor of Bone Marrow Extension Extent T1 Location: Diaphyseal Flat Bones Matrix: Permeative Cortical Destruction Aggressive T2 Periosteal Reaction Soft Tissue Extension >> Bone Extent H,M 13yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Ewing Sarcoma common in pelvis Ewing Sarcoma common in pelvis T2fs Unlike in the extremities Things can where radiographs are key, the usefulness of hide in the radiographs in the pelvis pelvis is limited. Air in colon Air in colon? In the pelvis, cross-sectional Things can imaging is crucial, hide in the preferably with MRI.

S,B 6yoM pelvis 3 months later… S,B 6yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Cortical Desmoid: Do Not Touch! Osteosarcoma Osteomyelitis resembles Tumor! Ewing Sarcoma <20 Osteomyelitis (Active) Whenever doing a bone biopsy, Mets (NB <5yo) ALWAYS send samples for Cortical Desmoid (Helms: “DNT”) BOTH surgical pathology AND microbiology culture!

20-40 They all present like this: “Do Not Touch” Athletic teenager lesions Just a little periosteal reaction MEDIAL posterior femoral condyle >40 Tug lesion: Adductor longus insertion Q,M 17yoM Medial gastrocnemius origin ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 10 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive Cortical Desmoid: Do Not Touch! age Lytic Blastic Cross-sectional imaging doesn’t really help Osteosarcoma ALWAYS consider Lymphoma! Ewing Sarcoma Lymphoma is 29x more common T2fs <20 Osteomyelitis (Active) than all Bone Tumors combined Mets (NB <5yo) Lymphoma = 74,490 CT Cortical Desmoid (Helms: “DNT”) 180,000 Lymphoma Other 12% 15% 13% Bone Renal/GU Breast 194,000 Tumors 20-40 221,000 2,570 273,000 192,000 Lung/Oral Prostate 0.17% Just a little periosteal reaction 18% 19% 13% GI MEDIAL posterior femoral condyle Mets/Mult Myeloma 276,000 Tug lesion: Adductor longus insertion >40 Osteomyelitis (Active) Q,M 17yoM Medial gastrocnemius origin 2ºOsteosarc (>60) New Cancer Cases, USA, 2009 ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Lymphoma Resembles Ewing Why Age is Important Tumor of bone marrow Location: Diaphyseal Can be lytic or blastic Soft tissue extension T1 Age: < 20 Ewing Sarcoma T1 Age: 20-40 Lymphoma Age: > 40 Metastases

R,H 22yoM T2fs Multiple Myeloma ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Chondrosarcoma Chondrosarcoma Cartilage malignancy Cartilage malignancy Chondroid Matrix: Chondroid Matrix: Chondroid “rings&arcs” Radiographs Location: Ends of bones Pelvis Soft tissues

S,B 39yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 11 of 31 In 1 Simple Chart Chondrosarcoma Chondrosarcoma Cartilage malignancy Chondroid Cartilage malignancy Chondroid Matrix: Chondroid “rings&arcs” Matrix: Chondroid MRI Radiographs T2: Bright CT T2fs T1fs Gd: peripheral +Gd enhancement Bulk of tumor doesn’t enhance

S,B 39yoM S,B 39yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Chondrosarcoma Chondrosarcoma Cartilage malignancy Cartilage malignancy Matrix: Chondroid Matrix: Chondroid Normal cartilage has no blood supply Normal cartilage has no blood supply Injured cartilage doesn’t regrow Injured cartilage doesn’t regrow Chondrosarcoma: poor blood supply Chondrosarcoma: poor blood supply Shows very little Gd enhancement Shows very little Gd enhancement Doesn’t respond to chemotherapy Doesn’t respond to chemotherapy Treatment: Complete tumor resection Treatment: Complete tumor resection S,B 39yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Chondrosarcoma Chondrosarcoma 30yoF 1 year history heal pain T1

other side 1 week later T2fs T1fs +Gd

W,A 30yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 12 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Fibrosarcoma Osteosarcoma Malignant Fibroblastic Cells Ewing Sarcoma <20 Osteomyelitis (Active) Malignant Fibrous Histiocytoma (MFH) Mets (NB <5yo) Cortical Desmoid Pt Age: > 20 (Helms: “DNT”) Lymphoma May involve the bones Chondrosarcoma Secondarily Fibrosarcoma/MFH 20-40 Primarily

Mets/Mult Myeloma >40 Osteomyelitis (Active) 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

MRI is useful for staging AGGRESSIVE NON-aggressive NON-aggressive Fibrosarcoma the extent of the tumor… age Lytic Blastic T1 T2fs Osteosarcoma Ewing Sarcoma <20 Osteomyelitis (Active) Mets (NB <5yo) Cortical Desmoid (Helms: “DNT”) Lymphoma Chondrosarcoma Fibrosarcoma/MFH 20-40 Osteomyelitis (Active) ...Mets Surface OS

Mets/Mult Myeloma >40 Osteomyelitis (Active) F,B 23yoF 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteogenic Sarcoma Osteogenic Sarcoma Pt Age: 10-20 years 1) Conventional Location: Metaphyseal Pt Age: 10-20 years Location: Metaphyseal Matrix: Osseous Matrix: Osseous 4 Subtypes: 2) Telangiectatic 1) Conventional Highly vascular/bloody 2) Telangiectatic Very aggressive Surface Osteosarcomas Nearly purely lytic 3) PERIosteal Usually present after 4) PARosteal pathologic fracture Diffuse metastases ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 13 of 31 In 1 Simple Chart Osteogenic Sarcoma Periosteal Osteosarcoma Surface Osteosarcoma Pt Age: 20-30 years Good prognosis if marrow not involved, can resect tumor. Aggressive If spreads to marrow, Periosteal conventional OS. Reaction 3) PERIosteal Looks like aggressive

Periosteal Osteosarcoma Osteogenic Sarcoma Soft Surface Osteosarcoma Tissue Pt Age: 20-30 years Extension Good prognosis if marrow not involved, Sparing can resect tumor Bone If spreads to marrow, Aggressive Marrow conventional OS. Periosteal 3) PERIosteal Reaction Looks like aggressive

Osteogenic Sarcoma CT Osteogenic Sarcoma CT Surface Osteosarcoma T1 MRI: No Marrow 4) PARosteal involvement Pt Age: 20-30 years Location: Back of Femoral Condyles Arise from cortex, grow outward T2fs Do NOT contain normal marrow (As opposed to osteochondroma) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 14 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Adamantinoma Osteosarcoma VERY RARE Ewing Sarcoma <20 Osteomyelitis (Active) 0.1% Primary Bone Tumors Mets (NB <5yo) Pt Age: 30-50 Cortical Desmoid (Helms: “DNT”) Matrix: Permeative Lymphoma Chondrosarcoma Location: TIBIA (90%) Fibrosarcoma/MFH Diaphyseal 20-40 Osteomyelitis (Active) ...Mets Anterior Cortex Surface OS Soft Tissue Mass: Adamantinoma Likely Malignant Mets/Mult Myeloma >40 Osteomyelitis (Active) 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Adamantinoma Adamantinoma VERY RARE VERY RARE 0.1% Primary Bone Tumors 0.1% Primary Bone Tumors Pt Age: 30-50 Pt Age: 30-50 Matrix: Permeative Matrix: Permeative Location: TIBIA (90%) Location: TIBIA (90%) Diaphyseal Diaphyseal Anterior Cortex Anterior Cortex Soft Tissue Mass: Soft Tissue Mass: Likely Malignant Likely Malignant

©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 15 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic A) Aneurysmal Bone Cyst Osteosarcoma ABC Pt Age: < 20 Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB FCD/NOF Matrix: None (Cyst) Mets (NB <5yo) Only tumor named for x-ray appearance Cortical Desmoid EG (Helms: “DNT”) Aneurysmal & Cystic Lymphoma Chondrosarcoma “AVM of Bone” Fibrosarcoma/MFH MRI: fluid/fluid level 20-40 Osteomyelitis (Active) ...Mets Location: Metaphyseal Surface OS Adamantinoma Posterior Spine Mets/Mult Myeloma Hands >40 Osteomyelitis (Active) 2ºOsteosarc (>60) Pelvis ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

A) Aneurysmal Bone Cyst A) Aneurysmal Bone Cyst CT

Aneurysmal T2 Aneurysmal Multi-septated Multi-septated looks like looks like soap bubbles soap bubbles N,N 15yoF fluid/fluid level ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

A) Aneurysmal Bone Cyst A) Aneurysmal Bone Cyst

T2 fluid/fluid level

Aneurysmal Aneurysmal T2 fluid/fluid level Multi-septated Multi-septated looks like looks like

D,R 12yoM soap bubbles soap bubbles ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 16 of 31 In 1 Simple Chart B) Unicameral (Simple) Bone Cyst B) Unicameral (Simple) Bone Cyst Uni-cameral: Latin “one” - “chamber” Normal Side (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” D,C 5yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

B) Unicameral (Simple) Bone Cyst B) Unicameral (Simple) Bone Cyst Fractures tend to heal Cysts tend to recur Although UBCs Fracture healed arise from metaphysis… end of bone grows away from cyst…

so cyst Cyst? becomes diaphyseal

D,C 5yoM after 1 month… after 3 months… 6m later… 12m later… 18m later ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

B) Unicameral (Simple) Bone Cyst B) Unicameral (Simple) Bone Cyst MRI shows cyst extent T1 T2fs T1

T2fs

Fallen Fragment 18m later Simple cyst M,T 4yoM after 3 months ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 17 of 31 In 1 Simple Chart B) Unicameral (Simple) Bone Cyst B) Unicameral (Simple) Bone Cyst T2fs

Simple cyst with hemorrhage fluid-fluid level

P,D 6yoM H,T 18yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

C) Chondroblastoma C) Chondroblastoma Pt Age: Skeletally immature T2fsPt Age: 10 – 30yo Location: Epiphyseal Location: Epiphyseal Matrix: Chondroid Matrix: Chondroid (No matrix if not calcified) (No matrix if not calcified) Benign… Benign… Aggressive appearance! Aggressive appearance! Periosteal Reaction Periosteal Reaction Surrounding Edema Surrounding Edema Bone Marrow Bone Marrow

Soft Tissues Soft Tissues 16yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

C) Chondroblastoma C) Chondroblastoma Cartilage-sensitive sequence Epiphyseal mass, skeletally immature Aggressive appearance Edema in surrounding marrow & tissues T1 IR Cartilage sequence

Cartilage unfused physis

Articular Cartilage

16yoM B,Q 15yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 18 of 31 In 1 Simple Chart D) Fibrous Cortical Defect D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) Non-Ossifying Fibroma (NOF) THE most common bone lesion Radiographic appearance: Occurs up to 40% ALL children Characteristic& Diagnostic (75% occur 10 – 20 years old) If asymptomatic, no Regress after skeletal maturity further workup is needed Asymptomatic, incidental finding Eccentric, sub-cortical (e.g. on knee MR for ACL tear) Cortex thinned, expanded If >50% bone diameter  Fx Sclerotic margin Location: Metaphysis Scalloped Femur & Tibia Multi-loculated F,M 18yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

D) Fibrous Cortical Defect D) Fibrous Cortical Defect Non-Ossifying Fibroma (NOF) Non-Ossifying Fibroma (NOF) Radiographic appearance:IR T1 9yo 11yo 13yo No aggressive characteristics Characteristic& Diagnostic Fx Healing If asymptomatic, no Callus further workup is needed Eccentric, sub-cortical Cortex thinned, expanded Sclerotic margin Scalloped Multi-loculated B,J 19yoM G,M 9yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 19 of 31 In 1 Simple Chart E) Eosinophilic Granuloma E) Eosinophilic Granuloma Non-neoplastic proliferation histiocytes Pt Age: < 12 Langerhans Cell Histiocytosis Matrix: None Pt Age: typically <12yo (can occur young adult) Location: Bone Marrow EG (aka Histiocytosis X) Skull (most common site) Hand-Schuller-Christian (>3yo) Triad: skull lesions, exophthalmos, DI Sharp Letterer-Siwe (<3yo, fatal) Punched-out “Beveled Edge” Pain, swelling, fever, ESR, eosinophilia due to uneven Diff.Dx: Osteomyelitis (Ewing, Lymph/Leuk) involvement of Bone lesions may resolve spontaneously outer/inner table

Often get Dx Bx/curettage. Steroids? W,J 2yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

E) Eosinophilic Granuloma E) Eosinophilic Granuloma Pt Age: < 12 Pt Age: < 12 Matrix: None Matrix: None Location: Bone Marrow Location: Bone Marrow Skull (most common site) Skull (most common site) Spine Spine vertebra plana Pelvis Can regrow supra-acetabulum height with Long bones (Femur) treatment! diaphysis

R,D 5yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive E) Eosinophilic Granuloma age Lytic Blastic Pt Age: < 12 Osteosarcoma ABC Ewing Sarcoma UBC Matrix: None <20 Osteomyelitis (Active) CB Mets (NB <5yo) FCD/NOF EG Location: Bone Marrow Cortical Desmoid (Helms: “DNT”) FD Skull (most common site) Lymphoma Spine Chondrosarcoma Fibrosarcoma/MFH Pelvis 20-40 Osteomyelitis (Active) supra-acetabulum ...Mets Long bones (Femur) Surface OS diaphysis Adamantinoma Mets/Mult Myeloma >40 Osteomyelitis (Active) W,J 2yoM F,D 5yoM 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 20 of 31 In 1 Simple Chart F) Fibrous Dysplasia McCune–Albright syndrome Pt Age: <30 years R Triad L R L R Polyostotic Location: Any bone Fibrous Matrix: Ground Glass Dysplasia Monostotic (one bone)  Unilateral Usually asymptomatic R L Polyostotic (many bones) Presents at younger age R L Usually symptomatic Syndromes McCune–Albright syndrome L,I 7yoM Base of skull Top of skull L,I 7yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

McCune–Albright syndrome McCune–Albright syndrome Triad Triad Polyostotic Fibrous Dysplasia Polyostotic Fibrous Dysplasia  Unilateral  Unilateral Endocrine Abnormalities Endocrine Abnormalities  Precocious puberty in girls  Precocious puberty in girls café au lait spots café au lait spots  “coast of Maine”  “coast of Maine” (as opposed to “coast of California” =Neurofibromatosis)

wikipedia.org ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Osteosarcoma ABC Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Mets (NB <5yo) FCD/NOF Cortical Desmoid EG (Helms: “DNT”) FD Lymphoma Chondrosarcoma Fibrosarcoma/MFH 20-40 Osteomyelitis (Active) ...Mets Surface OS Adamantinoma Mets/Mult Myeloma >40 Osteomyelitis (Active) 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 21 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Giant Cell Tumor Osteosarcoma ABC Pt Age: Skeletally Mature Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB (as opposed to Chondroblastoma) Mets (NB <5yo) FCD/NOF THE most common bone tumor EG Cortical Desmoid in young adults 20-40yo (Helms: “DNT”) FD Lymphoma GCT Location: Subarticular Chondrosarcoma Fibrosarcoma/MFH Arise from Metaphysis 20-40 Osteomyelitis (Active) Extend across fused ...Mets Growth Plate Surface OS Adamantinoma Matrix: Purely Lytic Mets/Mult Myeloma Narrow Zone of Transition >40 Osteomyelitis (Active) 2ºOsteosarc (>60) NO SCLEROTIC MARGIN ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Giant Cell Tumor Giant Cell Tumor Pt Age: SkeletallyT2fs MatureT1 (as opposed to Chondroblastoma) THE most common bone tumor in young adults 20-40yo Location: Subarticular Arise from Metaphysis Extend across fused Growth Plate Matrix: Purely Lytic NarrowBenign Zone of Transition Benign NOLocally SCLEROTIC Aggressive MARGIN V,R 21yoM Locally Aggressive B,J 25yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Giant Cell Tumor Giant Cell Tumor T1 T2fs T1fs+Gd 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 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 22 of 31 In 1 Simple Chart Why Age is Important Why Age is Important Location: Subarticular Location: Subarticular Matrix: Purely Lytic Matrix: Purely Lytic Age:< 20 (skeletally immature) Age:< 20 (skeletally immature) Chondroblastoma Chondroblastoma 1 Age:20-40 (skeletally mature) Age:20Lung-40 (skeletally mature) Giant Cell Tumor GiantCancer Cell Tumor Age:> 40 Age:> 40 Metastases GCT Metastases Met

Multiple Myeloma V,R 21yoM Multiple Myeloma C,G 61yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Herniation Pit of the Femoral Neck Osteosarcoma ABC aka “Pitt’s Pit” Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Michael Pitt, et.al. AJR 1982 Mets (NB <5yo) FCD/NOF vol 138, 6, p 1115-1121 Cortical Desmoid EG (Helms: “DNT”) FD Round lucency Lymphoma GCT Chondrosarcoma Thin sclerotic rim Fibrosarcoma/MFH FD Proximal Superior 20-40 Osteomyelitis (Active) “Pitts Pit” ...Mets Anterior courtesy Donna Blankenbaker, MD Surface OS Incidental finding ⅓ patients Adamantinoma Mets/Mult Myeloma Mechanical, not neoplastic >40 Osteomyelitis (Active) 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Lytic Lesion: Distal Phalanx Osteosarcoma ABC Enchondroma Giant Cell Tumor Ewing Sarcoma UBC Lytic: phalanges <20 Osteomyelitis (Active) CB Tendon Sheath Mets (NB <5yo) FCD/NOF Pathologic Fx (Localized PVNS) Cortical Desmoid EG (Helms: “DNT”) FD Glomus Tumor Felon Lymphoma GCT Nail bed (Fingertip infection) Chondrosarcoma Fibrosarcoma/MFH FD Dorsal 20-40 Osteomyelitis (Active) “Pitts Pit” Sarcoidosis PHALANX: Epidermoid ...Mets Enchon, Glomus Epidermoid,Felon Gout Surface OS GCTTS,Sarcoid Inclusion Cyst Adamantinoma Gout,Met(lung) Puncture Metastases Mets/Mult Myeloma Volar Lung >40 Osteomyelitis (Active) 2ºOsteosarc (>60) ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 23 of 31 In 1 Simple Chart Enchondroma Glomus Tumor Benign rests of hyaline cartilage Benign vascular tumor Common (neuromyoarterial apparatus) Often discovered incidentally Subungual, erodes bone Typically asymptomatic Dorsal cortex distal phalanx 50% small tubular bones Mostly lytic Age: 30 – 50 ( 3x> ) Pathologic Fracture Triad Sensitivity to cold Localized tenderness Severe intermittent

Glomus Tumor Epidermoid Inclusion Cyst Implantation of epidermal elements Amputation Puncture (seamstress) Dorsal cortex distal phalanx Volar cortex distal phalanx

S,D 53yoM T1fs T1fs+Gd T1fs+Gd T2fs ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Epidermoid Inclusion Cyst Gout

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 24 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic POEMS syndrome Osteosarcoma ABC Polyneuropathy Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Organomegaly Mets (NB <5yo) FCD/NOF Endocrinopathy Cortical Desmoid EG (Helms: “DNT”) FD Monoclonal gammopathy Lymphoma GCT Skin abnormalities Chondrosarcoma (Sclerotic bone lesions) Fibrosarcoma/MFH FD 20-40 Osteomyelitis (Active) “Pitts Pit” Medial Clavicle PHALANX: ...Mets Enchon, Glomus Pelvis Epidermoid,Felon Surface OS GCTTS,Sarcoid Adamantinoma Gout,Met(lung) Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) >40 Osteomyelitis (Active) FD 2ºOsteosarc (>60) http://www.scielo.br/scielo.php?pid=S0100-39842008000600002&script=sci_arttext&tlng=en ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Paget’s Disease Osteosarcoma ABC Becoming less common Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Three Phases Mets (NB <5yo) FCD/NOF Lytic: Wedge with sharp borders Cortical Desmoid EG (Helms: “DNT”) FD “Blade of grass”, “Candle flame” Lymphoma GCT Mixed: Bone destruction & formation Chondrosarcoma Fibrosarcoma/MFH FD Blastic: Cortical/Trabecular thickening 20-40 Osteomyelitis (Active) “Pitts Pit” PHALANX: ...Mets Enchon, Glomus Epidermoid,Felon Surface OS GCTTS,Sarcoid Adamantinoma Gout,Met(lung) 2 Osteosarcoma Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) 2ºOsteosarc (>60) Paget’s B,S 83yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Ivory Vertebra Osteosarcoma ABC Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Lymphoma Mets (NB <5yo) FCD/NOF Cortical Desmoid EG Paget (Helms: “DNT”) FD Lymphoma GCT Blastic Met Chondrosarcoma Breast Fibrosarcoma/MFH FD 20-40 Osteomyelitis (Active) “Pitts Pit” Prostate PHALANX: ...Mets Enchon, Glomus Treated Met Epidermoid,Felon Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met Chronic Osteo Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) (Sarcoid) rare >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) 2ºOsteosarc (>60) Paget’s K,K 76yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 25 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Enchondroma Osteosarcoma ABC Benign rests of hyaline cartilage Ewing Sarcoma UBC <20 Osteomyelitis (Active) CB Common Mets (NB <5yo) FCD/NOF Often discovered incidentally Cortical Desmoid EG (Helms: “DNT”) FD Typically asymptomatic Lymphoma GCT Bone Infarct can be painful (40%) Chondrosarcoma Enchondroma Pathologic Fracture Fibrosarcoma/MFH FD Stress Fracture 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) 50% long tubular bones PHALANX: ...Mets Enchon, Glomus Metaphyseal Epidermoid,Felon Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met Chondroid matrix Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) 2ºOsteosarc (>60) Paget’s ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Enchondroma Enchondroma Benign rests of hyaline cartilage Benign rests of hyaline cartilage Common Common Often discovered incidentally Often discovered incidentally Typically asymptomatic Typically asymptomatic can be painful (40%) can be painful (40%) Pathologic Fracture Pathologic Fracture 50% long tubular bones 50% long tubular bones Metaphyseal Metaphyseal Chondroid matrix Chondroid matrix 50% small tubular bones Mostly lytic

Chondrosarcoma Chondrosarcoma Malignant tumor of cartilage Histopathology Pelvis 1: Low Grade Ends of bones 2: Intermediate Presents with PAIN! 3: High Grade 99% Painful 40% Enchondromas Cellularity: Low Grade difficult to markedly differentiate from benign increased  Radiologist Nuclei Size:  Pathologist markedly 30% - Low Grade increased ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 26 of 31 In 1 Simple Chart Chondrosarcoma Chondrosarcoma Histopathology Histopathology 1: Low Grade 1: Low Grade 2: Intermediate 2: Intermediate 3: High Grade 3: High Grade Cellularity: Cellularity: markedly slightly increased increased Nuclei Size: Nuclei Size: markedly slightly IR increased T1fs + Gd increased ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Enchondroma Chondrosarcoma Enchondroma Chondrosarcoma Histopathology T1 T2fs 0.5: Borderline 1: Low Grade 2: Intermediate 3: High Grade Histologically: resembles enchondroma Radiologically:

Enchondroma Chondrosarcoma Enchondroma Chondrosarcoma How do you distinguish between them? Pt was very happy with outcome! She’s now pain free Very difficult, sometimes you can’t  She’s doesn’t have cancer Clues: Some Enchon All Chondrosarc Hot on BS Hot on BS

This pt had pain This pt had pain uncontrollable with uncontrollable with Histopathology: oral narcotics oral narcotics No malignant cells So was this: 40% Enchon All Chondrosarc Enchondroma? 0.5 Borderline Painful Painful(never incidental) B,B 42yoF Chondrosarcoma? ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 27 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic age Lytic Blastic Osteosarcoma ABC Osteosarcoma ABC Chondroid: UBC UBC Enchondroma Ewing Sarcoma Ewing Sarcoma Osseous: <20 Osteomyelitis (Active) CB <20 Osteomyelitis (Active) CB Osteoid Osteoma Mets (NB <5yo) FCD/NOF Mets (NB <5yo) FCD/NOF Osteoblastoma Cortical Desmoid EG Cortical Desmoid EG (Helms: “DNT”) FD (Helms: “DNT”) FD Lymphoma GCT Bone Infarct Lymphoma GCT Bone Infarct Chondrosarcoma Enchondroma Chondrosarcoma Enchondroma Fibrosarcoma/MFH FD Stress Fracture Fibrosarcoma/MFH FD Stress Fracture 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) PHALANX: PHALANX: ...Mets Enchon, Glomus ...Mets Enchon, Glomus Epidermoid,Felon Epidermoid,Felon Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) 2ºOsteosarc (>60) Paget’s 2ºOsteosarc (>60) Paget’s ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteoid Osteoma (Osteoblastoma) Osteoid Osteoma Pt Age: < 30 Radiographs Presents with PAIN! Cortical thickening 98% Painful Bone Scan Night pain, Rx NSAID Hot all 3 phases Matrix: Lucent Nidus Location: Diaphyseal Surrounding Sclerosis Intra-capsular No Sclerosis Posterior Elements (OB) Painful Scoliosis Flow Blood Pool Delayed W,N 13yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteoid Osteoma Osteoid Osteoma Radiographs CT:Gold Standard for OO Cortical thickening Diagnosis Pain Lucent Nidus MR Marker Edema  Central Dot Calcium Enhancement Marrow Rx  Nidus Edema CT Cortical Guided Thicken  RF Sub-Q Edema Ablation

T2fs T1fs +Gd T1fsIR +Gd W,N 13yoM W,N 13yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 28 of 31 In 1 Simple Chart Osteoblastoma (= Osteoid Osteoma) Osteoblastoma (= Osteoid Osteoma) Term osteoblastoma SPECT used for: (Sagittal) Larger lesions ( > ≈1cm) Lesion in spine SPECT posterior elements (Axial) Painful scoliosis (Typically scoliosis is painless) Bone Scan S,T 16yoM (Posterior) S,T 16yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteoblastoma (= Osteoid Osteoma) Osteoblastoma CT:Gold Standard Young woman Diagnosis with back pain Lucent Nidus Fetus is an Central Dot Calcium incidental finding

Years earlier… with back pain

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 29 of 31 In 1 Simple Chart AGGRESSIVE NON-aggressive NON-aggressive age Lytic Blastic Osteochondroma Osteosarcoma ABC Chondroid: UBC Enchondroma Most Common Benign Neoplasm of Bone Ewing Sarcoma Osseous: <20 Osteomyelitis (Active) CB Osteoid Osteoma “Exostosis” Bone Mets (NB <5yo) FCD/NOF Osteoblastoma Pedunculated (stalk) Model Cortical Desmoid EG Osseous & Chondroid: (Helms: “DNT”) FD Osteochondroma Sessile (flat) Lymphoma GCT Bone Infarct Cartilage Cap Chondrosarcoma Enchondroma Fibrosarcoma/MFH FD Stress Fracture seen only on MR 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) PHALANX: Point away from joint ...Mets Enchon, Glomus Epidermoid,Felon Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Continuity with Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met underlying bone Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) Cortex continuous with cortex >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) 2ºOsteosarc (>60) Paget’s Marrow continuous with marrow ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteochondroma Osteochondroma Most Common Benign Neoplasm of Bone Most Common Benign Neoplasm of Bone “Exostosis” “Exostosis” Pedunculated (stalk) Pedunculated (stalk) Sessile (flat) Sessile (flat) Cartilage Cap Cartilage Cap seen only on MR seen only on MR Point away from joint Point away from joint Continuity with Continuity with underlying bone underlying bone Cortex continuous with cortex Cortex continuous with cortex Marrow continuous with marrow Marrow continuous with marrow ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteochondroma Osteochondroma Most Common Benign Neoplasm of Bone Most Common Benign Neoplasm of Bone “Exostosis” “Exostosis” Pedunculated (stalk) Pedunculated (stalk) Sessile (flat) Sessile (flat) Cartilage Cap Cartilage Cap seen only on MR seen only on MR Point away from joint Point away from joint Continuity with Continuity with underlying bone underlying bone Cortex continuous with cortex Cortex continuous with cortex Marrow continuous with marrow Marrow continuous with marrow P,N 20yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 30 of 31 In 1 Simple Chart Osteochondroma Osteochondroma Most Common Benign Neoplasm of Bone Most Common Benign Neoplasm of Bone “Exostosis” “Exostosis” Pedunculated (stalk) Pedunculated (stalk) Sessile (flat) Sessile (flat) Cartilage Cap Cartilage Cap seen only on MR seen only on MR Point away from joint Point away from joint Continuity with Continuity with underlying bone underlying bone Cortex continuous with cortex Cortex continuous with cortex Marrow continuous with marrow Marrow continuous with marrow K,J 11yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteochondroma Osteochondroma T1 Most Common Benign Neoplasm of Bone Malignant Transformation to Chondrosarcoma Solitary: 1% Multiple Hereditary Exostoses (MHE):10-30% Signs of malignant transformation: T2fs Growth of lesion after skeletal maturity Cartilage Cap (can grow during childhood) Cartilage cap > 1cm No aggressive characteristics (can be 2-3cm during childhood) Cortex continuous with cortex Marrow continuous with marrow K,J 11yoM ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteochondroma Osteochondroma Malignant Transformation to Chondrosarcoma Malignant Transformation to Chondrosarcoma

T2fs T1fs+Gd CT: Tissue Window CT: Bone Window Chondroid matrix Aggressive appearance

Hot on BS Funny shaped femurs c/w Chondrosarc MHE? ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

©Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info Bone Tumors: page 31 of 31 In 1 Simple Chart Osteochondroma Osteochondroma Most Common Benign Neoplasm of Bone Can cause mechanical problems Multiple miscarriages Malignant Transformation to Chondrosarcoma T1 Solitary: 1% Multiple Hereditary Exostoses (MHE):10-30% Signs of malignant transformation: Growth of lesion after skeletal maturity T2fs (can grow during childhood) Cartilage cap > 1cm (can be 2-3cm during childhood) Can cause mechanical problems W,M 25yoF ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Osteochondroma Osteochondroma 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 T1 PDfs ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info

T1 AGGRESSIVE NON-aggressive NON-aggressive Osteochondroma age Lytic Blastic Osteosarcoma ABC Chondroid: vs PARosteal Osteosarcoma Enchondroma Ewing Sarcoma UBC Osseous: <20 Osteomyelitis (Active) CB Osteoid Osteoma Mets (NB <5yo) FCD/NOF Osteoblastoma Cortical Desmoid EG Osseous & Chondroid: NO cortex/marrow (Helms: “DNT”) FD Osteochondroma continuity Lymphoma GCT Bone Infarct Chondrosarcoma Enchondroma Fibrosarcoma/MFH FD Stress Fracture 20-40 Osteomyelitis (Active) “Pitts Pit” Osteomyelitis (Chronic) Cortex continuous with cortex PHALANX: Marrow continuous with marrow ...Mets Enchon, Glomus Epidermoid,Felon Surface OS GCTTS,Sarcoid “Ivory Vertebra”: Cartilage Adamantinoma Gout,Met(lung) Lymphoma,Paget,Met Cap Mets/Mult Myeloma Mets/MM Mets/MM (“POEMS”) >40 Osteomyelitis (Active) FD Osteomyelitis (Chronic) W,K 17yoM T1 T2fs 2ºOsteosarc (>60) Paget’s ©Ken L Schreibman, PhD/MD 2010 schreibman.info ©Ken L Schreibman, PhD/MD 2010 schreibman.info