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Differential Diagnosis in Conventional Radiology Bearbeitet von Francis A. Burgener, Martti Kormano, Tomi Pudas Neuausgabe 2007. Buch. 872 S. Hardcover ISBN 978 3 13 656103 4 Format (B x L): 21 x 29,7 cm Weitere Fachgebiete > Medizin > Klinische und Innere Medizin Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte. 75 5 Localized Bone Lesions Conventional radiography remains the primary imaging Fig. 5.1 Geographic lesion. modality for the evaluation of skeletal lesions. The combina- A well-demarcated lesion with tion of conventional radiography, which has a high speci- sclerotic border is seen in the distal femur (nonossifying ficity but only an intermediate sensitivity, with radionuclide fibroma). bone scanning, which has a high sensitivity but only a low specificity is still the most effective method for detecting and diagnosing bone lesions and differentiating between benign and malignant conditions. Conventional radiography, is, however, limited in delineating the intramedullary extent of a bone lesion and even more so in demonstrating soft- tissue involvement. Although magnetic resonance imaging frequently contributes to the characterization of a bone le- sion, its greatest value lies in the ability to accurately assess the intramedullary and extraosseous extent of a skeletal le- sion. A solitary bone lesion is often a tumor or a tumor-like ab- normality, but congenital, infectious, ischemic and traumatic disorders can present in similar fashion. Differentiation be- tween a benign or malignant bone lesion is not always possible. Signs of an aggressive or malignant osseous lesion include rapid growth, large size, poor demarcation, cortical violation, interrupted periosteal reaction and soft tissue ex- tension. Signs of a nonaggressive or benign osseous lesion include slow growth, small size, sharp margination, cortical expansion without cortical violation, solid periosteal reac- tion and no soft tissue extension. However these radiologic features are not infallible and many exceptions occur indi- cating the need for histologic confirmation in the appro- priate setting. In osteolytic lesions a geographic, moth-eaten and per- meative pattern of bone destruction are commonly dis- cerned. A geographic lesion (Figs. 5.1 and 5.2) has a well-de- fined margin separating it clearly from the surrounding nor- mal bone. The zone of transition of normal to abnormal bone is short and a sclerotic border of various thickness may surround the lesion. Geographic lesions are usually benign, especially when they are marginated by a sclerotic rim. Fig. 5.2 Geographic lesions. Multiple well-demarcated (punch- ed-out) purely lytic lesions are seen in the vault of the cranium Multiple myeloma and metastases, however, frequently pre- (multiple myeloma). sent as geographic lesions without sclerotic borders (Table 5.1). A moth-eaten lesion (Fig. 5.3) is a poorly demarcated focus Fig. 5.3 Moth-eaten lesion. A poorly demarcated osteo- of bone destruction with a long zone of transition from nor- lytic lesion (arrows) is seen in mal to abnormal bone indicating its aggressive nature and the distal femur (non- rapid growth potential. Malignant bone tumors, osteomyeli- Hodgkin lymphoma). tis and eosinophilic granulomas frequently present with this pattern of bone destruction (Table 5.2). A permeative lesion (Fig. 5.4) represents the most aggres- sive bone destruction pattern with rapid growth. The lesion merges imperceptibly with the normal bone. Highly malig- nant tumors infiltrating the bone marrow such as round cell sarcomas (e.g. Ewing’s sarcomas and lymphomas) typically are associated with this pattern of bone destruction. It is, however, also found in acute osteomyelitis and rapidly developing osteoporosis such as reflex sympathetic dystro- phy. Infiltration of the cortex may also be associated with these conditions, presenting as cortical striation or tunnel- ing. Burgener, Kormano, Pudas, Differential Diagnosis in Conventional Radiology (ISBN 9783136561034), © 2007 Georg Thieme Verlag KG 76 Bone Table 5.1 Solitary well defined osteolytic lesion The cortex represents a barrier to nonaggressive lesions. Benign medullary processes may leave the endosteal surface Subchondral cyst (associated with arthritis, osteonecrosis, or intact or produce endosteal scalloping (Fig. 5.5). The latter trauma) finding is, however, also frequently seen with multiple my- Gout (intraosseous tophus) eloma and metastases. Progressive endosteal erosion as- sociated with solid new periosteal bone deposition creates Amyloidosis an expanded osseous contour indicative of a nonaggressive Intraosseous ganglion benign skeletal lesion. Aggressive skeletal lesions may pene- Simple (unicameral) bone cyst trate the entire thickness of the cortex (Fig. 5.6) and some- times induce a variety of interrupted periosteal reactions in- Aneurysmal bone cyst cluding onion-peel, sunburst and hair-on-end patterns or a Epidermoid inclusion cyst Glomus tumor Intraosseous lipoma Table 5.2 Solitary poorly defined osteolytic lesion Enchondroma Chondroblastoma Hemangioma Chondromyxoid fibroma Chondroblastoma Nonossifying fibroma Osteoblastoma Desmoplastic fibroma Giant cell tumor Osteoblastoma Fibrosarcoma Giant cell tumor Malignant fibrous histiocytoma Fibrosarcoma Chondrosarcoma Clear cell chondrosarcoma Osteosarcoma Angiosarcoma Ewing’s sarcoma Plasmacytoma/multiple myeloma Angiosarcoma Metastasis Multiple myeloma Eosinophilic granuloma Metastasis Brown tumor (hyperparathyroidism) Lymphoma Hemophilic pseudotumor Langerhans cell histiocytosis (eosinophilic granuloma) Osteonecrosis (bone infarct) Hemophilic pseudotumor Brodie’s abscess/cystic osteomyelitis Osteonecrosis (bone infarct) Fibrous dysplasia Osteomyelitis Sarcoidosis Brodie’s abscess Sarcoidosis Fig. 5.4 Permeative lesion. Fig. 5.5 Endosteal scalloping. A poorly defined osteolytic Sharply demarcated erosions of the lesion merging imperceptibly inner cortex of the radius and ulna with the normal bone is seen caused by multiple osteolytic lesions in the proximal femur. Note is seen (multiple myeloma). also the beginning laminated periosteal reaction in the subtrochanteric area (Ewing sarcoma). Burgener, Kormano, Pudas, Differential Diagnosis in Conventional Radiology (ISBN 9783136561034), © 2007 Georg Thieme Verlag KG 5 Localized Bone Lesions 77 Codman’s triangle. They are most commonly associated with Table 5.3 Bone lesions with calcification osteosarcoma, Ewing’s sarcoma, and osteomyelitis and are discussed in greater detail in chapter 3. Intraosseous lipoma The matrix of a skeletal lesion may be inhomogeneous be- Osteochondroma cause it contains areas of calcification or ossification. Calcifi- cations appear as ring-like, flocculent or fleck-like radio- Enchondroma dense areas (Figs. 5.7 and 5.8). Intramedullary matrix calcifi- Periosteal (juxtacortical) chondroma cation is primarily associated with cartilaginous tumors and Bizarre parosteal osteochondromatous proliferation (BPOP) bone infarcts (Table 5.3). Foci of intramedullary ossifications Chondroblastoma are more homogeneous and often ivory-like and are most often caused by bone islands, osteoblastic metastases and Dysplasia epiphysealis hemimelica (Trevor’s disease) primary bone forming neoplasms (Fig. 5.9). They are dis- Fibrocartilagenous mesenchymoma cussed in detail in chapter 2. Chondromyxoid fibroma Osteoid osteoma (nidus) Fig. 5.6 Cortical Osteoblastoma (nidus) penetration. A poorly defined, mixed osteo- Ossifying fibroma lytic and osteoblastic Gnathic tumors (see chapter 11) lesion is seen in the Chordoma distal femur penetrat- ing through the me- Chondrosarcoma (all variants) dial cortex. The lateral Metastasis (especially thyroid carcinoma) cortex is expanded and thinned but still Gout (intraosseous tophus) intact (osteosarcoma). Osteonecrosis (bone infarct) Intraosseous hematoma Osteogenesis imperfecta (popcorn calcifications in enlarged epimetaphyses) Fig. 5.7 Matrix calcifica- tion. A flocculent, ring-like Fig. 5.8 Matrix calcifica- cluster of calcification is seen tion. An irregular, shell-like in the distal femur (enchon- calcification is seen in the dis- Fig. 5.9 Intramedul- droma). tal femur (bone infarct). lary ossification.An irregular, ivory-like area of sclerosis is seen in the proximal humerus (enostosis or giant bone island). Burgener, Kormano, Pudas, Differential Diagnosis in Conventional Radiology (ISBN 9783136561034), © 2007 Georg Thieme Verlag KG 78 Bone Fig. 5.10 Septation. A lytic Septation of the matrix represents another mechanism of lesion with extensive deli- new bone formation evoked by a neoplasm (Fig. 5.10). In cate trabeculation induced other instances intratumoral septations represent the rem- by the tumor is seen in the nants of the original bone matrix largely destroyed by the iliac wing. Note also the lo- neoplasm (Fig. 5.11). Septation is associated with both calized cortical violation (arrow) in the superolateral benign and malignant lesions. Delicate thin trabeculae typi- aspect of the lesion cally are found in giant cell tumors and aneurysmal bone (aneurysmal bone cyst). cysts, lobulated trabeculae in nonossifying fibromas, spicu- lated or radiating trabeculae