William Herring, M.D. © 2002
BoneBone TumorsTumors CluesClues andand CuesCues
In Slide Show mode, advance the slides by pressing the spacebar All Photos Retain the Copyright of their Authors Clues by Appearance of Lesion Patterns of Bone Destruction
O Geographic
O Moth-eaten
O Permeative Geographic Bone Destruction
O Destructive lesion with sharply defined border
O Implies a less-aggressive, more slow-growing, benign process
O Narrow transition zone PatternsPatterns ofof BoneBone DestructionDestruction
O Geographic
O Moth-eaten
O Permeative
© R3, 2000 Non-ossifying fibroma Geographic Lesions Examples
O Non-ossifying fibroma
O Eosinophilic granuloma Moth-eaten Appearance
O Areas of destruction with ragged borders
O Implies more rapid growth
Q Probably a malignancy PatternsPatterns ofof BoneBone DestructionDestruction
O Geographic
O Moth-eaten
O Permeative
© R3, 2000
Multiple Myeloma Moth-eaten Appearance Examples
O Myeloma
O Metastases
O Lymphoma
O Ewing’s sarcoma Permeative Pattern
O Ill-defined lesion with multiple “worm- holes”
O Spreads through marrow space
O Wide transition zone
O Implies an aggressive malignancy
Q Round-cell lesions PatternsPatterns ofof BoneBone DestructionDestruction
O Geographic
O Moth-eaten
O Permeative
Leukemia Permeative Pattern Round cell lesions
O Lymphoma, leukemia O Ewing’s Sarcoma O Myeloma O Osteomyelitis O Neuroblastoma Patterns of Destruction
Geographic Moth-eaten Permeative
Less malignant More malignant Periosteal Reactions
O Benign
Q None
Q Solid
O More aggressive or malignant
Q Lamellated or onion-skinning
Q Sunburst
Q Codman’s triangle Periosteal Reactions
O Benign
Q None
Q Solid
O Aggressive/malignant
Q Onion-skinning
Q Sunburst
Q Codman’s triangle
© R3, 2000 Non-ossifying fibroma Periosteal Reactions
O Benign
Q None
Q Solid
O Aggressive/malignant
Q Onion-skinning
Q Sunburst
Q Codman’s triangle
© R3, 2000
Chronic osteomyelitis Periosteal Reactions
O Benign
Q None
Q Solid
O Aggressive/malignant
Q Onion-skinning
Q Sunburst
Q Codman’s triangle
© Greenspan, 2000 Ewing’s sarcoma Periosteal Reactions
O Benign
Q None
Q Solid
O Aggressive/malignant
Q Onion-skinning
Q Sunburst
Q Codman’s triangle
© Greenspan, 2000 Osteosarcoma Periosteal Reactions
O Benign
Q None
Q Solid
O Aggressive/malignant
Q Onion-skinning
Q Sunburst
Q Codman’s triangle
© R3, 2000 Ewing’s-Codman’s triangle Periosteal Reactions
Solid Lamellated Sunburst Codman’s
Less malignant More malignant Tumor Matrix
O Osteoblastic
Q Fluffy, cotton-like or cloud-like densities
V Osteosarcoma
O Cartilaginous
Q Comma-shaped, punctate, annular, popcorn- like
V Enchondroma, chondrosarcoma, chondromyxoid fibroma Tumor matrix
O Osteoblastic
O Cartilaginous
© R3, 2000 Osteosarcoma Tumor matrix
O Osteoblastic
O Cartilaginous
© R3, 2000
Chondrosarcoma Expansile Lesions of Bone
O Multiple myeloma O Brown tumor
O Mets O Enchondroma
O Aneurysmal bone cyst O Lymphoma
O Fibrous dysplasia Expansile lesions
O Multiple myeloma
O Mets
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma Multiple Myeloma Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma Renal Cell Carcinoma Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma Aneurysmal Bone Cyst Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma
Fibrous Dysplasia Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma © R3, 2000 Brown Tumor Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
O Lymphoma © R3, 2000 Enchondroma Expansile lesions
O Multiple myeloma
O Mets
O Aneurysmal bone cyst
O Fibrous dysplasia
O Brown tumor
O Enchondroma
© R3, 2000 O Lymphoma Lymphoma Clues by Location of Lesion In the Transverse Plane
O Central
Q Enchondroma
O Eccentric
Q GCT, osteosarcoma, chondromyxoid fibroma
O Cortical
Q Non-ossifying fibroma, osteoid osteoma
O Parosteal
Q Parosteal osteosarcoma, osteochondroma Osteosarcoma
Parosteal sarcoma Osteochondroma
© Greenspan, Lippincott, 2000 In The Transverse Plane In the Longitudinal Plane
O Epiphyseal
Q GCT, chondroblastoma
O Metaphyseal
Q Osteomyelitis, osteo- and chondrosarcoma
O Diaphyseal
Q Round cell lesions, ABC, enchondroma Tumor Types Characteristic Locations
O Simple bone cyst
Q Proximal humerus
O Chondroblastoma
Q Epiphyses
O Giant Cell tumor
Q Epiphyses Characteristic locations
O Simple bone cyst
Q Proximal humerus
O Chondroblastoma
Q Epiphyses
O Giant Cell tumor
Q Epiphyses
© R3, 2000 Characteristic locations
O Simple bone cyst
Q Proximal humerus
O Chondroblastoma
Q Epiphyses
O Giant Cell tumor
Q Epiphyses
© R3, 2000 Chondroblastoma Characteristic locations
O Simple bone cyst
Q Proximal humerus
O Chondroblastoma
Q Epiphyses
O Giant Cell tumor
Q Epiphyses
© R3, 2000 Giant Cell Tumor Tumor Types Characteristic Locations
Q Tibia
O Chordoma
Q Sacrum, clivus
Q Spine, posterior Characteristic locations
O Adamantinoma
Q Tibia
O Chordoma
Q Sacrum, clivus
O Osteoblastoma
Q Spine, posterior
© R3, 2000 Adamantinoma Characteristic locations
O Adamantinoma
Q Tibia
O Chordoma
Q Sacrum, clivus
O Osteoblastoma
Q Spine, posterior
© R3, 2000 Chordoma CharacteristicCharacteristic locationslocations
O Adamantinoma
Q Tibia
O Chordoma
Q Sacrum, clivus
O Osteoblastoma
Q Spine, posterior
© R3, 2000 Osteoblastoma Tumor Types Characteristic Locations
O Parosteal sarcoma
Q Distal femur
O Periosteal sarcoma
Q Tibia Characteristic locations
O Parosteal sarcoma
Q Distal femur
O Periosteal sarcoma
Q Tibia
Parosteal sarcoma Characteristic locations
O Parosteal sarcoma
Q Distal femur
O Periosteal sarcoma
Q Tibia
© R3, 2000 Characteristic Tumors By Body Site Pelvic Lesions
O Chondrosarcoma
O Solitary plasmacytoma
O Chordoma Pelvic lesions
O Chondrosarcoma
O Solitary plasmacytoma
O Chordoma Pelvic lesions
O Chondrosarcoma
O Solitary plasmacytoma
O Chordoma
Plasmacytoma Pelvic lesions
O Chondrosarcoma
O Solitary plasmacytoma
O Chordoma
© R3, 2000
Chordoma Expansile Rib Lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
O Fibrous dysplasia Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
O Fibrous dysplasia Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
O Fibrous dysplasia Thyroid Carcinoma Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
© R3, 2000 O Fibrous dysplasia Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
© R3, 2000 O Fibrous dysplasia Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
© R3, 2000 O Fibrous dysplasia Expansile rib lesions
O Plasmacytoma
O Metastases
O Chondrosarcoma
O Eosinophilic granuloma
O Neurofibromatosis
O Fibrous dysplasia © R3, 2000 Lesions of the Spine
O Osteoblastoma
Q Expansile, with punctate densities within
O Chordoma
O ABC
O Metastatic disease Spine lesions
O Osteoblastoma
O Chordoma
O ABC
O Metastatic disease
© R3, 2000 Osteoblastoma Spine lesions
O Osteoblastoma
O Chordoma
O ABC
O Metastatic disease
© R3, 2000 Chordoma Spine lesions
O Osteoblastoma
O Chordoma
O ABC
O Metastatic disease
Aneurysmal bone cyst Spine lesions
O Osteoblastoma
O Chordoma
O ABC
O Metastatic
disease © R3, 2000 Metastatic Breast Carcinoma Clues by Density Of Lesion Sclerotic Cortical Lesions
O Brodie’s abscess
O Stress fracture Sclerotic cortical lesions
O Osteoid osteoma
O Brodie’s abscess
O Stress fracture
Osteoid Osteoma Sclerotic cortical lesions
O Osteoid osteoma
O Brodie’s abscess
O Stress fracture
© R3, 2000 Brodie’s abscess ScleroticSclerotic corticalcortical lesionslesions
O Osteoid osteoma
O Brodie’s abscess
O Stress fracture
Healing Stress Fracture Sclerotic Cortical Lesions
Osteoid Osteoma Brodie’s abscess Healing Stress Fracture Lytic Lesions in Children
O Eosinophilic granuloma
O Neuroblastoma
O Leukemia Lytic Lesions in Children
O Eosinophilic granuloma
O Neuroblastoma
O Leukemia
© R3, 2000 Eosinophilic granuloma Lytic Lesions in Children
O Eosinophilic granuloma
O Neuroblastoma
O Leukemia
© R3, 2000
Neuroblastoma Lytic Lesions in Children
O Eosinophilic granuloma
O Neuroblastoma
O Leukemia
© R3, 2000 Leukemia Lytic Lesions in Adults
O Metastatic lesions
Q Lung
Q Renal
Q Thyroid
O Multiple myeloma
O Primary bone tumor Lytic Lesions in Adults
O Mets
O Myeloma
O Primary bone tumor
Met from Thyroid Carcinoma Lytic Lesions in Adults
O Mets
O Myeloma
O Primary bone tumor
Multiple myeloma Lytic Lesions in Adults
O Mets
O Myeloma
O Primary bone tumor
Chondrosarcoma Blastic Lesions in Children
O Medulloblastoma
O Lymphoma BlasticBlastic LesionsLesions inin ChildrenChildren
O Medulloblastoma
O Lymphoma
© R3, 2000 Medulloblastoma BlasticBlastic LesionsLesions inin ChildrenChildren
O Medulloblastoma
O Lymphoma
Lymphoma Blastic Lesions in Adults
O Metastatic disease
Q Breast – female
Q Prostate – male
O Lymphoma
O Paget’s disease
O Etcetera-mastocytosis, fluorosis Blastic Lesions in Adults
O Mets
O Lymphoma
O Paget’s
Prostate Mets Blastic Lesions in Adults
O Mets
O Lymphoma
O Paget’s
Breast Mets BlasticBlastic LesionsLesions inin AdultsAdults
O Mets
O Lymphoma
O Paget’s
Lymphoma BlasticBlastic LesionsLesions inin AdultsAdults
O Mets
O Lymphoma
O Paget’s
Paget’s of Spine Other Clues Benign Lesions Without Sclerotic Boarders
O Giant Cell tumor
O Brown tumor
O Osteolytic phase of Paget’s Disease BenignBenign LesionsLesions withoutwithout ScleroticSclerotic BordersBorders
O Giant cell tumor
O Brown tumor
O Osteolytic Paget’s
© R3, 2000 Giant Cell Tumor BenignBenign LesionsLesions withoutwithout ScleroticSclerotic BordersBorders
O Giant cell tumor
O Brown tumor
O Osteolytic Paget’s
© R3, 2000 Brown Tumor BenignBenign LesionsLesions withoutwithout ScleroticSclerotic BordersBorders
O Giant cell tumor
O Brown tumor
O Osteolytic Paget’s
© R3, 2000
Osteolytic Paget’s Soft Tissue Extension
O Usually implies malignancy
Q More likely to form discrete soft tissue mass
O Benign conditions with soft tissue extension
Q Osteomyelitis
V Usually infiltration of fat © R3, 2000 Osteosarcoma Multiple Lesions
O More often benign
O Malignancies with multiple lesions
Q Metastatic disease
Q Multiple myeloma
Q Lymphoma
Q Ewing’s sarcoma (rarely)
Q Osteosarcoma (rarely) MultipleMultiple lesionslesions
O Metastatic
O Multiple myeloma
O Lymphoma
© R3, 2000 Mets from Ca of Prostate MultipleMultiple lesionslesions
O Metastatic
O Multiple myeloma
O Lymphoma
© R3, 2000
Multiple Myeloma MultipleMultiple lesionslesions
O Metastatic
O Multiple myeloma
O Lymphoma
© R3, 2000 Lymphoma MultipleMultiple lesionslesions
O Metastatic
O Multiple myeloma
O Lymphoma
O Osteosarcomatosis
© R3, 2000 Osteosarcomatosis Benign vs. Malignant
© Greenspan, Lippincott, 2000 The End