Benign bone tumours


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mainly discussion on bone forming tumors and cartillage forming benign tumors of bone ,
priority given to imaging

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  • Maffucci syndrome CARTILLAGE FORMING

  • Source WHIO manual
  • Enchondroma , Maffucii sybdrome and olliers disease will be discussed together.
  • pathognomonic
  • Despite being rare, they are one of the most frequently encoutered benign epiphyseal neoplasms in skeletally immature patients.
    *which may lead to the incorrect diagnosis of giant cell tumour) which may lead to the incorrect diagnosis of giant cell tumour)
  • cT demonstrates the plain film findings with better delineation of the relationship to the growth plate and articular surface
     well defined lytic lesions; either smooth or lobulated margins with a thin sclerotic rim
    Internal calcifications can be seen .
  • Fluid-fluid levels may occasionally be seen (see fluid fluid level containing bone lesions) presumably due to an associated aneurysmal bone cyst
  • T1 - lesion itself is of low to intermediate signal
    T2 / STIR - lesion is of intermediate to high signa
  • T1 and t2 images see the cartilage differences .
  • Examples have however been seen in patients up to the age of 75 years. In some series there is a male predilection 12 whilst in others no such distribution is found
  • STIR T2 FAST SAT T1 t1 FAST c++
  • T1 C+FAST
  • Tests like FNAC is usually non-diagnostic and is dominated by fresh blood 
  • . Occasionally they are also seen in appendicular long bones where they are known as solid aneurysmal bone cysts. Histologically these two entities are identical 6.
  • fluid-fluid levels,  no means unique to it, and is also seen in both benign and malignant lesions (e.g. giant cell tumours (GCT), chondroblastoma, simple bone cysts and telangiectatic osteosarcomas).

  • Also seen in giant cell tumour
    simple bone cyst

    On plain films (and to a lesser degree CT) the diagnosis includes most of the lesions
  • Allows detailed in view of the lesion can be of two types in general
  • T1 slices
  • the rightmandible with expansion of buccal and lingual cortical plates. Ameloblastoma
  • Explain the graphs
  • In some locations, such as in the humerus or around the knee, almost all bone tumors may be found.
  • Simple bone cyst
  • Anteroposterior radiograph of the pelvis shows expansile lytic lesion of right acetabulum with thinning of the cortex (arrow) and honeycomb trabeculation. Flat bones are a common location for aneurysmal bone cysts
  • Anteroposterior radiograph of proximal portion of tibia and fibula shows expansile lytic lesion in proximal fibular metaphysis, with mild honeycombing (black arrows). Eccentric origin of the lesion is hard to appreciate in thin bones such as the fibula; both cortices are ballooned, with focal loss laterally (white arrow).
  • Anteroposterior radiograph of distal forearm and wrist shows more typical eccentric location of aneurysmal bone cyst in distal metaphysis of the radius, although this particular lesion lacks a honeycomb appearance. Cortex on radial side is very thin
  • Lateral radiograph of proximal portion of tibia shows enchondroma with punctate and arclike mineralization (arrows).
  • Lateral margin of 10t rib
  • Benign bone tumours

    1. 1. BENIGN BONE TUMOURS Presenter :Dr.Arif khan S Moderator: Dr.Gururaj Sharma
    2. 2. BENIGN BONE TUMOURS • CLASSIFICATION: • BONE FORMING Eg; osteoid osteoma, osteoblastoma, enostosis (bone island), osteopoikilosis Osteoma, • CARTILLAGE FORMING Eg; enchondroma , enchondromatosis (Ollier disease),, Osteochondroma, chondroblastoma FIBROUS BONE LESIONS Eg; fibrous dysplasia, ossifying fibroma • Miscellaneous Simple bone cyst; Aneurysmal Bone cyst;
    3. 3. IMAGING • the role of imaging in the management of a patient with a suspected bone tumour can be broadly subdivided as follows; • 1. detection • 2. diagnosis • 3. surgical staging • 4. follow-up
    5. 5. ENCHONDROMA • common benign medullary cartilaginous neoplasm • usually found in children or young adults which can lead to pathological fractures or undergo malignant degeneration. • 3-10 % of all bone tumours and 12-24 % of benign bone tumours • Enchondromas are most frequently diagnosed in childhood to early adulthood with a peak incidence of 10-30 years. • complicated by a pathological fracture or malignant transformation into a low grade chondrosarcoma • (clinically if an enchondroma is painful in the absence of a fracture, it should be considered malignant
    6. 6. ENCHONDROMA • Enchondromas arise from rests of growth plate cartilage/chondrocytes that subsequently proliferate and slowly enlarge and are composed of mature hyaline cartilage. • they are seen in any bone formed from cartilage. • Two syndromes are associated with multiple enchondromas: Ollier disease Maffucci syndrome. • small tubular bones of the hands and feet : 50% • large tubular bones e.g. femur, tibia, humerus
    7. 7. ENCHONDROMA • Rarely an enchondroma may extend through the cortex and demonstrate a exophytic growth pattern. This is known as an enchondroma protuberans, and may either be seen sporadically or as part of Ollier disease. • Almost all enchondromas are located in the medullary cavity of tubular bones. The typical distribution is : D/ds: • bone infarct , chondrosarcoma, intraosseous ganglion • other benign lytic bone lesions, • metastases • granulomatous disease : sarcoidosis, tuberculosis
    8. 8. IMAGING • X-ray & CT Typically enchondromas are small 1 - 2cm lytic lesions with non- aggressive features. narrow zone of transition sharply defined scalloped margins : may have mild endosteal scalloping expansion of the overlying cortex may be present but there should not be cortical breakthrough unless fractured chondroid calcifications may be present : rings and arcs calcification no periosteal reaction no soft tissue mass. • The majority of enchondromas more frequently arise in the metaphyseal region,. A cartilaginous lesion in an epiphysis is more likely to be a chondrosarcoma .
    9. 9. IMAGES
    10. 10. IMAGING • MRI • MRI is useful in evaluating for soft tissue extension and for confirming the diagnosis. • Enchondromas appear as well circumscribed somewhat lobulated masses replacing marrow. • T1 intermediate to low signal • T1 C+ (Gd) enhancement is variable, and may be seen both peripherally or of translesional septae. Similar pattern of enhancement may be seen in chondrosarcomas. • T2 typically of background intense high signal they can be focal regions of signal drop out where calcification present no bone marrow or soft tissue oedema
    11. 11. IMAGES • T1 T2 STIR • Hypointense Hyperintense
    12. 12. • Ollier disease also known as enchondromatosis, is a non- hereditary, sporadic, skeletal disorder characterised by multiple enchondromas that are principally located in the metaphyseal regions. • Plain films show multiple enchondromas. Larger lesions can show cartilage calcification in a typical rings and arcs pattern. • Imaging characterestics are of same as ENCHONDROMAS
    13. 13. MAFUCCI’S SYNDROME • Maffucci syndrome is a congenital non hereditary mesodermal dysplasia characterised by multiple enchondromas with soft-tissue cavernous haemangiomas. • Imaging findings are multiple enchondromas seen associated with soft tissue swelling and phleboliths. • Enchondromas degenerate into chondrosarcomas in 15-51% 3 of cases and soft-tissue haemangiomas to vascular sarcomas in 3-5%.
    15. 15. CHONDROBLASTOMA • rare benign cartilaginous neoplasms • less than 1% of all primary bone tumours, occurring predominantly in young patients (< 20 years of age). There is a male predilection. • Pathologically composed of chondroblasts, chondroid matrix, cartilage with occasional giant multi-nucleated cells.* with surrounding chondroblasts. • Aneurysmal bone cysts can be seen secondarily to underlying chondroblastoma.
    16. 16. • epiphysis of a long bone (70% occurring in the humerus (most frequent), femur and tibia, ~ 10% are found in the hands and feet)
    17. 17. IMAGING • X-rays • epiphyseal • well defined lytic lesions; either smooth or lobulated margins with a thin sclerotic rim • Internal calcifications can be seen in up to 40-60% of cases • They range in size from 1-10cm, with most being 3-4cm at diagnosis • CT • better delineation of the relationship to the growth plate and articular surface • Solid periosteal reaction (seen in up to 50% of cases) and internal calcification (calcified matrix seen in ~ 1/2 of cases) and cortical breach are also more easily appreciated. • Endosteal scalloping may be seen
    18. 18. IMAGE
    19. 19. IMAGING • MRI • ideal for the evaluation of transphyseal or transcortical extension. • Demonstrating associated surrounding bone marrow oedema. • These lesions have signal typical of cartilage: T1 - lesion itself is of low to intermediate signal T2 / STIR - lesion is of intermediate to high signal • Fluid-fluid levels may occasionally be seen .
    20. 20. IMAGE • T1 T2 STIR
    21. 21. OSTEOCHONDROMA • Developmental anomalies rather than tumors. • They are usually sporadic, but can be part of: Hereditary multiple exostoses (HME) - also known as diaphyseal aclasis Trevor disease An osteochondroma can be either sessile or pedunculated, and is seen in the metaphyseal region typically projecting away from the epiphysis.
    22. 22. • They most commonly arise from appendicular skeleton, especially around the knee 3. • lower limb - 50% of all cases femur (especially distal) - most common : 30% • tibia (especially proximal) - 15-20% • less common locations - feet, scapula • upper limb • humerus - 10-20% • less common locations - hands, pelvis • spine - the posterior elements of spine are an uncommon, but not rare, site for these tumours
    23. 23. • Pathologically Osteochondromas are essentially a part of the growth plate. • Separates and continues growing independently, without an associated epiphysis • The medullary cavity is continuous with the parent bone, and they are capped by hyaline cartilage • D/ds • hands - bizarre parosteal osteochondromatous proliferation (BPOP) • humerus - supracondylar spur : projects towards the elbow joint • malunited fracture
    24. 24. • X-ray findings. • An osteochondroma can be either sessile or pedunculated, and is seen in the metaphyseal region typically projecting away from the epiphysis. • There is often associated broadening of the metaphysis from which it arises • The cartilage cap is variable in appearance. It may be thin and difficult to identify, or thick with rings and arcs calcification and irregular subchondral bone. • CT • Better visualisation of medullary continuity and the cartilage cap.
    25. 25. • MRI • MRI is best at assessing cartilage thickness (and thus assessing for malignant transformation), presence of oedema in bone or adjacent soft tissues and visualising neurovascular structures in the vicinity. • The cartilage cap of osteochondromas appears the same as cartilage elsewhere, with intermediate to low signal on T1 and high signal on T2 and STIR weighted images. • A cartilage cap of over 1.5cm in thickness is suspicious for malignant degeneration.
    26. 26. T1 T2 STIR
    27. 27. • Bone scan During growth osteochondromas demonstrate increased uptake, but with time they become no more active than normal bone. Presence of increased activity in adulthood should raise the possibility of a complication (fracture, malignancy).
    28. 28. CHONDROMYXOID FIBROMA • Extremely rare, benign cartilaginous neoplasms that account for < 1% of all bone tumours. • Second and third decades, with approximately 75% of cases occurring before the age of 30 years. • Pathologically comprises of a variable combination on chondroid, myxoid, and fibrous tissue components organised in a pseudolobulated architecture. • Occasional osteoclast-like giant multinucleated cells are encountered particularly at the periphery. • D/ds: aneurysmal bone cyst (ABC), giant cell tumour of bone (GCT), non ossifying fibroma: younger age group, chondroblastoma: younger age group
    29. 29. IMAGING • X-rays &CT often seen as a lobulated, eccentric radiolucent lesion long axis parallel to long axis of long bone no periosteal reaction (unless a complicating fracture present) geographic bone destruction: almost 100% well defined sclerotic margin: 86% there can be presence of septations (pseudotrabeculation): 57% 2 there can be presence of matrix calcification in small porportion cases: 12.5%1 • Bone Scan – Doughnut sign (non- specific)
    30. 30. IMAGES
    31. 31. • MRI • Non specific. • T1- low signal (hypointense) • T1 C+ (Gd) • the majority (~70%) tend to show peripheral nodular enhancement. • 30% diffuse contrast enhancement and this can be either homogeneous or heterogeneous . • T2 - hyperintense
    32. 32. IMAGES
    34. 34. SIMPLE BONE CYST • A.k.a Unicameral bone cysts. • Relatively common Radiolucent bony lesions • seen in childhood and typically remain asymptomatic. • 1st and 2nd decades (65% in teenagers), and are more common in males • frequently found in the metaphysis of long bones, abutting the growth plate. proximal humerus: most common 50-60% proximal femur: 30%
    35. 35. IMAGING • X-ray & CT Sharply demarcated. Radiolucent lesions. Periosteal reactions. Expand the bone with thinning of the overlying bone. • Fallen fragment sign: a dependent bony fragment within the lesion. Seen when assosciated fracture is present.
    36. 36. MRI MR signal characteristics for an uncomplicated lesion include T1 - low signal T2 - high signal Usually there no fluid-fluid levels unless there has been a complication with haemorrhage. CT and MRI add little to the diagnosis, but are however helpful in eliminating other entities that can potentially mimic a simple bone cyst
    37. 37. T1 T2
    38. 38. ANEURYSMAL BONE CYST (ABC) • Benign , Expansile • Primarily seen in children and adolescents (80% l <20yrs of age) • blood-filled spaces of variable size separated by connective tissue (trabeculae of bone or osteoid tissue) and osteoclast giant cells • Not lined by endothelium. Types • Primary • Secondary (e.g chondroblastoma, fibrous dysplasia, giant cell tumour (GCT), osteosarcoma)
    39. 39. • Location Long bones – tibia & fibula (24%), femur (13%), Spine 20-30% (posterior elements). sacrum • A variant of ABCs is the giant cell reparative granuloma. seen in the tubular bones – hand , feet craniofacial skeleton.
    40. 40. RADIOGRAPHIC FEATURES • X ray sharply defined, expansile osteolytic lesions, with thin sclerotic margins. Eccentricity is typical. But very often missed out due to cortical thinning due to ballooning. CT Demonstrates these findings to a greater degree, and is also better at assessing cortical breach and extension into soft tissues. Fluid fluid levels (better than MRI)
    41. 41. • MRI Demonstrate Fluid Fluid level in lesion. To distinguish between Primary and secondary (if solid component Is present.) The cysts are of variable signal, with surrounding rim of low T1 and T2 signal. Focal areas of high T1 and T2 signal are also seen presumably representing areas of blood of variable age.
    42. 42. • Bone scan: • Doughnut sign - increased uptake peripherally with a photopenic centre.
    43. 43. ADAMANTINOMA • LONG BONES (tibia exclusively)AND JAW. • 2nd to 3rd decades as a locally aggressive mass . • slight male predilection. • Since it is a low-grade malignancy, it can metastasise to distant locations including : lung, bone, lymph nodes, pericardium and liver. • D/ds • fibrous dysplasia • osteofibrous dysplasia : has a more ground glass texture on CT
    44. 44. • X-rays & CT Appears as a multi-locular or slightly expansile osteolytic lesion. areas of lysis interspersed with areas of sclerosis Lesions tend to have an eccentric epicentre. lack of periosteal reaction
    45. 45. . MRI • a solitary lobulated focus • multiple small nodules in one or more foci. • Separated tumour foci, defined as foci of high signal intensity on either T2 or T1-weighted contrast- enhanced images, interspersed with normal-appearing cortical or spongious bone . C+(Gd) : tends to show intense and homogeneous static enhancement, although there is no uniform dynamic enhancement pattern.
    46. 46. IMAGES
    47. 47. AMELOBLASTOMA • Ameloblastomas (previously known as an adamantinoma of the jaw) are benign, locally aggressive tumours that arise from the mandible, or less commonly from the maxilla. • They are slow growing and tend to present in the 3rd to 5th decades of life, with no gender predilection. • X-rays &CT findings • It is classically seen as a multilocualted (80%), expansile "soap-bubble" lesion, with well demarcated borders and no matrix calcification. • erosion of the adjacent tooth roots can be seen which is highly specific. • larger it may also erode through cortex into adjacent soft tissues. • MRI findings • ameloblastomas demonstrate a mixed solid and cystic pattern, with a thick irregular wall, often with papillary solid structures projecting into the lesion. • These components tend to vividly enhance
    48. 48. • d/ds • dentigerous cyst : 20% of ameloblastomas thought to arise from pre-existing dentigerous cysts • odontogenic keratocyst (OKC) -unilocular with thin poorly enhancing walls • odontogenic myxoma - can be almost indistiguishable • aneurysmal bone cyst (ABC) • fibrous dysplasia
    49. 49. SUMMARY
    50. 50. Most common location FD = Fibrous dysplasia EG = Eosinophilic Granuloma NOF = Non Ossifying Fibroma SBC = Simple Bone Cyst CMF = Chondromyxoid fibroma ABC = Aneurysmal bone cyst HPT = Hyperparathyroidism with Brown tumor GCT = Giant cell tumour
    51. 51. Most primary tumours are seen in patients less than 30 years of age In patients greater than 30 years , secondary tumours (eg ;brown tumours) and metastatic deposits are common.
    52. 52. COMMON LOCATIONS OF LESIONS FD = Fibrous dysplasia EG = Eosinophilic Granuloma NOF = Non Ossifying Fibroma SBC = Simple Bone Cyst CMF = Chondromyxoid fibroma ABC = Aneurysmal bone cyst HPT = Hyperparathyroidism with Brown tumor GCT = Giant cell tumour
    53. 53. MOST COMMON LOCATIONS • Aneurysmal Bone Cyst tibia, femur, fibula, spine, humerus • Adamantinoma tibia shaft, mandible • Chondroblastoma femur, humerus, tibia, tarsal bone (calc), patella • Chondromyxoid fibroma tibia, femur, tarsal bone, phalanx foot, fibula
    54. 54. • Enchondroma phalanges of hands and feet, femur, humerus, metacarpals, rib • Osteochondroma femur, humerus, tibia, fibula, pelvis • Solitary Bone Cyst proximal humerus, proximal femur, calcaneal bone, iliac bone
    55. 55. SPOTTERS