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Xray bone tumor UG lecture


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  • hi boss,,
    i attented ur mamc course... and ur presentation on pathological ortho specimens
    sir can i get that presentation to read and ny link for revision,, u said its on slide share ,,, but i dint got
    and sir kindly give ur email also for future help also

    dr. vikas
    resident chandigarh...
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  • 1. Dr Dhananjaya Sabat MS, DNB, MNAMSAssistant Professor OrthopedicsMaulana Azad Medical College, New Delhi
  • 2.  (1) Location of the lesion (2) Extent of the lesion (3) What is the lesion doing to the bone? (4) What is the bone doing to the lesion? (5) Hint as to its tissue type / matrix
  • 3.  Location and age of patient most important parameters in classifying a primary bone tumor. Simple to determine from plain radiographs.
  • 4.  EPIPHYSEAL  METAPHYSEAL  DIAPHYSEAL ◦ Chondroblastoma ◦ Nonossifying fibroma ◦ Adamantinoma ◦ Clear cell (close to growth plate) ◦ Leukemia, chondrosarcoma ◦ Chondromyxoid Lymphoma, ◦ Giant cell tumor fibroma (abutting growth plate) Reticulum cell ◦ Aneurysmal bone sarcoma cyst ◦ Solitary bone cyst, ABC, GCT ◦ Ewing sarcoma ◦ Geode (subchondral cyst) ◦ Osteochondroma ◦ Metastasis ◦ Infection ◦ Brodie abscess ◦ Osteoblastoma/ ◦ Eosinophilic ◦ Osteogenic sarcoma, osteoid osteoma granuloma chondrosarcoma ◦ Nonossifying fibroma
  • 5.  Central: Enchondroma Eccentric: GCT, CMF, osteosarcoma Cortical: osteoid osteoma, NOF Parosteal: osteochondroma, parosteal osteosarcoma
  • 6. BONE TUMOR COMMONEST SITESBC Proximal humerus > prox. FemurABC, GCT, Osteosarcoma Lowerend femur > upper end tibiaEnchondroma Metaphysis of small bones of hand & feetOsteochondroma Distal femur> prox. Tibia > prox. HumerusChondroblastoma Proximal humerus> prox femurEwing’s Femur > fibula > tibiaAdamantinoma Mandible > tibiaMyeloma VertebraFibrous dysplasia Ribs > Upper femur > Tibia > lower femurOsteoid osteoma Femur > tibiaChordoma Sacrum > clivus (spheno occipital) > anterior vertebral bodyIvory osteoma Frontal sinusChondromyxoid fibroma Tibia > femurChondroblastoma Pelvis > femurOsteoblastoma Posterior spine
  • 7. Patterns of bone destruction: •GEOGRAPHIC Well-defined smooth / irregular margin Short zone of transition Lytic Poorly demarcated lesion imperceptibly •PERMEATIVE merging with uninvolved bone Long zone of transition Areas of destruction with ragged borders. •MOTHEATEN Less well defined / demarcated lesional margin Longer zone of transition Sclerotic
  • 8.  Margin between tumor and native bone is visible on the plain radiograph. Slowly progressive process is “walled-off” by native bone, producing distinct margins. Rapidly progressive process destroys bone, producing indistinct margins.
  • 9.  Margin types 1A, 1B, 1C, 2, and 3 ◦ least aggressive 1A, to most aggressive 3 Aggressive lesions destroy bone. Aggressiveness increases likelihood of malignancy. ◦ BUT, not all aggressive processes are malignant. ◦ AND, not all malignant diseases are aggressive.
  • 10. A well circumscribed lesion with a narrow zone of transitionincreasing aggressiveness
  • 11.  simple cyst (UBC) enchondroma FD chondroblastoma GCT chondrosarcoma (rare) MFH (rare)
  • 12.  GCT enchondroma chondroblastoma myeloma, metastatsis CMF FD chondrosarcoma MFH
  • 13.  chondrosarcoma MFH osteosarcoma GCT metastasis infection EG lymphoma
  • 14.  myeloma, metastases  infection  EG  osteosarcoma  chondrosarcoma  lymphomaMultiple scattered holes that vary insize & seem to arise separately
  • 15.  Ewing  EG  infection  myeloma, metastasis  lymphoma  osteosarcomaPoorly demarcated from normal, numerouselongated holes/slots in cortex, run parallel tolong axis of bone
  • 16.  Limited responses of bone Destruction: lysis (lucency) Reaction: sclerosis Remodeling: periosteal reaction Rate of growth determines bone response ◦ slow progression, sclerosis prevails ◦ rapid progression, destruction prevails
  • 17.  Periosteal reaction must mineralize to be seen on X ray ( 10 days – 3 weeks) Configuration of periosteal reaction ◦ Nature of inciting process ◦ Intensity ◦ Aggressiveness ◦ Duration
  • 18.  Thick, uninterrupted ◦ long standing process, often non-aggressive  stress fracture  chronic infection  osteoid osteoma Spiculated, lamellated ◦ aggressive process ◦ tumor likely
  • 19. periosteal reactionCodmanTriangle advancing tumor margin destroys periosteal new bone before it ossifies tumor
  • 20. Sunburst Appearance
  • 21.  “Matrix” is the internal tissue of the tumor Most tumor matrix is soft tissue in nature. ◦ Radiolucent (lytic) on x-ray Cartilage matrix ◦ calcified rings, arcs, dots (stippled) ◦ enchondroma, chondroblastoma, chondrosarcoma Ossific matrix ◦ osteosarcoma
  • 22.  Exostosis: well defined bony projection growing away from physis Cartilage maybe calcified if lesions are large / malignant change
  • 23.  Nidus: a tiny radiolucent area If in diaphysis surrounded by dense bone and thickened cortex Metaphysis less cortical thickening Double density sign on bone scan – increased uptake in nidus and decreased uptake in reactive sclerotic zone (also seen in Brodie’s abcess) Lytic nidus surrounded by sclerotic bone in CT Centre of nidus may be calcified
  • 24.  Well demarcated osteolytic lesion sometimes containing flecks of calcification Less reactive bone than osteoid osteoma Bone scan - intense activity
  • 25.  Cystic radiolucency on the diaphysial side of the growth plate Cortex may be thinned and bone expanded with well defined thin sclerotic margin May have pseudo-loculated appearance secondary to irregular cortical thinning and thin septal ridges Falling fragment sign typical and the lesion is never wider than epiphysial plate Bone scan cold or minimal activity unless fractured
  • 26.  Gross honey comb lesion Often eccentrically placed Does not extend to the joint (unlike GCT) Warm to hot on bone scan
  • 27.  Usually well defined geographic lytic lesion in the epiphysis/metaphysis extending up to the joint surface without marginal sclerosis Junction with normal bone often poorly defined Cortex thinned and sometimes ballooned Bone scan warm to hot
  • 28. Fibrous cortical defect Margin well defined, sometimes scalloped and often sclerosed
  • 29. Non-ossifying Fibroma
  • 30.  Ground glass appearance typical Shepherds crook deformity of proximal femur Variable appearance with expansion of cortex
  • 31.  Scalloped erosions on endosteal surface May have flecks of calcification
  • 32.  Rounded or oval rare area Usually eccentrically placed May cross the growth plate Sharp outline and sclerotic rim Scalloped margin and thin cortex
  • 33.  Well defined area of rarefaction eccentrically placed in the epiphysis or across the growth plate No reaction in surrounding bone 50% show central calcification, 50% show linear periosteal reaction Bone scan increased uptake at margins
  • 34.  Multiple loose bodies
  • 35.  Large osteolytic lesion in the midline May contain flecks of calcification Marked bone destruction
  • 36.  Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton.
  • 37.  Characteristic honey comb appearance in diaphysis Cortical thinning with expansion
  • 38.  Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)
  • 39.  Mottled lytic defect usually no sclerotic rim May destroy cortex Usually endosteal or periosteal reaction Lesions in flat bones and ribs appear punched out May appear loculated due to sparing of large trabeculae Spinal lesions- collapse (vertebra plana), which may heal
  • 40.  Mottled or moth eaten lesion diffusely involving bone Lytic destruction common, often the cortex is perforated Onion skin appearance- layers of periosteal new bone are said to be characteristic May form Codman’s triangle
  • 41.  Variable with combination of bone destruction and bone formation Sun ray spicules/ sun burst appearance and Codman’s triangle may be evident Cortical breach common Adjacent soft tissue mass Joint space rarely involved ◦ 25% Lytic ◦ 35% Sclerotic ◦ 40% Mixed Telangiectatic type- purely lytic
  • 42.  Variable appearance with 60 - 70% have calcification and 50% have sub periosteal new bone May be a large cystic lesion with cortical destruction and central calcification, endosteal scalloping and cortical expansion; annular, punctate or comma shaped calcification
  • 43.  Bone often mottled or moth eaten with extension into soft tissue Osteolytic lesion may be surrounded by reactive bone Destructive appearance radiologically Usually little periosteal reaction
  • 44.  Osteolytic commonest - cortical destruction with little or no periosteal reaction; Lungs, Kidney, Adrenal, Thyroid, Uterus Osteoblastic deposits – Prostate, Bladder, Testis, Breast and Bowel secondaries. Also carcinoid lung tumors, lymphoma Mixed- Breast, Lung, Ovary, Cervix Lymphoma deposits may resemble prostatic deposits, i.e. sclerotic secondaries Lytic, expansile, with soft tissue mass- RCC, thyroid X-Ray- at least 50% loss of bone to produce lysis on X-ray, Loss of single pedicle produces a “winking owl sign”. CT scan, MRI
  • 45. Osteolytic bone metastases:breast carcinoma shows multiple osteolytic bone lesions.
  • 46. Osteoblastic bone metastases
  • 47. Mixed pattern bone metastases:
  • 48.  Early - vague mottled lucent areas Diffuse destructive lytic lesion with little periosteal reaction Usually combination of patchy sclerosis and mottled destruction Hogkins disease - typical appearance of ivory vertebrae
  • 49.  May be generalised decrease in bone density Multiple punched out defects Little bony reaction around lesions Solitary lesion = plasmacytoma; multilocular expanding lytic lesion in a red marrow area Frequently cold on bone scan