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Xray bone tumor UG lecture
This document discusses how to classify primary bone tumors based on location and age of the patient using plain radiographs. Key factors include the location of the lesion within the bone (epiphyseal, metaphyseal, diaphyseal), the extent of the lesion, and features of the lesion and bone's response that provide clues to the tissue type. Common bone tumors are listed for each location. Characteristic patterns of bone destruction and periosteal reactions are also described.
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Xray bone tumor UG lecture
- 1. Dr Dhananjaya SabatMS, DNB, MNAMS Assistant Professor Orthopedics Maulana 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.
- 5. 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
- 6. Central: Enchondroma Eccentric: GCT, CMF, osteosarcoma Cortical: osteoid osteoma, NOF Parosteal: osteochondroma, parosteal osteosarcoma
- 7. BONE TUMOR COMMONEST SITE SBC Proximal humerus > prox. Femur ABC, GCT, Osteosarcoma Lowerend femur > upper end tibia Enchondroma Metaphysis of small bones of hand & feet Osteochondroma Distal femur> prox. Tibia > prox. Humerus Chondroblastoma Proximal humerus> prox femur Ewing’s Femur > fibula > tibia Adamantinoma Mandible > tibia Myeloma Vertebra Fibrous dysplasia Ribs > Upper femur > Tibia > lower femur Osteoid osteoma Femur > tibia Chordoma Sacrum > clivus (spheno occipital) > anterior vertebral body Ivory osteoma Frontal sinus Chondromyxoid fibroma Tibia > femur Chondroblastoma Pelvis > femur Osteoblastoma Posterior spine
- 9. Patterns of bonedestruction: •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
- 10. 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.
- 11. 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.
- 12. A well circumscribedlesion with a narrow zone of transition increasing aggressiveness
- 13. simple cyst (UBC) enchondroma FD chondroblastoma GCT chondrosarcoma (rare) MFH (rare)
- 14. GCT enchondroma chondroblastoma myeloma, metastatsis CMF FD chondrosarcoma MFH
- 15. chondrosarcoma MFH osteosarcoma GCT metastasis infection EG lymphoma
- 16. myeloma, metastases infection EG osteosarcoma chondrosarcoma lymphoma Multiple scattered holes that vary in size & seem to arise separately
- 17. Ewing EG infection myeloma, metastasis lymphoma osteosarcoma Poorly demarcated from normal, numerous elongated holes/slots in cortex, run parallel to long axis of bone
- 18. 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
- 19. 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
- 20. Thick, uninterrupted ◦ long standing process, often non-aggressive stress fracture chronic infection osteoid osteoma Spiculated, lamellated ◦ aggressive process ◦ tumor likely
- 22. periosteal reaction Codman Triangle advancing tumor margin destroys periosteal new bone before it ossifies tumor
- 23.
- 24. “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
- 27. Exostosis: welldefined bony projection growing away from physis Cartilage maybe calcified if lesions are large / malignant change
- 28. 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
- 29. Well demarcated osteolytic lesion sometimes containing flecks of calcification Less reactive bone than osteoid osteoma Bone scan - intense activity
- 30. 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
- 31. Gross honey comb lesion Often eccentrically placed Does not extend to the joint (unlike GCT) Warm to hot on bone scan
- 32. 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
- 33. Fibrous cortical defect Margin well defined, sometimes scalloped and often sclerosed
- 34.
- 35. Ground glass appearance typical Shepherds crook deformity of proximal femur Variable appearance with expansion of cortex
- 36. Scalloped erosions on endosteal surface May have flecks of calcification
- 37. Rounded or oval rare area Usually eccentrically placed May cross the growth plate Sharp outline and sclerotic rim Scalloped margin and thin cortex
- 38. 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
- 39. Multiple loose bodies
- 40. Large osteolytic lesion in the midline May contain flecks of calcification Marked bone destruction
- 41. Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton.
- 42. Characteristic honey comb appearance in diaphysis Cortical thinning with expansion
- 43. Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)
- 44. 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
- 45. 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
- 46. 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
- 47. 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
- 48. 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
- 49. 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
- 51. Osteolytic bone metastases: breastcarcinoma shows multiple osteolytic bone lesions.
- 52.
- 53. Mixed pattern bonemetastases:
- 54. 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
- 55. 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