Approach to bone tumours
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Approach to bone tumours



Approach to bone tumours

Approach to bone tumours



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Approach to bone tumours Approach to bone tumours Presentation Transcript

  • IntroductionBone tumors and tumor like conditions are common in dayto day practice.Many imaging modalities like plain radiography, CT, Nuclearmedicine & MRI are available for the diagnosis.Plain radiography is the modality of choice in the diagnosis.MRI and CT are used only to stage the extent of the diseaseor as problem solving tools.A logical approach is needed for accurate diagnosis of bonetumors.
  • ApproachAge of the patient: Mature or immature skeleton.Location of the tumor: Epi/Meta/Diaphyseal.Number of lesions: Solitary or multiple.Nature of the lesion: Lytic/ Sclerotic/Mixed.Matrix: Osteoid/ Chondroid/ Fatty.Zone of transition.Periosteal reaction.Associated features.
  • Age Certain tumors are common in certain age groups. Knowledge of the age of the patient helps to narrow down the differentials.Age Benign Tumors Malignant Tumors<20y FCD,SBC,ABC, FD, Ewing’s sarcoma, Osteosarcoma, Chondroblastoma, LCH etc Neuroblastoma Mets, Lymphoma etc20-40y Enchondroma, GCT, FD etc Osteosarcoma (Parosteal), Adamantinoma etc>40y FD, Paget’s disease etc Chondrosarcoma, Lymphoma, Multiple Myeloma, Metastasis, Secondary osteosarcoma etc
  • Location Tumors may be epiphyseal / metaphyseal or diaphyseal. They can also be cortical or medullary. Most of the bone tumors are metaphyseal in location. Knowledge of the common tumors in these locations helps to narrow down the differentials.Site TumorsEpiphyseal Chondroblastoma, GCT(Sub articular), Articular osteochondroma (Trevor’s disease), ABC etcMetaphyseal SBC, ABC, FCD,NOF,CMF,Enchondroma, Osteosarcoma, Chondrosarcoma etcDiaphyseal Ewing’s sarcoma, Adamantinoma, Osteoid osteoma, Lymphoma, Metastasis etc
  • Metaphyseal Epiphyseal Diaphyseal ExostosisChondroblastoma Ewing’s sarcoma
  • Location Cortical FCD, NOF etc lesions Medullary FD, Myeloma, Lesions Metastasis etcCortical Medullary
  • Plasmacystoma & Adamantinoma isChordoma common Enchondroma isare common in sacrum in tibia & mandible. Common in hand bones
  • Number of lesionsPrimary bone tumors are usually solitary. Exceptions aremultiple exostoses, multiple myeloma and multicentricosteosarcoma etc.Most of the multiple bone tumors are usually metastatic.However multiple exostoses and fibrous dysplasia, thoughbenign are also multiple in number.Analysis of number of the lesions through skeletal surveyhelps in narrowing down the differentials.
  • Number of lesionsMultiple lesions areseen in Multiple Myeloma, Most of the primary boneMetastasis, FD etc tumors are solitary
  • Nature of the lesion1A: Geographic lytic lesion with 1B: Geographic lytic lesion withoutsclerotic rim. sclerotic rim.Eg: Benign lesions: FD, Intra-osseous Eg: Myeloma, EG, Fibrosarcoma etc.lipoma etc
  • 1C- Geographic lytic lesion with ill defined borders Type-2: Moth eaten lesion Type-3: Permeative lesionsEg: Osteosarcoma, Eg: Osteosarcoma, Eg: Ewing, Osteosarcoma,Large GCT etc Osteomyelitis, NB Mets etc. Lymphoma, Leukemia etc
  • Sclerotic lesion Mixed lytic and sclerotic lesionsEg: Sclerosing osteosarcoma, Eg: Metastasis from breast, prostate,Metastasis from Prostate Uterus etc.
  • MatrixThe term matrix refers to the substance or the major tissuecomponent of the tumor.The type of the matrix roughly suggests the cell of origin ofthe tumor.Bone forming tumors will have osteoid matrix, cartilageforming tumors will have chondroid matrix etc.
  • Osteoid matrix Chondroid matrix Fatty matrixEg: Osteosarcoma Eg: Chondrosarcoma Eg: LipomaOssifying fibroma etc Enchondroma etc.
  • Zone of transitionIt is the junction of normal and abnormal bone.The zone is narrow in benign conditions.The zone of transition is wide in malignant conditions. Dueto infiltrating nature of the malignant lesions, the zone maybe ill defined.
  • Narrow WideEg: SBC,ABC,Benign GCT Eg: Chondrosarcoma, OsteosarcomaFD etc Fibrosarcoma etc
  • This term refers to the response of the native bone to theinsult in terms of elevation of the periosteum.The reaction is continuous in benign conditions like trauma.It is discontinuous in malignancies.Periosteal reaction with discontinuous layers of bone mayalso be seen in infections.
  • Type of Periosteal Reaction ExamplesUnilamellar HPOA, Post traumaticOnion Peel Ewing’s sarcoma, Osteomyelitis(Probably Malignant)Codman’s triangle Osteosarcoma, Ewing’s sarcoma(Malignant)Hair on end Ewing’s sarcoma, Osteosarcoma(Highly malignant)
  • Periosteal reactionUnilamellar Onion Peel
  • Codman’s triangle Hair on end
  • Typical featuresCertain tumors & tumor like conditions have some typicalfeatures. Tumor Typical feature Soap bubble appearance GCT Cumulus cloud Osteosarcoma Rind of sclerosis Fibrous dysplasia Bony expansion and sclerosis Paget’s disease
  • Soap bubble - GCT Cumulus cloud - Osteosarcoma
  • DiscussionBone tumors are commonly encountered in day to daypractice.Sequential analysis as mentioned above is useful innarrowing the differentials and arriving at a specificdiagnosis.The age predilection of the bone tumors must always bekept in mind.Thorough knowledge of the nature of the condition isimperative in accurate diagnosis.
  • conclusionPlain radiography is the imaging modality of choicein the diagnosis of bone tumors.MRI and CT are used in staging of the disease.Logical evaluation of various plain radiographicfeatures of bone tumors will enable the radiologistto arrive at a proper diagnosis.
  • RefeRencesTheodore T Miller. Bone tumors and tumor like conditions: Analysis withconventional Radiography. Radiology2008;246 (Number-3):663-673.Priolo F, Cerase A. The current role of radiography in the assessment ofskeletal tumors and tumor-like lesions. Eur J Radiol 1998;27(suppl1):S77–S85.Resnick D. Diagnosis of bone and joint disorders.4th ed. Philadelphia,Pa: Saunders,2002.Yochum and Rowe’s Essentials of Skeletal Radiology. 3rd ed.Philadelphia, Pa: Lippincott Williams & Wilkins,1996.