Malignant Bone and Soft-Tissue Tumors

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Malignant Bone and Soft-Tissue Tumors

  1. 1. Malignant BoneMalignant Bone TumorsTumors Aaron KabbAaron Kabb Chicago Medical SchoolChicago Medical School August 2004August 2004
  2. 2. TopicsTopics  IntroductionIntroduction  Imaging ModalitiesImaging Modalities  Plain Film Radiographic FindingsPlain Film Radiographic Findings  Malignant TumorsMalignant Tumors
  3. 3. IntroductionIntroduction  X-ray examination of the skeletal system is veryX-ray examination of the skeletal system is very common.common.  Skeletal radiographs constitute the secondSkeletal radiographs constitute the second largest group of films seen in a busy radiologylargest group of films seen in a busy radiology practice.practice.  Primary malignant bone tumors are fortunatelyPrimary malignant bone tumors are fortunately very rare, however, it is important for thevery rare, however, it is important for the radiologist to recognize bone tumors andradiologist to recognize bone tumors and provide a differential diagnosis.provide a differential diagnosis.
  4. 4. Introduction cont.Introduction cont.  Approximately 2000 cases of primary malignantApproximately 2000 cases of primary malignant tumors are diagnosed each year in the UStumors are diagnosed each year in the US (excludes Multiple Myeloma).(excludes Multiple Myeloma).  (Contrast with the estimated 165,000 cases of(Contrast with the estimated 165,000 cases of Lung CA, 185,000 cases of Breast CA andLung CA, 185,000 cases of Breast CA and 130,000 cases of Colon CA).130,000 cases of Colon CA).
  5. 5. Imaging ModalitiesImaging Modalities  Plain Radiograph-Plain Radiograph-  Best modality for characterizing a bony lesion asBest modality for characterizing a bony lesion as benign or malignant.benign or malignant.  Many lesions have characteristic appearances thatMany lesions have characteristic appearances that allow for accurate diagnosis.allow for accurate diagnosis.  Provides the road map for further investigation andProvides the road map for further investigation and diagnosis.diagnosis.  CT scan-CT scan-  Provides diagnostic information of bones and softProvides diagnostic information of bones and soft tissue in another plane.tissue in another plane.
  6. 6. Imaging ModalitiesImaging Modalities  CT scan cont.CT scan cont.  Mainstay for safe and accurate biopsy procedures.Mainstay for safe and accurate biopsy procedures.  MRIMRI  Imaging procedure of choice for determining theImaging procedure of choice for determining the extent of a lesion, both in the skeleton and softextent of a lesion, both in the skeleton and soft tissues.tissues.  If resection of a tumor is contemplated, MRI shouldIf resection of a tumor is contemplated, MRI should be performed.be performed.
  7. 7. Radiographic FindingsRadiographic Findings  Cortical DestructionCortical Destruction  PeriostitisPeriostitis  Orientation or Axis of the LesionOrientation or Axis of the Lesion  Zone of transitionZone of transition -the above criteria are used to differentiate-the above criteria are used to differentiate an aggressive process i.e., malignant tumor froman aggressive process i.e., malignant tumor from a benign process, but with varying accuracya benign process, but with varying accuracy -the above criteria apply to plain films and-the above criteria apply to plain films and do not apply to CT or MRI in many instancesdo not apply to CT or MRI in many instances
  8. 8. Cortical DestructionCortical Destruction  Cortical destruction usually makes one think of aCortical destruction usually makes one think of a malignant lesion when using the “gestalt approach”.malignant lesion when using the “gestalt approach”.  However, there are benign processes that can causeHowever, there are benign processes that can cause cortical destruction and mimic a malignant tumor.cortical destruction and mimic a malignant tumor.  These include:These include: - infection- infection -eosinophilic granuloma-eosinophilic granuloma -benign fibro-osseous lesions (radiolucent fibrous-benign fibro-osseous lesions (radiolucent fibrous matrix replaces cortical bone)matrix replaces cortical bone) -aneurysmal bone cyst (thinning of the cortex-aneurysmal bone cyst (thinning of the cortex makes cortex radiographically undetectablemakes cortex radiographically undetectable
  9. 9. Cortical DestructionCortical Destruction Notice in this benignNotice in this benign Aneurysmal Bone CystAneurysmal Bone Cyst how the thinned cortexhow the thinned cortex could be mistaken forcould be mistaken for cortical destructioncortical destruction
  10. 10. Cortical DestructionCortical Destruction  Notice again in thisNotice again in this benign chondroblastomabenign chondroblastoma the noncalcifiedthe noncalcified chondroid tissuechondroid tissue replacing cortical bone.replacing cortical bone. There is no corticalThere is no cortical destruction but ratherdestruction but rather replacementreplacement
  11. 11. Cortical DestructionCortical Destruction  This radiographThis radiograph illustrates true corticalillustrates true cortical destruction seen in andestruction seen in an osteosarcoma affectingosteosarcoma affecting the lateral femurthe lateral femur
  12. 12. Cortical DestructionCortical Destruction  Therefore, the presence of cortical destruction isTherefore, the presence of cortical destruction is not a reliable indicator of whether the lesion is anot a reliable indicator of whether the lesion is a malignant process or a benign process.malignant process or a benign process.  Other radiographic findings must also beOther radiographic findings must also be examined.examined.
  13. 13. PeriostitisPeriostitis  A periosteal reaction will occur whenever theA periosteal reaction will occur whenever the periosteum is irritated.periosteum is irritated.  This may occur due to a malignant tumor,This may occur due to a malignant tumor, benign tumor, infection or trauma.benign tumor, infection or trauma.  There are two types of periosteal reaction,There are two types of periosteal reaction, Benign or Aggressive.Benign or Aggressive.
  14. 14. Periostitis cont.Periostitis cont.  BenignBenign processes such as a slow growing tumor willprocesses such as a slow growing tumor will causecause thick, wavy, uniformthick, wavy, uniform or dense periostitis. Sinceor dense periostitis. Since it is a low grade, chronic irritation, the periosteum hasit is a low grade, chronic irritation, the periosteum has time to lay down thick new bone and remodel into atime to lay down thick new bone and remodel into a more normal appearing cortex.more normal appearing cortex.  AggressiveAggressive processes such as a malignant tumor causeprocesses such as a malignant tumor cause a periosteal reaction that is more acute and high-grade.a periosteal reaction that is more acute and high-grade. The periosteum does not have time to consolidate. ItThe periosteum does not have time to consolidate. It appearsappears lamellated, “onion skinned”, amorphous orlamellated, “onion skinned”, amorphous or “sun-burst”.“sun-burst”.
  15. 15. Periostitis cont.Periostitis cont.  When periostitis is seen the radiologist shouldWhen periostitis is seen the radiologist should therefore try to classify it into benign ortherefore try to classify it into benign or aggressive.aggressive.  This classification also has its limitations.This classification also has its limitations.  These limitations are similar to those seen withThese limitations are similar to those seen with cortical destruction, such that benign processescortical destruction, such that benign processes such as infection or eosinophilic granuloma cansuch as infection or eosinophilic granuloma can cause an aggressive periostitis.cause an aggressive periostitis.
  16. 16. PeriostitisPeriostitis  However, seeing benign periostitis can be veryHowever, seeing benign periostitis can be very helpful, because malignant lesions CAN NOThelpful, because malignant lesions CAN NOT cause benign periostitis.cause benign periostitis.
  17. 17. Periostitis cont.Periostitis cont.  Notice the “onion skin”Notice the “onion skin” appearance of thisappearance of this aggressive periostitis seenaggressive periostitis seen in Ewing’s sarcomain Ewing’s sarcoma
  18. 18. Periostitis cont.Periostitis cont.  Notice the “sunburst”Notice the “sunburst” pattern seen in thispattern seen in this aggressive Osteosarcomaaggressive Osteosarcoma of the distal femur.of the distal femur.
  19. 19. Periostitis cont.Periostitis cont.  Notice the “thick”Notice the “thick” periostitis seen inperiostitis seen in Eosinophilic Granuloma,Eosinophilic Granuloma, a non-neoplastica non-neoplastic proliferation ofproliferation of histiocytes. Remember,histiocytes. Remember, EG may also cause anEG may also cause an aggressive periostitisaggressive periostitis
  20. 20. Periostitis cont.Periostitis cont.  Therefore, the characterization of periostitis asTherefore, the characterization of periostitis as Benign or Aggressive is helpful in determiningBenign or Aggressive is helpful in determining whether a lesion is benign or malignant, but it iswhether a lesion is benign or malignant, but it is not absolute.not absolute.
  21. 21. Orientation or Axis of lesionOrientation or Axis of lesion  Lesions growing in the long axis of long bones are saidLesions growing in the long axis of long bones are said to be benign.to be benign.  Lesions growing in a circular orientation are said to beLesions growing in a circular orientation are said to be malignant.malignant.  PoorPoor determinant of benign versus aggressive lesions.determinant of benign versus aggressive lesions.  Too many exceptions to each to be useful.Too many exceptions to each to be useful.  For example, Ewing’s sarcoma, a malignant lesion,For example, Ewing’s sarcoma, a malignant lesion, usually has its axis along the shaft of a long bone.usually has its axis along the shaft of a long bone.
  22. 22. Zone of TransitionZone of Transition  Describes the border of the lesion with the normalDescribes the border of the lesion with the normal bone.bone.  Most reliableMost reliable plain film indicator for benign versusplain film indicator for benign versus malignant lesions.malignant lesions.  ““Narrow”Narrow”, if it is so well defined that it can be drawn, if it is so well defined that it can be drawn with a fine-point pen. A benign process should bewith a fine-point pen. A benign process should be considered as the most likely possibility.considered as the most likely possibility.  ““Wide”Wide”, if it is imperceptible and can not be drawn at, if it is imperceptible and can not be drawn at all. An aggressive process should be considered,all. An aggressive process should be considered, although not necessarily a malignant lesion.although not necessarily a malignant lesion.
  23. 23. Zone of TransitionZone of Transition  Zone of transition is always present to evaluate,Zone of transition is always present to evaluate, whereas many lesions, whether benign orwhereas many lesions, whether benign or malignant, will not necessarily show evidence ofmalignant, will not necessarily show evidence of periostitis.periostitis.  Therefore Zone of Transition is the most usefulTherefore Zone of Transition is the most useful indicator of benign versus malignant lesion.indicator of benign versus malignant lesion.
  24. 24. Zone of TransitionZone of Transition  ““Narrow”Narrow” Zone ofZone of Transition seen in aTransition seen in a benign nonossifyingbenign nonossifying fibroma. The margins offibroma. The margins of this lesion can be drawnthis lesion can be drawn with a fine-point pen.with a fine-point pen.
  25. 25. Zone of TransitionZone of Transition  Permeative lesions seenPermeative lesions seen in this primaryin this primary lymphoma have alymphoma have a “Wide”“Wide” Zone ofZone of Transition and areTransition and are therefore aggressive.therefore aggressive. Notice also theNotice also the pathologic fracture seenpathologic fracture seen in the proximal humeralin the proximal humeral diaphysisdiaphysis
  26. 26. Summary of Radiographic FindingsSummary of Radiographic Findings  Cortical Destruction is less helpful thanCortical Destruction is less helpful than Periostitis in assessing whether a lesion is benignPeriostitis in assessing whether a lesion is benign or aggressive on plain film.or aggressive on plain film.  Axis of a lesion is not helpful.Axis of a lesion is not helpful.  Zone of Transition is the most reliable plain filmZone of Transition is the most reliable plain film indicator of benign versus aggressive processes.indicator of benign versus aggressive processes.  If a lesion is aggressive, it is not necessarilyIf a lesion is aggressive, it is not necessarily malignant!malignant!
  27. 27. Malignant TumorsMalignant Tumors  Once it is decided that a lesion is malignant theOnce it is decided that a lesion is malignant the differential diagnosis should take into accountdifferential diagnosis should take into account the age of the patient.the age of the patient.  Jack Edeiken, a bone radiologist evaluated 4000Jack Edeiken, a bone radiologist evaluated 4000 malignant bone tumors and found that theymalignant bone tumors and found that they could be diagnosed correctly 80% of the timecould be diagnosed correctly 80% of the time using the patient’s age.using the patient’s age.
  28. 28. Malignant TumorsMalignant Tumors  Edeiken classified malignant tumors into theEdeiken classified malignant tumors into the following age groups:following age groups:  1-301-30: Ewing’s sarcoma, osteosarcoma.: Ewing’s sarcoma, osteosarcoma.  30-4030-40: Giant cell tumor, parosteal sarcoma,: Giant cell tumor, parosteal sarcoma, fibrosarcoma, malignant fibrous histiocytoma, andfibrosarcoma, malignant fibrous histiocytoma, and reticulum cell sarcoma.reticulum cell sarcoma.  Over 40Over 40: Chondrosarcoma, metastatic disease,: Chondrosarcoma, metastatic disease, myeloma.myeloma.
  29. 29. Malignant TumorsMalignant Tumors  The following malignant tumors will beThe following malignant tumors will be discussed:discussed:  Ewing’s SarcomaEwing’s Sarcoma  OsteosarcomaOsteosarcoma  Malignant Fibrous HistiocytomaMalignant Fibrous Histiocytoma  ChondrosarcomaChondrosarcoma  Metastatic DiseaseMetastatic Disease  Multiple MyelomaMultiple Myeloma
  30. 30. Ewing’s SarcomaEwing’s Sarcoma  Primitive small and round blue cell tumorPrimitive small and round blue cell tumor possibly related to primitive neuroectodermalpossibly related to primitive neuroectodermal cells.cells.  Tend to occur in children and adolescentsTend to occur in children and adolescents (( 1-301-30 age group ).age group ).  Presentation of pain and a mass at the site ofPresentation of pain and a mass at the site of tumor with constitutional symptoms includingtumor with constitutional symptoms including fever, anemia, leukocytosis, and an increasedfever, anemia, leukocytosis, and an increased erythrocyte sedimentation rate.erythrocyte sedimentation rate.
  31. 31. Ewing’s SarcomaEwing’s Sarcoma  Most often permeative in appearance ( multiple smallMost often permeative in appearance ( multiple small holes ).holes ).  Often have an “onion skin” type of periostitis.Often have an “onion skin” type of periostitis.  40% of lesions occur in the diaphysis.40% of lesions occur in the diaphysis.  Most commonly affects the femur.Most commonly affects the femur.  Differential diagnosis should also include infection andDifferential diagnosis should also include infection and eosinophilic granuloma.eosinophilic granuloma.  Treatment is in evolution and includes neoadjuvantTreatment is in evolution and includes neoadjuvant chemotherapy followed by wide resection and furtherchemotherapy followed by wide resection and further chemotherapy.chemotherapy.
  32. 32. Ewing’s SarcomaEwing’s Sarcoma
  33. 33. Ewing’s SarcomaEwing’s Sarcoma
  34. 34. OsteosarcomaOsteosarcoma  Most common primary malignant bone tumor.Most common primary malignant bone tumor.  Typically metaphyseal in location.Typically metaphyseal in location.  More than half occur around the knee.More than half occur around the knee.  Typically affects patients in their second or thirdTypically affects patients in their second or third decade, however, there is a second peak indecade, however, there is a second peak in patients >60 years old (patients >60 years old ( 1-301-30 age group ).age group ).  Patients present with pain, a mass orPatients present with pain, a mass or occasionally a pathologic fracture.occasionally a pathologic fracture.
  35. 35. OsteosarcomaOsteosarcoma  Lesions are destructive in nature.Lesions are destructive in nature.  Sclerosis is present from either tumor new boneSclerosis is present from either tumor new bone formation or reactive sclerosis.formation or reactive sclerosis.  Plain films reveal permeative lesion with corticalPlain films reveal permeative lesion with cortical destruction.destruction.
  36. 36. OsteosarcomaOsteosarcoma  ““Codman’s triangle” of bone appears as tumorCodman’s triangle” of bone appears as tumor elevates periosteum from underlying bone.elevates periosteum from underlying bone.  Cortical soft tissue extension may produceCortical soft tissue extension may produce radiating spicules of bone called “sunray”radiating spicules of bone called “sunray” appearance.appearance.  Treatment includes chemotherapy and resection.Treatment includes chemotherapy and resection.
  37. 37. OsteosarcomaOsteosarcoma  Mixed sclerotic and lyticMixed sclerotic and lytic lesion of the proximallesion of the proximal humerushumerus
  38. 38. OsteosarcomaOsteosarcoma  Sclerotic lesion of theSclerotic lesion of the proximal tibiaproximal tibia
  39. 39. OsteosarcomaOsteosarcoma  ““Sunburst” pattern ofSunburst” pattern of distal femurdistal femur
  40. 40. OsteosarcomaOsteosarcoma  Elevated periosteumElevated periosteum described as “Codman’sdescribed as “Codman’s triangle”triangle”
  41. 41. Malignant Fibrous HistiocytomaMalignant Fibrous Histiocytoma  Pleomorphic high grade tumor composed ofPleomorphic high grade tumor composed of fibroblast, myofibroblasts and histiocytes.fibroblast, myofibroblasts and histiocytes.  May also be considered a soft tissue tumor.May also be considered a soft tissue tumor.  Found in extremities 70-75% of the time.Found in extremities 70-75% of the time.  Common inCommon in 30-4030-40 age group.age group.  Patients present with a painless mass of severalPatients present with a painless mass of several months’ duration.months’ duration.
  42. 42. Malignant Fibrous HistiocytomaMalignant Fibrous Histiocytoma  Radiologically, they appear as lytic lesions thatRadiologically, they appear as lytic lesions that may be permeative or fairly well defined.may be permeative or fairly well defined.  Periosteal reaction is not usually seen.Periosteal reaction is not usually seen.  Treatment is variable and includesTreatment is variable and includes chemotherapy and surgery.chemotherapy and surgery.
  43. 43. Malignant Fibrous HistiocytomaMalignant Fibrous Histiocytoma  Soft tissue sarcomaSoft tissue sarcoma invading cortical boneinvading cortical bone
  44. 44. ChondrosarcomaChondrosarcoma  Malignant cartilage forming tumor.Malignant cartilage forming tumor.  Occurs in patients in theOccurs in patients in the Over 40Over 40 age group.age group.  Affects men twice as common as women.Affects men twice as common as women.  Common sites include pelvis (30%), proximal and distalCommon sites include pelvis (30%), proximal and distal femur, ribs, proximal humerus, and proximal tibia.femur, ribs, proximal humerus, and proximal tibia.  Patients present with pain or mass.Patients present with pain or mass.  Treatment is excision with a wide margin, as theseTreatment is excision with a wide margin, as these lesions are resistant to chemotherapy and radiation.lesions are resistant to chemotherapy and radiation.
  45. 45. ChondrosarcomaChondrosarcoma  Plain film may show typical snowflake, orPlain film may show typical snowflake, or popcorn-like, amorphous calcification.popcorn-like, amorphous calcification.  Plain films may also show large osteolyticPlain films may also show large osteolytic lesions.lesions.  Difficult to distinguish between benignDifficult to distinguish between benign enchondroma and low grade chondrosarcoma.enchondroma and low grade chondrosarcoma.
  46. 46. ChondrosarcomaChondrosarcoma  Osteolytic lesion of theOsteolytic lesion of the skullskull
  47. 47. ChondrosarcomaChondrosarcoma  Lesion affecting theLesion affecting the femur before and afterfemur before and after surgical repairsurgical repair
  48. 48. Metastatic DiseaseMetastatic Disease  Most common malignancy in bone.Most common malignancy in bone.  Must be considered in any differential diagnosisMust be considered in any differential diagnosis of a bone lesion in a patientof a bone lesion in a patient Over 40Over 40 years old.years old.  May have virtually any appearance.May have virtually any appearance.  May be lytic or blastic.May be lytic or blastic.  Majority of metastases to bone originate inMajority of metastases to bone originate in Breast, Prostate, Lung, Kidney and Thyroid.Breast, Prostate, Lung, Kidney and Thyroid.
  49. 49. Metastatic DiseaseMetastatic Disease  Most common sites forMost common sites for bony metastases includebony metastases include thoracic and lumbarthoracic and lumbar spine, pelvis, femur, rib,spine, pelvis, femur, rib, proximal humerus andproximal humerus and skullskull
  50. 50. Metastatic DiseaseMetastatic Disease  Bone mets from LungBone mets from Lung CACA
  51. 51. Multiple MyelomaMultiple Myeloma  Tumor made up of malignant monoclonalTumor made up of malignant monoclonal plasma cells.plasma cells.  Usually affects patientsUsually affects patients Over 40Over 40 years of age.years of age.  Patients often present with malaise, bone pain,Patients often present with malaise, bone pain, or a pathologic fracture.or a pathologic fracture.  Classic radiographic appearance is multiple lyticClassic radiographic appearance is multiple lytic “punched out” areas in bone.“punched out” areas in bone.  Frequently involves the calvarium.Frequently involves the calvarium.
  52. 52. Multiple MyelomaMultiple Myeloma  Lesions often do not show uptake of isotope onLesions often do not show uptake of isotope on bone scan, making a skeletal survey the mostbone scan, making a skeletal survey the most important radiographic test.important radiographic test.  Treatment consists of palliative chemotherapy orTreatment consists of palliative chemotherapy or bone marrow transplant.bone marrow transplant.
  53. 53. Multiple MyelomaMultiple Myeloma  Characteristic “punched-Characteristic “punched- out” lesionsout” lesions
  54. 54. Multiple MyelomaMultiple Myeloma  ““Punched-out” lesionPunched-out” lesion
  55. 55. ConclusionConclusion  Plain film findings of Cortical Destruction,Plain film findings of Cortical Destruction, Periostitis and Zone of Transition are helpful inPeriostitis and Zone of Transition are helpful in assessing benign versus aggressive lesions.assessing benign versus aggressive lesions.  When combined with the age of the patient, andWhen combined with the age of the patient, and the location of the lesion, a reasonablethe location of the lesion, a reasonable differential diagnosis can be formulated.differential diagnosis can be formulated.
  56. 56. ResourcesResources  Brant, William E., Helms, Clyde A. Fundamentals of DiagnosticBrant, William E., Helms, Clyde A. Fundamentals of Diagnostic Radiology. 2Radiology. 2ndnd ed. 1999 Pgs 981-997.ed. 1999 Pgs 981-997.  Daffner, Richard H. Clinical Radiology The Essentials. 1993Daffner, Richard H. Clinical Radiology The Essentials. 1993 Pgs 271-321.Pgs 271-321.  Brown, David E., Neuman, Randall D. Orthopedic Secrets 3Brown, David E., Neuman, Randall D. Orthopedic Secrets 3rdrd ed. 2004 Pgs 76-85.ed. 2004 Pgs 76-85.  Images from Bonetumors.org, Radiologyeducation.comImages from Bonetumors.org, Radiologyeducation.com

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