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Imaging in malignant bone tumors


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Comprehensive presentation of the imaging of bone tumours.

Published in: Health & Medicine
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Imaging in malignant bone tumors

  1. 1. JSS Medical College, Mysuru IMAGING IN MALIGNANT BONE TUMOURS -Dr Suman T P Resident, JSS Medical College,Mysuru
  2. 2. JSS Medical College, Mysuru INTRODUCTION • Divided into two broad categories: Benign & malignant (primary and secondary). • Plain radiographs are initial and most important imaging modality for the diagnosis. • CT scan is particularly useful in evaluating the cortex and matrix. • MRI is useful in determining the intramedullary extent, soft tissue extent of focal bone lesion and also play vital role in detecting skip lesions. • Commonest bone tumour is secondaries from other sites. • Commonest primary bone tumour is multiple myeloma, second osteosarcoma.
  3. 3. JSS Medical College, Mysuru CLASSIFICATION OF PRIMARY MALIGNANT BONE TUMORS Please visit for more education
  4. 4. JSS Medical College, Mysuru Staging Enneking staging AJCC- International Union against Cancer (UICC)
  5. 5. JSS Medical College, Mysuru SYSTEMATIC APPROACH  Patient’s age  Location of the lesion LONGITUDINAL PLANE (epiphysis, metaphysis, diaphysis) TRANSVERSE PLANE (intramedullary, intracortical, surface).  Solitary or multiple  Pattern of bone destruction  Edge of lesion/zone of transition  Matrix mineralization  Cortical response  Periosteal reaction  Extraosseous extension/soft tissue mass Please visit for more education
  6. 6. JSS Medical College, Mysuru AGE AT PRESENTATION Edeiken classified malignant tumors into the following age groups: DIFFERENTIAL DIAGNOSIS CAN BE NARROWED CLUE TO AGE : FROM EPIPHYSEAL FUSION
  7. 7. JSS Medical College, Mysuru 1. In the transverse plane: a) Central – Enchondroma b) Eccentric -GCT, osteosarcoma, chondromyxoid fibroma c) Cortical - Non-ossifying fibroma, osteoid osteoma d) Parosteal - Parosteal osteosarcoma, osteochondroma LOCATION
  8. 8. JSS Medical College, Mysuru Patterns of Bone Destruction • Bone destruction can be described as – Geographic (type I) - benign lesions – Moth-eaten (type II) – Permeative (type III) - rapidly growing infiltrating tumors CHONDROBLASTOMA, BONE CYST Myeloma, EG, Fibrosarcoma Osteosarcoma, osteomyelitis etc. Osteosarcoma, GCT etc.Ewings, Osteosarcoma, Lymphoma etc. Less malignant More malignant Please visit for more education
  9. 9. JSS Medical College, Mysuru Zone of Transition • The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant. • The zone of transition only applies to osteolytic lesions since sclerotic lesions usually have a narrow transition zone. • A small zone of transition results in a sharp, well-defined border and is a sign of slow growth. A sclerotic border especially indicates poor biological activity. • An ill-defined border with a broad zone of transition is a sign of aggressive growth. SBC, ABC, GCT, FD etc. Osteosarcoma, Fibrosarcoma etc. Please visit for more education
  10. 10. JSS Medical College, Mysuru Patterns of mineralization of cartilaginous tumor matrix Stippled Flocculent Ring and arc Please visit for more education
  11. 11. JSS Medical College, Mysuru Solid Patterns of mineralization of osseous matrix Ivory-like opacityCloudlike Osteosarcoma, Ossifying fibroma, etc.Please visit for more education
  12. 12. JSS Medical College, Mysuru Types of Periosteal reaction • Benign – None – Solid/Continuous • More aggressive or malignant  Interrupted – Lamellated or onion-skinning – Sunburst – Codman’s triangle Please visit for more education
  13. 13. JSS Medical College, Mysuru Periosteal Reactions Less malignant More malignant Solid Eg: Post traumatic, HPOA Sunburst Eg: Osteosarcoma, Ewings sarcoma Codman's Triangle Eg: Osteosarcoma, Ewings sarcoma Lamellated Eg: Ewings, Osteomyelitis Please visit for more education
  14. 14. JSS Medical College, MysuruPlease visit for more education
  15. 15. JSS Medical College, MysuruPlease visit for more education
  16. 16. JSS Medical College, Mysuru Malignant Bone Neoplasms: Differentiating Radiologic Features between Primary and Secondary Lesions Feature Primary Secondary Incidence 30% 70% Expansion of bone +++ + Length of lesion > 6 cm 2-4 cm Periosteal response +++ + Solitary lesion +++ + Multiple lesions + +++ Soft tissue mass +++ + Please visit for more education
  17. 17. JSS Medical College, Mysuru OSTEOSARCOMA • It commonest primary malignant lesion of bone after myeloma. • Classified as – PRIMARY OSTEOSARCOMA a) CENTRAL(75%) b) INTRACORTICAL or SURFACE i. Parosteal ii. Periosteal iii. High-grade – SECONDARY OSTEOSARCOMA: Paget's disease (Paget's sarcoma), Radiotherapy (post-radiation sarcoma) or as the dedifferentiated part of chondrosarcoma. Osteosarcoma may occasionally be multicentric (osteosarcomatosis) or arise in the soft tissues (extraskeletal). Please visit for more education
  18. 18. JSS Medical College, Mysuru PLAIN FILM FEATURES OF OSTEOSARCOMA Most common primary bone tumor of adolescence. Peak incidence ages 8-25, and 40+ secondary to Paget’s Disease. • Commonly found in the metaphyses of long bones. • Appearance can be lytic(25%), sclerotic(50%) or mixed(25%). • Trabecular pattern typically permeative with wide zone of transition. • Periosteal reactions include: sunburst, hair on end, and Codman’s triangle. • Typically associated with a soft tissue mass. Please visit for more education
  19. 19. JSS Medical College, Mysuru Increase in bone density in the metaphysis and distal diaphysis of the femur. There is a sunburst or malignant spiculated periosteal response present surrounding the entire distal metaphysis of the femur. This sunburst appearance, the soft tissue mass, and the destructive lesion of the medullary portion of the femur are the cardinal radiographic features of osteosarcoma. Please visit for more education
  20. 20. JSS Medical College, Mysuru OSTEOSARCOMA Tibia. Diffuse ivory osteosarcoma in the proximal tibia. Approximately 50% of the osteosarcomas present as a sclerotic lesion, rendering an ivory or sclerotic appearance. Please visit for more education
  21. 21. JSS Medical College, Mysuru Sclerotic osteosarcoma affecting the ilium near the acetabulum. Note the lobulated margins of the medial surface of this osteosarcoma (arrows) called the CUMULUS CLOUD APPEARANCE. Please visit for more education
  22. 22. JSS Medical College, Mysuru Osteosarcoma with metastases: CANNONBALL METASTASES Extensive metastasis to the lungs. NOTE: Spontaneous pneumothorax is relatively common because subpleural nodules that have undergone excavation lead to rupture into the pleural space. Please visit for more education
  23. 23. JSS Medical College, Mysuru • Slow growing rare tumor with low grade malignancy. • Arises from periosteum, grows outwards & tends to surround the host bone - Dense mass of new bone away from the cortex with lucent area in the periphery. • Fine radiolucent line between cortex & dense tumour mass with central stalk(string sign ) – Characteristic. Paraosteal OS (Juxta cortical OS)
  24. 24. JSS Medical College, Mysuru Osteosarcoma (contd.) MRI • T1WI - Low/heterogenous signal intensity • T2WI - High signal intensity • Contrast - enhancing medullary cavity and solid components. • STIR - High signal intensity and helps in assessing involvement of neurovascular bundles and muscles. Please visit for more education
  25. 25. JSS Medical College, Mysuru Bone scintigraphy and sagittal T2-weighted MR images showing a large primary osteosarcoma of the distal femur with multiple proximal skip metastases.
  26. 26. JSS Medical College, Mysuru • Distinct from conventional OS. • Adolescence. • High grade – poor prognosis, more aggressive than paraosteal variety. • Sessile elliptical growth on periosteal aspect of the diaphysis. • Short spicules of bone perpendicular to shaft / laminated periosteal reaction. • Base of tumor attached to entire extent of cortex. • Absence of medullary invasion. Periosteal OS POORLY DEFINED OSSIFICATION OF MASS ATTACHED TO THE SURFACE
  27. 27. JSS Medical College, Mysuru TELANGIECTATIC OSTEOSARCOMA • Second to third decade • High degree of vascularity • Large cystic spaces filled with blood. • Osteolytic lesion with absence of sclerosis. • Telangiectatic OS shows that the tumor usually arises from the metaphysis of a long bone and is expansile and lytic. It contains multiple fluid levels due to layering haemorrhage. Please visit for more education
  28. 28. JSS Medical College, Mysuru Radiograph of the shoulder shows the expansile lesion of the scapula with a thick curvilinear band of mineralized matrix (osteoid) superolaterally Posterior bone scintigraphic image shows marked heterogeneous uptake of radionuclide peripherally and central photopenia (donut sign). Please visit for more education
  29. 29. JSS Medical College, Mysuru SECONDARY OSTEOSARCOMA Malignant degeneration of benign disorders, such as Paget’s disease, polyostotic fibrous dysplasia, hereditary multiple exostosis (osteochondromas), and enchondromatosis (Ollier’s disease), may lead to osteosarcoma. The radiographic features of permeative, moth- eaten bone destruction with periosteal reaction and soft tissue mass is largely indistinguishable from those osteosarcomas arising de novo. PAGET’S SARCOMA. Humerus. Pathologic fracture and extensive destruction of the proximal humerus and extensive cortical thickening of the visualized diaphysis of the humerus. Please visit for more education
  30. 30. JSS Medical College, Mysuru Chondrosarcoma • Chondrosarcoma is a malignant tumor of chondrogenic origin that remains essentially cartilaginous throughout its evolution.  Primary chondrosarcoma arises de novo.  Secondary chondrosarcoma arises in a pre-existing cartilaginous lesion (enchondroma, osteochondroma).  Central chondrosarcoma arises intramedullary.  Peripheral chondrosarcoma arises on the surface of the bone. • Age of presentation is 40-60 years, with 2:1 male predominance. • Common sites include pelvis (30%), proximal and distal femur, ribs, proximal humerus, and proximal tibia. • Patients present with pain or mass.
  31. 31. JSS Medical College, Mysuru Two distinct appearances: • Osteolytic lesion with short transitional zone & sclerotic rim – Irregular, fine calcific specks • Osteolytic lesion without sclerotic rim – “Snow-flake” calcified chondroid matrix – Scalloping of cortex Chondrosarcoma – Central Type Site : Neck of femur, pubic rami, prox. end of humerus
  32. 32. JSS Medical College, Mysuru • Arise from cartilagenous cap of osteochondroma. • Insidious growth. • Unusually large soft tissue mass (with calcification) & attached to bone • Later underlying bone destroyed • Dense radiopaque center with calcific streaks radiating towards periphery Peripheral Chondrosarcoma Site : Pelvis, Scapula, sternum, ribs
  33. 33. JSS Medical College, Mysuru CT • Lucent areas containing chondroid matrix calcification. Endosteal scalloping and cortical destruction. • CT scanning may be used to guide percutaneous biopsy MRI • T1: low to intermediate signal • T2: very high intensity in non mineralised/calcified portions • gradient echo/SWI: blooming of mineralised/calcified portions T1 C+ (Gd) • Heterogeneous moderate to intense contrast enhancement. • Enhancement can be septal and peripheral rim-like corresponding to fibrovascular septation between lobules of hyaline cartilage Please visit for more education
  34. 34. JSS Medical College, Mysuru Multiple Myeloma • The most common primary malignant bone tumor. • 75% of patients are between 50 and 70 years of age; 2:1 male preponderance. • Tumor made up of malignant monoclonal plasma cells. • Classic radiographic appearance is multiple lytic “punched out” areas in bone. • Lesions often do not show uptake of isotope on bone scan, making a skeletal survey the most important radiographic test. Please visit for more education
  35. 35. JSS Medical College, Mysuru Gross osteoporosis throughout the lumbar spine. There is a compression fracture of L2 (arrow). Diffuse osteoporosis throughout the entire lumbar spine. There are pathologic fractures of the T12 and L2 vertebral bodies. OSTEOPOROSIS: THE EARLIEST RADIOGRAPHIC SIGN OF MYELOMA. Please visit for more education
  36. 36. JSS Medical College, Mysuru PUNCHED-OUT LESIONS OF MULTIPLE MYELOMA. Radiologic hallmark of multiple myeloma is the sharply circumscribed osteolytic defect that is clearly demonstrated on these radiographs. The lesions are multiple, round, and purely lytic. The most frequent sites are bones with hematopoietic potential. Please visit for more education
  37. 37. JSS Medical College, Mysuru MULTIPLE MYELOMA Collapse of the T7 vertebral body (arrow). The pedicles have not been destroyed and are visualized on this frontal radiograph (arrowheads). Uniform collapse of the T7 vertebral body, collapse of the posterior third of the vertebral body, which strongly suggests a pathologic fracture. Characteristic appearance for a wrinkled vertebra Please visit for more education
  38. 38. JSS Medical College, Mysuru MULTIPLE MYELOMA: RAINDROP SKULL Diffuse, permeative, or punched- out lesions throughout the calvaria. NOTE: Multiple myeloma of the skull may be differentiated from metastatic carcinoma by the more uniform size of the lytic lesions in myeloma. The co-existence of both large and small lesions is often the mode of presentation of metastatic disease. Please visit for more education
  39. 39. JSS Medical College, Mysuru CT • Computed tomography (CT) scanning readily depicts osseous involvement in myeloma. • CT allowed a more accurate evaluation of areas at risk of fracture. • Tool of choice utilised in image guided spinal or pelvic bone biopsy. MRI • Most sensitive imaging modality at detecting diffuse and focal multiple myeloma in the spine, as well as the extra-axial skeleton • Mainly bone marrow based lesions. • T1WI - Low signal intensity • T2WI and STIR - High signal intensity. • Show enhancement on contrast enhanced images. Please visit for more education
  40. 40. JSS Medical College, Mysuru Differentiating points of myeloma and metastasis
  41. 41. JSS Medical College, Mysuru Metastatic Disease • Most common sites for bony metastases include thoracic and lumbar spine, pelvis, femur, rib, proximal humerus and skull THE VERTEBRAL VEIN SYSTEM (BATSON’S VENOUS PLEXUS). This venous network is a common two-way avenue of metastatic spread of pelvic, abdominal, and thoracic tumors. A large portion of bony metastases results from dissemination of neoplastic cells through the vertebral vein system. Pathways of Metastasis: Cancers metastasize through one of three routes: direct extension, lymphatic channels, or hematogenous dissemination. Please visit for more education
  42. 42. JSS Medical College, Mysuru •Technetium bone scans (99mTc-MDP) are more accurate in detecting early bone metastases than are conventional radiographs. •80% of all metastases are located in the central or axial skeleton, with the spine and pelvis being the most common sites •75% of all metastatic lesions are osteolytic, creating a moth-eaten or permeative pattern of bone destruction. •15% of all metastatic lesions are osteoblastic in nature, creating a snowball pattern with diffuse lesions. •10% of all metastatic lesions are solitary. •Vertebral body and pedicles are the most common sites for metastatic deposits.
  43. 43. JSS Medical College, Mysuru BLASTIC METASTASIS: LATERAL SKULL. Numerous well-defined radiopacities scattered throughout the calvaria. These represent osteoblastic metastatic deposits secondary to carcinoma of the prostate gland. NOTE: Approximately 10% of all metastatic lesions affect the calvaria, with > 90% of the calvarial metastatic deposits being lytic and only 10% being blastic. Please visit for more education
  44. 44. JSS Medical College, Mysuru ISCHIAL METASTASIS: Loss of bone density and a moth-eaten pattern of bone destruction scattered throughout the ischium. The poor zone of transition around the lytic lesion suggests an aggressive disorder of bone. This lytic metastasis is secondary to carcinoma of the breast. Degenerative changes surrounding the pubic articulation can be seen. Please visit for more education
  45. 45. JSS Medical College, Mysuru SPINAL METASTASIS Ivory Vertebra. Diffuse, homogeneous radiopacity of the T10 vertebral body, representing blastic metastatic disease from carcinoma of the prostate gland. B. Ivory Vertebra and Mixed Metastasis. homogeneous radiopacity of the L4 vertebral body. The visualized segments of L3, L5, and the sacrum demonstrate mixed lytic and blastic changes. A pathologic fracture is present in the L5 vertebral body. Please visit for more education
  46. 46. JSS Medical College, Mysuru NOTE: Sclerosis and enlargement of the pedicle adjacent to a missing pedicle are positive radiographic signs of congenital absence rather than of osteolytic metastatic disease. Congenital Absence: Agenesis of the pedicle of L4 (arrow), with compensatory sclerosis and hypertrophy of the contralateral pedicle (arrowhead). Please visit for more education
  47. 47. JSS Medical College, MysuruPlease visit for more education Technetium-99m bone scan of a patient with prostate cancer demonstrating abnormal isotope uptake in multiple skeletal metastases.
  48. 48. JSS Medical College, Mysuru METASTATIC NEUROBLASTOMA Striking sunburst spiculation of the skull tables, along with gross widening of the sutures and permeative destructive lesions affecting the calvari(arrowhead). NOTE: • Characteristic roentgen appearance of lytic lesions and diffuse widening of the sutures. • A soft tissue mass and striking sunburst spiculation on the skull tables are frequently encountered and virtually pathognomonic of metastatic neuroblastoma. Please visit for more education
  49. 49. JSS Medical College, Mysuru Primitive small and round blue cell tumor possibly related to primitive neuroectodermal cells. •The most common primary malignant bone tumor to metastasize to bone. •Fourth most common primary malignant bone tumor. •Most cases occur in the 10- to 25-year age range; rare < 5 years and > 30 years. •Classic presentation is a diaphyseal, permeative lesion with a delicate onion skin or peel periosteal response. •Cortical saucerization is a characteristic sign. EWING’S SARCOMA Please visit for more education
  50. 50. JSS Medical College, Mysuru EWING’S SARCOMA: CORTICAL SAUCERIZATION AND ONION SKIN PERIOSTEAL RESPONSE. Permeative destruction within the medullary portion of the mid-diaphysis of the femur. Disruption in the cortex, creating a saucerization appearance, is characteristic of Ewing’s sarcoma . Please visit for more education
  51. 51. JSS Medical College, Mysuru EWING’S SARCOMA: GROOMED OR TRIMMED WHISKERS EFFECT. A fine and delicate periosteal pattern of new bone formation is present around the metaphysis and diaphysis of the first metacarpal bone, causing the groomed or trimmed whiskers appearance (arrows). Please visit for
  52. 52. JSS Medical College, Mysuru CT • CT scanning helps to define the bone destruction that is associated with Ewing sarcoma. • Tumor size can be evaluated with contrast- enhanced CT scanning, which may be used in follow-up evaluation during chemotherapy. MRI • MRI is essential to elucidate soft-tissue involvement • T1: low to intermediate signal • T1 C+ (Gd): heterogeneous but prominent enhancement • T2: heterogeneously high signal, may see hair on end low signal striations Please visit for more education
  53. 53. JSS Medical College, Mysuru METASTASIS TO BONE. Aggressive permeative pattern of bone destruction present throughout the distal phalanx of the index finger. CHEST: CANNONBALL METASTASES Cannonball metastases, with sarcomatous growth within the lung parenchyma Please visit for more education
  54. 54. JSS Medical College, Mysuru CHORDOMA A rare primary malignant bone tumor arising from the vestigial remnants of the notochord. Chordoma affects males more commonly than females in a ratio of approximately 2:1 Lytic destruction, along with a soft tissue mass, is the most common roentgen sign. This destruction occurs in the sacral or base of skull area. Age 40 -70 years Location Features Sacrococcygeal (50%) Soft tissue mass Clivus (35%) Matrix calcification (50%) Vertebrae (15%) Ivory vertebra (rarely) Majority central Lytic destruction Please visit for more education
  55. 55. JSS Medical College, Mysuru SACROCOCCYGEAL CHORDOMA: Grossly destructive lesion in the midportion of the sacrum. Flocculent calcification is scattered throughout the tumor matrix. NOTE: Amorphous calcification of the tumor mass may be noted on plain films in approximately 50% of chordomas. SPHENO-OCCIPITAL CHORDOMA: Extensive destruction in the area of the clivus. Considerable flocculent calcification is present within the destructive soft tissue mass Please visit for more education
  56. 56. JSS Medical College, Mysuru CT • CT is helpful in defining bone destruction and calcification within lesion. • With contrast, the pseudocapsule may enhance. • Usually low attenuation soft tissue mass with destruction of the sacrum and/or coccyx, sometimes with marginal sclerosis. • May show sequestered bone fragments or calcifications within tumor. MRI • T1WI – intermediate to low signal intensity with a small foci of hyperintensity (hemorrhage or mucus) • T2WI - most exhibit very high signal . • T1 C+ (Gd): heterogeneous enhancement with a honeycomb appearance corresponding to low T1 signal areas within the tumourPlease visit for
  57. 57. JSS Medical College, Mysuru HODGKIN’S LYMPHOMA OF BONE • Hodgkin’s lymphoma of bone may occur as a secondary manifestation of systemic Hodgkin’s lymphoma or, rarely, as a primary bone lesion in the absence of nodal involvement. • The lytic lesions are usually more symptomatic than the sclerotic ones. Location: The primary site of skeletal(lower thoracic and upper lumbar spine) involvement in Hodgkin’s lymphoma is the vertebral body. • Other bones may be involved, such as the innominate, scapula, sternum, ribs, and femur. Please visit for more education
  58. 58. JSS Medical College, Mysuru There is scalloping of the anterior vertebral body (arrows). Diffuse radiopacity throughout the entire vertebral body (ivory vertebra). NOTE: • The anterior and lateral scalloping of the vertebral body is characteristic in Hodgkin’s lymphoma of the spine. • When this radiographic sign is present in an ivory vertebra, it inevitably eliminates Paget’s disease and osteoblastic metastatic disease from the differential diagnosis. Please visit for more education
  59. 59. JSS Medical College, Mysuru Lymphoma (contd.) CT • Useful adjuncts to conventional radiographs • Pattern appears as extensive evidence of disease within the marrow cavity associated with a surrounding soft-tissue mass but without extensive cortical destruction • Cortical breakthrough is well appreciated. MRI • T1WI - low signal intensity within the marrow • T2WI - High signal intensity • Contrast - diffuse heterogenous/homogenous enhancement Please visit for more education
  60. 60. JSS Medical College, Mysuru Adamantinoma • Rare primary malignant bony tumour, only approximately 200 cases have been reported. • Tumors in the tibia account for more than 80% of cases. The diaphyseal region is the area most commonly affected. Other bones affected are the jaw, ulna, humerus, femur, and fibula. • Typically presents in the 2nd to 3rd decade. • Adamantinoma may present as a solitary focus or multicentric lucencies or slightly expansile osteolytic lesion. • Lesions tend to have an eccentric epicenter and a lack of periosteal reaction. • Long-standing tumors produce marked cortical thickening and spool-shaped bulges of the outer cortex in an eggshell fashion. Please visit for more education
  61. 61. JSS Medical College, Mysuru MRI • Two morphologic patterns are seen : - A solitary lobulated focus - Multiple small nodules in one or more foci. • In some patients separated tumour foci may be seen, defined as foci of high signal intensity on either T2- or T1- weighted contrast-enhanced images, interspersed with normal-appearing cortical or spongious bone. • Fluid-fluid level may occasionally be seen. • C+(Gd): tends to show intense and homogeneous static enhancement, although there is no uniform dynamic enhancement pattern. Please visit for more education
  62. 62. JSS Medical College, Mysuru Please visit for more Radiology education THANK YOU Please visit for more education