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Radiology 5th year, 2nd lecture (Dr. Salah Mohammad Fatih)



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Radiology 5th year, 2nd lecture (Dr. Salah Mohammad Fatih)

  1. 1. Lecture no. 2 Prepared by Dr.Salah Mohammad Fatih MBChB,DMRD,FIBMS(radiology)
  2. 2. Bone tumors
  3. 3. Investigations; <ul><li>1- plain film radiography in general is the best imaging technique for making the Dx. </li></ul><ul><li>2- MRI&CT often shows the full extend of the tumor & show the effects on the surrounding structures& the relation ship to the neurovascular bundles </li></ul><ul><li>3- Isotope scan is used to Dx metastatic bone disease </li></ul>
  4. 4. Primary bone tumors 1- malignant 2- benign
  5. 5. 1- primary malignant bone tumors
  6. 6. <ul><li>1- plain radiograph ; usually have; </li></ul><ul><li>Poorly defined margin. </li></ul><ul><li>Wide zone of transition. </li></ul><ul><li>Lesion may destroy the cortex. </li></ul><ul><li>Periosteal reaction is often present. </li></ul><ul><li>Soft tissue mass may be seen. </li></ul>
  7. 7. Poorly defined margin & wide zone of transition. Soft tissue mass destroy the cortex Periosteal reaction
  8. 8. 2- Isotope scan Malignant bone tumor show increased activity in the lesion.
  9. 9. 3-MRI <ul><li>MRI is the most accurate technique in showing the local extend of the tumor with the advantage that images may be produced in coronal & sagittal planes & MRI provides this information better than CT </li></ul>
  10. 11. Osteosarcoma(osteogenic sarcoma) <ul><li>Age ; mainly 5-20 years but also seen in elderly following malignant transformation of paget’s disease. </li></ul><ul><li>Location; Is often arise in the metaphysis, most commonly around the knee joint. </li></ul><ul><li>X-ray finding; </li></ul><ul><li>often there is bone destruction & new bone formation with typical florid speculated periosteal reaction(sunray appearance). </li></ul><ul><li>The tumor may elevate periosteum to form Codman’s triangle </li></ul>
  11. 13. Chondrosarcoma <ul><li>Age; 30-60 years </li></ul><ul><li>Site; most common sites are pelvic bones,scapulae, humeri & femora </li></ul><ul><li>Radigraphic finding; </li></ul><ul><li>It produce lytic expansile lesion contains flecks of calcification. </li></ul><ul><li>It can be difficult to be distinguished from its benign counterpart (enchndroma), but condrosarcoma usually less well defined in at least one portion of its outline & may show a periosteal reaction & soft tissue component. chondrosarcoma may arise from malignant degeration of the benign cartilaginous tumors. </li></ul>
  12. 15. Fibrosarcoma & malignant fibrous histocytosis <ul><li>Are rare tumors. </li></ul><ul><li>Age; mostly in young & middle age </li></ul><ul><li>Site ; usually around the knee joint. </li></ul><ul><li>X-ray finding; </li></ul><ul><li>Ill defined area of lysis with periosteal reaction </li></ul><ul><li>Frequently the cortex is breached. </li></ul><ul><li>There are no imaging features that distinguish these tumors from secondary or lymphoma. </li></ul>
  13. 16. Ewing sarcoma <ul><li>Is a highly malignant tumor. </li></ul><ul><li>Age; most commonly occur in the children ,usually between 5-15 years. </li></ul><ul><li>site ; it arise mostly in the long bone, usually in diaphyseal region. </li></ul><ul><li>X-ray finding; </li></ul><ul><li>It produce an ill define bone destruction with periosteal reaction that is typically onion skin in appearance. </li></ul>
  14. 18. Giant cell tumor <ul><li>Has features of both malignant & benign tumor, it is locally invasive but rarely metastasizes. </li></ul><ul><li>Age; usually 20-40 years. </li></ul><ul><li>site; it is most commonly occur around the knee & wrist after the epiphysis have fused. </li></ul><ul><li>X-ray finding; </li></ul><ul><li>Expanding destructive lesion which is subarticular in position. </li></ul><ul><li>the margin is fairly well defined but the cortex is thin & may be in places completely destroyed. </li></ul>
  15. 20. Primary lymphoma of bone <ul><li>Is rare </li></ul><ul><li>Most osseous lymphoma is associated with generalized lymph node disease. </li></ul><ul><li>When solitary , bone lymphoma may produce sclerotic bone lesions or they may cause destruction of the bone, producing image finding that can’t be distinguished from fibrosarcoma or malignant fibrous histiocytosis. </li></ul>
  16. 21. 2-Benign bone tumors
  17. 22. <ul><li>Common x-ray finding ; </li></ul><ul><li>Narrow zone of transion with sclerotic rim. </li></ul><ul><li>Cause expansion but rarely produce cortical breakdown . </li></ul><ul><li>There is no soft tissue mass . </li></ul><ul><li>periosteal reaction is unusual unless there is has been a fracture through the lesion. </li></ul>
  18. 23. <ul><li>Isotope scan; shows little or no increase in the activity unless fracture has been occurred through the lesion. </li></ul><ul><li>MRI & CT scan: are rarely needed in their evaluation </li></ul>
  19. 24. Enchndroma <ul><li>Are seen as lytic expanding lesion . </li></ul><ul><li>Most commonly seen in the hand. </li></ul><ul><li>They often contain flecks of calcium & frequently present as a pathological fracture. </li></ul>
  20. 25. Hand multiple chondromas
  21. 27. Fibrus dysplasia <ul><li>May affect one or more bone </li></ul><ul><li>It occure most commonly in the long bones& ribs. </li></ul><ul><li>Radiologically it appear as lucent area with a well defined edge and may expand the bone, there may be sclerotic rim around the lesion </li></ul>
  22. 29. Simple bone cyst <ul><li>Occurs in children & young adult. </li></ul><ul><li>Most common sites are humerus & femur </li></ul><ul><li>X-ray; </li></ul><ul><li>Lucency across the width of the shaft of the bone with well defined edge. </li></ul><ul><li>The cortex may be thin & the bone expanded. </li></ul><ul><li>Often the 1 st clinical finding is pathological fracture </li></ul>
  23. 31. Aneurysmal bone cyst <ul><li>are neoplasm. </li></ul><ul><li>Mostly seen in children & young adult. </li></ul><ul><li>Common site; spine, long bone & pelvis. </li></ul><ul><li>Radiological finding; </li></ul><ul><li>X-ray; purely lytic & cause massive bone expansion of the cortex. </li></ul><ul><li>CT & MRI may show the blood pool within the cyst. </li></ul><ul><li>Major differential Dx is Giant cell tumor </li></ul>
  24. 33. Oseoid osteoma <ul><li>Is a painful condition found most commonly in the femur & tibia in young adults. </li></ul><ul><li>Radiological appearance; it has a characteristic appearance; </li></ul><ul><li>Small lucency sometime with central specks of calcification (nidus) surrounded by dense sclerotic rim & periosteal reaction may be seen. </li></ul>
  25. 36. oseomyelitis <ul><li>Usually occur in infant& children. </li></ul><ul><li>Initial radiographic appearance is normal & bone changes are not visible until 10-14 days of the infection. </li></ul><ul><li>Most sensitive imaging modalities are isotope scan & MRI which may shows the disease within 1-2 days. </li></ul>
  26. 37. Acute oseomyelitis <ul><li>Typically affect metaphysis of the long bone. </li></ul><ul><li>X-ray finding; </li></ul><ul><li>The earliest sign on the plan radiograph is soft tissue swelling with characteristic obliteration of fat plains & may be apparent with 1st 2 days of the clinical manifestations. </li></ul><ul><li>local osteoporosis may be seen within 10-14 days of the onset of the symptoms. </li></ul><ul><li>bone destruction in the metaphysis with periosteal reaction that eventually may become very extensive & surround the bone to form involucrum which is usually visualized after 3 weeks. </li></ul><ul><li>Part from the original bone may die & separate to form dense fragment called sequestrum. </li></ul>
  27. 39. sequestrum
  28. 40. <ul><li>Isotope scan; increased activity in both early & delay phase. </li></ul><ul><li>MRI; is the investigation of choice & may shows evidence of bone edema & pus accumulation in the bone & soft tissue </li></ul>
  29. 41. Chronic oseomyelitis <ul><li>The bone become thickeneed & loss diferentiation between the cortex & the medulla </li></ul>
  30. 42. TB oseomyelitis <ul><li>Spine is the most common site followed by large joints, but any bone may be affected. </li></ul><ul><li>The disease produce large areas of bone distruction & unlike pyogenic infection, the disease is relatively asymptomatic in the early stage. </li></ul>
  31. 44. Multiple focal lesions
  32. 45. <ul><li>Metastases & multiple myeloma are the commonest causes of multiple obvious lytic lesions in the bone, </li></ul>
  33. 46. metastases <ul><li>Is the commonest malignant bone tumor. </li></ul><ul><li>Those bones contains red marrow are the commonest site to be affected, namely spine, skull, ribs, pelvis, humeri & femora. </li></ul><ul><li>lytic secondry depisite ; in the adult most commonly from , breast & bronchus & less commonly from carcinoma of the thyroid, renal, colon & in the children from neuroblastoma. </li></ul><ul><li>Radiologically appearce as a well-defined or ill-defined areas of bone destruction without sclerotic rim. </li></ul><ul><li>Sclerotic metastases ; in the men most commonly from prostate & in the female from Ca breast, it appear as ill-defined areas of increased density of varying sizes with ill-defined margin. </li></ul><ul><li>Mixed lytic & sclerotic secondery deposite; they are most commonly from Ca breast </li></ul>
  34. 47. Notes; <ul><li>bone expansion uncommon in metastases except in Ca thyroid & kidney. </li></ul><ul><li>periosteal reaction is uncommon with metastases except in neuroroblastoma. </li></ul><ul><li>Isotope scan is much more sensitive than plain film in detecting bone metastases & if multiple areas of increased activity are seen in a patient with known primary Ca, then the Dx of metastases is virtually certain . </li></ul><ul><li>MRI is better than isotope scan for detecting & it shows more metastases but is more difficult to survey the whole skeleton with MRI. </li></ul><ul><li>CT less sensitive than MRI for detecting metastases, but can demonstrate lytic & sclerotic metastases & the image should be reviewed on bone windows . </li></ul>
  35. 48. Multiple myeloma <ul><li>They are more commonly seen in active heamopoetic areas . </li></ul><ul><li>It is resemble lytic metastases but it is often better defined. </li></ul><ul><li>Diffuse marrow involvement may cause generalized loss of bone density producing a picture similar to that of oseoporosis. </li></ul><ul><li>Most meyloma deposite show increased activity on isotope scan </li></ul>
  36. 51. Generalize decreased bone density(osteopenia)
  37. 52. <ul><li>Radiographic density of the bone depend on the amount of calcium present in the bone. </li></ul><ul><li>decrease in bone calcium lead to decrease in bone density. </li></ul>
  38. 53. <ul><li>Osteoporosis. </li></ul><ul><li>Osteomalacia. </li></ul><ul><li>Hyperparathyroidism. </li></ul><ul><li>Multiple myeloma. </li></ul>Main causes of generalized decrease in bone density;
  39. 54. <ul><li>Osteoporosis is the consequence of a deficiency of protein matrix(osteoid) & decrease amount of the normal bone (i.e. loss of bone mass) while remaining bone is normally mineralized (microstructure of the bone remain normal & histologically also normal) </li></ul>osteoporosis
  40. 55. <ul><li>Osteoporosis predispose to fractures , specially vertebral bodies & hips. </li></ul>
  41. 56. <ul><li>1- Idiopathic ; according to the age, subdivided to; </li></ul><ul><li>Juvenile </li></ul><ul><li>Senile </li></ul><ul><li>Postmenopausal; up to 50% of female over 60 years of age have osteoporosis. </li></ul><ul><li>2- Cushing’s disease & steroid therapy. </li></ul><ul><li>3- disuse </li></ul>Main Causes of osteoporosis
  42. 57. <ul><li>Change in bone density usually unapparent until 30-50% of the bone mass has been lost. </li></ul><ul><li>Decreased cortical thickness. </li></ul><ul><li>Decreased no. of the trabeculae present in the bone. </li></ul>Radiological features
  43. 58. Empty box Prminent vertical trabicuale VB compression fracture Generalized decrease in bone density
  44. 59. <ul><li>Changes best seen in the spine. </li></ul><ul><li>Resorption of the horizontal trabeculae. </li></ul><ul><li>Empty box ; apparent increased end plate density due to Resorption of the spongy bone. </li></ul><ul><li>VB compression fracture; wedged or biconcave types with apparent widening of the disc spaces </li></ul>
  45. 60. <ul><li>Local decreased bone density caused by localized pain or immobilization of a fracture </li></ul>Disuse osteoporosis
  46. 61. Indistinctness of the cortex of the right femoral head and osteopenia of the entire femoral head