Diagnostic Imaging of Bone Tumors

Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

Mohamed Zaitoun
Radiology Assistant Lecturer
Zagazig University-Egypt
zaitoun82@gmail.com

Introduction
-Benign Criteria of Bone Tumors :
1-Well defined margin
2-Sclerotic rim
3-Expanding lesion
4-No periosteal reaction
5-No extraosseous soft tissue component
6-Narrow zone of transition

-Malignant Criteria of Bone Tumors :
1-ill defined margins
2-Cortical destruction
3-Periosteal reaction
4-Extraosseous extension
5-Intra-articular invasion
6-Neurovascular bundle affection
7-Wide zone of transition

-Location Within Anatomic Regions :
a) Epiphysis :
1-Chondroblastoma
2-Infection
3-Geode
4-GCT
b) Metaphyseal :
-Lesions of different causes : neoplastic ,
inflammatory and metabolic

c) Epiphyseal / Metaphyseal :
-GCT
d) Diaphysis :
-After the 4th decade of life , most solitary
diaphyseal bone lesions involve the bone
marrow

Bone Tumors
(i) Bone Forming Tumors
(ii) Cartilage Forming Tumors
(iii) Fibrous Lesions
(iv) Bone Marrow Tumors
(v) Other Bone Tumors
(vi) Metastases
(vii) Miscellaneous

(i) Bone Forming Tumors :
a) Benign :
1-Bone Island
2-Osteoblastoma
3-Osteoma
4-Osteod Osteoma
b) Malignant :
-Osteosarcoma

a) Benign :
1-Bone Island
2-Osteoblastoma
3-Osteoma
4-Osteod Osteoma

1-Bone Island : (Enostosis)
a) Incidence
b) Location
c) Associations
d) Radiographic Features

a) Incidence :
-Common and benign bone lesions that are
usually seen as an incidental findings
-They constitute a small focus of compact
bone within cancellous bone
-N.B. : All the tumors are osteolytic except :
1-Bone Island
2-Osteoma

b) Location :
Bone islands may occur anywhere in the
skeleton although there is some
predilection for pelvis , long bones , spine
and ribs
c) Associations :
-Osteopoikilosis : multiple bone islands

d) Radiographic Features :
-They are commonly seen as small round or oval
foci of dense bone within the medullary space
-The appearance of radiating spicules at the
margins that blend with the surrounding
trabeculae is pathognomonic
-The size of a bone island is typically less than
1cm , although large ones may occur particularly
in the pelvis and are termed giant bone islands
-MRI : Low signal intensity on all sequences

2-Osteoblastoma :
a) Incidence
b) Location
c) Radiographic Features

a) Incidence :
-Rare benign primary bone tumor
-Young age
-It is histologically similar to an osteoid
osteoma except that it is much large
b) Location :
-Transverse process of vertebrae
-Sacrum

c) Radiographic Features :
-Lesions are predominantly lytic > 2 cm with
a rim of reactive sclerosis
-Expansile well-circumscribed lesion similar
to ABC
-Variable central calcification and matrix

3-Osteoma :
a) Location
b) Radiographic Features

a) Location :
-Skull & PNS
-When multiple consider Gardner’s
syndrome
b) Radiographic Features :
-Osteoma appears as very radiodense
lesions

4-Osteod Osteoma :
a) Incidence
b) Location

a) Incidence :
-Benign bone tumor that typically occur in children
(particularly adolescents)
-They have characteristic appearances and
classically cause night pain that is relieved by
the use of Aspirin
b) Location :
-Long bones of the limbs , femur (especially neck)
and mid-tibia (close to the cortex)
-Hand & Feet (navicular bone)

-Radiolucent nidus <2 cm in diameter (may
contain bone matrix)
-Nidus surrounded by sclerosis

b) Malignant :
Osteosarcoma
a) Incidence
b) Location
c) Types

a) Incidence :
-Malignant bone forming tumor and the
second most common primary bone tumor
after multiple myeloma
b) Location : eccentric
-Around knee (Femur & Tibia)
-Humerus (less common)

c) Types :
1-Primary osseous OSA (95%)
2-Juxtacortical OSA
3-Secondary OSA : to Paget’s disease

-Malignant criteria
-Aggressive periosteal reaction :
1-Sunburst type
2-Codman triangle

(ii) Cartilage Forming Tumors :
a) Benign :
1-Chondroblastoma
2-Enchondroma
3-Enchondromatosis
4-Maffucci’s Syndrome
5-Osteochondroma (Exostosis)
6-Hereditary Multiple Exostoses
7-Chondromyxoid Fibroma
b) Malignant :
-Chondrosarcoma

a) Benign :
1-Chondroblastoma
2-Enchondroma
3-Enchondromatosis
4-Maffucci’s Syndrome
5-Osteochondroma (Exostosis)
6-Hereditary Multiple Exostoses
7-Chondromyxoid Fibroma

1-Chondroblastoma :
a) Location

a) Location : Epiphyseal lesion
-Chondroblastoma most frequently arise in
the epiphyses of long bones with 70%
occurring in the humerus (most frequent) ,
femur and tibia

-Chondroblastoma is seen as well defined
lytic lesion with either smooth or lobulated
margins with a thin sclerotic rim

2-Enchondroma :
a) Associations
b) Location

a) Associations :
1-Ollier disease
2-Maffucci syndrome
b) Location :
-Small tubular bones of the hands and feet :
50 %, more in the proximal phalanges

-Benign Features
-Lytic lesion in bones of the hand or foot ,
expansile
-Chondroid calcifications : rings and arcs
pattern (O and C)

3-Enchondromatosis : (Ollier disease)
-Is multiple enchondromas
-Multiple radiolucent expansile masses in
hand and feet
-Hand and foot deformity
-Tendency for unilaterality

4-Maffucci’s Syndrome :
-Enchondromatosis and multiple soft tissue
hemangiomas
-Unilateral involvement of hands and feet
-Malignant transformation is much more
common than in Ollier disease

5-Osteochondroma (Osteocartilaginous
Exostosis) :
a) Incidence
b) Location

a) Incidence :
-Most common benign
-Young age
b) Location :
-Knee
-Humerus

1-Plain Radiography & CT : 5C
-Continuous with parent bone
-Uninterrupted cortex
-Continuous medullary bone
-Calcification in the chondrous portion of cap
, may be cauliflower-like
-Metaphyseal location (cartilaginous origin)
-Lesion grows away from joint

2-MRI :
-MRI demonstrates cortical and medullary continuity
between the osteochondroma and the parent bone
-The cartilage cap of osteochondroma appears the same
as cartilage elsewhere with intermediate to low signal on
T1 and high signal on T2
-A cartilage cap of over 1.5 cm in thickness is suspicious
for malignant degeneration
-With intravenous gadolinium administration , enhancement
of benign lesions is normally seen in the tissue that
covers the cartilaginous cap which is fibrovascular in
nature , however the cartilaginous cap itself should not
enhance

6-Hereditary Multiple Exostoses :
-Multiple osteochondromas

7-Chondromyxoid Fibroma :
-Eccentric position in the metaphysis of the long
bones (50 % around the knee)
-Often seen as a lobulated eccentric radiolucent
lesion
-Long axis parallel to long axis of long bone
-No periosteal reaction (unless a complicating
fracture present)
-Geographic bone destruction : almost 100%
-Well defined sclerotic margin

b) Malignant :
-Chondrosarcoma
a) Incidence
b) Location
c) Types

a) Incidence :
-Malignant cartilaginous tumors that account for
20-27% of all primary malignant bone tumors
-Typical presentation is in the 4th and 5th decades
b) Location :
-Long bones : 45%, femur
-Flat bone (Ribs, clavicle & scapula)

c) Types :
1-Primary
2-Secondary :
-Enchondroma
-Osteochondroma
-Malignant criteria (Lytic lesion) + Calcifications
(rings and arcs calcification or popcorn
calcification)

Chondrosarcoma , sphenoid wing

(iii) Fibrous Lesions :
a) Benign :
1-Fibrous Cortical Defect (FCD) & Non-Ossifying Fibroma
(NOF)
2-Fibrous Dysplasia
3-Ossifying Fibroma
4-Desmoplastic Fibroma
5-LipoSclerosing MyxoFibrous Tumor (LSMFT)
b) Malignant :
1-Malignant Fibrous Histiocytoma
2-Fibrosarcoma

a) Benign :
1-Fibrous Cortical Defect (FCD) & Non-
Ossifying Fibroma (NOF)
2-Fibrous Dysplasia
3-Ossifying Fibroma
4-Desmoplastic Fibroma
5-LipoSclerosing MyxoFibrous Tumor
(LSMFT)

1-Fibrous Cortical Defect (FCD) & Non-
Ossifying Fibroma (NOF) :
a) Incidence
b) Location

a) Incidence :
-FCD typically occur in children (usually 2-15 yrs)
and indeed are one of the most common benign
bony lesions which combined with NOF are seen
in up to 30-40% of skeletally immature children /
adolescents
b) Location :
-Tibia and fibula are most commonly affected
(90%)

-Oval radiolucent defect, small (< 2-3 cm) in
FCD and larger in NOF with sclerotic
margins

2-Fibrous Dysplasia :
a) Incidence
b) Types
d) Variants

a) Incidence :
-Benign developmental anomaly in which the
medullary cavity is replaced with fibrous
material, woven bone and spindle cells
-Fibrous dysplasia is found predominantly in
children and young adults with 75% of patients
presenting before the age of 30 years (highest
incidence between 3 and 15 years)

b) Types :
1-Monoostotic : single bone
Femur, Ribs (most common)
2-Polyostotic : multiple bones (often unilateral and
one limb)
Femur, Tibia, Pelvis & Foot
3-Craniofacial fibrous dysplasia : skull and facial
bones alone
4-Cherubism : mandible and maxilla alone (not
true fibrous dysplasia)

-Radiolucent expansile medullary lesions
-Ground glass matrix
-Well defined sclerotic margins
1-Long Bones :
-Bowing deformities
-Shepherd's crook deformity (refers to a coxa
varus angulation of the proximal femur)
-May lead to premature fusion of growth plates
leading to short stature

2-Base of the Skull :
-Lesions tend to be sclerotic (in contrast to lucent lesions
elsewhere)
3-Pelvis + Ribs :
-Ribs are the most common site of monostotic fibrous
dysplasia , Fibrous dysplasia is the most common cause
of a benign expansile lesion of a rib
-Bubbly cystic lesions
-Fusiform enlargement of ribs
-Protrusio Acetabuli (intrapelvic displacement of the medial
wall of the acetabulum)

Normal Pelvis Protrusio Acetabuli

Bilateral acetabular protrusio (white arrows) , the femoral head should not extend medial
to a line drawn from the lateral aspect of the pelvis and the lateral aspect of the
obturator foramen (blue line) , The distance between the acetabulum and the
ilioischial line (yellow arrow) should not be > 3mm in males and >6 mm in females

d) Variants :
1-Cherubism :
-Symmetrical involvement of mandible and
maxilla
2-McCune-Albright Syndrome :
-Polyostotic unilateral fibrous dysplasia
-Endocrine abnormalities (precocious
puberty, hyperthyroidism)
-Café au lait spots
-Predominantly in girls

3-Leontiasis ossea (craniofacial fibrous
dysplasia) :
-Involvement of facial & frontal bones
-Leonine facies (resembling a lion)
4-Fibrous dysplasia (pseudarthrosis of
the tibia) :
-Young infants
-Anterior tibial bowing

3-Ossifying Fibroma :
-They tend to occur in young children (often
under 10 years of age)
-Lower extremity, tibia : commonest site
(90%)
-Seen as a well-circumscribed lesion

4-Desmoplastic Fibroma :
-The most common areas of involvement
include the mandible , pelvis and femur
-Expansile lytic lesion containing thick
septations

5-LipoSclerosing MyxoFibrous Tumor
(LSMFT) :
-Tends to have a striking predilection for the
intertrochanteric region of the femur
-Typically seen as a geographic lytic lesion
with a sclerotic margin

b) Malignant :
1-Malignant Fibrous Histiocytoma
2-Fibrosarcoma

1-Malignant Fibrous Histiocytoma :
a) Incidence
b) Location

a) Incidence :
-MFH are aggressive tumors which account
for 25-40% of all adult soft tissue sarcoma
making them the most common type
-Old age
-They are the most frequent soft tissue
sarcoma to occur as a result of
radiotherapy and are also seen on a
background of Paget disease

b) Location :
-Although MFH can occur almost anywhere
in the body, they have a predilection for
the retroperitoneum and proximal
extremities
-They are usually confined to the soft
tissues but occasionally may arise in or
from bone (1-5%)

-Aggressive malignant criteria
-Density of tumor is similar to muscle (10 to 60
HU)
-MRI :
*T1 : intermediate (to low) signal intensity similar to
adjacent muscle
*T2 : intermediate to high signal intensity
*T1+C : prominent enhancement of solid
components

2-Fibrosarcoma :
-Fibrosarcoma & MFH are clinically &
radiologically indistinguishable

(iv) Bone Marrow Tumors :
1-Eosinophilic Granuloma
2-Multiple Myeloma
3-Ewing’s Sarcoma
4-Primary Lymphoma
5-Leukemia

1-Eosinophilic Granuloma :
a) Incidence
b) Location

a) Incidence :
-Age : 1st to 3rd decade
-Type of Langerhan’s Cell Histiocytosis
which is confined to bone

b) Location :
-Skull, most common
-Pelvis
-Spine
-Long bones
-Mandible

1-Plain Radiography
2-MRI

1-Plain Radiography :
a) Skull
b) Mandible
c) Spine
d) Long Bones

a) Skull :
-Solitary or multiple punched out lytic lesions with
or without sclerotic rim
-Double contour or beveled edge appearance may
be seen due to greater involvement of the inner
than the outer table (hole within hole sign)
-Button sequestrum (bone opacity surrounded by a
relatively well-defined lucent area)
-Geographic skull (destructive lytic bone lesion ,
edges of which may be bevelled, scalloped or
confluent)

On the left , lateral skull radiograph demonstrates two lytic lesions in the frontal
and parietal bones (white circles) with characteristic "beveled edges” , The
CT scan (at right) shows the lesion in the right frontal bone (white arrow)
and the beveling of the destructive process

b) Mandible :
-Irregular radiolucent areas mostly involving
superficial alveolar bone
-Floating tooth : loss of lamina dura

c) Spine :
-Vertebra plana :
Complete collapse of the vertebral body,
more often in thoracic spine

d) Long Bones :
-Mainly involves diaphysis and respect
growth plates
-Lytic lesion

Hole within a hole sign (multifocal eosinophilic granulomatosis in which two
lucent lesions of unequal size overlie one another , the smaller lucent focus
appears as an area of additional lucency within the larger osteolytic focus)

2-MRI :
*T1 : typically low signal
*T2 : isointense to hyperintense
*STIR : hyperintense
*T1+C : shows contrast enhancement

2-Multiple Myeloma
a) Incidence
b) Location
c) Types
e) Differential Diagnosis

a) Incidence :
-The most common primary malignant bone
neoplasm in adults
b) Location :
-Vertebrae (most common), vertebral bodies are
destroyed before the pedicles are, as opposed
to metastases in which pedicles are destroyed
first
-Axial skeleton is most commonly affected (skull,
spine, ribs & pelvis)

c) Types :
1-Multiple myeloma (multiple lesions) :
-Axial skeleton
2-Solitary plasmacytoma :
-Common in vertebral body, pelvis & femur

1-Diffuse Pattern : Two appearances
a) Numerous well circumscribed lytic bone lesions
(more common), punched out lucencies
e.g. pepperpot skull or raindrop skull with
endosteal scalloping
b) Generalized osteopaenia (less common), often
associated with vertebral compression
fractures / vertebra plana
2-Plasmacytoma : tends to be large and
expansile

-MRI :
1-Replacement of normal marrow (sensitive)
2-Normal fatty marrow is bright on both T1
and T2, while abnormal marrow is dark

e) Differential Diagnosis :
-The main differential is that of widespread bony
metastases
-Findings that favor the diagnosis of bony
metastases over that of multiple myeloma
include :
1-More commonly affect the vertebral pedicles
rather than vertebral bodies
2-Rarely involve mandible, distal axial skeleton
3-Although both entities have variable bone scan
appearances (both hot and cold) unlike
myeloma, extensive bony metastases rarely
have a normal appearance

3-Ewing’s Sarcoma :
a) Incidence
b) Location

a) Incidence :
-The second most common primary bone
tumor of childhood after osteosarcoma
-Typically occurs in children and
adolescents between 10 and 20 years of
age (95% between 4 and 25 years of age)

b) Location :
-Diaphysis of lower limb : 45%, femur most
common
-Pelvis : 20%
-Upper limb

-Aggressive malignant criteria
-Ewing sarcomas tend to be large poorly
marginated tumors with over 80%
demonstrating extension into adjacent soft
tissues
-Laminated (onion skin) periosteal reaction

Onion peel periosteal reaction

Frontal radiograph and lateral radiographs of the femur
demonstrate mottled osteolytic lesion (blue circle) with poorly
marginated edges in the diaphysis of the bone , there is sunburst
periosteal reaction (red circle) and lamellated periosteal reaction
(white arrows)

4-Primary Lymphoma :
-Very rare, most osseous lymphomas are
secondary
-Primary osseous lymphoma is usually of
non-Hodgkin's type
-Permeative lytic lesion with similar
appearance to other small round cell
tumors (e.g. Ewing's tumor)

5-Leukemia :
a) Metaphyseal lucent band
b) Generalized reduced bone density
(osteopenia)
c) Lytic bone lesions
d) Metaphyseal cortical bone erosions
e) Collapsed vertebra
f) Widening of sutures and periosteal
reactions

Metaphyseal lucent band (arrow) in radial and ulnar metaphyses , note
the lucent bony lesions of the first and third metacarpal bone on the
right side (arrows)

Metaphyseal hypodensity on both femurs with sclerotic lesions (arrows)
, there are also lytic lesions in the left femoral neck (arrowhead)

Metaphyseal translucency in both distal femurs and
proximal tibiae more prominent in the latter

(v) Other Bone Tumors :
1-Simple Bone Cyst
2-Aneurysmal Bone Cyst
3-Hemophiliac Pseudotumor
4-Giant Cell Tumor
5-Intraosseous Hemangioma
6-Adamantinoma

7-Chordoma
8-Intraosseous Lipoma
9-Hemangioendothelioma
10-Angiosarcoma
11-Massive Osteolysis (Gorham’s Disease)
12-Glomus Tumor

1-Simple Bone Cyst : Unicameral
a) Incidence
b) Location
d) Differential Diagnosis

a) Incidence :
-Common benign lucent bony lesions that
are seen in childhood and typically remain
asymptomatic
-They usually found in children in the
1st and 2nd decades

b) Location :
-Most common location : proximal
metaphysis of the humerus or femur
-Older patients : calcaneus and ileum

-Central (intramedullary) location
-Expansile lesion, fluid-filled cavities (fluid-
fluid levels)
-If there is fracture through this lesion a
dependent bony fragment may be seen
and this is known as the fallen fragment
sign

d) Differential Diagnosis :
Expansile bone lesions : FENGOMASHIC
1-Fibrous dysplasia
2-Enchondroma
3-Giant cell tumor
4-Osteoblastoma
5-Myeloma
6-Aneurysmal bone cyst
7-Simple bone cyst
8-Hyperparathyroidism
9-Infection (Hydatid)
10-Chondroblastoma

2-Aneurysmal Bone Cyst : (ABC)
a) Incidence
b) Location
c) Types

a) Incidence :
-Benign expansile tumor like bone lesion
-Primarily seen in children and adolescents
with 80% occurring in the patients less
than 20 years of age

b) Location :
-They are typically eccentrically located in
the metaphysis of long bones adjacent to
an unfused growth plate
-Long bones : tibia and fibula
-Spine : posterior elements
-Pelvis

c) Types :
1-Primary Non-Neoplastic Lesion, 70 %
2-Secondary Lesion, 30 % :
-Secondary to underlying lesions :
a) Chondroblastoma
b) Fibrous dysplasia
c) Giant cell tumor (GCT)
d) Osteosarcoma

-Eccentric location
-Sharply defined expansile osteolytic lesions
with thin sclerotic margins
-Fluid fluid level
-MRI :
The cysts are of variable signal with
surrounding rim of low T1 and T2 signal ,
focal areas of high T1 and T2 signal are
also seen presumably representing areas
of blood of variable age

3-Hemophiliac Pseudotumor :
a) Incidence
b) Location

a) Incidence :
-Rare complication that occurs in 1-2% of
hemophilia
-Pathologically , pesudotumors represent
hematomas with thick fibrous capsule

b) Location :
-Most develop in the muscles of the pelvis
and lower extremity where the large
muscles have a rich blood supply or in
bone following intraosseous bleeding
-Femur , pelvis & tibia

1-Soft tissue lesions :
-Large soft tissue mass with adjacent bone
destruction
-Calcifications common
-MRI shows characteristic appearance of
hematoma , fluid-blood levels may be present
-Bleeding in a joint (hemoarthrosis) :
Widened joint space , increase bone
trabeculations and elevated periosteum by soft
tissue mass

-Hemophilia and soft tissue
pseudotumor with secondary
infection
-Anteroposterior view shows
extensive soft tissue mass in
right thigh resulting in extrinsic
cortical erosion (arrowheads)
of femoral shaft
-Skin defect and air bubbles
reflect secondary infection and
skin necrosis
-Note hemophilic involvement of
knee joint

2-Intraosseous Lesions :
-Well defined unilocular or multiloculated
lytic expansile lesions of variable size
-It can involve metadiaphysis and epiphysis
of long bones
-Other findings include endosteal
scalloping , perilesional sclerosis , cortical
thinning or thickening , trabeculations and
septations
-Pathological fractures can also be present

4-Giant Cell Tumor : (Osteoclastoma)
a) Incidence
b) Location

a) Incidence :
-Relatively common bone tumors usually benign
and typically found in the metaepiphysis of long
bones
-After epiphyseal closure > 18 years of age
b) Location :
-Around the knee : distal femur and proximal tibia
-Distal radius

-Occurs only with a closed growth plate
-Expansile lytic subarticular
-No sclerotic margins

5-Intraosseous Hemangioma :
a) Incidence
b) Location

a) Incidence :
-Relatively common
-Typically seen in the 4th-5th decade of life
b) Location :
-Vertebral body > skull > face

-Sclerotic vertebra with vertical trabeculae ,
Corduroy sign
-MRI :
*T1 : high (fat rich)
-Intermediate to low signal intensity is seen in fat
poor hemangioma
*T2 : high
*T1+C : enhancement is often present
-Radiolucent slightly expansile intraosseous lesion
in extraspinal sites

6-Adamantinoma :
a) Incidence
b) Location

a) Incidence :
-Ameloblastoma (previously known as
an adamantinoma of the jaw) are benign locally
aggressive tumors that arise from the mandible
-Ameloblastoma is the second most common
odontogenic tumor (odontoma is the most
common)
-They are slow growing and tend to present in the
3rd to 5th decades of life

b) Location :
-Mandible
-Less commonly from the maxilla
-May occur in the tibia (adamantinoma) ,
bone destruction in the anterior tibial shaft

-Multiloculated (80%) lytic expansile soap-bubble
lesion with well demarcated borders and no
matrix calcification
-Occasionally erosion of the adjacent tooth roots
can be seen which is highly specific
-When larger it may also erode through cortex into
adjacent soft tissues
-MRI : In general ameloblastoma shows a mixed
solid and cystic pattern with a thick irregular wall
often with papillary solid structures projecting
into the lesion , these components tend to vividly
enhance

7-Chordoma :
a) Incidence
b) Location

a) Incidence :
-Uncommon malignant tumor
-Chordoma is usually seen in adults (30-60
years)
-Chordoma is the most common primary
malignant sacral tumor

b) Location :
1-Sacro-coccygeal :
-Most common
-Involving particularly the fourth and fifth sacral
segments
2-Speno-occipital (clivus) :
-Typically the mass projects in the midline
posteriorly indenting the pons (thumb sign)
3-Vetebral bodies :
-Commonly involve the cervical spine (particularly
C2) followed by the lumbar spine then the
thoracic spine

-Nonspecific expansile lytic lesion
-Large soft tissue component
-Variable calcification

8-Intraosseous Lipoma :
-Rare benign lesion, however the most
common lipogenic tumor in bone
-Osteolytic bone lesion with well-defined margins
-CT : Far attenuation
-MRI : Fat attenuation, hyperintense fat signal on
T1 and T2 that will be entirely suppressed by
STIR or fat saturated sequences

9-Hemangioendothelioma :
-Low-grade malignant lesion of adolescents
-Multifocal lytic lesions involving multiple
bones of a single extremity usually the
hands or feet
-Locally aggressive , rarely metastasize

10-Angiosarcoma :
-Highly malignant vascular tumor of
adolescents / young adults
-One third are multifocal
-Commonly metastasize

11-Massive Osteolysis (Gorham’s Disease) :
-Extensive cystic angiomatosis (hemangiomatous
and lymphangiomatous) of bone in children and
young adults
-Idiopathic
-Location : shoulder and hip most common
-Intramedullary or subcortical lucent foci may be
the earliest manifestation , this progresses to
profound osteolysis with resorption of affected
bone and lack of compensatory osteoblastic
activity or periosteal reaction

12-Glomus Tumor :
-Benign vascular tumor of the terminal
phalanx
-Well-circumscribed lytic and painful
-Clinical pain and terminal phalangeal
location are characteristic

(vi) Metastases :
a) Incidence
b) Etiology
c) Location
e) Secondary Lymphoma

a) Incidence :
-Skeletal metastases account for 70% of all
malignant bone tumors
-More with lung cancer , breast cancer ,
renal cell carcinoma and prostate cancer
(account for approximately 80% of all
skeletal metastases)

b) Etiology :
1-Adult Male :
-Prostate
-Lung
-Kidney
2-Adult Female :
-Breast
-Lung
-Kidney

3-Child :
-Neuroblastoma
-Lymphoma / Leukemia
-Medulloblastoma
-Sarcoma
-Wilm’s Tumor

c) Location :
1-Vertebrae , especially posterior vertebral
body extending into pedicles
2-Pelvis
3-Proximal femur
4-Proximal humerus
5-Skull

1-Lytic metastases :
-Kidney
-Lung
-Thyroid
-Breast
2-Sclerotic metastases :
-Breast
-Prostate

3-Mixed lytic and sclerotic metastases :
-Breast carcinoma, typically lytic but 25 % are
mixed
-Lung carcinoma, typically lytic but 15 % are mixed
-Carcinoma of the cervix
-Testicular tumors
-Prostate carcinoma , typically sclerotic but 15 %
are mixed
4-Metastases may be diffuse, focal or expansile

*N.B. :
-Destructive lesion in the pelvis of an adult
>>> metastases
-Single dense vertebra (Ivory Vertebra) :
1-Osteoblastic Metastases
2-Lymphoma
3-Paget’s Disease

e) Secondary Lymphoma :
-Skeletal abnormalities occur in 5%-50% of all
lymphomas
-Radiographic Features :
*Usually aggressive tumors with no specific
pathognomonic finding
*Suspect the diagnosis in lymphoma patients
*Ivory vertebra is a manifestation of Hodgkin's
lymphoma , lymphoma causes increased bone
density of the affected vertebrae but it is usually
accompanied by a destructive pattern and large
soft tissue mass

Lymphoma of L3 , note the destructive pattern of the bone and the soft tissue mass on
CT (arrow)

(vii) Miscellaneous :
1-Mastocytosis
2-Myelofibrosis
3-Pyknodysostosis
4-Radiation Induced Changes
5-Soft Tissue Tumors
6-Pigmented Villonodular Synovitis
7-Synovial Chondromatosis

1-Mastocytosis :
Mast cell infiltration of skin , marrow and
other organs
-Results in mixed lytic / sclerotic process
(dense bones) with thickened trabecula
-Focal or diffuse (more common)
-In some patients there is generalized
osteoporosis with risk of pathological
fractures

2-Myelofibrosis : (Myeloid Metaplasia)
-Is a hematological disorder where there is
replacement of bone marrow with collagenous
connective tissue and progressive fibrosis
-It is also classified as a myeloproliferative disorder
-Radiological Findings :
*Diffuse or patchy osteosclerosis
*Massive extramedullary hematopoiesis
*Massive splenomegaly (100%)
*Hepatomegaly
*Paraspinal mass

-Differential Diagnosis of Osteosclerosis :
Regular Sex Makes Occasional Perversions Much More
Pleasurable And Fantastic :
1-Renal osteodystrophy
2-Sickle cell anemia / Thalassemia
3-Myelofibrosis
4-Osteopetrosis
5-Pyknodystosis
6-Metastases
7-Mastocytosis
8-Paget’s disease
9-Athletes
10-Fluorosis

3-Pyknodysostosis :
a) Incidence

a) Incidence :
-Rare autosomal recessive bone
dysplasia characterised by osteosclerosis
and short stature

1-Hands
2-Cranial & Maxillofacial
3-Other

1-Hands :
-Short stubby fingers
-Partial agenesis / aplasia of terminal
phalanges simulating acro-osteolysis
-Delayed bone age

2-Cranial & Maxillofacial :
-Marked delay in sutural closure
-Wormian bones (lambdoidal region) ,
small intrasutural bones that lie between
the cranial sutures formed by the bones of
the skull vault
-Micrognathia (small mandible)
-Straight mandible
-Persistence of primary teeth

(A) Panorex radiograph reveals multiple disorganized crowded deciduous and
permanent teeth within the expanded alveolar processes , (B) Wormian
bones (arrows) within the lambdoid suture , obtuse angle of the mandible
and dental abnormalities are also visualized

3-Other :
-Osteosclerosis (of vertebral bodies)
-Underdeveloped paranasal sinuses and
mastoid air cells
-Hypoplastic clavicles
-Erosion of outer end of clavicles

4-Radiation Induced Changes :
a) Bone Growth
b) Osteonecrosis
c) Radiation-Induced Bone Tumors

a) Bone Growth :
-The major effect of radiation is on
chondroblasts in epiphyses :
1-Epiphyseal growth arrest
2-Slipped capital femoral epiphysis
3-Scoliosis (e.g. after radiation of Wilms'
tumor)
4-Hemihypoplasia (i.e. iliac wing)

b) Osteonecrosis :
-Radiotoxicity to osteoblasts results in
decreased matrix production
-Radiation osteitis is most common in :
1-Mandible , 30% (intraoral cancer)
2-Clavicle , 20% (breast carcinoma)
3-Humeral head , 14% (breast carcinoma)
4-Ribs , 10% (breast carcinoma)
5-Femur , 10%

c) Radiation-Induced Bone Tumors :
1-Enchondroma (exostosis) is the most
common lesion
2-OSA , chondrosarcoma and MFH are the
most common malignant lesions

5-Soft Tissue Tumors :
a) Malignant Fibrous Histiocytoma
b) Liposarcoma
c) Synovial Cell Sarcoma
d) Fibromatoses

a) Malignant Fibrous Histiocytoma :
-See before

b) Liposarcoma :
-Second most common soft tissue tumor in
adults
-Location : buttocks , lower extremity &
retroperitoneum
-Fatty component is progressively replaced
by soft tissue while degree of malignancy
increases
-Variable reactive pseudocapsule

c) Synovial Cell Sarcoma :
Soft tissue sarcoma
-Age : 15 to 35 years
-Location : most commonly around the knee
-Approximately one third contain
calcifications

d) Fibromatoses :
A spectrum of fibrous soft tissue lesions that
are infiltrative and prone to recurrence

6-Pigmented Villonodular Synovitis :
(PVNS)
a) Incidence
b) Location
c) Types

a) Incidence :
-Results from synovial proliferation and
hemosiderin deposition
-Affects adults in their second to fourth
decades

b) Location :
-knee (far the most frequently affected joint)
66-80%
-Hip
-Ankle
-Shoulder

c) Types :
1-Diffuse (within the joint)
2-Focal

1-Plain Radiography & CT :
-Soft tissue swelling around joint , from
effusion and synovial proliferation
-Never calcify
-Multiple sites of deossification appearing as
cysts
-No joint space narrowing (until late)

AP and lateral views of the knee demonstrate marked soft tissue
swelling , cystic changes in both the femur and tibia without
significant joint space narrowing

2-MRI : Hemosiderin
-Diffuse low signal masses on T1W and
T2W sequences lining the joint synovium
-Joint effusion

7-Synovial Chondromatosis :
a) Incidence
b) Location

a) Incidence :
-Benign monoarticular disorder of unknown
origin that is characterised by multiple
intra-articular cartilaginous loose bodies
-Most present in the 4th or 5th decade of life

b) Location :
-Usually the condition is monoarticular with
large joints preferentially affected
-The knee is the most commonly affected
joint (involved in up to 70% of cases)
followed by the hip (20%) , elbow and
shoulder

1-Plain Radiography & CT :
-When extensive ossification is present then
many calcific joint bodies are present
either fully ossified or demonstrating
the ring and arc calcification characteristic
of chondroid calcificaiton
-They are most often multiple and of uniform
size

2-MRI :
-Typical chondroid signal characteristic :
Lobulated intra-articular mass
*T1 : intermediate to low signal
*T2 : high signal
containing multiple foci of low signal
intensity

Diagnostic Imaging of Bone Tumors

Diagnostic Imaging of Bone Tumors

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