DAVID SUTTON PICTURES TUMORS AND TUMORS LIKE CONDITIONS OF BONE ONLY FOR STUDY

1. 39David Sutton

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

4. • Fig. 39.1 Multiple skeletal
metastasis is
demonstrated on a whole-
body radionuclide bone
scan. The primary tumour
was carcinoma of the
breast in a middle-aged
woman. Note the
predominantly axial
distribution of the lesions,
many of which were not
apparent on conventional
radiographs. (A) PA view.
(B) AP view.

5. • Fig. 39.2 Metastatic carcinoma of the bronchus. Sagittal T1
- weighted (A) and STIR(B) MRI sequences obtained in the
body coil demonstrate extensive metastasis throughout
the thoracolumbar spine and liver. The primary bronchial
carcinoma is also evident.

6. • Fig. 39.3 Two examples
of solitary metastasis
producing bone in the
adjacent soft tissues.
(A) Carcinoma of the
colon in a great toe
metatarsal. (B)
Transitional cell
carcinoma of the
bladder in the mid
tibia.

9. • Fig. 39.6 Carcinoma of the prostate with expansile lytic
metastasis. (A) A view of the pelvis before the onset of symptoms
reveals no abnormality in the pubic rings. (B) Five years later the
patient was complaining of severe pain in the groin. Note the ill-
defined trabecular pattern, expansion of bone and ill definition of
cortex that has developed since the previous examination.

10. • Fig. 39.6 Carcinoma of the prostate with expansile lytic metastasis. ( (C)
Blood-pool phase of a bone scan and (D) delayed image reveals a marked
increase in activity. Note the abnormality in the lesser trochanter of the
right femur. These features could not be distinguished from active
aggressive Paget's disease on purely scintigraphic grounds except that
the lesion in the right femur has not started at a joint. The diagnosis was
established by biopsy and the presence of a very high acid phosphatase
level in the blood.

11. • Fig. 39.7 (A,B) Two examples of solitary metastasis
from renal cell carcinoma. In both cases, these
metastases were the presenting abnormality. Both
are expansile and have crenellated margins, with
trabeculation in the lesion.

12. • Fig. 39.8 Metastasis from carcinoma of thyroid. (A) A localised view of the
anterior inferior iliac crest shows a small radiolucent defect with a faint sclerotic
margin (arrows). (B) Five years later a very large destructive bone lesion is
present with relatively well defined margins and apparent strands of calcification
within the lesion

13. • Fig. 39.8 Metastasis from
carcinoma of thyroid. (C)
CT confirms the very
extensive nature of the
tumour and shows the
soft-tissue planes to be
preserved (arrow). The
strands of calcification are
shown to be residual
bone anteriorly and
posteriorly and not new
bore in the metastasis.

14. • Fig. 39.8 Metastasis from carcinoma of thyroid. (D,E) Common iliac
arteriography (subtraction images) demonstrates the very
vascular nature of this metastasis. Note the increase in number of
abnormal vessels with changing calibre, the dense tumour blush
and early venous filling.

15. • Fig. 39.9 Pancoast tumour-carcinoma of the
apex of the lung invading and destroying the first
and second ribs.

16. • Fig. 39.10 Bone island-enostosis. (A) A dense area of endosteal
sclerosis present in the upper femoral shaft, discovered by chance
following injury. (B) A bone scan reveals slight increase in activity
localised to the area of sclerosis. Biopsy confirmation. (C) Enostosis,
acetabular roof. Uniformly dense circular lesion with characteristic
radiating spicules extending into the adjacent bone.

17. • Fig. 39.11 Ivory osteomas of the frontal sinus. (A) A typical,
compact, rounded, dense opacity is demonstrated on the
frontal view. (B) In another patient a larger lesion has
moulded to the shape of the sinus.

18. Fig. 39.12 Osteoid osteoma. (A) Involving the ulna in a 13-year-old boy. The
appearances are typical, with a well-defined area of radiolucency (arrow)
containing a dense nidus. Extensive cortical sclerosis is present around the
lesion. (B) Radioisotope bone scan in another patient demonstrating intense
focal increased scintigraphic activity in the distal tibia surrounded by a more
diffuse area of less intense activity, typical of an osteoid osteoma. (C) CT
section of the tibial lesion elegantly demonstrating the cortically located nidus.

19. • Fig. 39.13 Osteoid osteoma-a young man
complaining of groin pain. (A) Initially it
was thought the X-rays were normal;
however, in retrospect, a small
radiolucency (arrow) is present. A bone
scan was performed in order to detect
any occult cause of pain. (B) A localised
focus of increased vascularity is shown on
the blood-pool film (arrow).

20. • Fig. 39.13 Osteoid osteoma-a young man complaining of groin pain.
(C) Extensive abnormality on the delayed film. (D) CT demonstrates
the radiolucent defect anteriorly (closed arrow) with associated,
consolidated periosteal new bone. A nutrient artery is shown
posteriorly (open arrow) and is an incidental finding.

21. • Fig. 39.14 Osteoid osteoma in a young girl complaining of left hip and
knee pain, initially thought to be due to juvenile onset rheumatoid
arthritis. (A) A subtle radiolucency with a central density is shown in the
basi-cervical region of the left femur. (B) Coronal FFE-T 2 MR section
demonstrating high signal intensity within the proximal left femur due to
considerable bone marrow oedema. A joint effusion is evident also
together with some surrounding soft tissue oedema.

22. • Fig. 39.14 Osteoid osteoma in a young girl complaining of left hip and
knee pain, initially thought to be due to juvenile onset rheumatoid
arthritis (C) Axial T2 -weighted MRI showing a prominent left hip joint
effusion and bone marrow oedema within the femoral neck. The nidus,
however, is not evident. (D) Axial T 2 - weighted image through the
proximal femur demonstrating more striking bone marrow oedema distal
to the joint capsule and level of the osteoid osteoma. Periosteal new bone
formation is also shown anteriorly (arrow). (E) Thin section CT showing the
anteriorly located calcified nidus within the cortex of the femoral neck and
the large joint effusion.

23. • Fig. 39.15 Osteoid osteoma in the proximal phalanx of the index finger.
(A) The AP radiograph shows ill-defined periosteal new bone formation
and some sclerosis involving the proximal phalanx. Marked soft-tissue
oedema is also evident. (B) The lateral radiograph demonstrates apparent
expansion and scalloping of the distal anterior cortex of the proximal
phalanx with trabecular sclerosis distal to the radiolucent nidus (arrows).

24. • Fig. 39.16 Osteoblastoma of the right
transverse process and pedicle of L3. An ill-
defined radiolucency is shown within a
sclerotic and expanded transverse process and
pedicle.

25. • Fig. 39.17 Osteoblastoma of the left transverse process of L3. (A)
In this example the central area exhibits calcification. Expansion is
present with diffuse sclerosis. (B) Note on the bone scan (which
has been reversed for ease of comparison) the extensive area of
increased activity corresponding to the whole of the osteoblastoma
on the plain film. Note also the scoliosis, with which these patients
may present.

26. • Fig. 39.18 Osteoblastoma of the left pedicle and lamina of L3. (A)
Conventional oblique radiograph showing expansion and sclerosis.
(B) Radionuclide bone scan demonstrating extensive and marked
increase in activity and a scoliosis. (C) CT section showing punctate
calcification of the lesion with expansion of the pedicle and lamina
and prominent dense sclerosis. Considerable soft-tissue oedema is
also evident (arrows).

27. • Fig. 39.19 Aggressive osteoblastoma. (A)
Conventional radiograph demonstrates a large
area of ill-defined bone sclerosis extending into
the soft tissues above the acetabular roof. This
had been previously biopsied. A vague ill-
defined zone of radiolucency is demonstrated
within the proliferative new bone. (B) A T,-
weighted coronal MR image demonstrates
extensive low-signal abnormality throughout
the whole of the right iliac blade down to the
acetabular roof. A soft-tissue component is also
evident. This scan also illustrates how difficult it
can be to assess sclerotic lesions using MRI

28. • Fig. 39.20 Osteosarcoma
of the distal fibula-
predominantly
osteoblastic. Amorphous
calcification/ossification
is present in the soft
tissues with cortical
destruction and a little
periosteal new bone
formation.

29. • Fig. 39.21 Osteosarcoma of
the distal femur-
predominantly
chondroblastic. Note the
well-defined soft-tissue
mass and radiating
spiculation of calcification
within it. Sclerosis and lysis
are present within the
medullary cavity that is
slightly expanded.

30. • Fig. 39.22 Telangiectatic osteosarcoma of the distal femur. (A) A
predominantly radiolucent defect is shown on conventional radiograph
which angiographically (B) is shown to contain large, tortuous,
pathological vessels. Well-marked Codman's triangles are present together
with sclerosis in the shaft of the bone, surrounding the lesion.

31. • Fig. 39.23 An advanced
osteosarcoma of the
proximal humerus
presents with a
pathological fracture. A
large well-defined soft-
tissue mass contains
calcification and
ossification. Codman's
triangles are present.
Extensive tumour in the
medulla has caused both
bone destruction and
bone formation.

32. • Fig: 39.25
Osteosarcoma-
metastasis in the
lung present
with a
pneumothorax.

33. • Fig. 39.24 Osteosarcoma of the spine. (A) A conventional radiograph of the upper
lumbar spine shows a extensive area of tumour new bone formation arising from
the lamina of Ll and extending into the paravertebral soft tissues. (B) The CT
section demonstrates the origin and extent of the tumour. Marked compression of
the dural sac results from extension onto the spinal canal.

34. • Fig. 39.26 (A) Metastasis from osteosarcoma presents with an encysted
pleural effusion on the right after several months apparently disease free
after amputation. (B) A CT scan demonstrates the encysted effusion in the
horizontal fissure with calcification dorsally due to metastasis. This feature
had not been appreciated on conventional tomography. A second
metastasis is shown in the right lower lobe, again not obvious on
conventional radiographs.

35. • Fig. 39.27
Osteoblastic
osteosarcoma of the
proximal tibia. (A)
The conventional
radiograph reveals
patchy increased
density in much of
the upper tibia.
Note a little new
bone laterally.

36. • Fig. 39.27 Osteoblastic osteosarcoma of the proximal tibia. (B) A scan in
the early blood-pool (left) and delayed phases (right) demonstrates an
extensive abnormality. Note the activity is more uniform and extensive
than the apparent involvement shown on the plain film. The distal extent
of the tumour is confirmed however by (C), a CT scan which shows a
subtle change in marrow attenuation below the level of the apparent
tumour on plain film, an example of how CT may be used to gauge the
extent of marrow involvement.

37. • Fig. 39.28 Osteosarcoma of the distal femur of a young woman. (A) The full intraosseous
extent is difficult to assess on the plain film. (B) An arteriogram demonstrates a very
extensive pathological circulation and on the late capillary phase (C) note that the tumour
extends into the epiphysis, almost to the articular surface, and that there is a satellite or
'skip' lesion in the proximal femoral shaft (arrow).

38. • Fig. 39.28 Osteosarcoma of the distal femur of a young woman. (C) note
that the tumour extends into the epiphysis, almost to the articular surface,
and that there is a satellite or 'skip' lesion in the proximal femoral shaft
(arrow). This latter lesion is confirmed by CT (D), and is shown to be bone
forming (the upper image shows an attenuation of 188 HU in the lesion).

39. • Fig. 39.29 Osteoblastic osteosarcoma. A middle-aged woman
presented with pain and swelling in the mid ulna. (A) A radiograph
shows ill-defined sclerosis and cortical destruction. (B) An
angiogram demonstrates an egg-shaped soft-tissue mass with
displacement of both the ulnar and interosseous arteries. The
extraosseous extent of the tumour was thereby delineated.

40. • Fig. 39.30 Osteosarcoma. Coronal T,-weighted (A) and STIR (B)
sequences demonstrate an extensive osteosarcoma of the lateral
femoral condyle. The pleomorphic nature of the tumour can be
appreciated by the more superficial main neoplasm with
subadjacent marrow oedema. Note the overlying abnormal vessels
shown as a signal void and the joint effusion on the STIR sequence.
Clear extension across the metaphysis is also shown. These features
confirm an extracompartmental osteosarcoma.

41. • Fig. 39.31 Osteosarcoma of the proximal humerus. (A) Conventional radiograph showing permeative bone
destruction and focal areas of intramedullary sclerosis. A spiculated periosteal reaction is also evident. Axial T 1 -
weighted (B) and coronal STIR (C) images demonstrate the longitudinal extent of the tumour within the medullary
canal and the extraosseous involvement, including extension into the shoulder joint (arrows).

42. • Fig. 39.32 Osteosarcoma of the proximal tibia. (A) Conventional radiograph demonstrating an
osteosclerotic lesion with Codman's triangles and a pretibial soft-tissue mass. (B) Sagittal T1 –
weighted image showing intramedullary involvement throughout the whole of the tibia included in
the illustration and extension into the proximal epiphysis. Both posterior and anterior extraosseous
involvement is evident. (C) Axial turbo T 2 -weighted image demonstrating circumferential soft-
tissue involvement with radiating spicules of new bone within the soft-tissue component.

43. • Fig. 39.33 Osteosarcoma of the proximal tibia. (A) Conventional radiograph showing an osteoblastic lesion with
periosteal new bone medially. (B) Sagittal turbo T 2 -weighted image with fat suppression. (C) Axial T,-weighted
image with fat suppression. (D) Axial turbo T 2 -weighted image with fat suppression. The MR images elegantly
demonstrate the heterogeneity of the tumour, the intramedullary involvement (note the normal fatty marrow
within the distal femur and proximal fibula), periosteal new bone and involvement of the tibia origin of the
patellar tendon. Perilesional oedema and a joint effusion are also evident.

44. • Fig. 39.33 Osteosarcoma of the proximal tibia. (A) Conventional radiograph showing an
osteoblastic lesion with periosteal new bone medially. (B) Sagittal turbo T 2 -weighted image with
fat suppression. (C) Axial T,-weighted image with fat suppression. (D) Axial turbo T 2 -weighted
image with fat suppression. The MR images elegantly demonstrate the heterogeneity of the
tumour, the intramedullary involvement (note the normal fatty marrow within the distal femur and
proximal fibula), periosteal new bone and involvement of the tibia origin of the patellar tendon.
Perilesional oedema and a joint effusion are also evident.

46. • Fig. 39.35 Diaphyseal
osteosarcoma of the
midshaft of the femur.
Note the radiating
spiculation of bone,
Codman's triangles and
well-defined soft tissue
mass.

47. • Fig. 39.36 Diaphyseal
osteosarcoma. A pathological
fracture is present in the mid
humerus with extensive endosteal
sclerosis and cortical destruction
from the medullary aspect.
Tumour is present to the neck of
the humerus with areas of dense
sclerosis and surrounding faint
radiolucency. These 'skip' lesions
do not represent isolated tumour;
the shaft was involved
continuously. This variety carries a
poor prognosis.

48. • Fig. 39.37 Central
osteosarcoma of the
distal femoral
metaphysis
presenting as a dense
area of sclerosis with
ill-defined margins.

49. • Fig. 39.38 Soft-tissue
osteosarcoma. An
elderly vicar
complained of an
enlarging soft-tissue
mass adjacent to the
medial malleolus of his
right ankle. Note the
amorphous soft-tissue
ossification and
calcification and
normal bone
underlying the lesion.

50. • Fig. 39.39 Radiation sarcoma arising in the posterior
iliac crest on the left, in an elderly woman treated 6
years previously for carcinoma of the cervix. The lesion
is purely osteolytic with ill-defined surrounding

51. • Fig. 39.40 Parosteal
osteosarcoma of the
proximal humerus. A well-
defined mass of dense
tumour bone surrounds
the humeral shaft. A
typical radiolucent line is
present between the
tumour bone and the
proximal shaft
inferomedially (arrow).
The underlying bone
appears normal.

52. • Fig. 39.41 Parosteal
osteosarcoma arising
from the anterior
aspect of the femur (A)
is shown
angiographically (B) to
be unremarkable apart
from a slight increase in
the number of
branches going into the
tumour. The lesion was
found at biopsy to be of
very low-grade
malignancy.

53. • Fig. 39.42 Paget's sarcoma of the body of the pubis. (A) No
malignancy was seen in this man at initial presentation with
polyostotic Paget's disease. (B) Three years later, however,
he complained of local pain with the development of a
purely lytic destructive lesion involving the body of the
pubis.

54. • Fig. 39.43 Multiple chondromas
in the hand. This child presented
with painless swelling. Note the
cortical expansion and thinning,
well-defined defects, patchy
amorphous calcification and
moulding abnormalities
indicating slow growth

55. Fig. 39.44 Cartilage tumour. This patient presented with a longstanding ache in the thigh.
Coronal T 1 -weighted (A) and STIR (B) sequences demonstrate a mixed lesion within
the femoral shaft. Note that the cartilage has high signal on the STIR sequence. A
surrounding rim of sclerosis is shown by deficient signal on both images. Histologically,
this tumour was considered benign, in spite of giving rise to symptoms and to
increased activity on a radionuclide scan and showing a high water content on MRI. In
a different patient, presenting with signs of internal derangement, a similar lesion is
shown on coronal T,-weighted (C) and

56. • Fig. 39.44 Cartilage tumour. In a different patient,
presenting with signs of internal derangement, a
similar lesion is shown on coronal T,-weighted (C) and
STIR (D) images.

57. • Fig. 39.45 J uxtacortical
chondromas arising on
the volar aspect of the
proximal and middle
phalanges of the index
finger. Obvious pressure
defects are present with
new bone formation at
the margins. Punctate
calcification is present in
the middle of the
proximal lesion.

58. 39.46 Maffucci's syndrome
(woman aged 23).
Numerous chondromas
In this case of
dyschondroplasia are
accompanied by soft-
tissue swelling which
contains phleboliths
indicating
haemangiomas. These
skeletal lesions are more
liable than ordinary
chondromas to undergo
malignant
transformation.

59. • Fig. 39.47 Chondroblastoma in the proximal
epiphysis of the tibia. The tumour has thinned
the overlying cortex and extends across the
growth plate into the upper metaphysis.

60. • Fig. 39.48 Chondroblastoma. (A) A lytic lesion
with a thin rim of sclerosis is shown in the distal
femoral epiphysis. Axial gradient echo-image (B)
and sagittal T2 -weighted image (C) showing
speckled areas of high-signal intensity within the
subchondral lesion.

61. • Fig. 39.49 Chondroblastoma of the femoral
head. The CT image demonstrates a
destructive subchondral lesion containing
areas of calcification within it and bordered by
a sclerotic rim.

62. • Fig. 39.50 Chondromyxoid fibroma of the
proximal tibia. Note the extremely well defined
radiolucent defect with a sclerotic margin on the
endosteal aspect. (A) Ap view (B) Lateral view.

63. • Fig. 39.51 (A, B) Chondromyxoid fibroma-great toe metatarsal.
The tumour is eccentric in position with extreme cortical expansion
and thinning. The endosteal margin is well defined and faintly
sclerotic. No calcification is present.

64. • Fig. 39.52 Osteochondroma of
the distal femur. The cortex is
continuous with that of the
underlying bone and trabecular
bone merges with that of the
femur. A well-defined cartilage
cap contains calcification and is
directed away from the joint.

65. • Fig. 39.53 (A,B) A pedunculated osteochondroma exhibits
growth over a 2-year period in the humerus of a child. Such
growth is common and stops usually at, or soon after, puberty.

66. • Fig. 39.54 (A,B)
Osteochondromas may rarely
be shown to regress,
remodelling resulting in normal
appearances. Here an
osteochondroma of the
proximal humerus cannot be
visualised 6 years later.

67. • Fig. 39.55 Diaphyseal aclasia. (A) Multiple osteochondromas are
present in the proximal tibia and fibula. A large sessile lesion of the
proximal tibia has caused widening of the interosseous space and
secondary moulding abnormalities of both the tibia and fibula. In
another patient (B), similar modelling abnormalities are shown.

68. • On MRI, following ligamentous injury, only a minimal cartilage cap
can be identified on the medial osteochondroma, and a slightly
thicker cap on the laterally projecting osteochondroma: (C) coronal
T 1 - weighted, (D) coronal FFE-T2 and (E) axial T,-weighted images.

69. • Fig. 39.56 Chondrosarcoma
arising from the superior
public ramus on the left. A
huge mass is present
containing extensive
calcification. The femoral
artery is displaced by the
mass but note the absence
of any pathological
circulation. This is typical of
a low-grade
chondrosarcoma.

70. Fig. 39.57 Central chondrosarcoma.
The destructive lesion in the
femoral shaft has smooth well-
defined margins, but in the upper
portion, some characteristic
punctate calcification is visible. The
tumour is of a slow- growing type
because organised periosteal new
bone has thickened the minor
cortex around the lesion.

71. • Fig. 39.58 Central
chondrosarcoma. (A) The
tumour is more aggressive
than that in Fig. 39.57, and
has extended into soft
tissues. This is confirmed by
CT (B), showing extension
anterior to the femoral shaft.
Calcification is seen both in
the soft tissue mass and
within the shaft lesion.

72. • Fig. 39.58 Central
chondrosarcoma. (A) The
tumour is more aggressive
than that in Fig. 39.57, and
has extended into soft
tissues. This is confirmed by
CT (B), showing extension
anterior to the femoral
shaft. Calcification is seen
both in the soft tissue mass
and within the shaft lesion.

73. • Fig. 39.59 Chondrosarcoma arising in the acetabulum of a 45-year-
old man. (A) The tumour is purely lytic. Cortical thickening is shown
medially. (B) CT demonstrates disruption of the cortex posteriorly,
with a localised soft-tissue mass beneath the glutei and faint
calcification within the lesion.

74. • Fig. 39.60 Chondrosarcoma. Arising primarily in the region
of the acetabulum. A coronal T 1 -weighted (A) and axial
STIR (B) sequences demonstrate a large lobulated mass
occupying the floor of the acetabulum and extending
through into the pelvis and the obturator foramen. Note
the high signal on STIR, suggesting aggressive tumour, with
also some increased signal surrounding the lesion due to
oedema (secondary response). There is obvious
involvement of the hip joint.

75. • Fig. 39.61
Chondrosarcoma arising
in the sphenoid bone of
an adult woman. A large
soft-tissue tumour
extends from the nasal
cavity to the middle fossa.
A thin sclerotic margin
outlines the mass, which
contains faint punctate
calcification. Note the
displacement of the globe.

76. Fig. 39.62 Dedifferentiated
chondrosarcoma. A
chondrosarcoma is present
centrally within the distal
femoral shaft, characterized
by slight expansion and
amorphous calcification. In
addition, an area of
osteolysis is present with
cortical destruction around
the lower half of the tumour.
The latter represents a high-
grade malignancy arising in
conjunction with a
preexisting relatively low-
grade tumour.

77. • 1284 A TEXTBOOK OF RADIOLOGY AND IMAGING Fig. 39.63 Mesenchymal chondrosarcoma. A
hard mass had been present in this middle-aged man's calf for 8 years. Recently it had increased in
size. (A) Soft-tissue radiography shows extensive calcification in a well-defined tumour mass. (B)
The blood-pool phase of a bone scan reveals a marked increase in vascularity throughout the lesion
that is intensely active on the delayed images ((C) top right). Note also the presence of multiple
metastasis, particularly in vertebrae and the pelvis

78. • Fig. 39.63 Mesenchymal
chondrosarcoma (D) A femoral
arteriogram confirms the markedly
abnormal vascularity with
pathological vessels throughout the
tumour mass. The similarity
between the extent of the
abnormality shown angiographically
and on the blood-pool phase of the
bone scan is striking.