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benign bone lesions x ray radiology guide.pdf
- 1. BENIGN BONE LESIONSX RAY • PRESENTER : T SRIHARSHA • MODERATOR : DR PRUDVEESH
- 2. Epidemiology of bonetumors Incidence : Benign>Malignant It is likely that benign lesions are underestimated because they often are asymptomatic and not clinically recognized.
- 3. Classification of BenignBone Tumors • Bony origin • Bone island • Osteoma • Osteoid osteoma. • osteoblastoma • Cartilaginous • C h o n d r o m a • C h o n d r o b l a s t o m a • Chondromyxoid fibroma • Osteochondroma Presumed to arise from skeletal tissue • Fibrous • Fibrous cortical defect • Non-ossifying fibroma (NOF) • Desmoplastic fibroma • Fibromatosis • Giant cell containing • Giant cell tumor (GCT) • Aneurysmal bone cyst ( ABC)
- 4. • Blood vessels •Hemangioma • Cystic angiomatosis • Hemangiomatosis • Glomus tumor • Nerves • Neurofibroma • Neurilemmoma/Schwannoma Presumed to arise from other tissues in bone • Fat • Lipoma • Epithelium • Implantation dermoid
- 5. • Presumed toarise from joints • Intraosseous ganglion • Pigmented villonodular synovitis ( PVNS) • Synovial chondromatosis • Lipoma arborescens • No known origin • Solitary bone cyst (SBC) • Non-neoplastic tumors • Brodie's abscess • Hydatid • Hematoma • Infarction • Histiocytosis
- 6. Lytic benign bonetumors
- 7. Diagnostic modality ofchoice • Clinical feature • May be less useful As many lesions present with non-specific features of pain, swelling or pathological fracture. • Sex incidence is of little diagnostic value in primary bone tumors . • Plain radiograph • Mainstay of imaging modality • Views: Antero-posterior, lateral and oblique (at least 2 views 90* to each other) • • CT Scan • Can define matrix calcification , Fracture , Soft tissue extension and endosteal scalloping. • To assess bones like spine, pelvis, scapula and mandible. • Nidus in osteoid osteoma - CT is max we can do for osteoid osteoma.
- 8. • MRI • Givesidea about varieties of tissues present • To assess chondroid matrix, fluid fluid levels, bone marrow involvement, cortical breach and joint involvement. • Intraosseous edema and extraosseous inflammatory • response may be demonstrated • Pre-op planning / post-op evaluation • Angiography • To see tumor vessels • To see encasement of major adjacent vessels • To distinguish between tumors, e.g. Osteosarcoma is highly vascular and chondrosarcoma is hypovascular
- 9. • Bone scintigraphy •Compound - technetium labelled diphosphonate • Phases • Blood pool phase • Vascular lesion e.g. ABC, avascular Isesion e.g. Cartilage tumors • Delayed phase • • Helps to identify multiplicity of lesions • • To see distant metastases • • Patient is symptomatic (e.g. bone pain), but no lesion is identified in plain radiograph or CT Scan, then Bone scintigraphy can be helpful.
- 11. Peak age incidenceof bone neoplasms
- 12. L o ca t i o n
- 15. Behavior and morphologyof a lesion • Pattern of destruction • Zone of transition • Cortical integrity • Matrix calcification • Periosteal reaction. • Soft tissue vs bone • Septations
- 16.
- 18. Zone of transition •A) Narrow zone of transition • • Long-standing • • Non-aggressive • B) Wide zone of transition • • Fast-growing • • Aggressive
- 19. P e ri o s t e a l r e a c t i o n
- 21.
- 22. P a tt e r n s o f m a t r i x calcification
- 24. Septations • Coarse andthick - chondromyxoid fibroma. • Delicate and thin - Gaint cell tumor • Horizontal - ABC • Lobulated - NOF • Striated,radiating - hemangioma.
- 25. Benign bone tumorsof bony origin • Bone island • Osteoma • Osteoidosteoma • Osteoblastoma
- 26. Bone island /Enostosis • Common benign bone lesion • • Usually seen as an incidental finding • Constitute a small focus of compact bone within a cancellous bone • One of the " don't touch lesions" • Age - Any age • • May grow in size up to the age of skeletal maturity • • L o c a t i o n • • Can occur anywhere in the skeleton • • some predilection for pelvis, long bones, spine and ribs.
- 27. Plain radiographic findings •Single or multiple • Round or oval • Always medullary in location • Has radiating thorn-like spicules with narrow zone of t r a n s i t i o n • Size - usually < 15mm, can be large up to 4 cm • • No periosteal reaction, no cortical expansion • In diaphyseal bone, the long axis of a bone island typically parallels the long axis of the involved bone. In the metaphysis, and other regions, these are typically more spherical.
- 29. O s te o m a • Seen almost exclusively in bones formed in membrane • • Slow growing, usually asymptomatic, found incidentally • • L o c a t i o n - Paranasal sinus , Skull v a u l t , Mandible • • Size • • Varies, some > 2 . 5 cm • • Types • Ivory/dense • • Lacks haversian system • Spongy • • Resembles normal bone
- 30. • Ivory osteomasappear very radio-dense • Spongy osteomas may demonstrate central marrow • Complications • • Growth within PNS c a n cause mucocele • • Growth from inner table of skull may produce raised intracranial pressure • • Association - "Gardner syndrome" • Multiple osteomas of skull, mandible and long bones • > Familial adenomatous polyposis • Soft-tissue tumors of connective tissue origin Radiographic features
- 31.
- 32.
- 33. Mandibular osteomas inGardner syndrome
- 34. Osteoid o st e o m a • Age • • 10-35 yrS. • Sex i n c i d e n c e • M:F = 3:1 • • Clinical f e a t u r e • • Typical history of localized, intermittent bone pain of several weeks or months, occurring specially at night, with dramatic relief by NSAID's • • L o c a t i o n • • Long bones of limbs, majority in femur & tibia • • Can occur anywhere • • In spine, occurs in posterior elements. • • (careful scrutiny of the neural arches at the apex of the concavity of scoliosis)
- 35. • An osteoidosteoma is composed of three • concentric parts- n i d u s meshwork of dilated vessels, osteoblasts, osteoid a n d woven bone • 11. may have a central region of mineralization • I I . fibrovascular rim • I. surrounding reactive sclerosis • ***The nidus releases prostaglandins (via Cox-1 and • Cox-2) which in turn result in pain. Pathology
- 36. • A roundor oval radiolucency with a sclerotic margin and contains a small dense center, known as nidus • • Solid periosteal reaction with cortical thickening • • Size - usually < 2 cm • • C a n be multifocal Plain radiograph & CT features
- 37. • Most importantmeans in cases of medullary osteoid • osteoma, where radiographs remain normal • Also important in any young patients with bone pain • and normal radiographs • • Findings • • Intense focal area of increased activity surrounded by less intense activity from the reactive sclerosis. • • Evident in blood-pool image and persists in delayed • image. B o n e s c a n
- 39. • Osteoblastoma (>2cm) •Stress fracture - that c a u s e s c h r o n i c cortical • thickening • • Chronic osteomyelitis • • Area of radiolucency more irregular • • Sequestra are irregular or linear in shape, • differentiating from central nidus of osteoid • o s t e o m a Differentials
- 40. O s te o b l a s t o m a • Similar in histological characteristics as osteoid osteoma but usually larger • Less c o m m o n t h a n osteoid o s t e o m a • Age • • 80% of patients under the age of 30 • In 2nd and 3rd decades • Clinical feature • • Long insidious history of pain, often worsening at night • Not relieved by NSAID's • Limitation of movement • • L o c a t i o n • • Spine ( posterior element), flat bones • • Metaphysis and distal diaphysis of long bones. • • Pathology • Larger than osteoid osteoma • • Irregular in shape, friable and hemorrhagic • • Abundant osteoid tissue and many thin-walled capillaries
- 41. • S iz e = 2 - 1 0 c m • Radiolucent lesion • Margin - irregular but sharply demarcated • Surrounding sclerosis - varies but can be profound • Can cause cortical expansion and thinning • Calcification o r ossification o f osteoid tissue - • punctate or amorphous • Sometimes, lesion can be aggressive with soft tissue • masses containing calcification and ossification • • B o n e s c a n • • Active both in blood-pool and delayed phase Plain radiograph and CT features
- 44. Cartilage-forming benign bone tu m o r s • C h o n d r o m a • Chondroblastoma • Chondromyxoid • fi b r o m a • Osteochondroma
- 45. Chondroma/Enchondroma • Relatively commonbenign tumor • • Single/multifocal • • Usually central medullary • • Age • Childhood to adulthood, peak incidence = 10-30 years • • Clinical feature • Rarely symptomatic • • Patient may admit localized hard swelling for many years • • May be complicated by pathological fracture • • L o c a t i o n • • 50% in hands - commonly in phalanges, less commonly in metacarpals • • 10% in small bones of feet • • 20% - long bones • • 20% - flat bones - pelvis, scapula and vertebral bodies.
- 46. • Cartilaginous tissueis not radiopaque • • Radiolucent lesion • Expansion and thinning of overlying cortex • No periosteal reaction in the absence of fracture • Z o n e o f t r a n s i t i o n is n a r r o w a n d s c l e r o t i c • Endosteal scalloping + • Flecks o f c a l c i fi c a t i o n w i t h i n t h e lesion • usually purely lytic in phalanges, in other • locations, enchondromas are expansile, with • characteristic "rings and arcs" calcifications. Plain radiograph & CT scan features
- 47. • T1 • •Low to intermediate signal • T 2 • • typically of background intense high signal • (high water content of hyaline cartilage matrix) • • they can be focal regions of signal drop out where calcification • p r e s e n t • • P o s t - c o n t r a s t • • Variable e n h a n c e m e n t MRI
- 49. Special type- Juxtacorticalchondroma • R a r e • • Usually in young adults and • related to the cortex of a long • bone and phalanges • Radiologically - • • Well-defined soft tissue mass with • c a l c i fi c a t i o n • • Bordered by thin, incomplete shell • of overlying bone • • Pressure erosion causes scalloping • of underlying cortex • • Va r i a b l e s c l e r o t i c r e a c t i o n
- 50. • Ollier disease •• non-hereditary, sporadic, skeletal disorder characterized by multiple enchondromas that are principally located in the metaphyseal regions. • Maffucci's syndrome • • Rare association of dyschondroplasia with • cavernous hemangiomas in soft tissues A s s o c i a t i o n s
- 51. • Implantation dermoidcyst - in hands • B . Medullary bone infarct • A . Curvilinear peripheral calcification in the infarct Differentials
- 52. C h on d r o b l a s t o m a • R a r e • • Characteristically occur in epiphyses of apophyses • of long bones in young patients • Age • • < 2 o y r s • Sex prevalence • • Slight male predominant • • L o c a t i o n • • Most tumors occur in epiphyses of long bones, specially around • the hips, knees or shoulders • • Also occur in apophyses
- 53. • Well-defined ovallucent lesion • • S i z e = 1-10 c m • Position- eccentric in the epiphyses • Margin- thin sclerotic rim • • Cortical expansion = +- • Periosteal r e a c t i o n = +- • Internal calcification = about quarter of cases = stippled calcification Plain radiograph and CT Scan features
- 54. • Ideal forevaluating transphyseal or transcortical • expansion • • To see bone marrow & soft tissue edema • •Bone s c a n • • Increased activity in blood-pool phase • Differentials • • Osteomyelitis - Brodie's abscess (same location) • • Giant cell tumor - older age group MRI
- 56. Chondromyxoid fibroma • Predominantlychondroid, but contains myxomatous • tissue and giant cells as its name tells • • Age • • 2nd and 3rd decades • • L o c a t i o n • • 2/3"d around the knee joint - specially proximal tibia • (metaphyseal, may extend to epiphyseal line) • • Can occur in fl a t and short bones
- 57. • Lobulated radiolucent,eccentric lesion • Well-defined margin with surrounding sclerosis • Presence of septations • No periosteal reaction • • Calcification very uncommon • Sometimes, peripheral bony margin very hazy and poorly defined, appearing aggressive • • CT is helpful to delineate a cortical margin in the expanded soft-tissue mass • • B o n e s c a n • • Increased activity is usually localized to the reactive sclerosis rather t h a n t o t h e lesion itself Plain radiograph and CT Scan features
- 59. D i ffe r e n t i a l s • NOF - younger age group • • Chondroblastoma - younger age group • • ABC = ill-defined endosteal margin
- 60. O s te o c h o n d r o m a • Relatively common • Osseous outgrowth arising from bony cortex • • Single/multiple • • Capped by cartilage • In long bones, grows away from the metaphyses to the diaphysis, • i.e. away from the joint - typical characteristic • Age • • Develop during childhood • • Can present at any age • • L o c a t i o n • • Lower limb =50% • • Upper limb = 10-20% • • Flat bones like scapula and pelvis • • Types • • Sessile - usually in pelvis • • pedunculated
- 61. • In longbones, in the metaphysis & grows away from the joint • Size - varies, can be as long as 10 cm • Pedunculated type - cortex of lesion continuous with the underlying bone and medullary cavity merging through the cortical defect • • Cartilage cap best seen in CT • As age increases - calcification increases ( punctate or • curvilinear) • Growth ceases after skeletal maturation • Sessile type in flat bones may resemble cauliflower Plain radiograph & CT scan features
- 63. D i ffe r e n t i a l • Supracondylar/Supratrochlear /Avian spur • • Anatomic variant • • In distal antero-medial humeral cortex • • About 5 cm above the elbow joint • • Directed towards the elbow joint
- 64. Hereditary multiple exostoses/Diaphyseal aclasis • A u t o s o m a l d o m i n a n t d i s o r d e r • Multiple • o s t e o c h o n d r o m a s • • Diagnosed by the age • of 12 years
- 65. Malignant transformation ofcartilage forming tumors • T u m o r s that c a n t r a n s f o r m • • C h o n d r o m a • • O s t e o c h o n d r o m a • Common if location - in long and flat bones • More common in diaphyseal aclasis • When to suspect transformation?? • • Recent increase in pain • • Alteration of radiological appearances on serial films • • Late development of pathological fracture • • Cortical d e s t r u c t i o n • • S o f t t i s s u e m a s s • Benign bone
- 66. Benign bone tumorsfrom skeletal t i s s u e - F i b r o u s t u m o r s • Fibrous cortical defect • Non-ossifying fibroma • Desmoplastic fibroma • Fibromatosis
- 67. F i br o u s c o r t i c a l d e f e c t • Extremely common • Usually discovered by chance • Histologically identical to NOF • • Age • • Typically occur in children • • 2-15 y e a r s • • L o c a t i o n • • Occurs in distal femur, ends of tibia • • Metaphysis or diametaphyseal regions • • Less frequent in upper limbs
- 68. • Sharply definedlucent intracortical lesion • They are blister-like cortical expansion • Size = small than 2-3 c m • May appear only lucent lesion when on frontal view • • Have fine sclerotic margin • Increasing skeletal maturity = increasing sclerosis = • migrates to diaphysis = involutes • No periosteal reaction • Not reach medullary cavity Radiographic features
- 70. • N OF • • O s t e o i d o s t e o m a • • Stress fracture D i ff e r e n t i a l s
- 71. Non-ossifying fibroma (NOF) •Most common benign fibrous lesion • Similar to fibrous cortical defect, but much larger and • occurs in slightly older age • they spontaneously heal, being gradually filled in by • b o n e • Age • • 10-20 yrs. • Location • • Vast majority around the knee joint. • • Femur being the commonest
- 72. Radiographic features • Sharplydefined lobulated radiolucent lesion in the metadiaphysis, often eccentric • Larger than fibrous cortical defect • • Have thin sclerotic rim • Cortex - intact a n d t h i n n e d • • No periosteal reaction • • Skeletal matures - moves toward diaphysis - gradually • involutes by filling of bone • • D i f f e r e n t i a l s • • SBC • • Monostotic fibrous dysplasia
- 75. Desmoplastic fibroma • Extremelyrare • • Exhibits dense fibrous tissue • • Do not metastasize but locally aggressive • Age - usually in young adults • Clinical feature • • Constant pain • • Lesion is often t e n d e r • • L o c a t i o n • • Metadiaphysis of long bones • • Pelvis and spine • • Abundant collagenous stroma • • Fibroblasts, myofibroblasts & mesenchymal cells
- 76. • Tend tobe large, solitary and destructive • Expanded irregular sclerotic margin • • Trabeculated pattern • • Widening of host bone due to periosteal new bone formation Plain radiograph & CT Scan features
- 77. Giant cell containing •GCT • • ABC • • Brown tumor of hyperparathyroidism • • C h o n d r o b l a s t o m a • • Chondromyxoid fibroma.
- 78. GCT O st e o c l a s t o m a s • Name coming from its histological picture • • GCT containing richly vascular tissue with spindle cells and numerous giant cells • • It neither forms bone nor cartilage • • Locally aggressive • • Can recur after excision • • Age • • 20-40 y e a r s • • 3% develop in immature skeleton • • L o c a t i o n • •around the knee: distal femur and proximal tibia: 50-65% • • distal radius: 10-15% • • sacrum: 4-10% • • vertebral body: 5-10%
- 79. • A lucentlesion typically situated beneath the articular surface • E c c e n t r i c • Narrow z o n e o f transition • 'soap-bubble' pattern of calcification • No sclerotic margin • • overlying cortex is thinned, expanded or deficient • • Soft-tissue mass may be present • • No calcification or ossification until complicated by f r a c t u r e • • CT Scan & MRI • • To delineate soft tissue extension • • B o n e s c a n • • Increased activity in blood-pool phase Plain film & CT features
- 81. A B C •"Aneurysmal" name - is derived from macroscopic appearance of a blood-filled, expansile, sponge-like tumour containing numerous giant cells • May arise in association with NOF, fibrous dysplasia and chondromyxoid fibroma • Age • • Children and adolescents. • • 8 0 % before 20 yrs. of age • L o c a t i o n • • Long bones 50-60%, typically metaphysis, Lower>Upper limb • • Spines and sacrum = 20-30% • • Craniofacial - jaw, basisphenoid and pns
- 82. Plain film features •An expansile lytic lesion • S i z e = 2 - 2 0 c m • Z o n e o f transition - can be ill-defined • Thin sclerotic margin • • Cortical breach and soft tissue extension • CT & MRI • • To delineate soft tissue extension • • Shows characteristic fluid-fluid levels (representing areas of • blood of variable ages) • ***Other benign lesions with fluid-fluid levels • • G C T • • Chondroblastoma
- 85. Differentials of ABCin spines - Osteoid osteoma and Osteoblastoma (bone-forming nature differentiates these)
- 86. Benign tumors arisingfrom blood vessels • Hemangioma • • Cystic angiomatosis • • Hemangiomatosis • • G l o m u s t u m o r
- 87. Hemangioma • Typically solitary •• Frequent incidental finding in MRI of spine • Age • • 10-45 y e a r s • Types • • Cavernous - with large thin-walled vessels, occurring particularly in • spine and skull • • Capillary - spread in a sunburst pattern • • L o c a t i o n • • 50% spine • • 50% skull and long bones
- 88. Plain fi lm a n d CT f e a t u r e s • Osteolytic lesion with a trabecular pattern • • No expansion in spine • • Can cause cortical expansion in skull and long bones • with thin rim o f sclerosis • • In long bones, osteolytic lesion may have soap-bubble • appearance with stippled radiodensity • • Can affect posterior elements of vertebra
- 91. Glomus tumor/Glomangioma/ Hemangiopericytoma • Rare,highly differentiated vascular tumor • • Age • • 4th and 5th decades • Clinical feature • • Extremely painful, tender and sensitive to cold • L o c a t i o n • • Terminal phalanx, particularly subungual portion • • Pathology • • branching vascular channels • • aggregates of specialized glomus cells
- 92. Plain film fe a t u r e s • Lucent lesion with extremely sharp margin • • May show osseous erosion or thinning of adjacent • cortical b o n e • • B o n e S c a n • • Increased activity in early phase and blood-pool phases
- 93. Benign tumor arisingfrom fat - Intraosseous Lipoma • Extremely rare • • Age • • Wide range = 5-85 years • • Usually detected in 4th-5th decades • • L o c a t i o n • • Lower limb = 75% ( metaphysis) • • Calcaneum>femur >tibia>fibula • • Upper limb • • Skull and mandible • • Spine & pelvis • • Ribs
- 94. Plain radiograph feature •Expansile radiolucent lesion with sharply defined • sclerotic margin • • No periosteal new bone formation • Within calcaneum, lipoma has characteristic • appearance, osteolytic lesion with a central focus • o f o s s i fi c a t i o n • CT & MRI • • Can be homogenous fat content • • Fatty lesion with central necroses, central • calcifications o r o s s i fi c a t i o n s • • Fatty lesion with multiple central necroses, central • calcifications or ossifications
- 95. Differentials for intraosseouslipoma - SBC and Bone infarct
- 96. Benign tumor ofunknown origin • Always unilocular • • Found incidentally, more than half present due to a pathological • f r a c t u r e • Age • • Sex • 1st and 2nd decades • C a n o c c u r a f t e r s k e l e t a l i n c i d e n c e • • M:F = 2-3:1 • m a t u r a t i o n • • L o c a t i o n • Typically intramedullary in long bones • In childhood, near growth plate, then migrates to diaphysis, then involutes • Proximal humerus> Proximal femur>Other long bones • Calcaneum & Talus ( after skeletal maturation) • • Pathology • • Cyst contains clear liquid unless there has been contamination by bleeding • following a fracture. • • Cyst is lined by a thin layer of connective tissue. Simple bone cyst / Unicameral bone cyst/Solitary bone cyst
- 97. Plain radiograph &CT features • A central radiolucent lesion in metadiaphysis is • c h a r a c t e r i s t i c • • Cortex may be thinned and expanded • Sclerotic margin • • A serpiginous margin (by prominent ridges of bone) • may cause the cyst to appear multilocular. • • No periosteal reaction unless a fracture has occured • • No internal calcification
- 98. • Fallen fragmentsign • If there is fracture through this lesion, a dependent • bony fragment may be seen, and this is known as the • fallen fragment sign. • • Differentials for SBC - • • ABC • • G C T • • Eosinophilic granuloma
- 103. Summary • Age • Lo c a t i o n • Multiplicity • Shape • Size • X-ray appearance - lytic/dense • Z o n e o f transition • Sclerosis • • Periosteal reaction • Matrix calcification • Soft tissue involvement
- 104. Thank you • References •Yochum and Rowe’s essentials of skeletal radiology. • David Sutton’s textbook of radiology and imaging • Next presentation : Journal presentation by Dr ramudu on 17-12-2024.