Primary malignant bone tumors are rare. Imaging such as radiography, CT, and MRI play an important role in detecting, characterizing, staging, and following up on bone tumors. The document discusses several primary bone tumors seen at different ages such as osteosarcoma, which commonly arises in the metaphysis of long bones in teenagers; chondrosarcoma, which arises in flat bones in those over 40; and Ewing sarcoma, which typically affects the diaphysis of long bones in children and adolescents. Imaging features of these tumors are provided along with other bone tumors like chordoma, lymphoma, and fibrosarcoma.

1. MALIGNANT BONE TUMOURS
Dr.Archana Koshy

2. • Primary malignant bone tumours are relatively rare .
• The determination of the nature and extent of the tumour is
crucial .
• Conventional radiography , CT and MRI play an important role in
the detection , establishing the nature , assessing the extent and
in follow up in all suspected case of bone tumours .

4. Age in
years
Tumour
<1 Neuroblastoma
1-10 Ewing sarcoma-tubular bones
10-30 Osteosarcoma, Ewing sarcoma-flat bones
30-40 Fibrosarcoma,malignant fibrous histiocytoma,lymphoma,Malignant
GCT
>40 Chondrosarcoma,chordoma,multiple myeloma
AGE OF ONSET

5. SITE OF ORIGIN
EPIPHYSIS MALIGNANT GCT
METAPHYSIS OSTEOSARCOMA
CHONDROSARCOMA
FIBROSARCOMA
DIAPHYSIS EWING’S SARCOMA
MULTIPLA MYELOMA
ADAMANTINOMA
MFH

6. Radiographic features that may help differentiate benign from
malignant lesions

7. STAGING OF BONE TUMOURS

8. IMAGING MODALITIES
• Conventional radiographic techniques still remain the mainstay in initial
diagnosis and work up of a patient suspected to have any bony pathology .
• Demonstrate the location,pattern of bone destruction, size and shape of the
lesion, presence and nature of the visible tumor matrix, trabeculation,
periosteal response and the presence and characteristics of the adjacent soft
tissue mass.
• Due to its excellent contrast resolution and multiplanar capabilities, MRI has
now virtually replaced CT as the imaging modality for assessing the local
extent .
• Non specific in differentiating benign from malignant tumours .

9. • Dynamic contrast enhanced MRI – to determine response to chemotherapy .
•
• MR spectroscopy – Molecular characterisation of the tumours
• DWI – In assessing tumour response to therapy .
-Effective therapy in bone tumours leads to breakdown of tumour cell
membranes resulting in increased diffusion of water in the tumour on Diffusion
weighted images .
CT – Remains superior to MRI in the detection and characterisation of matrix
mineralisation , in assessment of cortical involvement , bone trabeculation and
periosteal reaction .
-Also the investigation of choice for detecting pumonary metastases .

10. • 99mTechnetium methylene diphosphonate bone scan -first additional
investigation in most instances to detect whether the lesion is monostotic or
accompanied by other skeletal lesions.
• The major limitation of bone scanning is its lack of specificity as number of
bone disorders may have similar scintigraphic appearances.
• FDG-PET - Evaluation of skeletal metastatic disease.
• FDG accumulation in skeletal lesions reflects direct uptake by tumor, in
contrast to 99mTc MDP activity on conventional bone scans, which reflects
increased new bone formation in response to destruction of bone by tumor.

11. OSTEOSARCOMA
• Commonest primary malignant bone tumour in the young .
• Characterised by the production of osteoid or bone by tumour cells .
• Malignant cells also retain the potential to form fibrous tissue or
cartilage .
• Constituents of the tumour matrix are highly variable and can include
osteoid tissue , calcification , fibrous tissue ,cartilaginous tissue or a
combination .

12. CLASSIFICATION

13. • Usually presents with localized pain or swelling , particularly
around the knee
• May present with a pathological fracture .
• The lesion commonly arises eccentrically in the medullary cavity ,
with ill defined cortical destruction and soft tissue involvement .
• The pleomorphic nature of the histology may cause misleading
biopsy results .

14. • Conventional radiographs – Eccentric area of permeative bone
destruction in the metaphysis adjacent to the knee joint
• Associated with a cortical erosion and a well defined soft tissue
mass
• CODMAN’S TRIANGLE- Elevation of the periosteum when
associated with new bone formation , formed at the margin of
the lesion .

15. AP and lateral radiographs of the distal femur in a 14-year-old boy showing a classical
osteocarcoma with mixed lytic and sclerotic areas, extraosseus mass with tumor bone
formation, and Codman’s triangles at the upper and lower margins of the lesion

16. OSTEOSARCOMA OF THE METADIAPHYSEAL REGION OF TIBIA
- MIXED LESION WITH A LARGE SOFT TISSUE COMPONENT AND THE CHARACTERISTIC
“SUNBURST” OR SPICULATED PERIOSTEAL REACTION

17. • A coronal T1W MR image
shows the large tumor
as a predominantly
hypointense mass with
evidence of cortical destruction
• Axial T2W images show the
cortical disruption with soft
tissue extension of the
tumor mass with loss of fat
planes with the
neurovascular bundle.
• Contrast
enhanced coronal, (C) and axial,
(D) MR images show
heterogeneous enhancement
of the tumor mass

18. • AP radiograph showing a destructive lesion in the distal femur with extensive cloud like
mineralization in the intra- and extraosseous component
(B) A coronal T1W MR image shows the large tumor as a predominantly hypointense mass with
evidence of cortical destruction
(C) An axial T2W image shows a heterogenous mass which is completely encasing the
neurovascular bundle.
(D) T2W (fat suppressed) coronal image shows the intra-articular extension of the tumor into
the knee joint

19. OSTEOBLASTIC VARIETY. (A) AP and lateral radiographs show a purely osteosclerotic lesion of the
proximal metaphysis of the tibia
(B) CT shows mineralization of tumor matrix within the soft tissue component and a spiculated
periosteal reaction

20. TELANGIECTATIC OSTEOSARCOMA. (A) AP radiograph of the distal femur shows a
predominantly lytic lesion in the distal femur with irregular cortical destruction and a large soft
tissue component,
(B) Sagittal T2W fat suppressed MR image shows the characteristic blood-fluid levels within the
tumor,
(C) On contrast enhancement, marked peripheral and septal enhancement is seen

21. • Mestastatic spread occurs by the hematogenous route
• Pulmonary metastasis is associated with an unudually high
incidence of pneumothorax .
• Any lung lesion arising in a patient with osteosarcoma should be
regarded with supicion .
• Lymphatic spread is relatively rare .

22. JUXTACORTICAL/PAROSTEAL OSTEOSARCOMA
• Comprise 1% of all primary
malignant bone tumours and
about 4% of all osteosarcomas .
• The tumous is slow growing by
comparison and has a much
better prognosis .
• Parosteal sarcomas occur most
commonly on the distal femur
and proximal humerus .

23. • Typically dense tumour surrounds a long
bone , particularly a femur or tibia .
• The margins are sharply defined , but
tend to undulate .
• The tumour is denser centrally and at
the base than peripherally .
• Characteristically , there is a radiolucent
zone between the ossified outer margins
of the tumour and adjacent host bone .

24. CHONDROSARCOMA
• Malignant cartilaginous tumour
• > 40 yrs
• SITES—LONG BONES,PELVIS,RIBS,SPINE,STERNUM, skull base)
• Types
• Primary - Intramedullary
Juxtacortical
Clear cell,myxoid,extraskeletal
• Secondary
-- Osteochondroma
• Solitary osteochondroma
• Hereditary multiple exostoses)
 Enchondroma – Maffuci’s syndrome .

25. Plain film
•Lytic (50%)
•Intralesional calcification
•Rings and arcs / popcorn calcification)
•Endosteal scalloping: affecting more than two thirds of the cortical
thickness (c.F. Less than 2/3 in enchondromas)
•Moth eaten /permeative appearance and periosteal
reaction distinguishing between enchondroma and chondrosarcoma

28. Proximal tibia diaphysis.
subtle calcifications,
Endosteal scalloping
hallmark of
chondrosarcoma.
MR better defines the
extension of the lesion.
endosteal scalloping.

29. CHONDROSARCOMA ARISING FROM OSTEOCHONDROMA
CALCIFIED MASS ARISING FROM THE PROXIMAL FIBULA.
HIGH UPTAKE ON THE BONE SCAN

30. CONVENTIONAL CHONDROSARCOMA.
(A) Plain radiograph shows an osteolytic, expansile lesion in the upper end of the fibula with
faint calcification seen within
(B) Coronal T2W Fat suppressed MR image shows the characteristic hyperintense, lobulated
lesion with internal septations.

31. CHONDROSARCOMA.
(A) A large expansile lesion in the anterior end of the left 7th rib
(B) CT shows specks of calcification within the lesion

32. (A) Radiograph of the hemipelvis shows a
mass extending from the left iliac blade
with the characteristic ‘popcorn’
calcification of a cartilaginous matrix
(B) T1W MR image shows the large soft
tissue component of the chondrosarcoma
as a low signal intensity lobulated mass
(C) On a coronal T2W MR image the tumor
is seen as lobulated mass of high signal
intensity with septations of low signal
intensity
(D) After intravenous administration of
gadolinium, a coronal T1W MR image
shows irregular peripheral and septal
enhancement

33. FIBROSARCOMA
• Fibrosarcoma is a tumor of mesenchymal cell origin that is composed of malignant
fibroblasts in a collagen background..
• It can occur as a soft-tissue mass or as a primary or secondary bone tumor.
• Primary fibrosarcoma - central (arising within the medullary canal) or peripheral
(arising from the periosteum)
• Secondary fibrosarcoma of bone arises from a preexisting lesion or after
radiotherapy to an area of bone or soft tissue.
• Fibrosarcomas of bone are typically seen between the third and sixth decades of life.

34. Plain Film
Highly destructive with a wide zone of transition and often expansile. Periosteal
reaction is uncommon. The lesion usually has not matrix mineralization, but may have
areas of sequested bone. Often associated with a large soft tissue mass.
CT
CT scanning is used to delineate bone involvement, bone destruction, or bone
reaction.
MRI
best modality overall for examining soft-tissue masses and for detecting the
intraosseous and extraosseous extent of many bony sarcomas.
T1WI - Isointense
T2WI - Hyperintense
Shows strong enhancement on contrast images

35. Lateral radiographs of the knee show an osteolytic lesion with a short zone of transition in
the distal femur. Note the absence of a periosteal reaction and tumor matrix mineralization

36. EWINGS SARCOMA
• Ewing sarcoma, a highly malignant primary
bone tumor that is derived from red bone
marrow and second most common primary
bone tumour of childhood.
• This tumor is most frequently observed in
children and adolescents aged 4-15 years and
rarely develops in adults older than 30 years.
• Affected bones include, long bones: 50-60%,
femur: 25%, tibia: 11%, humerus: 10%, flat
bones: 40%, pelvis: 14%, scapula, ribs: 6%
• As far as location within long bones, the tumor
is almost always metaphyseal or diaphyseal.
• It is the most lethal bone tumor. An
association exists between Ewing sarcoma and
primitive peripheral neuroectodermal tumor
(PNET).

37. PLAIN RADIOGRAPHY
• Typical presentation: ill-defined
osteolytic lesion with a moth-eaten or
permeative type of bone destruction,
irregular cortical destruction and
aggressive periostitis.
• Reactive sclerosis, irregular periosteal
reaction and soft tissue mass.
• Ewing sarcomas tend to be large poorly
marginated tumours, with over 80%
demonstrating extension into adjacent
soft tissues.
• Laminated (onion skin) periosteal
reaction: 57%

38. (A) CONVENTIONAL RADIOGRAPH SHOWS A PERMEATIVE LESION IN THE TIBIAL DIAPHYSIS
WITH A SOFT TISSUE COMPONENT WITH SPICULATED PERIOSTEAL REACTION BETTER
APPRECIATED ON THE AXIAL CT SCAN (B)

39. (A) Ewing’s sarcoma of the
femur shows an
illmarginated, lytic-sclerotic
lesion with cortical
irregularity, laminar
periosteal reaction, with a
large soft tissue mass in the
metadiaphyseal region
(B) In another case involving
the femoral diaphysis
“saucerization” is well seen,
with peripheral Codman’s
triangles and a
large soft tissue mass

40. (A) Plain radiograph
(B) Axial CT section of left shoulder shows a dense sclerotic involvement of the scapula with a
large soft tissue mass

41. (A) A T1W coronal scan shows the intramedullary extent of the tumor as low signal intensity of
the marrow with a small “skip” lesion proximally (arrow)
(B) The extraosseous component is better appreciated on the STIR coronal image
(C) The axial T2W image shows the tumor within the femur as high signal intensity with cortical
discontinuity.

42. Ewing’s sarcoma with skeletal metastases
(A) Pelvic radiograph shows the primary tumor as a large predominantly lytic lesion in
the left iliac bone with multiple lytic bony metastases in the right iliac blade and
both the femurs
(B) Humeral shaft
(C) skull

43. PRIMITIVE NEUROECTODERMAL TUMOR OF BONE (PNET)
• These rare tumours of bone resemble Ewings tumours clinically except that
they are commoner in the female sex
• Arise in the metaphyses and diaphyses of the lower limbs,humerus,pelvis and
scapula .
• Radiologically , ill defined neoplasms which readily spread to soft tissues.
• ASKIN TUMOUR – rare PNET of the thoracopulmonary region occring in
children and adults.
•
• A soft tissue mass involving the chest wall in seen in about half the patients
and a subpleural pulmonary mass with pleural involvement in ¼ th .

44. NON-HODGKIN’S LYMPHOMA OF BONE
(LYMPHOSARCOMA, RETICULUM CELL SARCOMA)
• Primary lymphoma of bone is a rare extranodal lymphoma, presenting
intially as a localised solitary bone lesion .
• -20-50 years of age
• Usually presents with localised dull aching pain of long duration . A
palpable mass is often felt .
• Common sites – diaphysis of long bones, femur , tibia , humerus Flat
bones may also be involved .

45. • The osseous destruction in this tumour is usually permeative or moth
eaten in type with an associated soft tissue mass .
• Relative absence of cortical destruction is a characteristic feature .
• Proximal spread within the bone , sometimes with skip areas may be
seen .
• MRI typically shows extensive involvement of the medullary canal with
little cortical destruction but a large soft tissue mass.
• D/D – EWING’S SARCOMA
-(older age group and lack of symptoms )
• Good response to local radiotherapy and adjuvant chemotherapy.

46. Non-Hodgkin’s lymphoma.
(A) AP radiograph of the humerus shows a mixed lytic and sclerotic lesion involving proximal
half of the shaft with little cortical destruction and a large soft tissue component.
(B) Sagittal T2W fat suppressed MR image through the shaft shows the extent of medullary
involvement

47. HODGKIN’S LYMPHOMA OF BONE
• Occurs more commonly as a secondary manifestation of systemic
hodgkin’s disease . Rarely as a orimary bone involvement
• Main site – Vertebral body of the lower thoracic and upper lumbar
spine .
• Radiologically , most lesions are osteolytic .
• Occasionally , a marked sclerotic reaction can be seen as an ivory
vertebra .
• In the lumbar vertebrae , lytic destruction is more common with
exuberant periosteal reaction .

48. IVORY VERTEBRA SEEN AS A HOMOGENEOUS INCREASED DENSITY OF A SOLITARY THORACIC
VERTEBRA

49. CHORDOMA
• Neoplasm which arises from ectopic cellular remnants of the notochord
which have persisted within the nucleus pulposus of the intervertebral
disk .
• Predilection for the sacrococcygeal and spheno occipital regions.
• 90% - occurs in the sacrococcygeal region
• Distant metastases are rare, mainly involving the lymph nodes , liver and
lungs .

50. • Sacral lesions usually show a large area of bone destruction with well
defined , scalloped margins and a large soft tissue mass .
• Amorphous calcification may occur within the mass .
• In the spheno occipital region , the dorsal aspect of the sella and clivus
may be destroyed with a soft tissue mass indenting the
nasopharyngeal air space .
• In the sacrum , the possibility of plasmacytoma or giant cell tumour
should be considered .

51. CHORDOMA OF THE SACRUM. PLAIN RADIOGRAPH (A) AND CT (B) SHOWING A LARGE PELVIC
MASS WITH CALCIFICATION

52. CHORDOMA OF THE SACRUM.
(A) PLAIN RADIOGRAPH SHOWS A LYTIC LESION DESTROYING THE DISTAL HALF OF THE
SACRUM
(B) AND (C) T1W SAGITTAL AND T2W AXIAL MR IMAGES SHOW THE LARGE TUMOR WITH
INHOMOGENEOUS SIGNAL INTENSITY ARISING FROM THE DISTAL SACRUM

53. VASCULAR TUMORS OF THE BONE
• ANGIOSARCOMA
- Rare vascular tumour of bone , affecting all ages
- Any bone may be affected, but the vertebrae and femur are most
commonly involved .
- A multilocular or “soap bubble “ appearance may be seen .
- Reactive sclerosis may be seen at the margins of some tumours .
- Highly malignant tumour usually treated by surgery and radiotherapy
with a 5 year survival rate under 10 % .

54. Adamantinoma
• Rare primary malignant bony tumour,
• Occurs almost exclusively in the long
bones.
• The diaphyseal region is the area most
commonly affected.
• May present as a solitary focus or
multicentric lucencies or slightly
expansile osteolytic lesion
• May extend into the marrow cavity
• An eccentric epicenter and a lack of
periosteal reaction.
• No periosteal reaction

55. MULTIPLE MYELOMA
• Most common primary malignant neoplasm of bone .
• Production of an abnormal paraprotein leading to a wide M band
on plasma electrophoresis .
• Hypercalcemia , hypercalciuria and amyloidosis can occur , but
serum ALK and serum Phosphorus are normal .
• CLASSICAL APPEARANCE - Well defined, osteolytic , punched
out lesions throughout the skeleton, most characteristic in the
skull .
• Generalised osteopenia
• A pathological fracture .
• Involvement of the spine Is usually in the lower thoracic and
upper lumbar regions and is seen as diffuse osteopenia .

56. Multiple myeloma. (A) AP and (B) Lateral skull radiographs showing small, well
defined, ‘punched out’ lesions in the calvarium

57. RADIOGRAPHS OF THE DORSAL SPINE SHOW OSTEOPOROSIS WITH SMALL DISCRETE LESIONS
IN THE FEMUR .

58. Multiple myeloma. T1W (A) and T2W (B) sagittal MR images of the dorsal spine
show complete alteration of the marrow signal in the seventh thoracic vertebra,
hypointense on T1W and hyperintense on T2W images, with evidence of collapse.

60. Metastases
• Metastatic bone tumors are the most common malignant
tumors of the skeleton. Approximately 70% of all malignant
tumors are metastatic in origin.
• Metastases are usually found in: Vertebrae - especially
posterior vertebral body, extending into pedicle, pelvis,
proximal femur, proximal humerus and skull.
• Metastases distal to the elbow and knee are distinctly
uncommon.
Types :
- osteolytic metastases
- sclerotic/osteoblastic metastases
- mixed lytic and sclerotic metastases

61. • Bone involvement in metastases occurs by
means of 3 main mechanisms:
• (1) direct extension
• (2) retrograde venous flow
• (3) seeding with tumor emboli via the blood
circulation which is the most common route of
spread.

62. • Usually no periosteal reaction
• May appear as moth-eaten, permeative or geographic lesions
• Indistinct zones of transition, no sclerotic margins and may be sharply circumscribed or have
indistinct borders
• Lesions distal to elbows and knees - 50% are from lung and breast
• Diffuse skeletal sclerosis or multiple round, well-circumscribed sclerotic lesions - Prostate &
Breast
• Expansile and lytic (soap-bubbly) – RCC
• Cookie-bite lesions of the cortices of long bones – Lung
• Bone scans are extremely sensitive but not very specific
• 10-40% of lesions will not be visible on plain film but will be positive on bone scans
• CT or MRI can be used to show findings in patients with negative conventional radiographs
and positive bone scans

63. SKELETAL METASTASES. LATERAL RADIOGRAPHS OF THE SKULL OF
TWO DIFFERENT PATIENTS SHOW MULTIPLE ILL-DEFINED LYTIC
LESIONS OF VARYING SIZES IN THE CALVARIUM

64. Metastasis from carcinoma
prostate.
AP radiograph of the
femur shows OSTEOBLASTIC
METASTASIS WITH
EXTENSIVE ‘SUNBURST’
PERIOSTEAL REACTION
resembling osteosarcoma

65. SKELETAL SCINTIGRAPHY IN METASTATIC DISEASE OF
THE SKELETON
SHOWS MULTIPLE RANDOMLY DISTRIBUTED FOCAL
LESIONS SCATTERED THROUGHOUT
THE SKELETON, PARTICULARLY THE SPINE, RIBS, AND
PELVIS

66. THANK YOU
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