Presentation1.pptx, radiological imaging of benign bone tumour.

DR/ ABD ALLAH NAZEER. MD.
Radiological imaging of benign bone tumours.

OSTEOID OSTEOMA
Definition:
- Benign bone-forming tumor.
- Similar to osteoblastoma but smaller size (1.5 - 2.0 cm).
Epidemiology:
- Children and adolescent.
Sites of involvement:
- Most common in long bones, femur/tibia (cortex of
metaphysis)
- May be found in any bone.
Clinical findings:
- Intense localized pain particularly at night.
- Pain relieved by aspirin, NSAIDs or surgery.
Imaging:
- Small, round lucency.
- Variable mineralization surrounded by extensive sclerosis.
BONE PRODUCING TUMORS

-OSTEOBLASTOMA
Definition:
- Benign bone forming neoplasm producing woven bone
spicules bordered by prominent osteoblasts (osteoid
osteoma measuring more than 2.0 cm)
Epidemiology:
- About 1% of bone tumors
- Age: 10-30 y/o ( male teenagers)
- Male: Female ratio 2.5:1,
- Predilection for the spine (40-55% of cases)
- Other common sites femur and proximal tibia
- Cementoblastoma of jaw is considered osteoblastoma
and is attached to the root of tooth.
Clinical findings:
- Osteoblastoma of spine may cause back pain, scoliosis
and nerve root compression.
- Jaw lesion may produce tooth pain.
- Aspirin does not relieve pain after long therapy.
Imaging:
- Lytic well circumscribed oval or round defect
-Almost always confined by a periosteal shell of reactive bone.

SIMPLE (UNICAMERAL ) BONE CYST (UBC)
Definition:
- Intramedullary, usually unilocular, bone cyst filled with
serous or sero-sanguineous fluid.
Epidemiology:
- 85% of patients in the first decades of life.
- Male: Female ratio 3:1.
- Most common locations:
- proximal humerus
- proximal femur
- proximal tibia
Clinical findings:
- Pain and swelling.
- Patients may present with pathological fracture.
Imaging:
- Well demarcated and radiolucent.
- Typically begins in the metaphysis and extends into the diaphysis.
Gross:
- Fragments of thin whitish membrane
- Usually during surgery you get scant tissue material.

SIMPLE (UNICAMERAL ) BONE CYST (UBC).

Unicameral bone cyst - Femur – MRI.

ANEURYSMAL BONE CYST (ABC).
Definition:
- Benign multiloculated , blood-filled cystic mass that is
often expansile and destructive.
Epidemiology:
- Affects all age groups but generally occurs during the
first two decades of life (median age approximately 13 years).
- No sex predilection.
- May affect any bone.
- Usually arise in the metaphysis of long bone especially
the femur, tibia and humerus.
Clinical findings:
- Pain and swelling which may be secondary to fracture.
Imaging:
- Usually eccentric, expansile lesion with well defined margins.
- Most lesions are completely lytic and often contain a
thin shell of reactive bone at the periphery.
- CT and MRI may demonstrate internal septa and
characteristic fluid-fluid level.

Aneurysmal bone cyst with Fluid-fluid level containing bone lesions

(a) Contrast CT head showing multi-loculated aneurysmal bone cyst of
(b) the occipital bone with total destruction of bone and peripheral wall .

FIBROUS DYSPLASIA
Definition:
- Benign medullary fibro-osseous lesion which may involve one (monostotic) or more bones
(polyostotic).
Epidemiology: - Children and adults
- Monostotic solitary lesion most common 70-80%
- No sex predilection.
- Gnathic (jaw) bones most common
- Long bones are more often involved in woman
- Ribs and skull are favored sites for man.
- Monostotic form, about 35% involve the head, 1/3 tibia and femur, and rest 20% ribs.
- Polyostotic form, the femur, pelvis and tibia are more common involved
Clinical findings:
- Fibrous dysplasia may present in monostotic or polyostotic form.
- Polyostotic form can be confined to one extremity or one side of the body or be diffuse.
- Polyostotic form often manifest earlier in life than the monostotic form.
- FD is often asymptomatic but pain and fractures may be part of clinical spectrum.
- FD may be associated with oncogenic osteomalacia.
-Imaging:
- Non aggressive geographical lesion with a ground glass matrix.
- In the appendicular skeleton, the margins are usually well defined and surrounded by
a rim of sclerotic bone.
- FD in the craniofacial skeleton seems to be less well defined and blends with surrounding bone.
FIBRO-OSSEOUS TUMORS

OSTEOFIBROUS DYSPLASIA
Definition:
- Self-limited benign fibro-osseous lesion of bone.
- Involving cortical bone of the anterior mid-shaft of the tibia during infancy and
childhood.
Epidemiology:
- Rare tumor that accounts for less than 1% of all bone tumors.
- Commonly seen in boys during the first two decades of
life with precipitous drop-off thereafter.
- Proximal or middle-third of the tibia is the most frequent (90%)
- Less common sites are ulna and radius.
Clinical findings:
- Rare after the age of 15.
- Most common presenting symptoms are swelling or
painless deforming (bowing) of the involved segment of the limb.
Imaging:
- Well-delineated, Intracortical lucency, surrounded by areas of sclerosis.
- May form as a single lytic lesion, but more commonly forms confluent oval-shaped,
scalloped, saw-toothed or bubbly multiloculated lytic lesions in cortex.

FIBROUS CORTICAL DEFECT/NON-OSSIFYING FIBROMA
Definition:
- Benign lesion of bone composed of spindle-shaped fibroblasts, arranged in a storiform
pattern, with a variable admixture of multinucleated osteoclast-like giant cells.
- Epidemiology:
- Patient have ranged in age from 6 to 74 years old. 30-40% in children.
- An average age of 4 years 54% of boys and 22% of girls, had a lesion involving the
cortex, and most regressed spontaneously over a period of approximately 2.5 years.
Site of involvement:
- Approximately 40% of NOF occur in the long bones, with distal femur, distal and proximal
tibia most frequently involved.
- As many as 25% of cases involve the pelvic bone, in particular the ilium.
Clinical findings:
- Majority of NOF cases are asymptomatic, and are an incidental discovery on X-rays
performed for other reasons.
- Larger lesion may cause pain that is probably secondary to microfractures or obvious
pathologic fracture.
- Most pathologic fractures develop through lesions that involve more than 50% of the
diameter of the bone.
-The vast majority of NOF are single, although they are multiple in 8% of cases.
- Multiple NOF may be associated with syndromes such as neurofibromatosis.
Imaging:
- Eccentric, lytic lesions centered within the metaphyseal cortex and adjacent medullary cavity
- of long tubular bones.
- Well demarcated with sclerotic margins and frequently harbor internal trabeculation.
FIBROUS TUMORS

MYOFIBROMA
Definition:
- Myofibroma and myofibromatosis are terms used to denote the solitary (Myofibroma) and
multicentre (myofibromatosis) occurrence of benign neoplasms composed of contractile
myoid cells arranged around thin-walled blood vessels.
- Myofibromatosis) forms a morphological continuum with myopericytoma and so-called
infantile.
Hemangiopericytoma.
Epidemiology:
- Myofibroma of bone affects very young children and many patients first develop lesions
in utero.
- Many cases are detected at birth or within first two years of life.
- Male predominance.
- Commonly involve the skull, jaw, ribs and pelvis.
- Lesions of the appendicular skeleton are less frequent and usually involve the metaphyses
of bones.
Clinical findings:
- May be asymptomatic, produce palpable mass or cause pain and even a pathologic fracture.
Imaging:
- Oval or elongate and lucent, with well circumscribed,
sclerotic margins and may expand the bone.

Solitary myofibroma of the long bone and mandible.

Solitary myofibroma of the mandible.

FDG-PET and PET/CT images. (A) FDG-PET coronal image of the mass. There is an abnormal
accumulation of FDG in the left mandibular region (arrow). (B) PET/CT fusion image showing
abnormal strong FDG accumulation corresponding to the mass on the left mandible (arrow).
CT, computed tomography; FDG, 18 F-fluorodeoxyglucose; PET, positron emission tomography.

Myofibroma. (a) Coronal STIR MR image obtained in a 2-year-old child demonstrates a
right supraclavicular mass (arrow) abutting the scalene muscles. The mass shows signal
that is hyperintense relative to that of muscle. (b) Contrast-enhanced T1-weighted MR
image depicts marked and relatively homogeneous enhancement of the mass. These
features are characteristic of myofibroma — the most common fibrous tumor in infants.

DESMOPLASTIC FIBROMA
Definition:
- Rare, locally aggressive, solitary tumor microscopically composed of well
differentiated myofibroblasts with abundand collagen production.
Epidemiology:
- Rare, 0.1% of all primary bone tumors.
- It tends to occur in adolescent and young adults with near equal gender distribution.
- May involve any bone but is most frequent in mandible.
Clinical findings:
- Pain and swelling of the affected area are the most common symptoms.
- Pathologic fracture or deformity of the affected bone can occasionally be presenting
symptom.
Imaging:
- Usually well defined, radiolucent lesion that may expand host lesion.
- Inter lesional trabeculation is frequent.
- Larger lesion often show destruction of overlying cortex with extension into soft
tissue.
- Features of more aggressive growth pattern with irregular, ill-defined margins and
pathological fracture may be present.
- Honeycombed or moth-eaten patterns have been described.
- Erosive, destructive pattern may mimic other, more aggressive lesions.
- DF has low signal intensity in both T1 and T2 weighted MRI images.

X-RAY IMAGES FOR DESMOPLASTIC FIBROMA

Axial magnetic resonance images of collagenous fibroma involving the right shoulder. A: T1-weighted
sequence shows that the mass has low-to-intermediate signal intensity. B: T2-weighted sequence
shows that the mass has low-to-slightly high signal intensity. C: Contrast-enhanced fat-suppressed T1-
weighted sequence shows heterogenous internal enhancement with rim enhancement.

Desmoplastic fibroma of bone - Proximal Fibula – MRI.

MRI SHOWING DESMOPLASTIC TUMOR IN FOREARM .

CHEST WALL HAMARTOMA/CHONDROMATOUS HAMARTOMA OF THE CHEST WALL
Definition:
- Known as vascular-cartilaginous hamartoma, vascular hamartoma of infancy,
mesenchymal hamartoma of chest wall, and chondromatous hamartoma of the
chest wall, is a rare mesenchymal tumor that usually develops during fetal life
or the first year of infancy.
Epidemiology:
- Fetal life or the first year of life.
- Males are affected slightly more than females.
- Arises from one or multiple ribs.
Clinical findings:
- May be asymptomatic or cause chest wall deformities or respiratory distress.
Imaging:
- Usually manifest as a large expansile mass that has well-defined sclerotic margins.
- Tumor erodes the cortex and extends into extrapleural soft tissues, but is
delineated by subperiosteal reactive bone.
- Intralesional radio densities are often present and may consist of calcified cartilage
that manifest as pop-corn like speckled foci and mineralized bone that may
produce irregular trabeculations through the mass.
- Hemorrhagic cystic cavities with fluid-fluid levels (secondary aneurysmal bone cyst
like regions) are common, and are seen by CT and T2-weighted MRI.
CARTILAGE TUMORS

HAMARTOMA/CHONDROMATOUS HAMARTOMA OF THE CHEST WALL.

OSTEOCHONDROMA (EXOSTOSIS)
Definition: Cartilage capped bony projection arising on the external surface of bone containing
a marrow cavity that is continuous with that of the underlying bone.
Epidemiology:
-Most common bone tumor.
-Osteochondroma may be solitary or multiple, the latter occurring in the setting of hereditary multiple
exostoses.
-Solitary lesions account for 80% of cases, and most affected patients are diagnosed in their second decade .
- Male preponderance with a male to female ratio 1.5-2:1.
- Hereditary multiple exostoses (HME) is an autosomal dominant genetic disorder, and has prevalence
of 1 per 50 000 in the general population making it one of the more common inherited skeletal disease.
- Patients with HME come to medical attention at the younger age , usually during first decade, because
they cause severe skeletal deformities and are frequently polyostic.
- Generally arise in bones performed by cartilage.
- Most common site of involvement is the metaphyseal region of distal femur, upper humerus, upper tibia
and fibula.
Clinical findings:
- Many, if not most lesions, are asymptomatic and found incidentally. In symptomatic cases, the symptoms
are often related to the size and location of the lesion.
- Most common presentation is that of a hard of long-standing duration.
Imaging:
- Bulbous lesions on X rays, and they a narrow or broad (sessile) osseous radiosense stalk, which is attached
to the underlying bone.
- The characteristic feature is a projection of the cortex in continuity with the underlying bone.
- Excessive cartilage type flocculent calcification should raise the suspicion of malignant transformation.
- CT scan or MRI images typically show continuity of the marrow space into the lesion. A thick cartilaginous
cap rises suspicion of malignant transformation.

(A and B) In the knees, radiographs showing multiple
lesions in the proximal regions of the tibias and fibulas.

(a, b): A chest CT
scan showing an
exostosis originating
from the outer
aspect of the
anterior right fifth
rib, with a bony
spicule projecting .

Tibial exostosis Femur exostosis.

ENCHONDROMA AND ENCHONDROMATOSIS
Definition: Benign hyaline cartilage neoplasm of medullary bone.
- Enchondromatosis, is defined as two or more enchondromas, and occurs in two clinical settings: 90% are
associated with Ollier disease (two or more enchondromas) 10% are seen in Maffucci syndrome
(enchondroma + hemangiomas).
Epidemiology:
- Relatively common, accounting for 10-25% of all benign bone tumors.
- Age distribution is wide, ranging from 5-80 years.
- Majority of patients present within the second through fourth decades of life.
- Solitary enchondromas are rare in young children, whereas multiple enchondromas are encountered more
frequently.
- Sexes are equally affected.
Sites of involvement: Usually metaphyseal-diaphyseal in location and frequently affect the short tubular bones of the hands.
- Followed by bones of the feet and the long tubular bones, especially proximal humerus and proximal and distal femur.
Clinical findings:
- In the small bones of the hands and feet typically present as palpable swellings, with or without pain.
- Because they often expand these small bones and attenuate the cortex, they frequently present with
pathological fractures.
- Long bone tumors are more often asymptomatic, and are detected incidentally in radiographs or bone scans taken
for other reasons.
Imaging:
- Well marginated tumors that vary from radiolucent to heavily mineralized.
- Mineralization pattern is characteristic, consisting of punctate, flocculent, or ring and arc pattern.
- Long bone tumors are usually centrally located within metaphysis.
- Diaphyseal long bone tumors are less common, and epiphyseal tumors are rare.
- Enchondromas in the small tubular bones can be centrally or eccentrically located, and larger tumors may
completely replace medullary cavity.
- More extensive endosteal erosion is considered suspicious for low grade chondrosarcoma.
- Cortical destruction and soft tissue invasion should never be seen in enchondromas and would be most
consistent with chondrosarcoma.

CHONDROBLASTOMA
Definition:
- Benign, cartilage producing neoplasm usually arising in the epiphyses of skeletally immature patients.
Epidemiology:
- Accounts for less than 1% of primary bone tumors.
- Most patients are between 10 and 25 years of age at diagnosis and there is a male predominance.
- Patients with skull and temporal bone involvement tend to present at an older age (40-50 years).
- Usually arises in the epiphyses of the distal and proximal femur, followed by the proximal tibia
and proximal humerus.
- Patients with tumors arising in the flat bones, vertebrae and short tubular bones tend to be
older and skeletally mature, although rare cases have been reported in children.
Clinical findings:
- Majority of patients complain of localized pain, often mild, but sometimes of many years
duration.
- Soft tissue swelling, joint stiffness and limitation, and limp are reported less commonly.
- Minority of patients may develop joint effusion, especially around the knee.
Imaging:
- Typically lytic, centrally or eccentrically placed, relatively small lesions (3 to 6 cm), occupying
less than one half of the epiphysis.
- Shapely demarcated, with or without a thin sclerotic border.
- The presence of sclerotic rim, along with the younger age of the patient, helps to differentiate
chondroblastoma from giant cell tumor of bone, which generally lacks sclerotic border and occurs
in patients less than 20 years.
- Often helpful, matrix calcifications are only visible in about 1/3 of patients.

Chondroblastoma in the proximal tibia.

GIANT CELL TUMOR
Definition: Benign, locally aggressive neoplasm.
- Composed of sheets of neoplastic ovoid mononuclear cells interspersed with
uniformly distributed large, osteoclast like giant cells.
Epidemiology:
- Giant cell tumour represents around 4-5% of all primary bone tumours.
- Peak incidence is between the ages of 20 and 45.
- 10-15% of cases occur in the second decade.
- Not commonly seen in adolescents, although cases were described.
- There is slight female predominance described.
- Giant cell tumours typically affect the ends of long bones, especially the distal femur, proximal tibia, distal
radius and proximal humerus.
- About 5% affect flat bones, especially those of the pelvis.
- Multicenteric giant cell tumors are very rare and tend to involve the small bones of the distal extremities.
Clinical findings:
- Patients typically present with pain, swelling and often limitation of joint movement
- Pathological fracture is seen in 5-10% of patients.
Imaging:
- X-rays of lesions in long bones usually show an expanding and eccentric area of lysis.
- Lesion normally involves the epiphysis and adjacent metaphysis.
- Extension up to the subchondral plate, sometimes with joint involvement may be present.
- Rarely, the tumour is confined to the metaphysis, usually in adolescents where the tumour lies in relation
to an open growth plate, but occasionally also in older adults.
- Diaphyseal lesions are exceptional.
- CT scanning gives a more accurate assessment of cortical thinning and penetration than plain radiographs.
GIANT CELL TUMOR

LANGERHANS CELL HISTIOCYTOSIS (EOSINOPHILIC GRANULOMA) OF BONE
Definition:
- Previously known as histiocytosis X, is an intraosseous mass of proliferating
Langerhans cells.
- Langerhans cells are dendritic cells that normally populate the skin, mucosal
surfaces, lymph nodes and other tissues where they function as specialized
antigen presenting cells.
- In Langerhans cell histiocytosis, the proliferating cells are monoclonal,
supporting the theory that the disease is neoplastic.
Epidemiology:
- LCH is relatively rare disorder, accounting for less than 1% of all osseous l
lesions.
- Age distribution is ranging from the first month to 8th decade of life with
80-85% of cases seen in patients under the age of 30, and 60% under the age
of 10.
- Males are affected twice as often as females.
- Any bone may be involved, although there is predilection for LCH to involve
the bones of the skull, notably the calvarium.
- Other frequently involved sites include the femur, the bones of the pelvis,
and the mandible.
OTHER LESIONS.

Clinical findings:
- Pain and swelling of the affected area occur most commonly.
- In cases of temporal bone involvement , the presenting features can show
significant clinical overlap with otitis media and mastoiditis.
- Mandibular involvement , loosening or loss of teeth can be encountered.
- Vertebral body involvement may result in compression fracture and possible
neurological impairment. LCH is associated with variety of clinical syndromes.
- Single or multiple lesion restricted to skeleton have been termed
eosinophilic granuloma.
- Multifocal bone disease associated with exophthalmos and diabetes
insipidus is known as Hand-Shuller-Christian disease, and Letterer-Siwe
disease is an aggressive disseminated form of the disorder that occurs in
infants.
- Letterer-Siwe disease usually affects very young children's less than 2 y/o,
whereas, Hand-Schuller-Christian disease and eosinophilic granuloma are seen
in older children and young adults.
Imaging:
- LCH lesions are well defined and lytic on radiographs, however, in a minority
of cases may have ill-defined and permeative margins.
- Cortical involvement may elicit a periosteal reaction.
- Complete resolution of radiographic abnormalities may follow
treatment or occasionally occurs spontaneously.

LANGERHANS CELL HISTIOCYTOSIS.

LANGERHANS CELL HISTIOCYTOSIS .

ROSAI-DORFMAN DISEASE
Definition:
- Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a rare,
proliferative, histiocytic disease characterized by the enlargement of lymph node sinuses
caused by an aggregation of histiocytic cells that exhibit marked lymphophagocytosis
(numerous phagocytized lymphocytes are present in cytoplasm).
- Primary or secondary involvement of extranodal sites, including the skeleton, is frequent.
Epidemiology:
- Majority of patients are teenagers and young adults.
- Mean age 20 years.
- No gender predilection.
- Solitary RDD in bones was described in young children's.
Clinical findings:
- Fever and massive cervical lymphadenopathy are the most frequent symptoms at
presentation.
- Other symptoms include weight loss, malaise and night sweats.
- Quite often the disease fully manifests after a short period of a nonspecific fever and
pharyngitis.
Imaging:
- Skeletal involvement manifests by the presence of solitary or multifocal defects with poorly
or well-demarcated borders.
-RDD lesions are intramedullary and are associated with cortical erosion, complete cortical
disruption, elevation of the periosteum, or a combination of these features.
- Radiographic manifestations and clinical symptoms suggest an inflammatory disorder,
such as osteomyelitis.

Rosai-Dorfman Disease Presenting with Isolated Bilateral Orbital Masses.

HEMANGIOMA OF BONE
Definition:
- Hemangioma is benign solitary tumor composed of newly
formed vessels of capillary or cavernous type.
Epidemiology:
- Wide age distribution, ranging from the first to eight decades
of life, with nearly 70% of the cases diagnosed in patients
between 30 and 60 years.
- Occasionally hemangiomas become clinically evident during
the first decade of life. There is no sex predilection.
- They are rare in newborns and infants and reported cases
have arisen in the skull bones.
- The tumors are usually solitary, but multifocal neoplasms
have been described most frequently in the vertebral
columns.
- Hemangiomas frequently occur in craniofacial bones ,
predominantly in calvarium (50%), followed by the
spine (20%).
Clinical findings:
- Relatively common asymptomatic.

Imaging:
- Hemangiomas present as lucent, well demarcated defects.
- In flat bones, they markedly expand the bone contour and
produce rarefaction with radially oriented striations.
- Vascular nature of the lesion often is suggested by its bubbly
or honeycomb trabeculated appearance.
- Overlying cortex is expanded and thinned, but complete cortical
disruption and invasion into soft tissue are not present.
- Characteristic sunburst appearance of hemangioma is seen
in skull lesion (not confuse with that seen in osteosarcoma
of long bones).
- Smaller lesions may present as Intracortical rarefaction with
or without a honeycombed appearance and adjacent
sclerosis.
- MRI of hemangiomas generally reveals a low signal on T1-
weighted images and a high signal on T2 weighted images
(fluid content of tumor vessels).

Intraosseous hemangioma in parietal bone

Multiple Vertebral Hemangiomas.

Computerized tomography demonstrates lesions with osseous spicules
in keeping with hemangiomas involved with left frontal bone

OSTEOMYELITIS
Definition:
Inflammation of bone and marrow also known as infection of bone
May manifest as a primary solitary focus of disease or as a complication of other systemic
disease.
May be caused by different bacterial organisms
Types of osteomyelitis:
Pyogenic Osteomyelitis
Hematogenous osteomyelitis commonly occurs in children.
Staphylococcus aureus is the most common organism responsible for pyogenic osteomyelitis
H. influenzae & group B streptococci are frequent pathogens in neonatal infection.
Gram negative organisms are isolated from patients with genitourinary infection or who are
IV drug abusers
Almost always caused by bacteria.
Organisms reach to the bone by:
1 hematogenous spread
2 extension from a contiguous site
3 direct implantation
The latter (3) occurs as a complication of a compound fracture or of surgery.
Symptoms:
High fever, localized pain and swelling
Labs:
high white cell count, high ESR.

Radiology:
Lytic focus of bone destruction with peripheral zone of sclerosis and reactive
periosteum.
Hot spots on bone scan.
MRI: increased signal intensity in the medullary space.
D.D.: small round blue cell tumor
Chronic osteomyelitis:
One week after the infection, host response evolves with infiltration by chronic
inflammatory cells and release of cytokines which in turn stimulates osteoclastic
bone resorption, ingrowth of fibrous tissue and reactive new bone formation.
Reactive bone in the form of a living tissue around the segment of necrotic bone
(sequestrum) is known as involucrum.
Variants of osteomyelitis:
Brodie abscess – small intraosseous abscess that frequently involves the cortex
and is walled of by reactive bone. It may mimic tumor.
Sclerosing osteomyelitis of Garre affects the jaw bone with extensive new bone
formation.
Chronic Recurrent Multifocal Osteomyelitis.

Osteomyelitis - Bone Infection

Patient with osteomyelitis. The radiograph shows thickening
of the cortical bone and an ovoid central lucency.

Presentation1.pptx, radiological imaging of benign bone tumour.

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