BONE TUMORS AND TUMOR LIKE LESIONS

1. Bone tumors and tumor
like lesions
Mekelle University ,Dep’t of Radiology
December, 2018 AD.
Dr . ZEGEYE RII

2. Bone tumors and tumor like
lesions
Outlines :
 Systematic approach
 Bone forming tumors
 Cartilage forming tumors
 Fibrous tumors
 Fatty tumors
 Multiple myeloma
 Metastatic tumors
 tumors and tumor-like lesions of
miscellaneous or unknown origin

3. Introduction
Characteristics of Non aggressive lesion:
 Well defined margin
 Sclerotic rim
 No periosteal reaction
 No extra osseous soft tissue component
 Narrow zone of transition

4. Cont’d
Characteristics of Aggressive lesion:
 Ill defined margin
 Cortical destruction
 Periosteal reaction
 Extra osseous extension
 Wide zone of transition
 Soft tissue component
NB: Aggressive lesions are commonly are malignant
and benign tumors are commonly non aggressive.

5. Systematic approach
 Clinical information
 Patients age
 Pattern of bone destruction
• Geographic
• Moth eaten
• Permeative
 Tumor size, Growth rate
 Presence and nature of tumor matrix
 Periosteal response
 trabeculation

6. Cont’d
 Cortical erosion, penetration, and expansion
 Lesion location in the transverse plane.
• Central :enchodroma,fibrous dysplasia, some Abc and simple
bone cyst
• Eccentric:
 medullary:osteosarcoma,chondrosarcoma,fibrosacoma and
chodromyxoid fibroma
 Cortical :NOF, osteoid osteoma
• Juxtacortical : periosteal (deep layer), Parosteal(outer layer):
enchondroma, osteosarcoma
• Soft tissue mass: frequently malignant

7. Cont’d
 location along the length of a tubular bone:
 Epiphysis: Adults: clear cell chondrosarcoma,mets,
lipoma and Intraossous ganglion.
-Originating in the metaphysis GCT involve the closed
epiphysis
Children :chondroblastoma,&osteomyelitis, less
frequently Eosinophilic granuloma,enchodroama and
osteoid osteoma
 Metaphysis:chondromyxoid fibroma, simple bone
cyst,osteochondroma,Brodie’s abscess
osteosarcoma and chondrosarcoma
 Diaphysis: Ewing, NOF, enchondroma,SBC, ABC etc.

8. Patients age

9. Patterns of bone destruction
Geographic destruction:
 Applies to lytic lesions:
 1A: Narrow zone of transition,
sclerotic margin; nonaggressive
 1B: Narrow zone of transition,
nonsclerotic margin; usually
nonaggressive
 1C: Wide zone of transition,
nonsclerotic margin; aggressive
IA: SBC
IB :GCT

10. Geographic pattern of destruction
1C pattern: both Lung mets

11. Patterns of bone destruction
Moth eaten pattern:
 More aggressive
 Mostly malignant
(exception: osteomyelitis&
Eosinophilic granuloma)

12. Patterns of bone destruction
Permeative:
More aggressive
Malignant except
Osteomyelitis and
osteoporosis
(sudecks dystrophy)

13. Presence and nature of visible
bone matrix
Chondroid
Arcs and rings
Cartilage-forming tumors: Enchondroma,
chondrosarcoma, chondroblastoma
Osteoid
Cloud-like, amorphous
Bone-forming tumors: Osteosarcoma,
osteoid osteoma, osteoblastoma;
also the ground-glass density in fibrous dysplasia
Also can be seen in early fracture healing and e
arly myositis ossificans

14. Osseous matrix

15. Trabeculation pattern

16. Trabeculation patterns
GCT NOF
Intraossous hemangioma

17. Periosteal response
 Solid: Nonaggressive process
 Interrupted: Aggressive
 Lamellated (“onionskin”)
 Hair-on-end
 Sunburst
 Codman’s triangle

18. Solid periosteal rxn

19. Lamellated
&hair on end

20. Codman's triangle

21. Sun burst pattern

22. Central Distribution
Centrally located lesion
at the shaft of fibula
Final dx:
simple bone cyst

23. Eccentric distribution
CMF

24. Cortical Distribution
Cortical distribution
Final Dx:NOF

25. Juxtacortical Distribution
Parosteal
osteosarcoma

26. Location in skeleton
 Certain tumor tends to occur in bones with rich in
red marrow.
 Myeloma, Mets ,Ewing's sarcoma and Lymphoma
 Many 1o bone tumors tends to arise from areas of
high blood supply such as distal femur and
proximal tibia.
 In addition , peculiar vascular anatomies like
looped vessels and sinusoidal channel promote
metastasis and infection.

27. Cont’d
 related to dentition: Ameloblastoma,Dentigerous
cyst
 upper and lower end of vertebrae: Chordoma
 Vertebral :
• Adult: metstasis,myeloma, hemangioma,
lymphoma and osteomyelitis
• Children:eosinophilic granuloma, aneurismal bone
cyst, osteomyelitis, osteoblastoma, osteoid
osteoma, lymphoma and leukemia.

28. Cont’d
 Sacrum : Chordoma, plasmacytoma, metastasis,
lymphoma and GCT.
 Sternum : typically malignant
Metstasis,myeloma, lymphoma and chondrosarcoma
 Clavicle: usually malignant in adults
 Ribs: Mets, fibrous dysplasia and enchondroma
 Metacarpal and phalanges: enchondroma, GCT and
less commonly ABC and fibrous dysplasia.
 Patella : generally benign

29. Classification of bone tumors
1.Bone forming tumors:
1a)Benign :
 Enostosis(bone island)
 Osteoma
 Osteoid osteoma
 Osteoblastoma
 Ossifying fibroma
1b) malignant:
 osteosarcoma

30. Cont’d
2. Cartilage forming tumors
2a) benign :
 Enchondroma
 Chodromyxoid fibroma
 Osteochondroma
2b) malignant :
chondrosarcoma

31. Cont’d
3. Tumors arising from or forming fibrous connective tissue
3.1 Benign:
 Nonossifying fibroma/Fibrous cortical defect
 Desmoplastic fibroma
 Giant cell tumor
3.2 Malignant:
 Fibrosarcoma

32. Cont’d
4. Bone tumors with fatty differentiation
4.1 benign
• Intraossous Lipoma
• Epidermoid cyst
4.2 Malignancy
• Liposarcoma

33. Cont’d
5. Metastasis
6. Miscellaneous and tumor like processes

34. Enostosis(Bone island)
 a region of compact bone within the medullary space, surrounded by
trabecular bone.
 Any age, but less common in children.
 Asymptomatic, Single or multiple.
 Pelvis, proximal femur and ribs
 Osteopoikilosis is multiple bone islands clustered around joints.
 Uniformly radio dense with variable size
 Low signal on both T1 and T2 WI
 No uptake on Bone scan
 DDX: mets,osteoma,ostoid osteoma, bone infarction, enchondroma
and fibrous dysplasia

35. Enostosis( Bone island)

36. Osteoma
 Are actually hamartomas
 Abnormal proliferation of compact bone with out
stromal cell proliferation
 4-5th decade of life
 Predominantly skull and facial bones (paranasal
sinuses)
 Generally asymptomatic
 Single or multiple homogenous
 Smooth or lobulated margin
 Low signal on MR imaging

37. osteoma

38. osteoma

39. Osteoid osteoma
 Age : 7-25 years
 Frequently male(3:1)
 Pain is the hall mark of the lesion.
 usually diaphysis of long bones.
 Classic radiographic features are
 Typically cortical
• Centrally located round or oval radiolucent(nidus)
measuring <1cm with sclerotic rim
DXX: 1.stress#- no nidus
2.osteoblastoma –larger size

40. Osteoid osteoma

41. Osteoid osteoma

42. Osteoid osteoma

43. Osteoblastoma
Two forms: conventional and aggressive
 70% of cases <30 years of age.
 More frequently in males(2:1)
 Mild local pain , scoliosis, torticollis
 Most common location: Posterior elements of the spine & Long
bones diaphysis
 Radiologic features
 It may look like ABC or large osteoid osteoma
 Ranges from lytic (most common) to densely sclerotic.
 small risk of malignant transformation to osteosarcoma.

44. Osteoblastoma

45. Osteoblastoma

46. Aggressive osteoblastoma

47. Ossifying Fibroma(osteofibrous dysplasia
 Extremely rare .occur in 1st -3rd decade of life.
 Almost exclusively in the anterior proximal tibia and
mandible.
 appears as a cortically based geographic, oval lesion. It
is associated with cortical bowing and generally causes
local expansion of bone.
 Can be purely lytic .
DDX:
 fibrous dysplasia
 NOF
 Adamantinoma

48. Ossifying Fibroma(osteofibrous dysplasia

49. Osteosarcoma
 Malignant proliferation of undifferentiated connective
tissue and formation of neoplastic osteoid.
 2nd most common 1o bone malignancy.
 Most commonly encountered b/n ages10-25 years.
 Rare before 5 years and above 30 years.
 Five clinical types: central , Multicentric, juxtacortical
(periosteal and parosteal ) ,Secondary , and extra osseous
osteosarcomas .
 Location : metaphysis of long bones.

50. Radiologic features
 Usually metaphysis of long bones are involved.
 Most frequently distal femur and proximal tibia.
 Typical radiographic finding is either mottled, Permeative
lesion with a poorly defined zone of transition or a dense
ivory or sclerotic region filling the medullary space.
 Sun burst periosteal reaction
 Cortical destruction

51. Conventional Osteosarcoma

52. conventional osteosarcoma

53. Conventional osteosarcoma

54. Talangiectatic osteosarcoma

55. Periosteal osteosarcoma

56. Parosteal osteosarcoma

57. Multicentric osteosarcoma

58. 2. Cartilage forming tumors
2a) benign :
 Chondroma
 Chodromyxoid fibroma
 Osteochondroma
2b) malignant :
chondrosarcoma

59. Enchondroma

60. Enchondroma

61. Enchondroma

62. Collier's diseases

63. Mafucci’s syndrome

64. Chondroblastoma
 Age:5-25 years
 Relatively uncommon
 Arises at epiphysis and apophasis long bones
 Oval or spherical well defined lytic lesion in the
tarsal bones, patella and epiphysis or apophysis of
long bone w/h may have sclerotic rim.
 30-50% has calcification.
 Abundant edema is almost always present.
 DDX: Ganglion cyst, osteomyelitis, GCT
,Eosinophilic granuloma, enchondroma and
osteoblastoma

65. Chondroblastoma

66. Chodromyxoid fibroma
 Least common cartilage forming benign neoplasm.
 Occur in 2nd and 3rd decades of life.
 Well defind slightly expansile eccentric lytic
metaphyseal lesion with thick trabeculation.
 Calcification is rare.

67. Chodromyxoid fibroma

68. Osteochondroma (exostosis)
 Bony protrusion covered by cartilage cap.
 Affect bones of endochondral ossification.
 In the metaphysis of long bones.
 Mostly in children and adolescents.
 May transform to malignancy. A thick cartilaginous cap in an
adult is suspicious of chondrosarcoma
 patterns of calcification are variable and commonly irregular
 On MR imaging, the central part of a mature
osteochondroma consists of fatty bone marrow, continuously
with the marrow cavity of the underlying bone.
 1% risk of malignant transformation but higher risk if
multiple(25%). Usually to chondrosarcoma.

69. Osteochondroma(exostotsis)

70. Chondrosarcoma
 arises from chondroblasts and collagenoblasts.
 3rd common 1o bone malignancy.
 Usually in age of 40–60 years .
 Location: pelvis and proximal femur (50%),proximal
humerus (10%),ribs (15%), scapula (6%), distal femur and
proximal tibia (7%) and craniofacial bones and sternum(5%).
 Radiographic features:
• Radiographs usually reveal a large, radiolucent, round or
oval lesion with poorly defined margins.
• Foci of irregularly scattered calcification.

71. Chondrosarcoma

72. Chondrosarcoma

73. Fibrous tumors
Benign:
 Non ossifying fibroma/ fibrous cortical defect
 Desmoplastic fibroma
 GCT
Malignant:
 Fibrosarcoma

74. NOF/fibrous cortical defect
 Common benign lesions. Unknown etiology.
 Terms Used interchangeably.
 Generally , NOF is for larger lesions(>2cm ).
 Usually long tubular bones(metaphysis).
 Radiographically:
 Cortical eccentric lytic with sclerotic rim.

75. NOF

76. Desmoplastic fibroma
• Rare benign neoplasm
• Characterized by abundant collagen formation
• 2nd & 3rd decades
• Locations: mandible, long tubular bones ,innominate bone
(ilium).
• Osteolytic lesions with a trabeculated, soap bubble, or
honeycomb pattern .
DDX:
• nonossifying fibroma
• chodromyxoid fibroma,
• giant cell tumor,
aneurysmal bone cyst
• fibrous dysplasia.

77. GCT
 Arbitrary localization since precise origin is unknown.
 Age :20–40 years
 Location
• Distal femur, proximal tibia
• Distal radius
• Proximal humerus
• Sacrum, ilium
 Radiographic Features
1.Epiphyses closed
2. Abuts the articular surface (in long bones)
3. Well defined with a nonsclerotic margin (in long bones)
4. Eccentric

78. GCT

79. Fibrosarcoma
 Rare malignant bone tumor.
 Primary or secondary
 From 3rd -6th decade of life
 Fibrous tissue no Chondroid or osteoid matrix.
 Location : similar to osteosarcoma
 Radiographic features:
• (1)Osteolytic foci with a geographic, moth-eaten, or
Permeative pattern of bone destruction and, generally,
a wide zone of transition between normal and
abnormal bone and
• (2) little osteosclerosis or periostitis

80. Fibrosarcoma

81. Fatty bone tumors
 Intraossous Lipoma: rare neoplasm
 Affects any age but more common from 4th -6th
decade.
 Location : Fibula, femur , tibia and calcaneus in
descending order of frequency.
 Radiographic features:
 Well defind lytic lesion with sclerotic margin
 Femur : marked internal ossification
 Calcaneus :in the triangular region(like SBC) with
central ossification or calcification.

82. Intraossous Lipoma

83. Multiple myeloma
 Malignant proliferation of plasma cells.
 The most common 1o bone malignancy.
 Together, myeloma and osteosarcoma account for
almost half (46% ) 1o bone malignancies.
 Typical age 50-70 yrs;average 60 yrs.
 Rare below 40 yrs.
 Locations: spine, skull ,pelvis, ribs, clavicles,
scapula and diaphysis of long bones.

84. Radiologic features
 Conventional radiography: 1o imaging method.
 The typical appearance in the skull, pelvis, long bones, clavicles, and
ribs is multiple circumscribed lytic (pouched out ) lesions. Sclerosis is
rare(<3%)
 In the spine: osteoporosis and pathologic fractures
 Affect vertebral body, pedicles are rarely involved.
 CT scan: Further defining lesions
 MRI : highly sensitive for marrow infiltration
 T1 hypointense and heterogeneous on T2 WI.
 Bone scan : relatively in sensitive
 OAF
 Only fracture sites are hot.

85. Multiple myeloma

86. Cont’d

87. Solitary plasmacytoma
o Localized form of plasma cell proliferation.
o The mandible, ilium, vertebrae, ribs, and proximal femur and
scapula are the favored sites.
o ~ 50% of cases are < 50 yrs.
o Typical appearance is a geographic radiolucent lesion, often
highly expansile, with a soap bubble internal architecture.
o somewhat less aggressive than the diffuse form of multiple
myeloma.
o Reported cases of progression to multiple myeloma.

88. Cont’d

89. Metastasis
 The most common malignant skeletal tumor(70%).
 most common primary sites are in the breast, lung,
prostate, kidney, thyroid, and bowel (80%).
 the target sites are the axial skeleton, skull, and
proximal extremities.
 Metastasis to bone represents the third most common
site of metastatic carcinoma.
 ~90 % are multiple
 Breast and prostate are most common 1O sites in
females and males respectively.

90. Radiologic features
 Axial skeleton predilection
 Multiple sites
 Osteolytic metastases (75%)
• Cortical and trabecular destruction
• Lack of periosteal response
• Moth-eaten, Permeative destruction
• Small or absent soft tissue mass.
• Variants (lung, thyroid, kidney); solitary expansile soap bubble lesion
 Osteoblastic metastases (15%)
• Localized or diffuse increased bone density
• Poorly defined margins, multiple sites
 Mixed metastases (10%)
• Combination of blastic and lytic features

91. Lytic metastasis

92. Sclerotic metastasis

93. Mixed metastasis

94. TUMORS AND TUMOR-LIKE LESIONS OF
MISCELLANEOUS OR UNKNOWN ORIGIN
 Solitary (unicameral ) bone cyst
 Aneurysmal bone cyst
 Intraossous Ganglion cyst
 Ewing's sarcoma
 Paget’s disease
 Fibrous dysplasia
 Neurofibromatosis

95. Solitary (unicameral) bone cyst
 Benign neoplasm ,unknown origin.
 In the 2nd and 3rd decade of life
 Male: female(2:1)
 Location:
• Metaphysis of long bones(Femur,Tibia and humerus)
• Calcaneus
• Rare in small bones of the hand and foot.
• Radiographic features:
• Central well defind lytic metaphyseal with cortical thinning
and marginal sclerosis.
• Rarely septated .

96. SBC

97. Aneurysmal bone cyst
 Hemorrhagic lesion containing thin-walled, blood-
filled cystic cavities
 Generally regarded as non neoplastic.
 Exact pathogenesis is unknown
 Associated with trauma and benign
neoplasms(chondroblastoma, CMF, NOF ,GCT etc.)
 Occur in 2nd -3rd decades; Usually < 20years.
 Radiographically:Eccentrical ,expansile,
occasionally trabeculated lytic lesion in the long
tubular bones.

98. ABC

99. Intraossous ganglion cyst
 Common lesion of un certain pathogenesis.
 Occur in any age but more common in adults.
 Location: Subchondral lesion in a long tubular bone
is most characteristic .
 femoral head , distal radius and ulna, carpal bones
and acetabulum.
 Radiographically: Osteolytic well defind with
marginal sclerosis , solitary or multiple .

100. Intraossous ganglion cyst

101. Ewing’s Sarcoma
 4th common malignant bone tumor.
 Less common in black race.
 Found most commonly B/n 10-25 years.
 Rare before 5 years and after 30 years.
 Age:5-20 years= axial bones
 Age:20-35 Years=peripheral skeleton
 Male :female=2:1.
 Diaphysis is classic location .


102. Radiographic features
 Classic presentation is a diaphysis Permeative lesion with a
delicate onion skin or peel periosteal response.
 Cortical saucerization is a characteristic sign.
 Pathologic fracture is noted in 5% of cases.
 One third of cases affecting flat bones present with diffuse
sclerosis.
 Occasionally, the sunray periosteal pattern occurs and has
been called groomed, or trimmed, whiskers effect.
 The most common primary malignant bone tumor to
metastasize to bone.

103. Ewing’s sarcoma

104. Paget’s disease
 Osteitits deformans
 The origin of this disease remains unknown.
 Highest incidence in united kingdom.
 Rare before age of 40 years.
 Location: in diminishing order of frequency, are the pelvis
(including the sacrum), femur, skull, tibia, vertebrae,
clavicle, humerus, and ribs.
 The fibula is the bone least likely to be involved.

105. Complications
 Deformity
• shepherd’s crook deformity
• saber shin deformity
• frontal and parietal bossing
• basilar invagination.
 Pathologic fracture
 Pseudo-fracture
 Spinal stenosis
 Malignant degeneration
 Paget’s coxopathy
 urinary calculus formation

106. Paget's disease
osteoporosis
circumscripta.

107. Cont’d

108. Paget’s disease

109. Fibrous dysplasia
 Benign congenital process
 Age of presentation varies from 8 to 14 years
 No pain and periostitis
 Location : pelvis, proximal femur ,skull and ribs
 Fibrous dysplasia is often purely lytic and becomes
hazy or takes on a ground-glass look as the matrix
calcifies.
 Monostotic or polyostotic
 Cherubism
 Mc Cune Albright syndrome
 café au lait spots

110. Fibrous dysplasia

111. Cont’d

112. Neurofibromatosis
 Inherited autosomal dominant disorder.
 To clinical forms:
 NF1: café au lait spots, neurofibromas, bone changes
 NF2:acoustic nerve tumors

113. Skeletal manifestations
 The most frequently involved areas are the spine and skull .
 ~ 50% of the patients with NF develop skeletal lesions .
 Spine:
• short segment acutely angular kyphoscoliosis.
• Vertebral body scalloping
• Intrathracic meningocele
 Orbital defects
• Sphenoid wing agenesis (bare orbit)
• Optic canal expansion
• Lambdoidal defect or asterion defect
• Macro cranium

114. Spinal manifestations

115. Cont’d

116. skull manifestations

117. References
 Essentials of skeletal radiology 3rd edition
 Diagnostic imaging of bone tumors and tumor like
lesion 3rd edition
 Fundamentals of MSK radiology the requisite 3rd
edition