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Case 3. 20 y/o male referred from outside hospital. . . T1. GRE. T2 FS. Cartilage Cap. . . Diagnosis?. . Osteochondroma. Osteochondroma. Most common benign bone lesion accounting for 20-50% of all bone tumorsIf multiple, associated with Multiple Hereditary ExostosesResults from the separation of a fragment of epiphyseal growth plate cartilage which subsequently herniates through the periosteal bone surrounding the growth plate.
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1. Musculoskeletal MRI Unknown CasesTexas Radiologic Society93rd Annual Scientific MeetingAustin, TXApril 21-23, 2006 Lezlie R Warren, MD CPT USAF
Justin Q Ly, MD CPT USAF
Douglas P Beall, MD
Wilford Hall Medical Center
San Antonio, TX Intro self and say what talk this is
Say only 2nd yr resident
Want to emphasize MRI, so those images first followed by other modalities
I like nature // got distracted by internetIntro self and say what talk this is
Say only 2nd yr resident
Want to emphasize MRI, so those images first followed by other modalities
I like nature // got distracted by internet
2. ******
3. 20 y/o male referred from outside hospital
4. Exophytic pedunculated lesion arising from dist femur w/ both cortical and medullary continuity
Can see displacement of popliteal arteryExophytic pedunculated lesion arising from dist femur w/ both cortical and medullary continuity
Can see displacement of popliteal artery
5. T2 FS
Shows continuity of medullary portion of lesion and of cortex
High signal cartilage cap w/ not well seen low signal lining (perichondrium)
Just say “with this entity you will see……”T2 FS
Shows continuity of medullary portion of lesion and of cortex
High signal cartilage cap w/ not well seen low signal lining (perichondrium)
Just say “with this entity you will see……”
6. Axial and sagittal CT shows medullary and cortical continuity
Pedunculated, well marginated process affecting the distal femurAxial and sagittal CT shows medullary and cortical continuity
Pedunculated, well marginated process affecting the distal femur
7. Angio shows compromise of the popliteal artery by this lesionAngio shows compromise of the popliteal artery by this lesion
8. Diagnosis?
9. Osteochondroma Most common benign bone lesion accounting for 20-50% of all bone tumors
If multiple, associated with Multiple Hereditary Exostoses
Results from the separation of a fragment of epiphyseal growth plate cartilage which subsequently herniates through the periosteal bone surrounding the growth plate Cases after surgery and traumaCases after surgery and trauma
10. Osteochondroma Complications:
Deformity (cosmetic or osseous)
Fracture (host bone or lesion)
Vascular or neurologic compromise
Bursae formation (bursa exostotica)
Malignant Transformation to chondrosarcoma (1%)
Also known as osteocartilaginous exostosis
A developmental lesion, rather than a true neoplasm (results from the separation of a fragment of epiphyseal growth plate cartilage which subsequently herniates through the periosteal bone surrounding the growth plate
There are cases of secondary osteochondroma, from sx or trauma, tansplantation of physeal tissue, or even after xrt
Accounts for 15% of ALL bone tumors (B9 & malig)
Malignant tx 3-5% in HME (from 1%)
Fxr can be of host bone or of lesion
Usuall dx’d before third decade w/ male predominance
Osteochondroma has it’s own growth plate (therefore should stop growing at skeletal maturity)
Likes metaphyses of long bones (knee and prox humerus)
Usually directed away from neighboring growth plate
Most important feature for dx is the uninterrupted merging of cortex with the host bone, and communication of medullary portion w/ parent bone
The narrow band of low signal surrounding the cap represents the overlying perichondrium
Can have calcs in stalk, B9 finding
Can get inflammatory chgs of bursa covering cartilage cap
NM not reliable for malig tx as both have incr uptake
HME also known as multiple hered osteochondrom; familial osteochondromatosis, diaphyseal aclasis (AD); more frequently sessile type of lesion
Calcs in cartilaginous cap, worrisome for malig tx
Most common benign bone lesion accounting for 20-50% of all bone tumors
The least common complication of an osteochondroma occurring in less than 1% of cases is malignant transformation to chondrosarcoma
Clinical features suggestive of malignant transformation are pain (in the absence of fracture or bursitis), pressure on adjacent nerve, or growth of lesion beyond age of skeletal maturity
Also known as osteocartilaginous exostosis
A developmental lesion, rather than a true neoplasm (results from the separation of a fragment of epiphyseal growth plate cartilage which subsequently herniates through the periosteal bone surrounding the growth plate
There are cases of secondary osteochondroma, from sx or trauma, tansplantation of physeal tissue, or even after xrt
Accounts for 15% of ALL bone tumors (B9 & malig)
Malignant tx 3-5% in HME (from 1%)
Fxr can be of host bone or of lesion
Usuall dx’d before third decade w/ male predominance
Osteochondroma has it’s own growth plate (therefore should stop growing at skeletal maturity)
Likes metaphyses of long bones (knee and prox humerus)
Usually directed away from neighboring growth plate
Most important feature for dx is the uninterrupted merging of cortex with the host bone, and communication of medullary portion w/ parent bone
The narrow band of low signal surrounding the cap represents the overlying perichondrium
Can have calcs in stalk, B9 finding
Can get inflammatory chgs of bursa covering cartilage cap
NM not reliable for malig tx as both have incr uptake
HME also known as multiple hered osteochondrom; familial osteochondromatosis, diaphyseal aclasis (AD); more frequently sessile type of lesion
Calcs in cartilaginous cap, worrisome for malig tx
Most common benign bone lesion accounting for 20-50% of all bone tumors
The least common complication of an osteochondroma occurring in less than 1% of cases is malignant transformation to chondrosarcoma
Clinical features suggestive of malignant transformation are pain (in the absence of fracture or bursitis), pressure on adjacent nerve, or growth of lesion beyond age of skeletal maturity
11. Osteochondroma Features suggestive of malignant transformation:
Pain (in the absence of fracture or bursitis)
Growth of lesion beyond age of skeletal maturity (own growth plate)
Thick cartilage cap > 1.5 cm (is normally 1-3 mm, rarely > 1 cm)
12. Osteochondroma Imaging Findings:
Pedunculated with slender pedicle, usually directed away from adjacent growth plate
Or sessile, with a broad base attached to the cortex
*There is communication of the cortex and the medullary portion of the lesion and host bone
Calcifications in the chondro-osseous portion of the stalk (sign of benignity)
Cartilaginous cap (high signal on GRE and T2 images)
13. Osteochondroma DDx:
Osteoma
Periosteal chondroma
Juxtacortical osteosarcoma
Soft tissue osteosarcoma
Juxtacortical myositis ossificans
Treatment:
Solitary osteochondromas can be monitored in the absence of clinical symptoms or complications
If malignant transformation is suspected, the lesion is surgically resected Osteoma:
Ivory like sclerotic mass attached to bone; assoc w/ cutaneous and subcutaneous masses and intestinal polyps (Gardner syndome)
Periosteal chondroma
Lack of medullary and cortical continuity
Juxtacortical osteosarcoma
Aggressive features: periosteal reaction, soft tissue mass
Soft tissue osteosarcoma
Aggressive features: periosteal reaction, soft tissue mass
Juxtacortical myositis ossificans
History of trauma; lack of continuity w/ cortex and medullary space
Osteoma:
Ivory like sclerotic mass attached to bone; assoc w/ cutaneous and subcutaneous masses and intestinal polyps (Gardner syndome)
Periosteal chondroma
Lack of medullary and cortical continuity
Juxtacortical osteosarcoma
Aggressive features: periosteal reaction, soft tissue mass
Soft tissue osteosarcoma
Aggressive features: periosteal reaction, soft tissue mass
Juxtacortical myositis ossificans
History of trauma; lack of continuity w/ cortex and medullary space