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Imaging of B one T umors

Imaging of B one T umors. Dr. Bashar Adnan. Introduction. Forms 0.2% of human tumor burden Primary malig bone tumors make 1% of all malignant tumors Most have male predominance except GCT, ABC. Most common malignant tumour is secondary metastatic deposits, mostly from.

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Imaging of B one T umors

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  1. Imaging of Bone Tumors Dr. BasharAdnan

  2. Introduction • Forms 0.2% of human tumor burden • Primary malig bone tumors make 1% of all malignant tumors • Most have male predominance except GCT, ABC. • Most common malignant tumour is secondary metastatic deposits, mostly from

  3. X-rays - the question need to ask: • (1) Location of the lesion • (2) Extent of the lesion • (3) What is the lesion doing to the bone? • (4) What is the bone doing to the lesion? • (5) Hint as to its tissue type / matrix

  4. A. Location • Location and age of patient most important parameters in classifying a primary bone tumor. • Simple to determine from plain radiographs.

  5. Location

  6. DIAPHYSEAL Adamantinoma Leukemia, Lymphoma, Reticulum cell sarcoma Ewing sarcoma Metastasis Osteoblastoma/ osteoidosteoma Nonossifyingfibroma Location in Longitudinal Plane • METAPHYSEAL • Nonossifyingfibroma (close to growth plate) • Chondromyxoidfibroma (abutting growth plate) • Solitary bone cyst, ABC, GCT • Osteochondroma • Brodie abscess • Osteogenic sarcoma, chondrosarcoma • EPIPHYSEAL • Chondroblastoma • Clear cell chondrosarcoma • Giant cell tumor • Aneurysmal bone cyst • Geode (subchondral cyst) • Infection • Eosinophilicgranuloma

  7. Location in Transverse Plane • Central: Enchondroma • Eccentric: GCT, CMF, osteosarcoma • Cortical: osteoidosteoma, NOF • Parosteal: osteochondroma, parostealosteosarcoma

  8. Specific Location

  9. Cysts and cyst like lesions of bone

  10. B: What is the lesion doing to the bone? Patterns of bone destruction: • Lytic • Sclerotic • GEOGRAPHIC Well-defined smooth / irregular margin Short zone of transition Poorly demarcated lesion imperceptibly merging with uninvolved bone Long zone of transition • PERMEATIVE Areas of destruction with ragged borders. Less well defined / demarcated lesional margin Longer zone of transition • MOTHEATEN

  11. MARGIN • Margin between tumor and native bone is visible on the plain radiograph. • Slowly progressive process is “walled-off” by native bone, producing distinct margins. • Rapidly progressive process destroys bone, producing indistinct margins.

  12. Radiographic Margins • Margin types 1A, 1B, 1C, 2, and 3 • least aggressive 1A, to most aggressive 3 • Aggressive lesions destroy bone. • Aggressiveness increases likelihood of malignancy. • BUT, not all aggressive processes are malignant. • AND, not all malignant diseases are aggressive.

  13. Margins: 1A,1B,1C A well circumscribed lesion with a narrow zone of transition increasing aggressiveness

  14. 1A: sclerotic margin • simple cyst (UBC) • enchondroma • FD • chondroblastoma • GCT • chondrosarcoma (rare) • MFH (rare)

  15. 1B: well-defined, non-sclerotic • GCT • enchondroma • chondroblastoma • myeloma, metastatsis • CMF • FD • chondrosarcoma • MFH

  16. 1C: lytic, ill-defined margins • chondrosarcoma • MFH • osteosarcoma • GCT • metastasis • infection • EG • lymphoma

  17. 2: “motheaten” • myeloma, metastases • infection • EG • osteosarcoma • chondrosarcoma • lymphoma Multiple scattered holes that vary in size & seem to arise separately

  18. 3: “permeative” • Ewing • EG • infection • myeloma, metastasis • lymphoma • osteosarcoma Poorly demarcated from normal, numerous elongated holes/slots in cortex, run parallel to long axis of bone

  19. B. Reaction of bone to tumor • Limited responses of bone Destruction: lysis (lucency) Reaction: sclerosis Remodeling: periosteal reaction • Rate of growth determines bone response • slow progression, sclerosis prevails • rapid progression, destruction prevails

  20. Periosteal Reaction • Periosteal reaction must mineralize to be seen on X ray ( 10 days – 3 weeks) • Configuration of periosteal reaction • Nature of inciting process • Intensity • Aggressiveness • Duration

  21. Periosteal Reaction • Thick, uninterrupted • long standing process, often non-aggressive • stress fracture • chronic infection • osteoidosteoma • Spiculated, lamellated • aggressive process • tumor likely

  22. Codman Triangle periosteal reaction Codman Triangle advancing tumor margin destroys periosteal new bone before it ossifies tumor

  23. Sunburst Appearance

  24. C: Tumor Matrix • “Matrix” is the internal tissue of the tumor • Most tumor matrix is soft tissue in nature. • Radiolucent (lytic) on x-ray • Cartilage matrix • calcified rings, arcs, dots (stippled) • enchondroma, chondroblastoma, chondrosarcoma • Ossific matrix • osteosarcoma

  25. Osteochondroma • Exostosis: well defined bony projection growing away from physis • Cartilage maybe calcified if lesions are large / malignant change

  26. Osteoidosteoma • Nidus: a tiny radiolucent area • If in diaphysis surrounded by dense bone and thickened cortex Metaphysis less cortical thickening • Double density sign on bone scan – increased uptake in nidus and decreased uptake in reactive sclerotic zone (also seen in Brodie’sabcess) • Lyticnidus surrounded by sclerotic bone in CT • Centre of nidus may be calcified

  27. Osteoblastoma • Well demarcated osteolytic lesion sometimes containing flecks of calcification • Less reactive bone than osteoidosteoma • Bone scan - intense activity

  28. Simple bone cyst • Cystic radiolucency on the diaphysial side of the growth plate • Cortex may be thinned and bone expanded with well defined thin sclerotic margin • May have pseudo-loculated appearance secondary to irregular cortical thinning and thin septal ridges • Falling fragment sign typical and the lesion is never wider than epiphysial plate • Bone scan cold or minimal activity unless fractured

  29. Aneurysmalbone cyst • Gross honey comb lesion • Often eccentrically placed • Does not extend to the joint (unlike GCT) • Warm to hot on bone scan

  30. Giant cell tumor • Usually well defined geographic lytic lesion in the epiphysis/metaphysis extending up to the joint surface without marginal sclerosis • Junction with normal bone often poorly defined • Cortex thinned and sometimes ballooned • Bone scan warm to hot

  31. Fibrous cortical defect • Margin well defined, sometimes scalloped and often sclerosed

  32. Non-ossifying Fibroma Geographic Well marginatedMultilocular appearance Inter cortical osteolysis - single or multiple bubble like areas

  33. Fibrous Dysplasia • Ground glass appearance typical • Shepherds crook deformity of proximal femur • Variable appearance with expansion of cortex

  34. Enchondroma • Scalloped erosions on endosteal surface • May have flecks of calcification

  35. Chondromyxoidfibroma • Rounded or oval rare area • Usually eccentrically placed • May cross the growth plate • Sharp outline and sclerotic rim • Scalloped margin and thin cortex

  36. Chondroblastoma • Well defined area of rarefaction eccentrically placed in the epiphysis or across the growth plate • No reaction in surrounding bone • 50% show central calcification, 50% show linear periosteal reaction • Bone scan increased uptake at margins

  37. Synovial Chondromatosis • Multiple loose bodies

  38. Chordoma • Large osteolytic lesion in the midline • May contain flecks of calcification • Marked bone destruction

  39. Brown Tumor • Diffuse osteopenia with multiple osteolytic lesions dispersed throughout skeleton.

  40. Adamantinoma • Characteristic honey comb appearance in diaphysis • Cortical thinning with expansion

  41. Hemangioma • Vertical striations without bone expansion and coarse trabecular appearance (corduroy appearance)

  42. Eosinophillicgranuloma • Mottled lytic defect usually no sclerotic rim • May destroy cortex • Usually endosteal or periosteal reaction • Lesions in flat bones and ribs appear punched out • May appear loculated due to sparing of large trabeculae • Spinal lesions- collapse (vertebra plana), which may heal

  43. Ewing’s sarcoma • Mottled or moth eaten lesion diffusely involving bone • Lytic destruction common, often the cortex is perforated • Onion skin appearance- layers of periosteal new bone are said to be characteristic • May form Codman’s triangle

  44. Osteosarcoma • Variable with combination of bone destruction and bone formation • Sun ray spicules/ sun burst appearance and Codman’s triangle may be evident • Cortical breach common • Adjacent soft tissue mass • Joint space rarely involved • 25% Lytic, 35% Sclerotic, 40% Mixed • Telangiectatic type- purely lytic

  45. Chondrosarcoma • Variable appearance with 60 - 70% have calcification and 50% have sub periosteal new bone • May be a large cystic lesion with cortical destruction and central calcification, endosteal scalloping and cortical expansion; annular, punctate or comma shaped calcification

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