Radiology of Bone Tumors

Kenneth Buckwalter, M.D.

Indiana University
kbuckwal@iupui.edu
(317) 274-1837

Outline
Work-up and Radiologic assessment
Approach
Normal bone anatomy
Radiographic Analysis

Location
Margins
Periosteal reaction
Matrix

Examples

Work-up
History
Age is critical.
Smoker?
Malignancy?

Physical examination
Breast mass?

Good radiographs of affected region

2 views minimum

Multiple vs. Solitary

Multiple
metastatic
congenital
fibrous dysplasia

acquired
Paget

Solitary
metastatic
primary bone tumor, malignant or benign

Multiple
50+ y/o
known malignancy?
myeloma, get SPEP
otherwise, do metastatic work-up

child to early adult

known malignancy?
EG?
polyostotic fibrous dysplasia?
otherwise, do metastatic work-up

Solitary
Aggressive radiographic appearance
bone scan to stage and verify solitary nature
metastatic work-up
baseline CXR
spiral CT for pulmonary nodules

Staging for surgery

cross-sectional imaging: CT or MR

Need tissue biopsy

Biopsy
obvious superficial mass, blind biopsy
tissue compartments must not be
contaminated
Biopsy should be done in consultation with a
tumor surgeon.

skinny needle most helpful with metastatic

disease
core best for primary tumor

Cross-sectional imaging
Pictures are pretty, but diagnosis established
at histology
MRI best for most tumors
optimal results at sites with experience

Role of CT limited
may assist in assessing tumor matrix
useful in directing biopsy

Normal Anatomy
cortex

diaphysis

metaphysis

epiphysis

physis

medullary
space

physeal scar

childhood

adult

How are Bone Tumors

Like Real Estate?
Location!
Location!
Location!

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

Location

Rad Clin N Am,

Dec 1981

Reaction of bone to tumor

Limited responses of bone
destruction:
reaction:
remodeling:

lysis (lucency)
sclerosis
periosteal reaction

Rate of growth determines bone response

slow progression, sclerosis prevails
rapid progression, destruction prevails

Reaction of bone to tumor

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.

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.

Margins: 1A,1B,1C

Rad Clin N Am,

Dec 1981

increasing aggressiveness

1A: sclerotic margin

simple cyst (UBC)

enchondroma
FD / FX
chondroblastoma
GCT
chondrosarcoma (rare)
MFH (rare)

1B: well-defined, non-sclerotic

Rad Clin N Am,

Dec 1981

GCT
enchondroma
chondroblastoma
myeloma, metastatsis
CMF
FD
chondrosarcoma
MFH

1C: lytic, ill-defined margins

Rad Clin N Am,

Dec 1981

chondrosarcoma
MFH
osteosarcoma
GCT
metastasis
infection
EG
lymphoma

2: motheaten

Rad Clin N Am,

Dec 1981

myeloma, metastases
infection
EG
osteosarcoma
chondrosarcoma
lymphoma

3: permeative

Rad Clin N Am,

Dec 1981

Ewing
EG
infection
myeloma, metastasis
lymphoma
osteosarcoma

Types of
Periosteal
Reaction

Rad Clin N Am,

Dec 1981

Periosteal Reaction
Limited usefulness
Thick, uninterrupted
long standing process, often non-aggressive

stress fracture
chronic infection
osteoid osteoma

Spiculated, lamellated
aggressive process
tumor likely

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

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

Matrix

Rad Clin N Am,

Dec 1981

Examples

Example 1

AGE
13
Location metadiaphysis
Margins
1A-1B
Periosteal Reaction
none
Matrix
none
Other trabecular struts
DX
UBC

Example 2

Example 2

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

adult
metaphysis
1B
none
none
fx
ABC

Example 3: 13 y/o with knee pain

Example 3

AGE
13
Location
epiphyseal
Margins
1B
Periosteal Reaction
none
Matrix
none
Other
DX chondroblastoma

Example 4: 45 y/o with knee pain

Example 4

AGE
45
Location metaphysis
Margins
1B
Periosteal Reaction
none
Matrix
none
Other epi involvement
DX
GCT

Example 4*, 35 y/o F, GCT

Example 5

AGE
66
Location
diaphyseal
Margins
1A
Periosteal Reaction minimal, thick
Matrix
none
Other
2nd lesion
DX
wait..

Example 5

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

66
diaphyseal
2
none
none
wait..

Example 5

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

66
flat bone
1B
none
none
multiple
myeloma

Example 6: 14 y/o with claudication

Example 6

Example 6

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

14
metaphysis
1B
none
mature bone
claudicat'n
exostosis

Example 7: 25 y/o woman with knee pain

Example 7

Example 7

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

25
metaphysis
1A
none
?
multiple
NOF

Example 8: 45 y/o with thigh pain

Example 8

AGE
45
Location
diaphysis
Margins
1B
Periosteal Reaction
thick
Matrix
faint
Other
DX osteoid osteoma

Example 9

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX

12
diaphysis
3
lamellated
none
Ewing

Example 9

onion-skin

Example 10

Example 10

AGE
16
Location
diaphysis
Margins
3
Periosteal Reaction
spiculated
Matrix
bone
Other
fx
DX osteosarcoma

Example 10*, osteosarcoma

AGE
20
Location metaphysis
Margins
3
Periosteal Reaction
irregular
Matrix
bone
Other
DX osteosarcoma

Example 11

AGE
56
Location metaphyseal
Margins
1A
Periosteal Reaction
none
Matrix
chondroid
Other
DX enchondroma

Summary
Radiographs are essential
Aggressiveness of process dictates the
response of the bone
Most helpful information in analysis
Age
Location
Margins

Dont Touch Me
Fibrous lesions
fibrous dysplasia
NOF (non-ossifying fibroma)

enchondroma
exostosis
unicameral (simple) bone cyst

Example

AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX