Intro

Bone tumors are very diverse in morphology

and biological potential (can be no big deal or
rapidly fatal)
MOST bone tumors are benign lesions
Most benign lesions are seen <30 years of age
A new bone tumor in the elderly is more likely
to be malignant
No bone is safe (though most primaries are in
long bones)
Locale in the bone gives important Dx info
More common benign lesions typically present
as incidental findings (non-painful, stable size)
Be cautious with painful lesions and those that
grow relatively fast (over weeks or months)
Pathological fracture can be the first sign of
tumor

Bone neoplasms are very difficult to

diagnose specifically on radiologic
testing alone
So why is radiology important?
Exact location of lesion
Extent of growth/metastasis
Aggressiveness

Best test for Dx= X-ray

Best test for staging= CT or MRI
Quick shout out to the pathologists
histologic grade is the most important
prognostic feature of bone sarcomas and
essential for staging most of the bone
tumor types.

Cases
Find the lesion

Example:

Cases
Find the lesion

Example:

RIGHT THERE!

Case I

16 yr old white male with pain in his

left upper arm.
Mild swelling and tenderness
Pain progressively getting worse for ~ 3
months
Recent onset of mild fever

Imaging:

Imaging:

**

Biopsy material showed a highly cellular, infiltrative

neoplasm consisting of sheets of tightly packed, round
cells with very scant cytoplasm ("round blue cell tumor").

Dx: Ewings Sarcoma (or

PNET)

#2 primary bone malignancy in kids (515 is most common age group

Much more common in Caucasians
Typically in the diaphysis of long
tubular bones or in large flat bone
Lytic tumor w/ permeative margins
extending into the soft tissue
Periostial rxn creates sheets of reactive
bone in an onion-skin fashion

Another most
excellent example of
onion-skinning

Case II

33 yr old black female with sudden

severe hand pain after very minor
trauma.
Completely healthy otherwise.
All labs normal

Dx: Enchondroma

Benign cartilagenous tumors but hard to

distinguish from a low grade
chondrosarcoma
Acral bones-- the most common primary
hand tumor
Usually solitary, usually incidental finding
(non-painful unless associated with
fracture)
Get hand films and look for dec. lucency
but not so much as a cyst (more groundglass) w/ or w/o areas of stippled
calcifications or rings

For boards and wards:

Multiple enchondromas =
____________
Multiple enchondromas +
hemanigiomas of soft tissue =
_____________

For boards and wards:

Multiple enchondromas = Olliers Dz

Multiple enchondromas +
hemangiomas of soft tissue =
Maffucci syndrome

Case III

50 yr old white male with back pain

Mainly lower spine/sacral pain,
progressive ~ 8 months
New onset rectal pain and constipation

CT guided FNA
confirmed

Dx: Chordoma

Arises from notochord remnants. Thus is

typically midline along the spine and
usually at the ends (Sacrococc or
occ/cervical jxn)
Males>Females, middle age
+ staining w/ S-100 and epithelial
markers
Locally invasive until very late in disease
where mets can go to the lungs, LN, skin.

Case IV

21 yr old male with new onset chest

pain today, worse on inhalation.

ROS significant for an ongoing aching

leg pain for the past 6 months which he
has put off seeing a doctor for.

Dx: The dreaded

Osteosarcoma

#1 primary bone malignancy

Associated with RB1 and p53 gene
mutations

1000x greater risk w/ Hx of hereditary

retinoblastoma
Member of the Li-Fraumeni Syndrome family

Bimodal age spike: young and elderly

75% <age 20
Osteosarcoma in elderly usually from
predisposing mechanism (secondary)

Paget Dz, bone infarcts, history of radiation, etc

Most patients die from pulmonary

complications after metastatic seeding of

the lungs (ex: pneumothorax)

Metaphysial tumor
60% at the knee (distal femur or prox
tibia)
Radiographic terms to know:

Codmans Triangle:

Sunburst periostial formation:

AKA Hair on end

For the future Surgeons:

Rotationplasty is a new solution to

disfiguring surgical resections of
lower limb sarcomas:

Quick Hits:

Gout

Incidenta
l finding
on knee
xray

Fabella = posterior
sesmoids or little confused

13 yr old
boy with
superior
tibial
pain, r/o
neoplasm
w/ xray
shows:

Osgood Schlatter

Metastatic Disease

Most common malignant lesion of bone

Bone is # 3 on the list of favorite places for
mobile cancers to go
Malignant lesions are more likely to be in
axial bones
Typically multifocal BUT renal and thyroid
carcinomas are notorious for producing only a
solitary lesion
Can be lytic, blastic, or both:

Lung is Lytic, Prostate Produces, Breast does Both

Mets (cont)

Adults

Lung
Prostate
Breast
Kidney

Kids

NB
Wilms
OS
Ewings
Rhabdomyosarcom
a

The End

Thanks for your attention and

good luck on applications!

Bibliography

Robbins and Cotran, Pathological Basis of Disease, 7th

Edition
MD Murphey, MR Robbin, GA McRae, DJ Flemming, HT
Temple, and MJ Kransdorf
The Many Faces of Osteosarcoma
RadioGraphics 1997; 17: 1205
William R. Reinus, Louis A. Gilula IESS Committee
Radiology of Ewing's sarcoma: Intergroup Ewing's
Sarcoma Study (IESS)
RadioGraphics 1984; 4: 929-944.
Washington Univ. in St. Louis (website)
Harvard Medical School (website)
Learning Radiology.com (website duh)
Bonetumor.org (Youre not even reading this are you?)