Bone Tumors

Clues and Cues

Bone Tumors

Clues and Cues

Clues by Appearance

of Lesion

Patterns of Bone Destruction

Geographic

Moth-eaten

Permeative

Geographic Bone Destruction

Destructive lesion with sharplydefined border

Implies a less-aggressive, moreslow-growing, possibly benignprocess

Narrow transition zone

Non-ossifying fibroma

Geographic

Moth-eaten

Permeative

Patterns of Bone Destruction

Geographic LesionsExamples

Non-ossifying fibroma

Eosinophilic granuloma

Chondromyxoid fibroma

Moth-eaten Appearance

Areas of destruction with raggedborders

Implies more rapid growth

Probably a malignancy

Multiple Myeloma

Patterns of Bone Destruction

Geographic

Moth-eaten

Permeative

Moth-eaten AppearanceExamples

Myeloma

Metastases

Lymphoma

Ewing’s sarcoma

Permeative Pattern

Ill-defined lesion with multiple “worm-holes”

Spreads through marrow space

Wide transition zone

Implies an aggressive malignancy

Round-cell lesions

Myeloma

Patterns of Bone Destruction

Geographic

Moth-eaten

Permeative

Permeative PatternRound Cell lesions

Leukemia, lymphoma

Ewing’s Sarcoma

Myeloma

Osteomyelitis

Neuroblastoma

Patterns of Destruction

Geographic

Moth-eaten

Permeative

Less malignant

More malignant

Periosteal Reactions

Benign

None

Solid

More aggressive or malignant

Lamellated or onion-skinning

Sunburst

Codman triangle

Non-ossifying fibroma

Benign

None

Solid

Aggressive/malignant

Onion-skinning

Sunburst

Codman triangle

Periosteal Reactions

Chronic osteomyelitis

Benign

None

Solid

Aggressive/malignant

Onion-skinning

Sunburst

Codman triangle

Periosteal Reactions

Benign

None

Solid

Aggressive/malignant

Onion-skinning

Sunburst

Codman triangle

Periosteal Reactions

Ewing Sarcoma

Osteosarcoma

Benign

None

Solid

Aggressive/malignant

Onion-skinning

Sunburst

Codman triangle

Periosteal Reactions

Ewing-Codmantriangle

Benign

None

Solid

Aggressive/malignant

Onion-skinning

Sunburst

Codman triangle

Periosteal Reactions

Periosteal Reactions

Solid

Lamellated

Codman

Sunburst

Less malignant

More malignant

Tumor Matrix

Osteoblastic

Fluffy, cotton-like or cloud-like densities

Osteosarcoma

Cartilaginous

Comma-shaped, punctate, annular, popcorn-like

 Enchondroma, chondrosarcoma, chondromyxoidfibroma

Osteoblastic

Cartilaginous

Tumor matrix

Osteosarcoma

Osteoblastic

Cartilaginous

Tumor matrix

Chondrosarcoma

Expansile Lesions of Bone

 Multiple myeloma

 Brown tumor

 Mets

 Enchondroma

 Aneurysmal bone cyst

 Lymphoma

 Fibrous dysplasia

Multiple Myeloma

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Renal Cell Carcinoma

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Aneurysmal Bone Cyst

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Fibrous Dysplasia

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Brown Tumor

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Enchondroma

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Lymphoma

Expansile lesions

 Multiple myeloma

 Mets

 Aneurysmal bone cyst

 Fibrous dysplasia

 Brown tumor

 Enchondroma

 Lymphoma

Clues by Location

of Lesion

In the Transverse Plane

Central

Enchondroma, simple cyst, fibrous dysplasia

Eccentric

GCT, osteosarcoma, chondromyxoid fibroma

Cortical

Non-ossifying fibroma, osteoid osteoma

Parosteal

Parosteal osteosarcoma, osteochondroma

Parosteal sarcoma

Osteochondroma

Osteosarcoma

In The Transverse Plane

Greenspan

In the Longitudinal Plane

Epiphyseal

GCT, chondroblastoma

Metaphyseal

Osteomyelitis, osteo- and chondrosarcoma

Diaphyseal

Round cell lesions, ABC, enchondroma

Tumor TypesCharacteristic Locations

Simple bone cyst

Proximal humerus

Chondroblastoma

Epiphyses

Giant Cell tumor

Epiphyses

Simple bone cyst

Proximal humerus

Chondroblastoma

Epiphyses

Giant Cell tumor

Epiphyses

Characteristic locations

Chondroblastoma

Simple bone cyst

Proximal humerus

Chondroblastoma

Epiphyses

Giant Cell tumor

Epiphyses

Characteristic locations

Giant Cell Tumor

Simple bone cyst

Proximal humerus

Chondroblastoma

Epiphyses

Giant Cell tumor

Epiphyses

Characteristic locations

Tumor TypesCharacteristic Locations

Adamantinoma

Tibia

Chordoma

Sacrum, clivus

Osteoblastoma

Spine, posterior

Adamantinoma

Tibia

Chordoma

Sacrum, clivus

Osteoblastoma

Spine, posterior

Characteristic locations

Adamantinoma

Adamantinoma

Tibia

Chordoma

Sacrum, clivus

Osteoblastoma

Spine, posterior

Chordoma

Characteristic locations

Osteoblastoma

Adamantinoma

Tibia

Chordoma

Sacrum, clivus

Osteoblastoma

Spine, posterior

Characteristic locationsCharacteristic locations

Tumor TypesCharacteristic Locations

Parosteal sarcoma

Distal femur

Periosteal sarcoma

Tibia

Characteristic locations

Parosteal sarcoma

Distal femur

Periosteal sarcoma

Tibia

Parosteal sarcoma

Characteristic locations

Parosteal sarcoma

Distal femur

Periosteal sarcoma

Tibia

Periosteal sarcoma

Characteristic Tumors

By Body Site

Pelvic Lesions

Chondrosarcoma

Solitary plasmacytoma

Chordoma

Chondrosarcoma

Solitaryplasmacytoma

Chordoma

Pelvic lesions

Chondrosarcoma

Plasmacytoma

Chondrosarcoma

Solitaryplasmacytoma

Chordoma

Pelvic lesions

Chordoma

Chondrosarcoma

Solitaryplasmacytoma

Chordoma

Pelvic lesions

Expansile Rib Lesions

Fibrous dysplasia

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilic granuloma

Neurofibromatosis

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Plasmacytoma

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Thyroid Carcinoma

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Chondrosarcoma

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Eosinophilic Granuloma

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Neurofibromatosis

Plasmacytoma

Metastases

Chondrosarcoma

Eosinophilicgranuloma

Neurofibromatosis

Fibrous dysplasia

Expansile rib lesions

Fibrous Dysplasia

Lesions of the Spine

Osteoblastoma

Expansile, with punctate densitieswithin

Chordoma

ABC

Metastatic disease

Osteoblastoma

Osteoblastoma

Chordoma

ABC

Metastaticdisease

Spine lesions

Chordoma

Osteoblastoma

Chordoma

ABC

Metastaticdisease

Spine lesions

Aneurysmal bone cyst

Osteoblastoma

Chordoma

ABC

Metastaticdisease

Spine lesions

Metastatic Breast Carcinoma

Osteoblastoma

Chordoma

ABC

Metastaticdisease

Spine lesions

Clues by Density

Of Lesion

Sclerotic Cortical Lesions

Osteoid osteoma

Brodie’s abscess

Stress fracture

Osteoid Osteoma

Osteoid osteoma

Brodie’s abscess

Stress fracture

Sclerotic cortical lesions

Brodie’s abscess

Osteoid osteoma

Brodie’s abscess

Stress fracture

Sclerotic cortical lesions

Healing Stress Fracture

Osteoid osteoma

Brodie’s abscess

Stress fracture

Sclerotic cortical lesions

Sclerotic Cortical Lesions

Healing StressFracture

Osteoid Osteoma

Brodie’s abscess

Lytic Lesions in Children

Eosinophilic granuloma

Neuroblastoma

Leukemia

Eosinophilicgranuloma

Neuroblastoma

Leukemia

Lytic Lesions in Children

Eosinophilic granuloma

Neuroblastoma

Eosinophilicgranuloma

Neuroblastoma

Leukemia

Lytic Lesions in Children

Leukemia

Eosinophilicgranuloma

Neuroblastoma

Leukemia

Lytic Lesions in Children

Lytic Lesions in Adults

Metastatic lesions

Lung

Renal

Thyroid

Multiple myeloma

Primary bone tumor

Met  from Thyroid Carcinoma

Mets

Myeloma

Primary bonetumor

Lytic Lesions in Adults

Plasmacytoma

Mets

Myeloma

Primary bonetumor

Lytic Lesions in Adults

Chondrosarcoma

Mets

Myeloma

Primary bonetumor

Lytic Lesions in Adults

Blastic Lesions in Children

Medulloblastoma

Lymphoma

Medulloblastoma

Medulloblastoma

Lymphoma

Blastic Lesions in Children

Lymphoma

Medulloblastoma

Lymphoma

Blastic Lesions in Children

Blastic Lesions in Adults

Metastatic disease

Breast – female

Prostate – male

Lymphoma

Paget’s disease

Etcetera-mastocytosis, fluorosis

Prostate Mets

Mets

Lymphoma

Paget’s

Blastic Lesions in Adults

Breast Mets

Mets

Lymphoma

Paget’s

Blastic Lesions in Adults

Lymphoma

Mets

Lymphoma

Paget’s

Blastic Lesions in Adults

Paget’s of Spine

Mets

Lymphoma

Paget’s

Blastic Lesions in Adults

Clues by Ageof Patient

Age

Think of

0-10

EG, Neuroblastoma, LeukemiaEwing, Osteosarcoma

10-20

20-40

40+

Age

Think of

0-10

EG, Neuroblastoma, LeukemiaEwing, Osteosarcoma

Age

Think of

0-10

EG, Neuroblastoma, LeukemiaEwing, Osteosarcoma

10-20

NOF, EG, Chondroblastoma, ABC,SBC, Ewing, Osteosarcoma

Age

Think of

0-10

EG, Neuroblastoma, LeukemiaEwing, Osteosarcoma

10-20

NOF, EG, Chondroblastoma, ABC,SBC, Ewing, Osteosarcoma

20-40

GCT, Brown, Osteoblastoma,Chondrosarc, Parosteal osteosarc

Age

Think of

0-10

EG, Neuroblastoma, LeukemiaEwing, Osteosarcoma

10-20

NOF, EG, Chondroblastoma, ABC,SBC, Ewing, Osteosarcoma

20-40

GCT, Brown, Osteoblastoma,Chondrosarc, Parosteal osteosarc

40+

Mets, Myeloma, Chondrosarcoma

Other Clues

Benign LesionsWithout Sclerotic Boarders

Giant Cell tumor

Brown tumor

Osteolytic phase of Paget’s Disease

Benign Lesions without ScleroticBorders

 Giant cell tumor

 Brown tumor

 Osteolytic Paget’s

Giant Cell Tumor

Brown Tumor

Benign Lesions without ScleroticBorders

 Giant cell tumor

 Brown tumor

 Osteolytic Paget’s

Osteolytic Paget’s

Benign Lesions without ScleroticBorders

 Giant cell tumor

 Brown tumor

 Osteolytic Paget’s

Soft Tissue Extension

Usually implies malignancy

More likely to form discrete soft tissue mass

Benign conditions with soft tissueextension

Osteomyelitis

Usually infiltration of fat

Osteosarcoma

Multiple Lesions

More often benign

Malignancies with multiple lesions

Metastatic disease

Multiple myeloma

Lymphoma

Ewing’s sarcoma (rarely)

Osteosarcoma (rarely)

Mets from Ca of Prostate

Multiple lesions

 Metastatic

 Multiple myeloma

 Lymphoma

Multiple Myeloma

Multiple lesions

 Metastatic

 Multiple myeloma

 Lymphoma

Lymphoma

Multiple lesions

 Metastatic

 Multiple myeloma

 Lymphoma

Benign vs. Malignant

Greenspan

Your Turn

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Leukemia

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Aneurysmal bone cyst

Eosinophilic granuloma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Unicameral bone cyst

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Multiple myeloma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Aneurysmal bone cyst

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Chondrosarcoma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Non-ossifying fibroma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Metastatic ca to right claviclefrom thyroid ca

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Osteosarcoma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Chondrosarcoma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Mets from breast cancer

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Mets from Renal Cell

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Fibrous dysplasia

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Mets to spine-renal cell

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Multiple myeloma

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

Mets from renal cell ca

• Age of patient

• Tumor density

• Sclerotic, lytic, mixed

• Well-circumscribed, poorly-marginated,septated

• Expansile or not

• Location

• Epiphyseal, diaphyseal, metaphyseal

• Pattern of destruction

• Geographic, moth-eaten, permeative

• Tumor matrix

• None, bony, cartilaginous

• Cortical destruction

• None, some, marked

• Periosteal reaction

• None, solid, lamellated, onion-skinning, Codman’s triangle

• Soft tissue extension

The End