Radiographic Evaluation of Musculoskeletal Tumors

1
Radiographic Evaluation of Musculoskeletal Tumors

• James C. Wittig, MD
• Associate Professor of Orthopedic Surgery
• Chief, Orthopedic Oncology Mount Sinai Medical
  Center

2
Staging Studies

• Plain Radiograph
• MRI
• CT scan
• Chest CT
• Bone Scan

3
Plain Radiographs

• Evaluate
• Rate of tumor growth
• Tumor interaction with surrounding non-neoplastic
  tissue
• Internal composition of tumor

4
MRI

• Visualize entire bone and adjacent joint
• Best test for intraosseous extent and soft tissue
  extent
• Identify skip metastases
• Tumor proximity to neurovascular structures
• Occasionally helpful in diagnosis of bone or soft
  tissue tumors (experienced radiologist)

5
(No Transcript)
6
CT

• Good for evaluating cortical details and
  destruction
• Subtle cortical erosions (endostealperiosteal)
  not detectable on plain x-ray or MRI
• Subtle calcifications / ossification (Visible
  tumor matrix mineralization)

7
Pain Radiographs

• The next three slides demonstrates how plain
  radiographs should be utilized to evaluate a bone
  tumor
• There are specific characteristics that should be
  identified on plain radiographs that aid in the
  differential diagnosis of a bone tumor

8
Plain Radiographs

• Bone involved
• Is involved bone normal?
• What part of the bone?
• Open or closed growth plate
• Epicenter of lesion (cortex or medullary canal)
• Tumor contour and zone of transition between
  tumor and host bone

9
Plain Radiographs

• Mineralized matrix?
• Cortical destruction?
• Periosteal reaction? What type
• Involvement of joint space?
• Tumor multifocal?
• Is tumor of uniform appearanceor does it have
  several different components?

10
Radiographic Evaluation

• Bone Involved and Position in the Bone
• Pattern of Bone Destruction
• Geographic, Permeative, Moth Eaten
• Margin of the Lesion
• Presence of Visible Tumor Matrix
  (Calcification/Ossification)
• Internal Trabeculations
• Cortical Erosion, Penetration, Cortical Expansion
• Periosteal Response
• Continuous or Interupted

11
(No Transcript)
12
Patterns of Bone Destruction

• Geographic
• Motheaten
• Permeative

13
(No Transcript)
14
Geographic Bone Destruction

• Least Aggressive Pattern
• Slow Growing Lesion-Usually Benign
• Clearly Demarcated Lesion
• Clearly Delineated Borders of Lesion
• Narrow Zone of Transition between Tumor and
  Normal Bone
• May have Sclerotic Margin
• Thicker Sclerotic Margin is Less Aggressive
• No Surrounding Sclerosis means more
  Aggressive/Faster Growing
• Usually Benign also Myeloma, Mets, Osteomyelitis
  (Especially Granulomatous) can be Geographic

15
Geographic Bone Destruction
16
(No Transcript)
17
Giant Cell Tumor
18
Giant Cell Tumor
19
Geographic Bone Destruction
20
(No Transcript)
21
(No Transcript)
22
Chondroblastoma
23
Geographic Bone Destruction
24
Geographic Bone Destruction
25
Geographic Bone Destruction
26
Geographic Bone DestructionABC- Aneurysmal Bone
Cyst
27
(No Transcript)
28
Geographic Bone DestructionFluid-Fluid Levels on
MRIABC
29
(No Transcript)
30
I WANT YOU!!!!!!!!
BE ALL THAT YOU CAN BE!!! NYU NURSE
PRACTITIONERS GOOOO TUMORS!!!!!!!!
31
Geographic Bone DestructionGiant Cell Tumor
32
(No Transcript)
33
MRI
34
CT Scan
35
Geographic Bone Destruction

• Types of Margins Around Lesion
• IA (Thick Complete Sclerotic Margin)
• Indolent Lesion
• IB (Thin and Incomplete)
• Active Lesion
• IC (No Sclerotic Margin)
• Aggressive Lesion

36
(No Transcript)
37
(No Transcript)
38
IA
39
IA-Non Ossifying Fibroma
40
IBGiant Cell Tumor
41
IB
42
IB
43
IB
44
IC
45
IC
46
ICGiant Cell Tumor
47
IB/IC
48
IC
49
ICCT Demonstartion
50
Motheaten Bone Destruction

• More Aggressive Bone Destruction
• Less Well Defined Margins
• Larger Zone of Transition From Normal to Abnormal
  (Tumor)
• Multiple Punched Out Holes in the Bone
• Malignant Bone Tumors, Osteomyelitis,
  Eosinophilic Granuloma

51
Motheaten Bone Destruction
52
Permeative Bone Destruction

• Aggressive Lesion
• Rapid Growth Potential
• Poorly Demarcated and May Merge Imperceptibly
  with Uninvolved Bone
• Can Not Delineate Where Tumor Begins and Ends
• Tumor Not Clearly Demarcated From Normal Bone
• Malignant Bone Tumors (Ewings sarcomaOsteosarcoma
  ), Osteomyelitis, Osteoporosis

53
Permeative Bone DestructionLymphoma
54
Permeative
55
(No Transcript)
56
Permeative--Osteosarcoma
57
(No Transcript)
58
Permeative--Osteosarcoma
59
(No Transcript)
60
Permeative--Lymphoma
61
(No Transcript)
62
Permeative
63
(No Transcript)
64
Permeative
65
Permeative
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
PermeativeMRI Shows Extent
70
Permeative Lesion Barely Perceptible on X-Ray
71
Permeative
72
PermeativeMRI Demonstrates Tumor Extent Better
73
PermeativeCT ExampleThe Tumor is Not Clearly
Demarcated
74
Permeative
75
Permeative
76
Visible Tumor Matrix

• Calcification
• Stippled, Flocculent, Rings and Arcs
• Ossification
• Solid, Cloud-Like, Ivory-Like
• Must Differentiate Mineralization from
  Calcification Due to Dead or Necrotic Tissue,
  Fracture Callus (Pathologic Fracture), Sclerotic
  Response of Non-Neoplastic Bone to Adjacent Tumor
  Deposit

77
(No Transcript)
78
Visible Tumor Matrix

• Calcification
• Rings, Arcs, Flocculent, Fleck-like
• Cartilage Tumors
• Enchondroma
• Chondrosarcoma
• Chondroblastoma
• Chondromyxofibroma

79
Visible Tumor Matrix

• Cartilage grows in a lobular manner or in a ball
  like manner
• Calcification occurs around the periphery of
  these lobules
• If the calcification occurs completely around the
  periphery (circumference) it forms a circle or a
  Ring of calcification that is detectable on the
  Xray
• If the calcification occurs only partially around
  the lobule, it forms only part of a circle or an
  Arc that is detectable on the Xray

80
Cartilage Matrix
81
(No Transcript)
82
Enchondroma or Low Grade Chondrosarcoma
83
Enchondroma
84
(No Transcript)
85
Chondrosarcoma
86
(No Transcript)
87
Intraosseous Lipoma
88
(No Transcript)
89
Chondrosarcoma
90
(No Transcript)
91
(No Transcript)
92
(No Transcript)
93
Osteochondroma
94
(No Transcript)
95
(No Transcript)
96
(No Transcript)
97
(No Transcript)
98
Dedifferentiated Chondrosarcoma
Rings and Arcs Calcifications
Lytic Destruction by Dedifferentiated Component
99
(No Transcript)
100
Rings and Arcs
101
(No Transcript)
102
(No Transcript)
103
(No Transcript)
104
(No Transcript)
105
Rings and Arcs-CalcificationsCartilage Tumor
106
Visible Tumor Matrix

• Ossification
• Cloudlike, Fluffy, Marble-like
• Osteosarcoma
• Parosteal Osteosarcoma
• Osteoblastoma
• Osteoma

107
(No Transcript)
108
(No Transcript)
109
Osteosarcoma
110
(No Transcript)
111
(No Transcript)
112
Osteosarcoma
113
(No Transcript)
114
(No Transcript)
115
Periosteal Osteosarcoma
116
(No Transcript)
117
Periosteal Osteosarcoma CT Scan
118
Conventional Intramedullary Osteosarcoma
119
(No Transcript)
120
(No Transcript)
121
(No Transcript)
122
Conventional Intramedullary Osteosarcoma
123
Marble-Like OssificationOsteosarcoma
124
(No Transcript)
125
(No Transcript)
126
(No Transcript)
127
Parosteal Osteosarcoma
128
Parosteal Osteosarcoma
129
Parosteal Osteosarcoma CT Scan
130
Parosteal Osteosarcoma
131
Parosteal Osteosarcoma CT Scan
132
Internal Trabeculations

• Residual Trabeculae or New Bone Formation Due to
  Adjacent Tumor
• Differential Diagnosis
• Giant Cell Tumor
• Chondromyxofibroma
• Desmoplastic Fibroma
• Nonossifying Fibroma
• Aneurysmal Bone Cyst
• Hemangioma

133
Giant Cell Tumor
134
Desmoplastic Fibroma
135
Chondromyxofibroma
136
Nonossifying Fibroma
137
Hemangioma
138
ABC
139
Cortical Erosion, Expansion, Penetration

• Bone Cortex Can Be an Effective Barrier To Tumor
  Growth of Certain Tumors
• Certain Tumors Penetrate the Cortex Partially or
  Completely (Benign and Malignant)
• Progressive Endosteal Erosion that is Accompanied
  by a Periosteal Reaction Leads to an Expanded
  Bony Contour (Like an ABC)
• Aggressive lesion that Penetrates the entire
  Cortex or Penetrates Haversian Canals will
  Elevate the Periosteum and Lead to a Periosteal
  Reaction

140
Cortical Erosion, Expansion, Penetration

• It is important to understand that both benign
  and malignant tumors can penetrate the cortical
  bone and form a soft tissue mass. The fact that
  there is a soft tissue mass does not
  automatically confer that the tumor is malignant.
  Certain benign tumors can also form a soft tissue
  mass. The periosteum usually remains intact
  around a benign soft tissue mass. This may only
  be detectable on a CT scan demonstrating an
  Egg-Shell rim of calcification around the
  periphery of the mass. The periosteum is usually
  destroyed by malignant tumors and does not remain
  intact around the soft tissue component of a
  malignant tumor.

141
(No Transcript)
142
(No Transcript)
143
(No Transcript)
144
Periosteal Reactions as Related to Tumor Growth
145
Periosteal Response

• Benign Buttressing Pattern Single Lamellar
  Cortical Thickening Bony Expansion
• Endosteal Erosion Leads to Periosteal
  Proliferation
• Can Be Same or Diminished Thickness Compared to
  Normal Cortex
• Buttressing Interface Between Normal and
  Expanded Cortex is Filled In with Bone

146
Buttressing
147
Buttressing
148
Buttressing
149
Periosteal Response

• Malignant Tumors Rapid Tumor Growth May Lead to
  Single or Multiple Concentric Layers
• Types of Malignant Periosteal Reactions
• Onion Skin Multiple Concentric layers
• Codmans Triangle Occurs at the Periphery of a
  Lesion or Infective Focus
• Sun Burst Delicate Rays that Extend Away from
  the Bone (Angled with Bone)
• Hair On End Rays are Perpendicular to Bone

150
Onion Skin Appearance
151
Onion Skin
152
Onion Skin
153
Onion Skin
154
Codmans Triangle
155
Codmans Triangle
156
Codmans Triangle
157
CODMANS TRIANGLE
158
CT Scan of Codmans triangle
159
Sunburst Pattern
160
Sunburst Pattern
161
Hair On End
162
Hair on End Periosteal Reaction
163
(No Transcript)
164
Soft Tissue Mass

• Primary Malignant Bone Tumors
• Benign Aggressive Bone Tumors
• Mets
• Osteomyelitis

165
(No Transcript)
166
Benign Aggressive Tumor
167
(No Transcript)
168
Periosteum Intact Around Periphery of Soft Tissue
Mass
169
Benign Aggressive Giant Cell Tumor
170
Periosteum Intact Around Periphery
171
(No Transcript)
172
Malignant-- Osteosarcoma
173
Periosteum Not Intact Around Soft Tissue Mass
174
MRI of OsteosarcomaPeriosteum Not Intact Around
Soft Tissue Mass
175
Distribution in Bone

• Position in Transverse Plain
• Central
• Eccentric
• Cortical
• Juxtacortical (Periosteal/Parosteal)
• Soft Tissue Location

176
(No Transcript)
177
Central Axis

• Enchondromas
• Fibrous Dysplasia
• Simple Bone Cysts

178
UBC
179
UBC
180
Fibrous Dysplasia
181
Fibrous Dysplasia
182
Fibrous Dysplasia
183
Enchondroma
184
Eccentric Lesions

• Giant Cell Tumor
• Osteosarcoma
• Chondrosarcoma
• Chondromyxofibroma

185
GCT
186
Osteosarcoma
187
Osteosarcoma
188
Osteosarcoma
189
Osteosarcoma
190
Chondrosarcoma
191
Chondromyxofibroma
192
Cortical Lesions

• Nonossifying Fibromas
• Osteoid Osteomas

193
Nonossifying Fibroma
194
Osteoid Osteoma
195
Osteoid Osteoma
196
Osteoid Osteoma
197
Osteoid Osteoma
198
Osteoid Osteoma
199
Osteoid Osteoma
200
Brodies Abscess
201
Brodies Abscess
202
Brodies Abscess
203
Juxtacortical Lesions

• Juxtacortical Chondroma
• Periosteal Osteosarcoma/Chondrosarcoma
• Parosteal Osteosarcoma

204
Periosteal Chondroma
205
Periosteal Chondrosarcoma
206
Periosteal Osteosarcoma
207
Periosteal Osteosarcoma
208
Periosteal/High Grade Surface Osteosarcoma
209
Periosteal/HGS Osteosarc
210
Periosteal/HGS Osteosarc
211
Periosteal/HGS Osteosarcoma
212
Parosteal Osteosarcoma
213
Parosteal Osteosarcoma
214
Osteochondroma
215
OsteochondromaCortico-Medullary Continuity
216
Surface Osteoma
217
Myositis Ossificans
218
Myositis OssificansZonal PhenomenonCentral
Lucency
219
MelorrheostosisCandle Wax Drippings
220
Position of Lesion in Longitudinal Plane

• Epiphysis
• Metaphysis
• Diaphysis

221
Epiphyseal Lesions

• Adults
• Clear Cell Chondrosarcoma
• Metastasis, Myeloma, Lymphoma
• Lipoma
• Intraosseous Ganglion

222
Epiphyseal Lesions

• Children
• Chondroblastoma
• Osteomyelitis
• Osteoid Osteoma
• Enchondroma
• Eosinophilic Granuloma

223
Metaphyseal Lesions

• GCT (extends to epiphysis)
• Nonossifying Fibroma
• Chondromyxoid Fibroma
• Simple Bone Cyst (Unicameral Bone Cyst)
• Osteochondroma
• Brodies Abscess
• Osteosarcoma
• Chondrosarcoma
• MFH/Fibrosarcoma

224
Diaphyseal Lesions

• Ewings Sarcoma
• Nonossifying fibroma
• Simple Bone Cysts
• Aneurysmal Bone Cysts
• Enchondromas
• Osteoblastomas
• Fibrous Dysplasia
• Adamantinoma
• Osteofibrous Dysplasia

225
Epiphyseal Equivalent Areas

• Subchondral Regions of Acetabulum and Scapula
• Tarsal Bones
• Calcaneus, Talus

226
Growth Plate

• Tumors Usually Do Not Cross Growth Plate
• Think Infection

227
(No Transcript)
228
(No Transcript)
229
(No Transcript)
230
(No Transcript)
231
(No Transcript)
232
Specific Bones

• Heamatopoietic Marrowpredilection for sites with
  red marrow rich sinusoidal vasculature
• Axial and Appendicular Skeleton in Children
• Axial Skeleton in Adults
• Metastatic Disease
• Myeloma
• Ewings Sarcoma
• Histiocytic Lymphoma

233
Specific Bones

• Areas of Rapid Growth
• Primary Bone Tumors
• Distal Femur
• Proximal Tibia
• Proximal Humerus

234
Specific Bones

• Vertebrae (Adults)
• Skeletal Mets
• Myeloma
• Hemangioma
• Lymphoma
• Osteomyelitis
• Vertebrae (Children)
• Eosinophilic Granuloma
• ABC
• Osteoblastoma
• Osteoid Osteoma
• Lymphoma
• Leukemia
• Osteomyelitis

235
Specific Bones

• Sacrum
• Chordoma
• Myeloma/Plasmacytoma
• Giant Cell Tumor
• Mets
• Simple Cysts
• Neurogenic Tumors /Schwannoma

236
Specific Bones

• Ribs
• Mets
• Fibrous Dysplasia
• Enchondroma

237
Specific Bones

• Metacarpals and Phalanges
• Giant Cell Tumor
• Giant Cell Reparative Granuloma
• Sarcoidosis
• ABC
• Fibrous Dysplasia
• Enchondroma

238
Specific Bones

• Terminal Phalanges
• Inclusion Cyst
• Glomus Tumor
• Mets (Lung)

239
(No Transcript)
240
Unknown Examples
241
Unknown 1
242
Unknow 1

• Epiphyseal Lesion with Geographic Pattern of Bone
  Destruction (Probably Benign)
• Eccentric
• Internal Mineralization/Calcifications (indicates
  most likely cartlaginous nature)
• Sclerotic IA/IB Margin

243
Chondroblastoma
244
Unknown 2
245
Unknown 2

• Spine Lesion
• Posterior Elements
• Geographic Pattern of Bone Destruction (Probably
  benign)
• Internal Mineralization indicative of bone
  producing or cartilage producing tumor

246
Osteoblastoma
247
Unknown 3
248
Unknown 3

• Small Cortical Lesion
• Geographic pattern of Bone Destruction
• Extensive Surrounding Sclerosis
• Buttressing Periosteal Reaction (Benign
  Periosteal Reaction)
• Internal Mineralization

249
Osteoid Osteoma
250
Unknown 4
251
Unknown 4

• Central, Diaphyseal Lesion
• No Periosteal Reaction
• No Cortical destruction
• Calcifications in a Ring and Arc Like Manner

252
Enchondroma
253
Unknown 5
254
Unknown 5

• Metaphyseal Eccentric Lesion
• Permeative Lesion (Malignant)
• Cortical Destruction
• Calcifications in a Ring and Arc Manner
  indicative of a cartilage tumor

255
Dedifferentiated Chondrosarcoma
256
Unknown 6
257
Unknown 6

• Permeative Pattern of Bone Destruction
• Diaphyseal
• Cortical penetration
• Hair on End Periosteal Reaction
• No Internal Mineralization (probably not bone or
  cartilage producing)
• Malignant Appearing

258
Ewings Sarcoma
259
Unknown 7
260
Unknown 7

• Metaphyseal, Central lesion
• Permeative Pattern of Bone Destruction
  (malignant)
• No Internal Mineralization (probably not
  cartilage or bone producingno visible matrix)
• No Periosteal Reaction
• Malignant Appearing

261
Fibrosarcoma of Bone
262
Unknown 8
263
Unknown 8

• Central Lesion
• Geographic Pattern of Bone Destruction (Benign
  Appearing)
• Metadiaphyseal
• Bone is Expanded (Benign Periosteal reaction)
• No Internal Mineralization (Probably not
  Cartilaginous or Bone Producing)
• Ground Glass Appearance

264
Fibrous Dysplasia
265
Unknown 9
266
Unknown 9

• Eccentric Lesion
• Metaphyseal with Epiphyseal Extension
• No Internal Mineralization
• Cortex is Thinned and Slightly Expanded
• Thin, Incomplete Sclerotic Margin (Type IB)
• Benign Appearing

267
Giant Cell Tumor
268
Unknown 10
269
Unknown 10

• Metadiaphyseal Lesion
• Motheaten and Permeative (Malignant Appearing)
• No Internal Mineralization
• Cortical Destruction
• No Periosteal Reaction

270
Malignant Fibrous Histiocytoma of Bone
271
Unknown 11
272
Unknown 11

• Central Location
• Metaphyseal
• Multiloculated
• Geographic
• Bone is Expanded
• Skeletally Immature
• No Mineralization
• Benign Appearing

273
Unicameral Bone Cyst
274
Unknown 12
275
Unknown 12

• Eccentric/Cortical Lesion
• Metaphyseal
• Geographic pattern of Bone Destruction
• Well Circumscribed (Type IA Margin Indolent)
• No Internal Mineralization
• Bone has Expanded Contour
• Benign Appearing

276
Nonossifying Fibroma
277
Unknown 13
278
Unknown 13

• Geographic, Central Lesion in a Phalange
• Lobular Growth Contour with Endosteal Erosion
• Punctate calcifications (arrows)--Cartilaginous
• Appears Benign

279
Enchondroma
280
Unknown 14
281
Unknown 14

• Cortical based, Geographic Lesion in Tibia
• Extensive Sclerotic Margin
• Tibial bowing

282
Osteofibrous Dysplasia
283
Unknown 15
284
Unknown 15

• Permeative/Moth Eaten Lesion (Malignant)
• Eccentric, Metaphyseal
• Ossification Present within Neoplasm
• Codmans Triangle
• Skeletally Immature Spares Growth Plate
• Cortical Destruction
• Appears Malignant and is Producing Osteoid

285
Osteosarcoma
286
Unknown 16
287
Osteofibrous Dysplasia