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The most
important
determinators in the analysis of a potential bone tumor are:
The morphology of the bone lesion on a plain radiograph
1 Well-defined osteolytic
2 ill-defined osteolytic
3 Sclerotic
The age of the patient
It is important to realize that the plain radiograph is the most useful examination for
differentiating these lesions
!T and "#I are only helpful in selected cases
"ost bone
tumors are
osteolytic
The most
reliable
indicator
in
2
determining $hether these lesions are benign or malignant is the zone of transition
bet$een the lesion and the ad%acent normal bone &1'
(nce $e ha)e decided $hether a bone lesion is sclerotic or osteolytic and $hether it has
a $ell-defined or ill-defined margins* the next +uestion should be: ho$ old is the patient,
-ge is the most important clinical clue
.inally other clues need to be considered* such as a lesion/s localization $ithin the
s0eleton and $ithin the bone* any periosteal reaction* cortical destruction* matrix
calcifications* etc
In the
table on
the left
the
morphology of a bone lesion is combined $ith the age of the patient
1otice the follo$ing:
3
Infections* a common tumor mimic* are seen in any age group
Infection may be $ell-defined or ill-defined osteolytic* and e)en sclerotic
23 and infections should be mentioned in the differential diagnosis of almost any
bone lesion in patients "any sclerotic lesions in patients 4 25 years are healed*
pre)iously osteolytic lesions $hich ha)e ossified* such as: 1(.* 23* S6!* -6! and
chondroblastoma
7one of transition
In order to classify osteolytic lesions as $ell-defined or ill-defined* $e need to loo0 at the
zone of transition bet$een the lesion and the ad%acent normal bone
The zone of transition is the most reliable indicator in determining $hether an osteolytic
lesion is benign or malignant &1'
The zone of transition only applies to osteolytic lesions since sclerotic lesions usually
ha)e a narro$ transition zone
Small
zone of
transition
- small
zone of
transition
results in
a sharp*
$ell-
defined
border
and is a
sign of
slo$
gro$th
- sclerotic border especially indicates poor biological acti)ity
In patients In patients 4 35years* and particularly o)er 85 years* despite benign
radiographic features* metastasis or plasmacytoma also ha)e to be considered
(n the left three bone lesions $ith a narro$ zone of transition
6ased on the morphology and the age of the patients* these lesions are benign
1otice that in all three patients* the gro$th plates ha)e not yet closed
In patients
4 85 years
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metastases and multiple myeloma are the most common bone tumors
"etastases under the age of 85 are extremely rare* unless a patient is 0no$n to ha)e a
primary malignancy
"etastases could be included in the differential diagnosis if a younger patient is 0no$n to
ha)e a malignancy* such as neuroblastoma* rhabdomyosarcoma or retinoblastoma
Wide zone
of
transition
-n ill-
defined
border
$ith a
broad
zone of
transition
is a sign
of
aggressi)e gro$th &1'
It is a feature of malignant bone tumors
There are t$o tumor-li0e lesions $hich may mimic a malignancy and ha)e to be included
in the differential diagnosis
These are infections and eosinophilic granuloma
6oth of these entities may ha)e an aggressi)e gro$th pattern
Infections
and
eosinophilic granuloma are exceptional because they are benign lesions $hich may seem
malignant due to their aggressi)e biologic beha)ior
These lesions may ha)e ill-defined margins* but cortical destruction and an aggressi)e
type of periosteal reaction may also be seen
23 almost al$ays occurs in patients Infections ha)e to be included in the differential
diagnosis of any bone lesion at any age
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-ge
-ge is the
most
important
clinical
clue in
differentiating possible bone tumors
There are many $ays of splitting age groups* as can be seen in the first table
Some prefer to di)ide patients into t$o age groups: 35 years
"ost primary bone tumors are seen in patients In patients 4 35 years $e must al$ays
include metastases and myeloma in the differential diagnosis
:eriosteal
reaction
-
periosteal
reaction is
a non-
specific
reaction
and $ill
;
occur $hene)er the periosteum is irritated by a malignant tumor* benign tumor* infection
or trauma
There are t$o patterns of periosteal reaction: a benign and an aggressi)e type
The benign type is seen in benign lesions such as benign tumors and follo$ing trauma
-n aggressi)e type is seen in malignant tumors* but also in benign lesions $ith
aggressi)e beha)ior* such as infections and eosinophilic granuloma
6enign
periosteal
reaction
<etecting
a benign
periosteal
reaction
may be
)ery
helpful*
since
malignant
lesions
ne)er
cause a benign periosteal reaction
- benign type of periosteal reaction is a thic0* $a)y and uniform callus formation
resulting from chronic irritation
In the case of benign* slo$ly gro$ing lesions* the periosteum has time to lay do$n thic0
ne$ bone and remodel it into a more normal-appearing cortex
-ggressi)e periosteal reaction
This type of periostitis is multilayered* lamellated or demonstrates bone formation
perpendicular to the cortical bone
It may be spiculated and interrupted - sometimes there is a !odman=s triangle
- !odman=s triangle refers to an ele)ation of the periosteum a$ay from the cortex*
forming an angle $here the ele)ated periosteum and bone come together
In aggressi)e periostitis the periosteum does not ha)e time to consolidate
>
-ggressi)e periosteal reaction &2'
left:
(steosarcoma $ith interrupted periosteal rection and !odman=s triangle proximally
There is periosteal bone formation perpendicular to the cortical bone and extensi)e
bony matrix formation by the tumor itself
middle:
2$ing sarcoma $ith lamellated and focally interrupted periosteal reaction &blue
arro$s'
right:
Infection $ith a multilayered periosteal reaction
1otice that the periostitis is aggressi)e* but not as aggressi)e as in the other t$o
cases
.ibrous
dysplasia*
2nchondroma* 1(. and S6! are common bone lesions
They $ill not present $ith a periosteal reaction unless there is a fracture
If no fracture is present* these bone tumors can be excluded
!ortical
destruction
?
!ortical destruction is a common finding* and not )ery useful in distinguishing bet$een
malignant and benign lesions
!omplete destruction may be seen in high-grade malignant lesions* but also in locally
aggressi)e benign lesions li0e 23 and osteomyelitis
"ore uniform cortical bone destruction can be found in benign and lo$-grade malignant
lesions
2ndosteal scalloping of the cortical bone can be seen in benign lesions li0e .< and lo$-
grade chondrosarcoma
The images on the left sho$ irregular cortical destruction in an osteosarcoma &left' and
cortical destruction $ith aggressi)e periosteal reaction in 2$ing=s sarcoma
6allooning is a special type of cortical destruction
In ballooning the destruction of endosteal cortical bone and the addition of ne$ bone on
the outside occur at the same rate* resulting in expansion
This =neocortex= can be smooth and uninterrupted* but may also be focally interrupted in
more aggressi)e lesions li0e 3!T
left: !hondromyxoid fibroma
- benign* $ell-defined* expansile lesion $ith regular destruction of cortical bone and
a peripheral layer of ne$ bone
right: 3iant cell tumor
- locally aggressi)e lesion $ith cortical destruction* expansion and a thin* interrupted
peripheral layer of ne$ bone
1otice the $ide zone of transition to$ards the marro$ ca)ity* $hich is a sign of
aggressi)e beha)ior
@
!ortical
destruction &3'
In the group of malignant small round cell tumors $hich include 2$ing=s sarcoma* bone
lymphoma and small cell osteosarcoma* the cortex may appear almost normal
radiographically* $hile there is permeati)e gro$th throughout the Aa)ersian channels
These tumors may be accompanied by a large soft tissue mass $hile there is almost no
)isible bone destruction
The image on the left sho$s an 2$ing=s sarcoma $ith permeati)e gro$th through the
Aa)ersian channels accompanied by a large soft tissue mass
The radiograph does not sho$n any signs of cortical destruction
Bocation:
epiphysis
-
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metaphysis - diaphysis
2piphysis
(nly a fe$ lesions are located in the epiphysis* so this could be an important finding
In young patients it is li0ely to be either a chondroblastoma or an infection
In patients o)er 25* a giant cell tumor has to be included in the differential diagnosis
In older patients a geode* ie degenerati)e subchondral bone cyst must be added to
the differential diagnosis
Boo0 carefully for any signs of arthrosis
"etaphysis
1(.* S6!* !".* (steosarcoma* !hondrosarcoma* 2nchondroma and infections
<iaphysis
2$ing=s sarcoma* S6!* -6!* 2nchondroma* .ibrous dysplasia and (steoblastoma
<ifferentiating bet$een a diaphyseal and a metaphyseal location is not al$ays possible
"any lesions can be located in both or mo)e from the metaphysis to the diaphysis during
gro$th
Barge lesions tend to expand into both areas
Bocation:
centric -
eccentric -
%uxtacortical
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!entric in long bone
S6!* eosinophilic granuloma* fibrous dysplasia* -6! and enchondroma are lesions
that are located centrally $ithin long bones
2ccentric in long bone
(steosarcoma* 1(.* chondroblastoma* chondromyxoid fibroma* 3!T and
osteoblastoma are located eccentrically in long bones
!ortical
(steoid osteoma is located $ithin the cortex and needs to be differentiated from
osteomyelitis
Cuxtacortical
(steochondroma The cortex must extend into the stal0 of the lesion
:arosteal osteosarcoma arises from the periosteum
2 S6!: central diaphyseal
3 1(.: eccentric metaphyseal
8 S6!: central diaphyseal
9 (steoid osteoma: cortical
; <egenerati)e subchondral cyst: epiphyseal
> -6!: centric diaphyseal
"atrix
!alcifications or mineralization $ithin a bone lesion may be an important clue in the
differential diagnosis
There are t$o 0inds of mineralization: a chondroid matrix in cartilaginous tumors li0e
enchondromas and chondrosarcomsa and an osteoid matrix in osseus tumors li0e osteoid
osteomas and osteosarcomas
!hondroid matrix
!alcifications in chondroid tumors ha)e many descriptions: rings-and-arcs* popcorn*
focal stippled or flocculent
left: 2nchondroma* the most commonly encountered lesion of the phalanges
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middle: middle: :eripheral chondrosarcoma* arising from an osteochondroma
&exostosis'
right: !hondrosarcoma of the rib
(steoid
matrix
"ineralization in osteoid tumors can be described as a trabecular ossification pattern in
benign bone-forming lesions and as a cloud-li0e or ill-defined amorphous pattern in
osteosarcomas
Sclerosis can also be reacti)e* eg in 2$ing/s sarcoma or lymphoma
left
!loud-li0e bone formation in osteosarcoma
1otice the aggressi)e* interrupted periosteal reaction &arro$s'
right
Trabecular ossification pattern in osteoid osteoma
1otice osteolytic nidus &arro$'
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:olyostotic or multiple lesions
"ost bone tumors are solitary lesions
If there are multiple or polyostotic lesions* the differential diagnosis must be ad%usted
:olyostotic lesions
1(.* fibrous dysplasia* multifocal osteomyelitis* enchondromas* osteochondoma*
leu0emia and metastatic 2$ing= s sarcoma
"ultiple enchondromas are seen in "orbus (llier
"ultiple enchondromas and hemangiomas are seen in "affucci=s syndrome
:olyostotic lesions 4 35 years
!ommon: "etastases* multiple myeloma* multiple enchondromas
Bess common: .ibrous dysplasia* 6ro$n tumors of hyperparathyroidism* bone infarcts
"nemonic for multiple oseolytic lesions: .22"AI:
.ibrous dysplasia* enchondromas* 23* "ets and myeloma* Ayperparathyroidism*
Infection

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