oncology

1. Plain Radiographic Analysis of
Bone Tumors

2. • Plain radiographs are the most important
investigation for bone tumors
• The Presenting Complaints
– Soft tissue mass - myositis ossificans
– Painless bony mass
– Incidental finding
– Painful bone lesion
– Pathologic fracture

3. Seven Questions to Ask
1. Where is the lesion? What bone, and in which part of the bone?
2. How large is the lesion? How extensive are the abnormalities
seen on Radiographs?
3. What is the lesion doing to the bone?
4. What is the bone doing in response?
5. Is the lesion making matrix? What kind of matrix is being made?
6. Is the cortex eroded?
7. Is a soft tissue mass evident?

4. Answers + clinical assessment
Biological activity of the lesion can be classified as
• Benign
– Latent, Active , Aggressive
• Malignant
– Mesenchymal , Myeloproliferative , Metastatic

5. 1.Where is the lesion ?
• Most important question to ask when
developing a differential diagnostic list
• The particular bone involved as well as the
portion of the bone affected must be
determined

6. The Affected Bone

7. • Symptomatic metastatic tumors are usually found proximal
to the knees and elbows
• The metastatic lesion found distal to knees and elbows are
usually from lung cancer, renal cell cancer and melanoma
• The phalanges are a common site for enchondromas
• Aggressive and malignant primary bone tumors sites
include the metaphyses of the distal femur, proximal tibia,
proximal femur, proximal humerus
• Chondrosarcoma is more frequently found in the proximal
skeleton (pelvis, scapula, proximal humerus and femur)
• Chordoma is most commonly found in the sacrum and at
the base of skull

8. The Affected Portion of the Bone

9. • Epiphyseal
– These lesions in adults may extend across the growth
plate
– This is typical of a chondroblastoma
• Epiphyseal-metaphyseal
– This is a classic location for locally aggressive tumors
such as giant cell tumor of bone
• Metaphyseal or metaphyseal-diaphyseal
Lesions that do not cross the growth plate and tend to
grow away
– enchondroma, unicameral bone cyst
– Bone abscesses (Brodie's abscess)
– The metaphysis is the most common site for primary
mesenchymal malignancies (osteosarcoma,
chondrosarcoma)

10. • Diaphyseal
This is a relatively uncommon location for bone tumors
– Infections and fractures may cause tumor-like
changes
– Ewing's sarcoma, eosinophilic granuloma, osteoid
osteoma, and metastases
• Peri-articular
Changes are present on both sides of the joint
– Infectious, Inflamatory, Metabolic (Gout) joint
– vascular tumor, such as disappearing bone disease
(Gorham's disease- angioma or lymphangioma of
bone) or angiosarcoma of bone

11. • Central
– Enchondroma
– Fibrous Dysplasia
• Eccentric
– Non-ossifying Fibroma
– Chondromyxoid Fibroma
• Juxtacortical
– Osteochondroma
– Parosteal Osteosarcoma
• Cortical
– Osteoid Osteoma
– Periosteal Chondroma

12. 2.How large is the lesion ?
• In general, the larger the lesion, the more likely it is to be
aggressive or malignant
• Conversely, smaller lesions, such as an osteoid osteoma,
are usually benign. This is not universally true

13. How extensive are the abnormalities seen
on Radiographs?
• The assessment begins with local radiographs
• Xrays of other sites or a bone scan may be needed
• In metastatic bone disease and multiple myeloma,
other lesions may be seen in the same Xray
• endocrine conditions, congenital diseases (familial
osteochondromatosis), or developmental skeletal
dysplasia (Ollier's disease, Maffucci's disease) may
become obvious when the skeleton surrounding the
primary lesion is examined

14. 3.What is the lesion doing to the bone ?
• Bone tumors have a limited number of potential
effects on the skeleton
• The most common is to produce bone lysis
• The pattern of lysis and the extent of the host
response to lysis provide major clues as to
whether the lesion is latent, active, aggressive, or
malignant
• Margin or interface is present between the host
bone and the lesion

15. Margin
• The margin of the lesion and the zone of
transition between lesion and adjacent bone
are key factors in determining if a lesion is
aggressive or nonaggressive.
• A lesion with sharp margins and a narrow
transition zone – nonaggressive
• Illdefined margin and wide zone transition –
aggressive

16. Pattern of Bone Destruction
• Geographic - Focal discrete lesion +/- sclerosis
(Lodwick pattern I)
• Moth-eaten (Lodwick pattern II)
• Permeative (Lodwick pattern III)

17. Type 1a : geographic lesion - well-defined lucency with
sclerotic rim
Eg. Non ossifying Fibroma

18. Type 1b : geographic lesion-well-defined lucent lesion
without sclerotic rim
Eg. Aneurysmal bone cyst

19. Type 2 : moth-eaten lesion- patchy lysis of
medullary cavity
Eg. metastasis

20. Type 3 : permeated lytic lesion - small patchy lucencies in
medullary cavity
Eg. Ewing’s Sarcoma

21. Geographic Moth-eaten Permeative
Non agressive Agressive
Pattern Of Destruction

22. 4.What is the bone doing in response?
• Often, the bone responds by making new bone,
which can be seen in either the medullary bone
or in the cortex and periosteum
• The pattern of bone response, especially
combined with the pattern of lytic destruction,
is very useful in determining whether the
lesions is latent, active, aggressive or malignant

23. Periosteal Reaction
• Periosteum is an envelope of highly
vascular tissue consisting of an outer
fibrous layer and an inner cellular
(cambium) layer that possesses
osteoblastic potential
• It may be elevated from its location
adjacent to the underlying cortex by
dilated periosteal vessels or edema from
passive hyperemia or it may be elevated
directly by tumour, pus, or haemorrhage

24. • The presence and appearance of periosteal reaction
are features that help characterize a bone lesion
• Solid & unilamellated- slow growing , nonaggressive
lesion eg. Osteoid osteoma.
• Multilamellated or onion skin appearance -
intermediate aggressive process eg. Ewing’s sarcoma
or acute osteomyelitis
• Interruption of uni or multilamellated periosteal
reaction – aggressive process eg. osteosarcoma

25. Types of Periosteal Reaction
Lamellated (single layer)
Unilamellated periosteal reaction
Diagram shows single
layer of reactive periosteum (arrow)
Lamellated (multiple layers)
Multilamellated periosteal reaction
Diagram shows
multilamellated, or onionskin,
periosteal reaction (arrow)

26. Solid periosteal reaction
Spiculated periosteal reaction /
Perpendicular (hair on end)
Perpendicular periosteal reaction
Diagram shows spiculated, or hair-on-end,
periosteal reaction (arrow)
Sunburst
Diagram shows radial, or sunburst,
periosteal reaction (arrow)

27. Codman’s triangle : Diagram shows elevated
periosteum forming an angle with the cortex

28. Solid Lamellated Codman’sSunburst
Non agressive Agressive
Periosteal Reaction

31. 5.What kind of matrix is being made ?
• This question is fundamental to the diagnosis of
primary mesenchymal tumors, especially benign
and malignant bone and cartilage forming
tumors
• It may be difficult to differentiate calcified
cartilage from ossification in tumor matrix
• Calcium deposition in cartilage is typically less
well organized than bone

32. Matrix and minerlisation
• Matrix : refers to the type of tissue of the tumor -
such as osteoid, chondral, fibrous, or adipose, all of
which are radiolucent
• Mineralization : refers to calcification of the matrix
• Tumors may be lytic, sclerotic, or mixed
• For example, simple bone cysts and giant cell tumors
are lytic, bone islands are sclerotic, and
adamantinomas are often mixed

33. • Pattern of mineralization can be a clue to the type of
underlying matrix and, thus, the diagnosis
• Chondral tissue often produces punctate, flocculent,
comma shaped, or arclike or ringlike mineralization
– enchondroma,chondrosarcoma, or
chondroblastoma
• Bone-forming tumors have fluffy, amorphous,
cloudlike mineralization, causing an opaque
radiographic appearance
– osteosarcoma

34. Chondral mineralization
Diagram shows patterns and
of mineralization of
cartilaginous tumor matrix:
stippled (left), flocculent
(middle), and ring and arc
(right)

35. • Diagram shows patterns of
mineralization of osseous
matrix with solid (left),
cloudlike (middle), and ivory-
like (right) opacity

36. 6.Is the cortex eroded ?
• Cortical erosion is the hallmark of the active,
aggressive or malignant tumor
• The pattern of cortical erosion may be highly
correlated with the histology of the lesion
• In chondrosarcoma, (unicameral bone cyst, non-
ossifying fibroma) may cause cortical erosion with
minimal periosteal response
• The erosion of the endosteum caused by
chondrosarcoma is often accompanied by well
ordered periosteal bone formation on the bone's
surface, leading to a pattern of endosteal expansion

37. • In an aneurysmal bone cyst or giant
cell tumor, the cortex may be
completely destroyed, but a thin
layer of periosteal neo-
corticalization may surround the
lesion
• High-grade malignant tumors, be
they primary or metastatic, may
erode through the cortex with only
an ineffective periosteal response to
the erosion

38. 7.Is a soft tissue mass evident
• MRI and CT scan are generally better
• The presence of a soft-tissue component with a
bone lesion suggests aggressive process
• The soft-tissue component with obscuration of
adjacent fat planes – benign ( acute
osteomyelitis)
• Soft tissue component with displacement of fat
planes - malignant

39. • Aggressive tumors almost always
develop a soft tissue component
by destroying the cortex and
expanding into the surrounding
tissues
• Alternately they may grow
directly through the haversian
system of the cortex leaving
cortex structurally intact

40. • The hallmark of a soft tissue mass associated with
bone sarcoma is that it lies on top of the intact
cortex, with sarcoma present inside and outside
the cortex.
• The presence of "malignant" matrix in the soft
tissue mass is almost always a sign of a
mesenchymal malignancy.
• Tumors that often have a soft-tissue component
are osteosarcoma, chondrosarcoma,Ewing’s
sarcoma, and lymphoma

42. Biological Potential of Bone Lesions
• Benign latent bone lesions
• Benign active bone lesions
• Benign aggressive bone lesions
• Malignant bone lesions

43. Benign latent bone lesions
• Benign latent lesions have generally been
active at some time in the past, but they show
evidence of healing at the time of evaluation
• Examples include adult osteochondromas and
non-ossifying fibromas

44. Benign active bone lesions
• Benign active lesions may have been present in the bone
for substantial periods of time and exist in a type of
symbiosis with the skeleton
• The best example is fibrous dysplasia, which may be
present for a lifetime and cause minimal symptoms.
However and it is possible for the bone to fracture in
response to minimal trauma
• This description applies to active unicameral bone cysts
and non-ossifying fibromas that may cause pain and
present a risk for fracture in children
• Another example is an osteoid osteoma. Such lesions are
usually active and symptomatic, causing pain but limited
destruction of the host bone

45. Benign aggressive bone lesions
• Benign aggressive lesions cause more substantial bone
destruction than active lesions and may also result in pathological
fractures.
• This group of tumors includes giant cell tumor, aneurysmal bone
cyst, osteoblastoma, chondroblastoma, and chondromyxoid
fibroma.
• Small soft tissue masses may result from the lesion growing
through the cortex, but the periphery of the lesion is often
defined by a periosteal neo-cortical response.
• There is typically no risk of metastasis in these lesions, although a
small percentage of giant cell tumors may spread to the lungs.

46. Malignant bone lesions
• Malignant lesions may be characterized by a number of
radiographic changes, including multiple lesions
(metastatic lesions seen on bone scan), permeative
bone destruction with poorly defined margins, cortical
erosion, malignant matrix formation, and the
development of a soft tissue mass
• In differentiating mesenchymal from metastatic bone
malignancies, it is useful to determine if the tumor is
solitary or multiple
• Matrix formation and an associated soft tissue mass are
more frequent with mesenchymal lesions

47. Radiologic characteristics of benign and
malignant bone tumors
Benign
Well defined
Sclerotic border
Less aggressive
periosteal reaction
Absence of soft
tissue mass
Slow growth
Metastasis rare
Malignant
Destructive poorly
defined, permeative
Infiltrative border
More aggressive
periosteal reaction
Soft tissue
mass or extension
Rapid growth
Metastasis common

48. Benign Bone Tumors
Osteoid Osteoma
Enchondroma
Fibrous Dysplasia
Haemangioma
Aneurysmal Bone Cyst
Giant Cell Tumor

49. Malignant Bone Tumors
Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Lymphoma
Multiple Myeloma
Metastasis

50. Thank u