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Pediatr Radiol (2010) 40:468473

DOI 10.1007/s00247-010-1547-4

REVIEW

Evaluation of pediatric bone lesions


Mary R. Wyers

# Springer-Verlag 2010

Abstract The radiologist is commonly confronted with common primary malignant lesions include osteosarcoma
bone lesions in children. Knowledge of the age of the and Ewing sarcoma.
patient, the lesion location, and various imaging character- In most cases, the differential diagnosis of a bone lesion
istics are all important in making an accurate diagnosis, and can be narrowed based on knowledge of the age of the
determining benign from malignant etiologies should be a patient, the location of the lesion within the body and
primary goal. Various imaging features seen on cross- within a bone, and general radiographic characteristics.
sectional imaging, including marrow edema, periosteal While some bone lesions follow very typical imaging
reaction patterns, and fluid-fluid levels, are discussed. The patterns and are easy to diagnose, others are more
advantages of different imaging modalities, including CT complicated. Primary bone lesions may be complicated by
and MRI, are reviewed. pathologic fractures, which can increase the amount of
edema and blood products in and around a lesion,
Keywords Bone lesion . Tumor . MRI . CT complicating the imaging characteristics. In such cases, a
broader differential diagnosis may be necessary. Benign
lesions that may present with a pathologic fracture include
Introduction unicameral bone cyst, non-ossifying fibroma, aneurysmal
bone cyst, and fibrous dysplasia. Malignant bone tumors
Bone lesions in children are very common and include true less commonly present with a pathologic fracture, although
bone tumors and tumor-like lesions. Up to 42% of all bone making an accurate diagnosis before treatment of the
lesions, including both benign and malignant etiologies, fracture is more important. Other complicating issues
occur in the first two decades of life [1]. This may be include distinguishing a primary bone lesion from osteo-
underestimated, since many benign-appearing lesions are not myelitis, due to a wide overlap of imaging features. Bone
biopsied or recorded in databases. More than half of all lesions complicated by a secondary aneurysmal bone cyst
childhood bone neoplasms are benign [2]. The most also may have confusing imaging characteristics. The
common benign bone lesions in children include osteochon- workup of a bone lesion is typically a team approach, with
droma, non-ossifying fibroma, Langerhans cell histiocytosis, the clinician, radiologist and pathologist working together
unicameral bone cyst, and aneurysmal bone cyst. The most to make the diagnosis. The bone pathologist requires good
clinical and radiological information in interpreting a
Dr. Wyers has indicated that she has no relevant financial relationships biopsy specimen. The highest accuracy in diagnosing bone
or potential conflicts of interest related to the material presented. lesions has been shown to be at dedicated bone tumor
M. R. Wyers (*)
centers [3].
Feinberg School of Medicine, Northwestern University,
Chicago, IL, USA
e-mail: MWyers@childrensmemorial.org Imaging modalities
M. R. Wyers
Department of Medical Imaging, Childrens Memorial Hospital, The choice of an appropriate imaging modality to evaluate
Chicago, IL, USA a bone lesion is important. Plain films are still considered
Pediatr Radiol (2010) 40:468473 469

best for defining the characteristics and assessing the true


nature of a primary bone lesion [4]. If a lesion is clearly
benign radiographically, cross-sectional imaging should not
be necessary. Bone scintigraphy has a role in the evaluation
of metastatic disease or a multifocal process, but its lack of
specificity limits its use in the initial workup of a single
bone lesion. CT and MRI each have specific advantages
and disadvantages.
CT may be helpful in providing more detailed radio-
graphic information [5]. However, the decision to do a CT
in children should be weighed against the amount of
anticipated useful information in order to avoid unnecessary
radiation. Certain areas of the body may be difficult to
profile by plain films due to overlapping structures, and the
cross-sectional abilities of CT allow such areas as the pelvis
or spine to be better depicted. CT can better define the
location of a lesion, such as involving the periosteal,
cortical, or medullary portion of the bone. CT can also
evaluate changes in the cortex more accurately, including
focal destruction or endosteal scalloping. In fact, CT is
often better than MRI in assessing subtle cortical erosion or
diagnosing a nondisplaced pathologic fracture, especially if
the cortex is very thin. Early periosteal reaction is best
visualized on CT, which has good spatial resolution and
often better visualization of the bony cortex, which may be
obscured on plain films. CT can detect more subtle matrix
mineralization, particularly in bone or cartilage forming
tumors, which may not be visible on plain film or MRI
(Fig. 1). CT is also the best modality to guide bone
biopsies. Fig. 1 Chondrosarcoma arising from a lower right rib. a The mass is
well depicted on CT and is seen to contain small whirls and arcs of
MRI is the modality of choice when a malignant bone chondroid matrix. b The mass in the lower right chest is poorly
tumor is suspected; it is best for a staging evaluation. It is profiled by the correlative plain film due to the location and many
the most sensitive modality for evaluation of bone marrow overlapping structures
changes and defining the extent of a lesion. MRI has the
best contrast resolution for demonstrating an adjacent soft more specific diagnosis. For example, a lesion with low
tissue mass as well as invasion of adjacent neurovascular signal on T1 and T2 may contain osteoblastic matrix,
structures or an adjacent joint space. Considerations for fibrous matrix or blood products [6]. Bone islands and
doing MRI in children include the need for sedation in healing non-ossifying fibromas are typical benign lesions
younger children, and more difficulty in obtaining quality that may have low signal on both T1-weighted (T1-W) and
images on smaller body parts. Optimization of MR T2-weighted (T2-W) sequences. Osteosarcoma is an example
technique is very important in children, where standardized of a malignant lesion that may have areas of low T1 and T2
protocols are more difficult to fit to each case due to signal due to osteoblastic matrix. Lesions containing fat,
different-sized patients, and greater flexibility and involve- which have high signal on T1 and suppression with fat-
ment by the radiologist is needed in altering imaging saturation techniques, are usually either lipomas, hemangio-
parameters. mas, or bone infarcts.
Although MRI is considered the most advanced imaging Both CT and MRI have a role in evaluation of a bone
modality, it is often not the most specific. Many lesions following tumor resection. CT can detect subtle areas of
demonstrate low T1 and high T2 signal and are fairly new bone destruction at a bone-cement interface [5]. MRI
nonspecific. Edema, pus and tumor infiltration can all is very sensitive for detection of T2 signal changes,
demonstrate these signal characteristics. When a bone although the findings are not specific. In general, if there
lesion contains certain specific tissue components, such as is a mass present, a recurrence should be suspected. Some
blood products, vascular tissue, cysts, fat, or non- authors have advocated using dynamic gadolinium-
mineralized cartilage matrix, MRI may be able to make a enhancement techniques, since tumor will enhance earlier
470 Pediatr Radiol (2010) 40:468473

than reactive tissue. However, these techniques are techni- assessed only 55% of the time, with malignancy over-
cally challenging and time consuming and cannot com- estimated in 39% of the cases [7]. If plain films and clinical
pletely replace biopsy/histology for diagnosing tumor information were included, the accuracy would have
recurrence [4]. improved with correct assessment of malignancies in 73%
of the cases. Features on MRI such as T1 and T2 signal
intensity, homogeneity versus heterogeneity, and surround-
Diagnostic accuracy: benign versus malignant ing marrow edema were not shown to be helpful in
assessing malignant from benign. In addition, while many
The radiologist can be most helpful by determining which malignant bone tumors are poorly defined on plain radio-
lesions can be ignored and which ones deserve a biopsy or graphs, they are often more sharply defined on MRI,
further treatment, either because of a suspicion of malig- leading to confusion.
nancy or because of a risk for pathologic fracture. Typical
radiographic characteristics of benign lesions include a
well-defined or sclerotic border, sharp zone of transition, Specific imaging features
and lack of periosteal reaction or solid periosteal reaction.
Characteristics of more aggressive lesions include poor Several imaging features are more nonspecific than generally
definition, cortical destruction, spiculated or interrupted believed and deserve a more complete discussion in the
periosteal reaction, and presence of a soft tissue mass. assessment of whether a lesion is benign or malignant.
While MRI is generally believed by clinicians to be the
most advanced and best imaging modality to diagnose a Marrow edema
bone lesion accurately, this is not necessarily true. In a
study by Ma and colleagues [7], the accuracy of MRI was Reactive marrow edema is actually unknown in etiology.
evaluated prospectively. Readers were asked to assess When peritumoral edema has been biopsied, some studies
imaging characteristics on MRI and determine if a lesion have demonstrated normal histology and others have found
was benign or malignant. The lesions were correctly tumor infiltration [8]. In general, lesions that cause an

Fig. 2 Osteoid osteoma of the


spine at the L5 level. a Axial
T2-W MR image demonstrates
diffuse, marked edema on the
right at the L5 level, involving
both the soft tissues and the
bone, including the right aspect
of the vertebral body, pedicle
and lamina. b Post-gadolinium
MR image shows enhancement
throughout the same areas. The
nidus itself is not seen by MR
(c and d). CT demonstrates
sclerosis and thickening of the
right lamina and pedicle at L5,
and more clearly demonstrates
the nidus in the right lamina,
centrally within the sclerosis
Pediatr Radiol (2010) 40:468473 471

inflammatory reaction tend to have more reactive marrow The amount of surrounding bone marrow edema
edema. Possible etiologies include local trabecular destruc- compared to the size of a lesion has been shown to be
tion, capillary leakage, or elevated intramedullary pressure inversely proportional to the likelihood of malignancy
with release of inflammatory mediators [8, 9]. [8, 9]. So, a large amount of reactive edema around a
MRI is the best imaging modality for evaluation of small lesion more likely indicates a benign etiology. A
marrow edema. Water-sensitive sequences such as T2 with lesion with a small amount of surrounding edema is
fat saturation or short tau inversion recovery (STIR) can nonspecific, however, and may be either benign or
depict marrow edema with high sensitivity. Marrow edema malignant. There are several classic benign bone lesions
does not change the normal architecture of the marrow of childhood that have a large amount of surrounding
space, and also tends to enhance in a homogeneous fashion. edema and can appear more aggressive than they actually
Since a bone lesion and the surrounding marrow edema are. These include chondroblastoma, osteoid osteoma/
may both demonstrate high T2 signal and enhancement, the osteoblastoma, Langerhans cell histiocytosis, and some
lesion margins may be difficult to see on T2-weighted aneurysmal bone cysts. Lesions with a pathologic fracture,
images. The T1-W sequence is sometimes better for stress fractures, and osteomyelitis can also have a large
assessing the true lesion margin. In studies obtained with amount of associated edema and have confusing imaging
dynamic gadolinium injection, the peritumoral edema has characteristics. Osteoid osteoma is frequently misdiagnosed
been shown to be differentiated from the primary lesion by at MRI because the large amount of edema may obscure the
an enhancement curve with a slope of 20% or less than the nidus. In some studies, CT has been shown to be more
actual lesion [10]. accurate than MRI in assessing the location of the nidus [5]

Fig. 3 Benign and malignant


etiologies of FFLs. a and b
Axial and sagittal T2-W MR
images showing a primary
aneurysmal bone cyst of the left
pubic bone with multiple FFLs
occupying the entirety of the
lesion. c Axial T2-W MR
image showing an osteosarcoma
demonstrating FFLs that
comprise less than one-third
of the whole lesion
472 Pediatr Radiol (2010) 40:468473

(Fig. 2). Also, an intraarticular osteoid osteoma may cause to a primary bone lesion or even trauma, leading to
a large amount of adjacent joint effusion and synovitis, and difficulty in interpretation. Approximately one-third of
therefore may not be recognized. ABCs are secondary and have a preexisting lesion that
can be identified, most commonly giant cell tumor. Other
Periosteal reaction common associated primary lesions include osteoblastoma,
angioma and chondroblastoma [14]. However, because the
The term periosteal reaction can include either new bone secondary ABC may become large, distort the architecture of
formation or elevation of the periosteum related to the bone, and even lead to bone destruction, it can actually
infiltration and extension of tumor or infection to the cortex obscure the primary lesion both radiographically and patho-
of the bone. Periosteal reaction is visible earlier in children, logically. Therefore, FFLs are a nonspecific finding that may
where elevation of the periosteum occurs more easily due to be seen in primary or secondary aneurysmal bone cysts, as
a looser attachment than in adults [11]. Many different types well as in other benign and malignant lesions.
of periosteal reaction have been described, including single
layer, multilayer, solid, spiculated, interrupted, etc. In general,
the type or characteristic of the periosteal reaction is not Conclusion
specific. Benign and malignant lesions can have a high degree
of overlap in the type of periosteal reaction pattern, although Bone lesions in children are very common. The role of the
some generalizations can be made. Solid periosteal reaction radiologist includes working with the clinician and pathologist
typically is associated with a benign or slow-growing lesion. to help make an accurate diagnosis, acting as consultant to
Spiculated, sunburst, and interrupted (Codmans triangle) suggest the best imaging modalities for the suspected
patterns are typically associated with rapidly growing aggres- diagnosis, and defining the extent of disease. Determining
sive tumors or infections. However, in a series by Wenaden et benign from malignant lesions is one of the most important
al. [11], there were a large number of aggressive lesions that goals. Knowledge of the age of the patient, the lesion location,
had benign-appearing periosteal reaction, or none at all. and various imaging characteristics will help to narrow the
Therefore, caution is suggested when interpreting periosteal differential diagnosis. Attention to meticulous MR technique
reactions around a lesion. for quality images and correlation with clinical history and
plain radiographs should be emphasized.
Fluid-filled levels

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