Bone tumor

• Appearance of Lesion
• Location of Lesion
• Density of Lesion
• Other Clues
 Clues by Appearance of Lesion
• Patterns of Bone Destruction
• Periosteal Reactions
• Tumor Matrix
• Expansile Lesions of Bone
 Periosteal Reactions
• Benign
– None
– Solid
• More aggressive or malignant
– Lamellated or onion peel
– Sunburst
– Codman’s triangle
 Periosteal Reactions

Sunburst onion-peel Codman’s triangle

 Expansile Lesions of Bone
Multiple myeloma
Mets
Brown tumor
Enchondroma
Aneurysmal bone cyst
Fibrous dysplasia
 .
• Epiphyseal
GCT, chondroblastoma

• Metaphyseal
Osteomyelitis, osteo-and
chondrosarcoma
.
• Diaphyseal
Round cell lesions, ABC,
. enchondroma
 Characteristic Locations

• Simple bone cyst • Chondroblastoma

Proximal humerus Epiphyses
 Characteristic Locations

Giant Cell tumor Adamantinoma Chordoma

Epiphyses Tibia Sacrum, clivus
 Soft Tissue Extension

• Usually implies malignancy : More likely to form discrete

soft tissue mass
• Benign conditions with soft tissue extension : Osteomyelitis
 Age of Tumors
• 20>…..Osteogenic Sarcoma, Ewings.

• 40……GCT, Chondrosarcoma, MFH,

Lymphoma, Mets.

• 60……Mets, Myeloma, Chondrosarcoma, late

Osteogenic, MFH, Fibrosarcoma.
 Osteoma
• Clinical features 40-50 yr.
old, M:F = 2:1 Slow
growing, multiple lesions
• No malignant potential
• Radiographic features
Sharply circumscribed
radiopaque mass
protruding from the bone
surface.
 Osteoid Osteoma
• Osteoblastic lesion with
central area of new bone
formation, known as a
nidus
• Known to cause pain,
especially at night. Pain
relieved by aspirin.
• 7.5% seen in the foot
• Age 5-25
• Male 2:1
 Osteochondroma

• Most common benign lesion

• Protruding, mushroom-shaped
exostosis with cartilage cap
• Points away from joint
• Male 2:1
• Typically originates from the
metaphysis
Fibrous Cortical Defect
• Asymptomatic
• Self-healing may regress
spontaneously.
• Age 4-8, rare after 14
• Round to oval radiolucent
intracortical lesion that
typically erodes the outer
cortical surface
Non ossifying fibroma
 Fibrous Dysplasia
• Localized developmental
arrest
• Monostotic vs
Polyostotic
• Fractures and
deformities - "shepherd
crook" proximal femur;
rare malignant
transformation to
sarcomas
• Well-defined
intramedullary lesion
Ground glass appearance
Giant Cell Tumor of Bone

• 20-45 yrs old

• Female > male
• Only bone tumor with female
prevalence
• Rapidly expansile radiolucent lesion
• Epiphyseal and metaphyseal in adults;
metaphyseal in adolescents
• Phalanges and metatarsals most
commonly affected also seen in the
talus and posterior calcaneus
 Enostosis (Bone Island)
• Discrete intramedullary
sclerotic zone comprised of
compact bone
• Asymptomatic
• Incidental findings on xray
• Posterior calcaneus, lesser
metatarsal heads, talar neck,
and distal tibia are most
frequent in foot and ankle.
 Enchondroma
 Most common tumor of the
phalanges (hand 6:1)
 Age 10-35
 Male = Female
 Usually painless except with
pathologic fracture
 Central intramedullary oval
geographic lesion with sharp
margination and a thin rim of
reactive sclerosis
 Ollier’s Disease
• Multiple enchondromatosis, especially
involving the hands and feet.
• One extremity is affected more than the other
Maffucci’s Syndrome
• Multiple
enchondromatosis with
soft tissue hemangiomas
 Simple Bone Cyst
(Unicameral or Solitary Bone Cyst)

• Fluid filled intramedullay cavity

• Fluid may be serous,
serosanguineous, or frank blood.
• Peak incidence in first two
decades of life
• Asymptomatic -- pathologic
fracture occurs
• Common in calcaneus neutral
triangle
 Aneurysmal Bone Cyst
(ABC)

• Is a reactive process
• Rapidly expansile lesion with
multiple blood filled cystic
cavities.
• Age 5-20
• Rapid onset of pain
 Osteosarcoma
• Malignant mesenchymal tumor
• Produce bone matrix
• Bimodal age distribution; 75% < 20
y.o.
• Metaphysis around the knee, either
in the distal femur or proximal tibia
• > 25 y.o. in flat bones and long
bones is almost equal.
 Osteosarcoma
• Large, destructive,
mixed lytic and blastic
mass. The tumor
frequently breaks
through the cortex
and lifts the
periosteum, resulting
in reactive periosteal
bone formation.
• The triangular shadow
between the cortex
and raised ends of
periosteum is known
radiographically as
Codman triangle
 Ewing’s Sarcoma
• Related to primitive neuroectodermal cells.
• ( 1-30 age group ).
• Presentation of pain and a mass
• Fever, anemia, leukocytosis, and an increased
erythrocyte sedimentation rate.
 Ewing’s Sarcoma
• Permeative in appearance
( multiple small holes )
• Often have an “onion skin”
type of periostitis.
• 40% of lesions occur in the
diaphysis.
• Femur.
• DD/ infection and
eosinophilic granuloma.
 Chondrosarcoma
• Malignant cartilage
• > 40 age group.
• Pelvis (30%), proximal and
distal femur, ribs, proximal
humerus, and proximal
tibia.
• Pain or mass.
 Chondrosarcoma
• Typical snowflake, or popcorn-
like, amorphous calcification.
• Plain films may also show large
osteolytic lesions.
• Difficult to distinguish between
benign enchondroma and low
grade chondrosarcoma.
Metastatic Disease
• Most common
• Considered in any
differential diagnosis of a
• > 40 years old.
• Virtually any
appearance.
• May be lytic or blastic.
• Majority of metastases
to bone originate in
Breast, Prostate, Lung,
Kidney and Thyroid.
Metastatic Disease
• Most common sites for
bony metastases
include thoracic and
lumbar spine, pelvis,
femur, rib, proximal
humerus and skull
Multiple Myeloma
• Malignant monoclonal
plasma cells.
• > Over 40 years of age.
• Malaise, bone pain, or a
pathologic fracture.
• Classic radiographic
appearance is multiple
lytic “punched out”
areas in bone.
• Frequently involves the
calvarium.
 Multiple Myeloma
• Lesions often do not show uptake of isotope
on bone scan, making a skeletal survey the
most important radiographic test.
• Treatment consists of palliative chemotherapy
or bone marrow transplant.
Osteoarthritis
• Degenerative joint process
• Focal loss of cartilage, new
bone formation (spurring),
and subsequent pain and loss
of function
• > 55 have radiographic
evidence, goes up to 90% at
age 70
• Slight female predominance in
older age, but both sexes
affected
Osteoarthritis –
pathogenesis
• Genetic factors play a
role
• Clear environmental or
secondary triggers
– injury
– history of
inflammatory joint
condition, neuropathic
(Charcot joint)
– rare
endocrine/metabolic
such as
hemochromatosis,
acromegaly, Wilson’s
disease
 Osteoarthritis –
diagnosis
• History is important
– Gradual onset of
symptoms, lack of
inflammation,
sometimes history of
prior injury or overuse
or other secondary
trigger
Osteoarthritis – Hip and Knee

• Very common
• Associated with obesity
• Bilateral disease is common although one
may be worse
• Treatment – NSAIDs or Tylenol, PT and
weight loss, then steroid injections for knee
and potentially X-ray guided for hip, and if
these fail total joint replacement surgery is
very effective
X-ray – classic changes due to OA
?
 Osteoarthritis –
Hands
• Heberden’s nodes –
DIP joint bony
nodules
• Bouchard’s nodes –
PIP joint bony
nodules
• Base of thumb (1st
CMC joint) very
commonly affected,
more likely due to
wear-and-tear than
nodes
Osteoarthritis –Joints Not Typically
Affected

• Joints which are not typically affected by

OA unless injury/secondary cause:
– MCPs
– Wrist
– Ankle
– Elbow
• If these are affected, think inflammatory!!
 Rheumatoid Arthritis – definition and
prevalence
• Symmetric inflammatory joint condition
• Pannus formation, joint erosion, and systemic
inflammation
• Most common inflammatory arthritis
• , 1% of the population, 2:1 female to male ratio
• Ages 40 to 60
• Onset usually insidious over months
 Rheumatoid Arthritis – X-ray
• Classical findings of inflammatory arthritis:
– Periarticular joint erosions
– Periarticular osteopenia
– Symmetric joint space narrowing

• Note that each of these is the opposite of

OA!!
– (erosions instead of spurs, osteopenia instead
of sclerosis, and symmetric instead of
asymmetric joint narrowing)
 Rheumatoid Arthritis – Diagnosis
• History and physical are
majority of diagnosis – lab
not that helpful
– Symmetric pain and
swelling in small joints of
hands, wrists, feet, ankles
most common, followed by
knees, elbows, shoulders
– Morning stiffness – better
with activity
– Constitutional symptoms –
fatigue, even weight loss
are common, but fever is
VERY RARE
– Steady, progressive,
additive onset is by far most
common presentation
 Early Radiographic Progression
Joint-space narrowing and
erosion are seen in up to
two thirds of patients
within the first 2 to 5 years
of disease

Reproduced with permission from Wolfe F, et al. Arthritis Rheum. 1998;41(9):1571-1582.

Joints Commonly Involved
 Patterns of Onset
Insidious 55%-65% Joint stiffness, swelling,
pain, fatigue

Acute 8%-15% Fever, weight loss, fatigue,

joint abnormalities present
but often not prominent

Intermediate 15%-20% Systemic complaints more

noticeable than insidious onset

Harris ED Jr, et al. In: Firestein GS, et al, eds. Kelley’s Textbook of Rheumatology, 8th ed. 2008.
 Early RA: Radiographic Findings

High-Detail X-Ray Low-Field MRI

Courtesy of Charles Peterfy, MD.

Rheumatoid
arthritis
erosions on
X-ray
 Spondylarthropathies – Patterns of
Disease
• Inflammatory spinal involvement is typical,
and differentiates from other arthridities
• Enthesitis or inflammation of tendon
insertions is classical
• Asymmetric oligoarthritis is typical pattern of
peripheral joint arthritis
• Eye involvement (uveitis) is common
• Aortitis with valvular insufficiency is also an
important complication
 Spondylarthropathies
• Ankylosing Spondylitis

• Psoriatic Arthritis

• Enteropathic Arthritis and Reactive Arthritis

 Spondylarthropathies - Ankylosing
Spondylitis
• Sacroileitis in all cases, ascending ankylosis of spine
gradually over the years
• Symptoms are inflammatory back pain
• Can also affect hips and shoulders, rare to affect more
distal joints
• HLA-B27 in 90% of European ancestry
• Diagnosis – Sacroileitis and anklyosis on X-ray
X-ray of sacroileitis
Ankylosing spondylitis: lumbar vertebrae,
bamboo spine
 CRYSTAL DEPOSITION DISEASE

GOUT

• Disorder of purine metabolism characterised by

hyperuricaemia & recurrent attacks of acute synovitis

• M:F = 20:1

• 2 Types:
– Primary (95%): inherited disorder with overproduction or
under excretion of uric acid
– Secondary (5%): myeloproliferative disorders, renal
disease
• Only a small number of people with hyperuricaemia develop
gout.
73 PROF SDS
 CDD - GOUT
Clinical:
The joints most commonly affected by gout are:
• Forefoot
– podagara: - classic presentation of acute attack of first MTP joint
Elbows and hands
– preserved joint spaces and normal mineralization
• The large joints (hips, knees, ankles and shoulders) are infrequently
involved
• Spine very rarely affected.

Nephrolithiasis is major extraarticular manifestation; - only small % of pts w/

gout get tophi, but many get renal stones; - pure uric acid stones are
found in 80%, & uric acid is probably nidus for Ca-Phos & oxalate calculi in
remainder; - in 1/2, sx from renal stones actually precede arthritis

74 PROF SDS
 What is Osteoporosis?
• Loss in total mineralized bone
• Disruption of normal balance of bone breakdown
and build up
• Osteoclasts: bone resorption, stimulated by PTH
• Calcitonin: inhibits osteoclastic bone resorption
• Major mechanisms:
– Slow down of bone build up: osteoporosis seen in older
women and men (men after age 70)
– Accelerated bone breakdown: postmenopausal
• Normal loss .5% per year after peak in 20s
• Up to 5% loss/year during first 5 years after menopause
 Defining Osteoporosis
• “systemic skeletal disease characterized by
low bone mass and microarchitectural
deterioration of bone tissue, leading to
enhanced bone fragility and a consequent
increase in fracture risk”
• True Definition: bone with lower density and
higher fracture risk
• WHO: utilizes Bone Mineral Density as
definition (T score <-2.5); surrogate marker
 Methods to evaluate for osteoporosis
• Quantitative Ultrasonography
• Quantitative computed tomography
• Dual Energy X-ray Absorptiometry (DEXA)
– ?”gold standard”
– Measurements vary by site
– Heel and forearm: easy but less reliable (outcome of
interest is fracture of vertebra or hip!)
– Hip site: best correlation with future risk hip fracture
– Vertebral spine: predict vertebral fractures; risk of falsely
HIGH scores if underlying OA/osteophytes
TERIMA
KASIH