Musculo Skeletal Radiology

Ovid: Fundamentals of Diagnostic Radiology
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Editors: Brant, Will iam E.; Helms, Clyde A. Title: Fu ndamentals o f Diagnostic Radio logy, 3 rd Edition Copyright 2 00 7 Lippinco tt Williams & Wilkins
> Table of Conte nts > S ection X - Musculosk ele tal Radiolog y > Chapte r 41 - Benign Cy stic Bone Les ions
Chapter 41 Benign Cystic Bone Lesions

Clyde A. Helms A benign, bubbly, cystic les ion o f bone is on e of t he m ore com mon skeletal lesions that a radiologist enco unt ers. Th e differential diagnosis c an be quite length y and is usu ally structu red on how th e lesio n loo ks to th e ra diologist, using h is or h er experience as a guide. This m ethod, called pa ttern iden tificatio n, c ertainly has merit, but it can lead to a very long differential dia gn osis an d m any erro neous con clu sio ns if no t tempered with some lo gic. I n gen eral, if a differen tia l diagn osis will yield th e correct diagn osis 9 5% of t he t im e, mo st w ou ld consider it a usefu l differential list; h owever, it w ould n ot be a ppropriate to accept a 1 -in-2 0 miss rate for fract ures and dislocation s. In gen eral, th e sho rter th e differential diagnosis list, the m ore helpfu l it is to c linician s an d th e easier it is to rem ember. A sh orter differen tia l list will u sually h ave a lo wer accuracy rate th an a lon g list; h ow ever, man y times the lon ger lists c ontain such rare en tit ies that the accuracy does not really increase s ubstant ially. For mo st o f the entities in bo ne radiolo gy, a 95% accu rate differen tial is acceptable. If o ne w ants to be m ore accurate t han that , mo re diagno ses can simply be added to the list o f differential possibilities. Wh en the differen tial diagno sis is long, as in the differential for bubbly, cystic lesions of bo ne, it can be difficult to recall all of th e entities th at shou ld be m entioned. A mnem onic can be helpful in recalling long lists of info rm atio n and is recom mended.
FEGNOMASHIC
F EGNO MASHI C is a mnem onic t hat serves as a nice startin g point for discu ssin g po ssibilities t hat appea r a s benign, cyst ic lesion s in bone. Th is mnem onic has been in gen eral u se for man y years. By itself, it is merely a long list 1 4 en tit ies an d it n eeds to be c oupled with ot her criteria to shorten the list into a m anageable form for each particu lar case. For instan ce, th e age of the patient w ill h elp add or elim in ate m any o f the possibilities. If mu ltiple lesion s are present, only h alf a dozen ent ities n eed to be discussed. Metho ds o f narrow in g t he differen tial are discussed lat er in this chapter. The firs t step in approaching a ben ign, cystic bon e lesio n is to be certa in it is really ben ign. The crit eria for differentiating ben ign les ion s fro m malignan t
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lesions are covered in Chapter 4 2. Once it is establish ed th at t he lesio n is tru ly a ben ign, cystic lesio n, F EGNO MAS HI C will enable a differen tial diagn osis th at is at least 95 % a ccurat e. Mem orization o f the 14 entities in this different ial is eas ily do ne (Table 41 .1). The next step after learning t he n ames of all of th e lesio ns is get tin g so me idea o f each lesion 's radio graph ic appearance. This is w hen experience becomes a facto r. For the medical studen t o r first-year residen t, it is difficult to go beyon d s aying that they all loo k cystic, bubbly, an d benign. Th e fourth-year resident s hould have no trou ble P.10 64 differen tiat in g between a unicameral bon e cyst a nd a gia nt cell tu mor becau se he o r she has seen examples o f each many tim es before and kn ows their a ppearance.
TABLE 41.1 Discriminators for Benign Lytic Bone LesionsMnemonic: FEGNOMASHIC

Letter Represents Characteristics
Fibrou s dyspla sia
No periosteal reactio n
En chon drom a
1. Calcifica tio n present (except in phalanges) 2. Painless (no periostitis)
Eo sin ophilic granu lom a
You nger than age 30
Gian t cell tu mor
1. E piphyses clos ed 2. Abu ts t he articular surface (in long bon es) 3. Well defined w it h a n onsclerot ic margin (in long bon es) 4. E ccen tric
Nono ssifyin g fibro ma
1. Youn ger than age 3 0 2. Painless (no periostitis) 3. Cortically based
Osteo blasto ma
M en tioned when aneu rysmal bo ne
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cyst (AB C) is ment ion ed (es pecially in the posterior elements of th e spine)
Metast atic disea ses and myelo ma
Older than age 40
An eu rysmal bo ne cyst
1. E xpan sile 2. Youn ger than age 3 0
So litary bone cyst
1. Central 2. Youn ger than age 3 0
Hyperparath yroidism (brow n t umo r)
M ust have o ther evidence of h yperpa rath yroidism
Infection
Alwa ys ment io n
Chon droblasto ma
1. Youn ger than age 3 0 2. E piphyseal
Chon drom yxo id
No calcified matrix
A fter getting a feel fo r wh at each lesio n loo ks like radio graphically and o vercom ing the frustration that builds wh en one realizes that ma ny o f them lo ok a like, on e sho uld try to lea rn ways to differentiate each lesio n fro m the others. I h ave developed a n umber of keys that I call discriminato rs, wh ich help to differen tiat e each lesion . These discrim ina tors are 90 % to 95 % u sefu l (I will m ention wh en they are mo re or less accurate, in my experience) an d are by n o m eans in tended to be absolutes or dogma . They are guidelines but have a high a ccuracy rate. Textboo ks rarely state t hat a fin din g always o r never o ccurs. They t emper descriptio ns w ith virt ually alw ays, in va riably, usually, o r characteristically. I have tried to pick out fin dings that c ome as close to always as I can , realizing that I will o nly be a pproximately 95 % accura te. That is goo d eno ugh fo r most radiologists. The fo llow in g is o nly a brief description o f ea ch en tit y; m ore com plete description s are readily available in any skelet al radiology text. What is em phasized h ere are th e point s th at are u niqu e for each entity, t hereby ena bling
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differen tiat io n fro m the others. Table 41 .1 is a syn opsis of these discriminato rs.
Fibrous Dysplasia
Fi brous dysplasia is a benign co ngenital pro cess th at can be seen in a patien t o f any age and can lo ok like alm ost any pa thologic process radiograph ically. It c an be wild looking, discretely lucent, patch y, sclerotic, expansile, mu lt iple, an d m any other descriptions. It is, th erefo re, difficult t o loo k at a bu bbly lytic lesion a nd u nequivocally sa y it is o r is not fibrous dys plasia. I t w ould be better if t he F EGNO MAS HI C differential started o n a positive no te, say, with gian t cell tum or o r chon droblasto ma, for w hich there are som e definite crit eria. How ever, becau se fibrou s dyspla sia is firs t o n t he list, w e might as well deal with it . Ho w do yo u kno w wh et her to in clu de or exclude fibrous dysplasia if it can loo k like almost anyth ing? Experience is the best guideline. In oth er words, look in a few texts an d fin d as man y different exam ples as po ssible; get a feelin g for w hat fibrou s dyspla sia lo oks like.
FIGU RE 41 .1. Fibro us Dysplasi a. Th is patient has po lyost otic fibrous dyspla sia with diffu se involvem ent of th e pelvis as well as the proximal femurs.
P.10 65 F ibrous dysplasia w ill no t h ave periostitis asso ciat ed with it; therefore, if perio stit is is present , on e m ay safely exclude fibrous dysplasia. Fibrous dysplasia
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virtu ally n ever un dergoes malign ant degen eration and sho uld no t be a painful lesion unless there is a fracture. An occu lt fractu re oft en o ccurs in lon g bon es w ith fibrou s dyspla sia; th erefore, it is n ot unu sual to ha ve it present w ith pain a nd n o obviou s fract ure seen in a lon g bo ne. P ain in a flat bon e, such as the ribs o r pelvis (non weight-bearin g bo nes), shou ld no t o ccur with fibro us dysplasia. F ibrous dysplasia can be eith er m ono stotic (mo st comm only) or polyo stotic and h as a predilect ion for th e pelvis, proxim al fem ur, ribs, and sku ll. Wh en it is present in th e pelvis, it is in variably present in th e ipsilateral proximal femur (Figs. 4 1.1, 41 .2). I have seen o nly one case in wh ich th e pelvis w as invo lved w ith fibrou s dyspla sia, and the proximal femur w as spared. The proximal femur, h ow ever, ma y be affected alo ne, withou t involvement in t he pelvis (Fig. 4 1.3 ). F ibrous dysplasia o ften involves the ribs. I t typically h as an expansile, lytic a ppearance in th e post erio r ribs (Fig. 41 .4) an d a sclerotic appearance in the a nterior ribs. The classic descriptio n of fibrous dysplasia is t hat it has a grou nd-glass or smo ky m atrix. This descript ion co nfuses peo ple as often as it helps th em, a nd I do no t recom mend usin g groun d-glass a ppearance as a bu zz word for fibrous dysplasia . Fibrou s dysplasia is often purely lytic and becomes hazy or takes o n a grou nd-glass loo k as the matrix P.10 66 c alcifies (Fig. 41 .5). I t can go on to calcify significant ly, and t hen it present s as a sclerot ic lesion. Also, I oft en see lytic lesio ns with a pat hologic diagnosis other t han fibro us dysplasia th at h ave a distinct gro und-glass appearan ce; therefore, t he grou nd-glass qualifier can be mislea ding.
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FIGU RE 41 . . Fibro us Dysplasi a. Th is patient has po lyost otic fibrous dyspla sia with in vo lvemen t o f the right femu r as w ell as th e supraacetabular portion of th e ilium . When th e pelvis is in vo lved w it h fibrou s dysplasia, the ipsilateral fem ur on the affected side is in varia bly also in volved.
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FIGU RE 41 .3. Fibro us Dysplasi a. Th is patient has a w ell-defined lytic lesio n with a h azy, gro und-glass appearan ce in the neck of the righ t femu r. The pelvis wa s un in vo lved. I t is n ot un usual for m ono stotic fibrou s dysplasia to involve the pro ximal femu r and spa re t he pelvis.
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FIGU RE 41 .4. Fibro us Dysplasi a. When fibro us dysplasia affects the ribs, th e post erior ribs o ften demo nstrate a lytic expansile appeara nce, as in t his example. Wh en th e an terior ribs a re involved, th ey are most often sclerotic in appearance. Note also th e involvem ent of the tho racic spine.
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FIGU RE 41 . . Fibro us Dysplasi a. Polyostot ic fibro us dysplasia is seen in th e radius in this ch ild. Parts of th is lesion have a h azy, gro und-glass appearance, w hereas ot hers are more lytic appearing. A h azy, groun d-glass appearance is oft en present in fibrous dysplasia, bu t j ust as o ften, th e appearance ca n be purely lytic or even sclerotic.
Adamantinoma
Wh en a lesio n is encou ntered in th e tibia tha t resem bles fibro us dysplasia , an a damantino ma shou ld also be considered. An adaman tin oma is a malign ant t umo r that radiographically an d histologically resembles fibrous dysplasia (Fig. 4 1.6 ). It occurs almo st exclusively in the tibia a nd t he j aw (for un kn own reason s) and is rare. Becau se it is rare, on e may choo se n ot to in clude it in the differen tial a misdiagn osis w ill no t o ccur mo re than on ce or t wice in a lifetim e.
McCune Albrig t Syndrome

P olyo stotic fibrou s dyspla sia occasion ally occu rs in asso ciat ion w it h ca f -au -lait
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s po ts on the skin (dark-pigm ented, frecklelike lesion s) and precociou s puberty. This complex is called McCun e-Albright syndro me. The bon y lesion s in this s yn drom e, and even in the sim ple polyo stotic form, oft en o ccur u nilat erallyth at is, t hro ugho ut one half of th e body. Th is P.10 67 do es n ot happen oft en en ough to be o f any diagno stic use in differen tiat ing fibrou s dyspla sia from oth er lesions.
FIGU RE 41 . . Adamantino ma. This mixed lytic an d sclero tic pro cess in the m idsha ft of th e tibia is ch aracteristic for fibrou s dysplasia. An adam antinom a h as an identical appeara nce an d sh ould be considered in any tibial lesion th at resembles fibro us dysplasia. Biopsy show ed th is to be an adam antinom a.
The presence of m ultiple lesio ns of fibrous dysplasia in the jaw has been termed c er ism This is fro m t he ph ysical appearance o f the child with puffed-o ut c heeks having a n an gelic loo k. The j aw lesions of ch erubism regress in
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a dult hoo d.
Discriminator
No periosteal reaction.
Enchondroma and Eosinophilic Granuloma

E nchon dromas occur in any bone fo rmed from cart ilage an d may be cent ral, eccen tric, expansile, or n onexpansile. They invariably cont ain calcified cho ndro id m atrix, except when in the ph alan ges. An en chon drom a is t he m ost comm on ben ign cystic lesio n in the phalanges (Fig. 4 1.7 ). If a cystic lesion is presen t w ithou t calcified ch ondroid mat rix anywh ere except in th e phalanges, I do n ot include encho ndro ma in my differential. O ften it is difficult to differen tia te betw een an ench ondroma and a bo ne infarc t. A n in farct u sually has a w ell-defined, densely sclerotic, serpiginou s bo rder (Fig. 4 1.8 ), wh ereas an en chon drom a does no t (Fig. 41 .9). A n en chon drom a o ften c auses en dosteal scallopin g, w hereas a bo ne infarct w ill no t. A lth ough th ese c riteria are helpfu l in separating an infarct from an ench ondroma, they are not foo lproof.
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FIGU RE 41 . . E nc on droma. A lytic lesio n in the phalanges is mos t co mmo nly an encho ndro ma. Th is is the on ly locat io n in the skeleton w here an ench ondroma does not con tain calcified ch ondroid ma trix. These m ost o ften presen t w ith path ologic fractu res, as in this example.
I t is difficult, if no t impo ssible, to different iate an encho ndro ma from a c hondrosarcoma. Clinical fin din gs (prim arily pain ) serve as a bet ter indicato r t han radiographic fin dings, and in deed pain in an apparen t ench ondroma sho uld w arrant surgical investigation. Periostitis sh ould n ot be seen in an ench ondroma either. Trying to differen tiate h isto lo gically an en chon drom a fro m a c hondrosarcoma is also difficult, if n ot im possible, at times. Biopsy o f an a ppa rent encho ndro ma shou ld not be perfo rmed ro utinely fo r his tologic differen tiat io n. M ultiple en ch ondro mas o ccur on o ccasio n; th is condition has been t ermed
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O llier disease (Fig. 41 .10 ). It is not P.10 68 P.10 69 h ereditary a nd do es no t h ave an increased rate of m alignant degenera tio n. Th e presence o f mu ltiple encho ndro mas associated w it h s oft tissue heman giom as is kn own as Maffu cci syndro me (Fig. 41 .11 ). Th is syndro me also is n ot hereditary; h ow ever, it do es ha ve an in creased incidence of malign ant degeneration o f the en chon drom as.
FIGU RE 41 . . B one Inf arct. These lytic les ion s in the dista l femu rs with calcified, serpigin ous borders are t ypical for bon e infa rcts. Occasionally, the different ial betw een a bon e infarct and an en chon drom a ca n be difficult on plain films; h owever, in t his example, infarcts are easily diagnosed.
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FIGU RE 41 . . E nc on droma. Th is lesion in the distal righ t femu r show s th e stippled, punct ate calcification typical for ch ondroid mat rix seen in an ench ondroma .
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FIGU RE 41 .1 . Oll ier Di sease. M ultiple en chon drom as are pres en t th rou ghou t t he h and. Th is is a t ypical example o f Ollier disease.
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FIGU RE 41 .11. Maffu cci Syn drome. Multiple encho ndro mas associated w ith ph lebolit hs are present in th e phalanges. Th is com bin atio n of findings invariably represen ts h emangiom as an d ench ondromas in M affucci syndrome.
Discriminators
1 . M ust have ca lcification (except in phalanges). 2 . No periostitis o r pain. E osino phili c granu loma (EG) is a form of histiocytosis X, t he o ther form s being L etterer-Siwe disease and Hand-S ch ller-Christian disease. Alt hou gh t hese forms may be merely different phases of th e sam e disease, mo st investigators c ategorize them separately. The bony manifesta tio ns of all three disorders are s imilar and are discussed in th is review simply as EG. U nfo rtu nately for radiologists, E G has man y appeara nces (1). It can be lytic or s clero tic, it m ay be w ell defined o r ill defined, it might or might no t h ave a s clero tic border, and it might or might no t elicit a periost eal respon se. The perio stit is, wh en presen t, is typically benign in appearance (t hick, uniform ,
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w avy) bu t ca n be lam ellated o r amo rpho us. E G can mimic Ewing sarco ma and present as a perm ea tive (mu ltiple small ho les) lesio n.
FIGU RE 41 .1 . Eosin op il ic G ran ulo ma
EG . A well-defined lytic lesion
is seen involving the midfemu r in th is 20 -year-old patient. Biopsy sh owed th is to be E G.
Ho w, then, can on e distin guis h E G from an y of th e o ther lytic lesions in th is differen tial? Rem em ber that it is diffic ult to exclu de EG from almost any differen tial of a bony lesion, be it ben ign or m alignan t. E G occu rs alm ost exclusively in patien ts u nder 30 years (u sually <20 years); th erefo re, t he pa tient 's age is th e best criterion. I recom mend ment ion in g EG as a differential po ssibility for an y lesio n in a pat ient less th an the age of 3 0. Becau se EG can loo k like an ything, so lon g as the radiograph is n ot of an arthritide o r trau ma, E G c an be ment ion ed w ith out even loo king at the film ! E G is m ost often m ono stotic (Fig. 4 1.1 2), but it can be polyo stotic (Fig. 41 .13 ) a nd, t hus, has to be included w henever multiple lesion s are presen t in a patient yo unger tha n t he age of 3 0 years.
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E G might or m igh t n ot have a soft t issu e mass associated, so the presence o r a bsen ce o f a so ft tissue m ass w ill n ot help in th e different ial diagno sis. I kn ow of n o entity in which the presence or absence of an asso ciated soft t issue mass will w arrant inclu sio n or exclu sion o f the process from a differen tial. It is im port ant t o note the presence of a soft tissue mass (o r its absence), but th is will do little t o narrow th e differential diagnosis. M ost radiologists a re inept at evaluat ing the soft t issu es because they are difficult t o see, and CT and MR h ave made P.10 70 it unn ecessary in mo st cases to rely on plain films alone fo r the soft tissues. F ortu nately, in most cases, the presence or absence of a soft tissue mass will not a lter th e differential diagnosis. Th e treatin g physician w ill un doubtedly w ant to kn ow wh ether the soft t issu es are in volved and t o what extent; th is can be s atisfacto rily dem onstrated w it h MR.
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FIGU RE 41 .13. Eosin op il ic G ran ulo ma EG . Well-defin ed lytic lesions are presen t t hro ugho ut the pelvis in th is 24 -year-old patient. In additio n t o th e lesio n a rou nd t he righ t h ip, a lesio n is seen a t th e right sacroiliac j oint. B iopsy show ed th is to be E G.
E G occ asio nally h as a bon y sequestrum (Fig. 4 1.1 4). On ly a few other ent ities h ave been des cribed that on o ccasio n have bon y sequestra: osteo myelitis , lympho ma, and fibrosa rcom a; therefore, w hen a sequ est rum is identified, E G, o steom yelit is, lymph oma, and fibro sarco ma shou ld be con sidered. As discu ssed in Chapter 4 7, an o steoid o steoma will often give an appearance o f a s equ estration w hen the nidu s is pa rtially calcified. Clinically, EG m ight o r m igh t n ot be asso ciat ed with pain; therefore, clinic al history is no ncon tributo ry for th e m ost part.
Discriminator
M ust be u nder age 3 0 years.
Giant Cell
umor
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G ian t cell tumor is an unco mm on, somew hat con troversial lesio n with several s choo ls of th ough t as to it s radio graphic a ppearance. I su bscribe to th e mo st w idely u sed appro ach, as do th e maj ority o f radiologists a nd pat hologists (2).
FIGU RE 41 .14. Eosin op il ic G ran ulo ma
EG . Th is well-defined lytic
lesio n contains a bo ny sequ es trum (arro ), w hich is typical for o steom yelitis o r EG. B iopsy revealed this to be EG.
F irst, it is im port ant to realize that o ne is u nable to tell wh ether a giant cell t umo r is benign o r maligna nt, regardless o f it s radiographic appearance. Histologically, a giant cell t umo r canno t be divided in to eith er a benign or a m alignan t ca tegory. Most surgeons curettage an d pack t he lesions and consider t hem benign u nless th ey recur. E ven th en, t hey can still be benign a nd recur a s eco nd or third time. A bout 15 % of giant cell t umo rs a re t hou ght to be malign ant o n the basis of th eir rec urrence rate. Wh en m alignan t, t hey can met astasiz e to t he lun gs, but th ey do so infrequ en tly. F our classic radiographic crit eria for dia gn osing giant cell tum ors exist. If an y of t hese crit eria are no t m et w hen lo okin g at a lesion, gia nt cell tu mor can be eliminated fro m the differen tia l diagn osis .
1. Giant cell tumo r occurs o nly in pat ient s w ith closed epiphyses; this is va lid a t least 98% to 9 9% of t he time and is extremely useful. I do no t ent ertain t he diagno sis of giant cell t umo r in a patien t w it h o pen epiphyses. 2. The lesion m ust be epiph yseal and a bu t t he articular surface (Fig. 4 1.15 ).
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There is disagreem en t a s to w hether giant cell t umo rs begin in th e epiphyses o r metaphyses or from th e physeal plate itself; h owever, except for rare cases, w hen radiologists see the lesions, they are epiphyseal an d a re flush again st the a rticular surface. Th e metaph ysis also h as so me o f the t umo r in it becau se th e les ion s are generally very large. When on e sees a giant cell tum or, it w ill be epiphyseal. Perh aps m ore im port antly, it sh ould be flush against the art icular surfac e of t he j oin t. Th is occurs in 98 % to 9 9% o f gian t cell tum ors; t herefore, if I h ave a lesion that is P.10 71 s eparated fro m the articular surface by a defin it e margin o f normal bo ne, I w ill n ot in clude gian t cell tu mor in the diagno sis. This rule does not apply in flat bo nes, su ch as in the pelvis or in the apophyses (Fig. 4 1.16 ), wh ich h ave no articula r s urfaces.
FIGU RE 41 .1 . Giant Cell T umor. A w ell-defin ed lyt ic lesion with out a sclerotic m argin is seen abutting the articular surface of th e dist al femur in a pat ient wh o has clo sed epiph yses. These are all
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ch aracteristics of a gian t cell tum or.
3. Giant cell tumo rs are said to be eccent rically located in th e bon e, as o pposed t o being centra lly placed in the m edullary cavity. When a bo ny lesion is quite large, it can be difficult t o t ell w hether it is centra l or eccen tric. I do no t fin d th is to be a terribly u seful description , bu t it is one o f the cla ssic ru les o f a giant cell tumo r. 4. The lesion m ust have a sharply defin ed zo ne o f tra nsit io n (border) that is n ot sclerotic. This is a very helpful finding in gian t cell tu mor. The only places this does no t apply is in flat bones, such as the pelvis (Fig. 41.1 7) a nd t he calcaneu s.
I t is im po rtan t t o realize that the fo ur criteria fo r a giant cell tumo r apply o nly to giant cell tum ors and not to an y oth er lesion. For instan ce, I know o f no oth er lesion that depends on whet her the epiphyses are o pen or clo sed. No oth er lesion in any of my lists uses a s a diagn ostic factor w hether t he zo ne of transitio n is s clero tic or n ot (m any lesio ns, such as n ono ssifyin g fibromas, will usually have a s clero tic ma rgin , bu t it does n ot occur o ften eno ugh to in clu de as a discriminat or). No oth er lesion mu st alwa ys abut the articular surface, and no o ther lesio n h as t he classic P.10 72 description o f being eccentrically placed (altho ugh several lesio ns, including n ono ssifyin g fibroma and chon drom yxo id fibro ma, are eccen tric m ost of th e t im e).
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FIGU RE 41 .1 . Giant Cell T umor. Th is well-defined lytic lesio n t hat does n ot have a sclerotic m argin completely in vo lves t he greater tro chant er. The apo physes have the same differen tial diagno sis as lesions in t he epiphyses, w hich m akes giant cell t umo r a strong possibility in t his example. Biopsy sh owed this t o be a giant cell tumo r.
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FIGU RE 41 .1 . Giant Cell T umor. A large, well-defined lytic lesio n in the iliac wing is seen , w hich does co ntain a sclero tic margin an d does not appear to abut an y art icular surfac e. The pelvis is a go od lo catio n for giant cell tum or, wh ich th is pro ved to be at bio psy. The u sual rules for giant cell tu mors su ch as presen ce o f a n onsclero tic margin do no t apply in flat bo nes.
FIGU RE 41 .1 . Fibrous Co rtical Def ect. A well-defined lytic lesion is seen in the medial metaphysis o f this tibia (arro s), w hich is typical for a fibro us co rtical defect.
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FIGU RE 41 .1 . Non ossifyin g Fibroma. A large, w ell-defin ed lyt ic lesion, w hich is slightly expansile with scalloped sclerotic m argins, is seen in the distal tibia in this you ng pat ient . This is a characteristic appearance of a n ono ssifying fibro ma. Th e examination w as o bt ain ed for a sprain ed an kle an d no t for th is asympto matic lesio n.
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FIGU RE 41 .
. Non ossifyin g Fibroma. A well-defined, expan sile lytic
lesio n in the dist al fibula is noted in th is asympto matic patient, wh ich is ch aracteristic for a no nossifying fibro ma.
A lt hough th ese four criteria apply well fo r gian t cell tu mor, th ey do not apply at a ll for an y oth er lesions. Residents have a ten den cy to apply these criteria t o every lytic lesio n encou ntered fo r the simple reason th at th ey have learned th e fou r criteria. O nce one of the criteria is violated, the remainder do no t even have to be used t o eliminate a giant cell t umo r. For instance, if a lytic lesion is fou nd in the middiaphysis o f a bo ne, giant cell tumo r can be exclu ded. There is no need to check further to see wheth er it is eccentric, wh ether it ha s a non sclerotic m argin, or
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w heth er t he epiphyses are closed. A gain , th ese ru les will be greater t han 95 % effect ive an d, in my experience, c lose to 99 % effective. I t sh ould be not ed tha t th ese criteria only apply to giant c ell tu mors o f lo ng bo nes. Th ey wou ld not w ork, fo r inst ance, in the pelvis o r the c alcan eus, t wo lo cations wh ere giant cell tum ors often occur. I f one or tw o ca ses a re fou nd t hat do n ot fit the criteria, an oth er pat hologist sh ould review th e s lides. P.10 73 M any pa thologists refer to an eurysma l bone cys ts as gian t cell tu mors; hence, t hey ha ve gian t cell tum ors th at do n ot obey any of th e criteria. Th ese pa thologists may be correct, bu t t hey are no t in the mainstream of wh at m ost peo ple use for giant cell tumo r criteria, bo th radiograph ically and histologically.
Discriminators
1 . E piph yses must be clo sed. 2. Mu st abu t t he articula r surface. 3 . M ust be w ell defin ed w ith a non sclerotic m argin. 4. Must be eccen tric.
onossifying Fibroma
on ossifyin g fibroma (NO F) is pro bably the m ost com mon bon e lesio n en coun tered by radiologists. I t reportedly occ urs in u p to 2 0% of ch ildren and u sually sponta neously regresses, so as to be seen on ly rarely after the age o f 3 0. Fibrou s co rtical defect is a c omm on syn onym , altho ugh some people differen tiat e th e tw o lesions on the basis of size, with a fibrou s co rtical defect being smaller th an 2 cm in len gth (Fig. 4 1.1 8) an d an NOF being larger than 2 c m (Fig. 41 .19 ). Histo lo gically, these lesions are iden tica l; th erefo re, it seems a ppropriate to refer to them all as NOFs rat her than to su bdivide them by th eir s ize.
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FIGU RE 41 . 1. Non ossifyin g Fibroma. A. A well-defined, lytic lesio n t hat is m in im ally expansile is seen in th e distal tibia in th is child wh o was examined for a sprained ankle. B. A CT exam in atio n show ed apparen t co rtical destru ction (arro ), wh ich w as believed to be suggestive of an aggres sive lesio n. Biopsy sho wed this to be a n ono ssifying fibro ma. Bot h CT an d MR will o ft en sh ow apparen t co rtical destruction, wh ich is m erely co rtical replacement by benign fibro us tissu e.
NOF s are benign, asym ptom atic lesion s th at typically occur in the metaphysis o f a long bone, eman atin g from th e co rtex. They classically h ave a thin, sclerotic bo rder tha t is sca lloped an d sligh tly expan sile (Fig. 41 .20 ); h owever, this is a gen eral description tha t probably applies to o nly 75 % of the lesion s an d co uld equ ally apply to mo st o f the lesion s in FEGNO MAS HI C. They do no t h ave to have expansion o r a scalloped or sc lero tic border and a re n ot limited t o t he m etaphyses. Then h ow are they best reco gnized? The best w ay is to familiarize o neself with their gen eral appearance by lo okin g at examples in t extbo oks. That c an be done in 1 5 minutes. It is important to reco gniz e th ese lesion s becau se t hey are w hat I call do n t touc h lesion s (see Chapter 4 6); that is , th e radiolo gist's diagno sis shou ld be th e fin al wo rd and t hereby su pplan t a bio psy. These lesion s are so characteristic t hat no differential diagnosis sh ould be
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en tertained, alt hou gh a few en tities can indeed occasionally simulate t hem. I f a CT o r MR is obtained o f an NO F, th ere will o ften appear to be interru pt io n o f t he co rtex, which can be misinterpreted as cortica l destruct io n (Fig. 41 .21 ). Th is m erely repres en ts co rtical replacemen t by ben ign fibrous tissue an d sh ould n ot w arrant fu rth er investigation. P.10 74
FIGU RE 41 . . Healin g No nossifyi ng Fibro ma. A predo minantly sclero tic lesio n, which is minimally expan sile an d w ell defin ed, is seen in th e proxim al h umerus in this child who is asym pt omat ic. Th is is a typical appearance of a disappearing or healin g no nossifying fibro ma. With time, this lesio n will m elt into th e no rm al bone and essen tially disappea r.
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FIGU RE 41 . 3. Non ossifyin g Fibroma. This large, well-defined lytic lesio n w ith fain t sclero tic ma rgins is seen in the distal femu r. It has a very t ypical appearance for a gian t cell tu mor; how ever, it has sclerotic m argins and does no t abu t t he articula r surface. The lesion un derwen t biopsy a nd w as foun d to be a n ono ssifying fibro ma.
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FIGU RE 41 . 4. Osteobl asto ma. A. A lytic expan sile lesio n invo lvin g th e right T12 pedicle (arro ) and tran sverse process is seen o n this an teropo sterior plain film. B. Th e lesion is seen on CT t o extend in to the vertebral body. I t h as intact co rtices an d con tains s ome calcified m atrix. This is a classic example of an o steoblastom a o f the spin e.
P.10 75 I f the patien t is older th an 30 years of age, NO F sh ould n ot be included in the differen tial diagno sis. NOFs must be as ym ptomat ic and exh ibit n o perio stitis, u nless th ere is an antecedent history of t raum a. They rou tin ely heal with s clero sis and even tually disappear (Fig. 41 .22 ), usually aro und the ages of 20 to 3 0 years. Du ring th is healin g period, they can appear h ot on a radionu clide bon e s can becau se th ere is osteoblastic act ivit y. These lesio ns can occasionally get qu it e large (Fig. 41 .23 ); th erefo re, grow th or cha nge in siz e sho uld no t alter th e diagno sis. They are mo st co mmo nly seen about th e knee bu t can o ccur in an y lon g bon e. Oc casio nally, m ultiple NOF s are seen about th e knee, each o f which is c haract eristic in appearance.
Discriminators
1 . M ust be you nger than age 30 years. 2. No perio stitis or pain. 3 . Co rtically ba sed.
steoblastoma
steoblasto mas are rare lesions tha t co uld ju stifia bly be excluded from this differen tial withou t t he fear of m issing a diagnos is more th an once in a lifet im e. Wh y, th en , include them? Th e m nemon ic FEGNOMA SHIC w ou ld not have nearly t he sa me rin g w ith out the extra vo wel, so o steobla stoma rem ain s. O steoblastom as h ave two appearances: (1 ) They look like large o steoid o steomas a nd are o ften called ian t o steoid ost eomas Becau se ost eo id osteo mas are
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s clero tic lesio ns a nd do no t resemble bubbly lyt ic lesions, th is is no t th e type o f o steoblastom a w e are con cerned with in t his differential. (2) They simu late a neurysm al bone cysts (ABCs). They are expansile, often having a so apbu bble appearance. I f an ABC is bein g con sidered, so sho uld an o steoblastom a. O steoblastoma s com mon ly occur in the posterior elements of t he vertebral bodies, a nd abo ut half of th e cases demon strate speckled ca lcifications (Fig. 4 1.24 ). A classic radiology differential is t hat of an expansile lytic lesio n of t he po sterior elem ents of th e spine, w hich in clu des osteo blasto ma, ABC, and t ubercu los is.
Discriminator
M entioned wh en A BC is mentioned (especially in the posterior elements of t he s pine).
Metastatic Disease and Myeloma

M etastatic disease sho uld be co nsidered for an y lytic lesion ben ign or a ggressive in appearan cein a patient over 40 years of age. Metastatic disease c an a ppear perfectly benign radiograph ically (Fig. 41.2 5), so it is not valid t o s ay, Becau se th is lesion looks benign , it shou ld not be a metas tasis. Most m etastatic disease has an a ggressive appearance and will n ot be in the F EGNO MAS HI C differential, but a sign ifican t n umber o f metastases appear ben ign. In fact, m etastases can have an y radiographic appearance; therefore, a ny bon e lesio n in a patien t o lder tha n t he age of 4 0 shou ld have m et astatic disease a s a considerat ion , u nles s trauma or arthritis is the primary conc ern.
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FIGU RE 41 .
. Metastatic Disease. A well-defined lytic lesio n is seen in
th e pro xim al fem ur in th is 50 -year-old patient wh o had pain associated with th is lesion . B iopsy show ed th is to be a ren al metastasis. A significan t n umber of m etastatic lesions can have a com pletely benign appea rance, as in this example.
F or statistical purposes, I do no t m ention metasta tic disease in a patient yo unger t han age 4 0. I will be correct m ore tha n 9 9% of the t im e using 40 as a cu toff a ge. Oth erwise, m etastatic diseases wou ld have to be mention ed in every sin gle c ase of a lyt ic lesion , and I prefer t o limit th e list of differen tial possibilities. I a m n ot cla iming that met astatic disease does no t o ccur in pat ient s youn ger than a ge 40 on ly t hat I c onsider it acceptable to miss it (u nless given a history of a kn own prima ry n eo plasm ).
Myeloma
A lt hough m yelom a mo st comm only presen ts as a diffu se perm eative process in t he skeleton (Fig. 41.2 6), it can present as either a solit ary lesio n (Fig. 4 1.2 7) o r as m ultiple lytic lesio ns. B ubbly, lytic bo ne lesions of m yelom a are mo re
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c orrectly called p asmac to mas I m ention plas macytom a separately fro m m etastatic disease becau se it can occur in a sligh tly youn ger po pula tio n (age greater than 3 5 years is my cu toff) and can precede c linical or hem atologic evidence o f myelo ma by 3 to 5 yea rs. In gen eral, th ere is no harm in lumping all m etastatic disease, inc luding myelo ma, in to one grou p an d using greater th an a ge 40 as the limiting facto r. V irtually any m etastatic process can present as a lytic, benign-appearin g lesio n; t herefore, it serves no purpose t o P.10 76 t ry t o gu ess th e sou rce of th e metast atic disea se from its appearance. In gen eral, lytic expan sile m etastatic diseases tend t o co me from thyro id and renal t umo rs (Fig. 4 1.2 8). The o nly metast atic lesion t hat is said to always be lytic is renal cell carcino ma.
FIGU RE 41 .
. Mul tiple Myeloma. A. A diffu se permeative pattern is
pres en t t hro ugho ut the femu r in th is patien t w it h m ultiple m yelom a. B . A lateral sku ll film sho ws a typical present atio n of mu lt iple myeloma in t he skull with mu lt iple sma ll h oles throu gh out th e calvaria, w hich a re w ell defin ed.
Discriminator
M ust be o lder tha n age 40 years.
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FIGU RE 41 . . lasmacytoma. A large, w ell-defin ed lytic lesion is seen in th e left ilium (arro s) in this patient with mu ltiple myelo ma. Th is is a co mmo n locat io n for a pla smacytom a. L ike m etastases, plasm acyt omas often h ave a co mpletely ben ign appearan ce.
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FIGU RE 41 .
. Metastatic Disease. An expansile lesion with a soap-
bubble appearance is present in t he proxim al radius in a patient with renal cell carcino ma. An expan sile lytic lesio n is a co mmo n findin g w ith renal or th yroid m etastatic disease.
P.10 77
neurysmal
one Cyst
n eu rysmal bon e cysts (AB Cs) are the only lesion s I kno w of that are na med for th eir radio graphic a ppearance. Th ey are virtually alw ays an eu rysmal o r expansile (Figs. 41 .29, 41 .30 ). Ra rely, an ABC will present before it is expan sile, bu t t hat is un usual en ough no t t o w orry abo ut. Aneu rysmal bo ne cysts occu r prim arily in patients wh o are yo unger tha n a ge 30 , altho ugh occasion ally o ne w ill be encou ntered in o lder patients. I use bo ny expansion and age o f less than 3 0 years as fairly rigid gu idelin es and seldo m miss th e diagnosis o f ABC. They often h ave flu id flu id levels on CT o r MR (Fig. 41 .31 ), alth ough th is is a non specific
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findin g, as man y oth er lesions can have fluidfluid levels. A BCs a re, like gian t cell tu mors, so mewh at co ntroversial. There are apparently t wo types o f ABCs: a primary type an d a secondary type. The secondary type o ccurs in conj unction w ith an other lesio n or from trauma , w hereas a prim ary A BC h as n o kn own cau se o r associatio n with oth er lesio ns. Secon da ry A BCs h ave been s aid to occur w it h giant cell tum ors, osteo sarco mas, and almo st a ny ot her lesion . I h ave seen do zens of AB Cs an d have seen o nly a few in asso ciat io n w it h a noth er lesion. As to occurring after traum a, I do not un derstan d w hy th ey wo uld be agelimited if trau ma were causat ive. A lso , m alignant tu mors P.10 78 w ere once tho ught to occu r after traum a because of th e frequen t asso ciat io n o f a h ist ory of ant ec eden t traum a w ith m alignan t bo ne tu mors. This is not seriou sly c onsidered t oday an d is th ough t t o be coinciden tal. I suspect that AB Cs an d t raum a a re also coincidental, bu t t his is m ere speculation .
FIGU RE 41 .
. An eu rysmal B one Cyst. An expan sile lytic lesion is present
in the distal femu r in th is 24 -year-old patient who presents with pain . This is a fairly typical appearance for an an eu rysmal bo ne cyst .
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FIGU RE 41 .3 . An eu rysmal B one Cyst. A w ell-defin ed expansile lesion is seen in t he m idsh aft of th e ulna in a child w ho presented with pain in this region . This is a ch aracteristic appea rance fo r an aneurysm al bon e cyst.
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FIGU RE 41 .31. An eu rysmal B one Cyst. An axial T2WI th rou gh a th oracic vertebral body sh ow s an expansile lesion involving the posterior elements th at h as severa l fluidfluid levels (arro s). Th is is a typical a ppearance for an aneu rysmal bo ne cyst.
A BCs t ypically present because o f pain . They can o ccur an yw here in th e skeleto n, a nd t here is no location tha t w ould m ake them m ore highly ran ked in th e differen tial diagno sis. As with osteo blasto ma, they o ften o ccur in th e po sterior element s of the s pine.
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FIGU RE 41 .3 . Soli tary Bo ne Cyst. A w ell-defined lytic lesion is present in th e pro xim al hum erus in t his child wh o suffered a fract ure through th e lesio n. Th e location and central appearan ce, as well as t he age of th e patient, are characteristic for a solitary bon e cyst. A piece o f cortical bone h as broken o ff an d descended through the sero us fluid con tained w ith in th e lesio n and ca n be seen in the depen dent portion o f the lesion (arro ) as a fallen fragment sign. A fallen fragment sign is said to be path ogno mon ic fo r a unicam eral bon e cyst.
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Discriminators
1 . M ust be expansile. 2. Mu st be yo unger th an age 30 years.
olitary
one Cyst
one c st s or nicamera one c st s
olitary bon e cysts are a lso called sim p e
They are not necessarily un icam eral (one com partm en t), ho wever. Th is is the o nly lesion in FEGNOMA SHIC th at is alw ays cent ral in lo catio n. Many of th e ot her lesions may be central, but a solitary bon e cyst can be excluded if it is no t. It is o ne of the few lesio ns that does not occu r most com mon ly arou nd the kn ees. Two t hirds t o three fo urt hs o f these lesions occu r in th e pro xima l hum erus (Fig. 4 1.3 2) an d pro xima l femu r (Fig. 4 1.3 3). Applica tio n o f this rule alon e is n ot that h elpful, o r one third to one fo urt h o f lesion s w ould be missed. S olita ry bon e cysts are usually asympto matic u nless fractu red, w hich is a c omm on occurren ce. Even wh en path ologic fractu res occur, th ey rarely fo rm perio stit is. A classic radiograph ic finding for a solitary bo ne c yst is th e fallen fra gm ent sign (see Fig. 4 1.32 ). This occu rs wh en a piece of co rtex breaks off a fter a fracture in a so litary bone cyst, an d th e piec e of co rtical bon e sinks t o t he gravity-depen den t po rtion of t he lesio n. Th is has not been P.10 79 described in an y oth er lesion and in dicates a fluid-filled cyst ic lesion , rather than a lesio n filled w ith m atrix.
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FIGU RE 41 .33. Soli tary Bo ne Cyst. A w ell-defined lytic lesion, wh ich is cent ral in lo cation, is seen in th e pro ximal femu r in th is child. Th is is ch aracteristic for a solitary bo ne cyst .
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FIGU RE 41 .34. Soli tary Bo ne Cyst. A w ell-defined lytic lesion is seen in th e calcaneus abut tin g th e inferio r surface, which is typica l in location and appearance for a solit ary bo ne cyst. A solitary bon e cyst in th e calcaneus o ccurs almost exclu sively in th is lo cation and is not su bj ect t o pat hologic fractu re as readily as when o ne o ccurs in t he proxim al fem ur and hu meru s.
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FIGU RE 41 .3 . Bro
n T umor. A. An expan sile lytic lesion is seen in the
fifth metaca rpal (arro s), an d a second, smaller lytic lesion is seen in the proxim al port io n o f the fo urt h proxim al phalanx. B. This pa tien t is n oted to h ave subperiosteal bo ne resorptio n, best seen in th e radial a spect of the m iddle phalanges (arro s) as in distinct, interrupted cortex. Th is makes t he diagnosis of hyperparathyroidism with mu ltiple bro wn tum ors mo st likely.
S olita ry bon e cysts occur a lmo st exclusively in yo ung patients (un der age 30 ). A lt hough lon g bon es are mo st co mmo nly involved, solitary bon e cysts have been described in almo st every bo ne in the body. They begin at the ph yseal plate in lon g bon es an d grow in to the shaft o f the bone; th erefo re, they are n ot epiphyseal lesion s. They can, how ever, extend up int o an epiphysis after the plate clo ses, but th is is un usual. A fairly comm on location is in the calcan eus, w here they have a characteristic location adja cen t t o the inferior surfa ce of t he c alcan eus (Fig. 41 .34 ).
Discriminators
1 . M ust be cent ral. 2 . M ust be youn ger than age 3 0 yea rs. 3. No periost itis.
yperparathyroidism
ro
umors
ro n tumors of hyperparathyroidism (HPT) can ha ve alm ost any a ppearance, fro m a pu rely lytic lesion (Fig. 4 1.3 5) to a sclerotic process. Gen erally, w hen the pa tient 's HP T is trea ted, th e bro wn tum or un dergoes sclerosis an d w ill even tually disappear. If a bro wn tum or is going to be co nsidered in the differen tial diagno sis, addit io nal ra diographic fin din gs of HP T shou ld be seen. Su bperio steal bo ne resorptio n is pathogn omo nic for HPT an d sh ould be P.10 80 s earched fo r in the phalanges (part icu larly in th e radial aspect of th e m iddle ph alan ges) (Fig. 4 1.3 5), distal clavicles (resorptio n), medial aspect of th e proximal tibias, and sacro iliac jo in ts. I f the physes are open , th ey shou ld have a fra yed, ragged appearance, as in ricket s, ow ing to t he effect of paratho rmo ne. O steoporosis o r osteosclero sis might suggest that ren al osteodystrophy with s eco ndary HPT is presen t, bu t su bperiosteal res orption m ust be present , or brow n t umo r can be safely excluded fro m t he different ial.
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FIGU RE 41 .3 . Osteomyeliti s. A. A plain film o f the proximal h umerus in th is child with sho ulder pain reveals a well-defined lytic lesion in the medial m et aphysis. B. T2 WI o f the hum erus sho ws the lesion to have h igh signal an d an asso ciated joint effusion . The probable site o f con nectio n to the joint can be seen (arro ), w hich likely represents a drainin g abscess. Aspiration o f the joint fluid revealed pu s. This is a large focu s o f osteom yelitis or B rodie abscess.
M ost auth orities believe t hat brow n tum ors occu r most com mon ly in primary HP T; h owever, because we see so many more patients with secon dary HPT, more brow n t umo rs are seen in patien ts w it h seco ndary rath er than primary HPT.
Discriminator
M ust have o ther eviden ce of HPT.
Infection
Infection
U nfo rtu nately, th ere is n o reliable w ay radiographically to exclu de a fo cus of o steom yelit is. It has a protean radiographic appeara nce an d can o ccur at any loca tio n a nd in a pat ient of any age. It migh t o r might not be expansile, have a s clero tic or n onsclero tic border, o r have ass ocia ted periostitis (3). Therefore, infection will be in almo st every differential diagn osis o f a lytic lesion , w hich is a ccept able, as it is one of th e m ost comm on lesion s enco unt ered. S oft tissue findin gs su ch as o bliteration of adjacent fat planes are noto riously u nreliable a nd even misleading, because t umo rs and EG can do the same thing. Wh en osteom yelit is occurs n ear a j oint, if th e articu lar su rface is abu tted, invariably th e jo in t w ill be involved and sho w cartila ge loss, a n effu sio n (Fig.
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4 1.3 6), o r bo th. This finding is no t particula rly helpful, as an y lesion can cau se a n effu sio n, but it is occasion ally u seful in ru ling out ost eo myelitis w hen no effu sio n is present and the lesion abut s th e articu lar su rface. I f a bo ny sequest rum is present, osteom yelit is shou ld be strongly co nsidered (Fig. 4 1.37 ). As mention ed previously, th e on ly lesions described th at dem onst rate sequ estra are in fection , EG, lym ph oma , and fibro sarco ma, with o steoid o steoma som etim es m imickin g a sequestrum. Th e fin ding of a s equ estrum in osteo myelitis can be significant for trea tment in t hat it usu ally requires surgical rem oval ra ther than an tibiotics alo ne becau se a sequestru m is a focu s o f devitalized bone that does no t h ave a bloo d supply an d w ill not be effect ively treated with parent eral medication. For t his reaso n, CT is ro utinely recom mended w hen osteo myelitis is co nsidered.
Discriminator
No ne.
Chondroblastoma
Ch ondro blastomas are rare les ion s bu t are am ong the easiest lesion s for radiolo gists to deal w ith because they occur o nly in th e epiphyses (Fig. 41 .38) (a h andful of cases ha ve been reported in th e m et aphyses, but th is is rare) and t hey oc cur alm ost exclus ively in patients youn ger th an the age of 30 years. B etween 40 % and 60% demo nstrate calcification, so the absence o f calcificat ion is not helpfu l. Presen ce P.10 81 o f calcificat io n is helpful, as long as o ne is certain that it is n ot detritus or s equ estra from infect ion o r EG, bo th of wh ich can oc cur in th e epiphyses.
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FIGU RE 41 .3 . Osteomyeliti s. A. A lytic lesio n is present in t he proxim al h umerus, w hich has some associated perio stit is lat erally. B . CT scan th rou gh th is area reveals a lytic lesio n that con tain s a calcific density w ith in (arro ), w hich is a bo ny sequestrum. This is an area o f osteom yelitis with a bony sequestration.
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FIGU RE 41 .3 . C on dro blastoma. A plain film in this yo ung patien t show s a well-defined lytic lesio n in the greater tu berosity o f the hum erus. Biopsy sh owed this t o be a ch ondroblastom a.
The differential diagnosis o f a lytic lesio n in the epiphysis o f a pat ient un der 30 years o f age is simple: (1 ) infection (m ost comm on), (2) ch ondroblastom a, an d (3) giant cell tum or (w hich has its ow n diagno stic criteria, so it can usu ally be defin it ely ruled ou t o r in ). Th is is an old, classic different ial an d probably en compasses 98 % of epiph ys eal lesions. A caveat on epiph yseal lesions is to always consider the possibility of a s ubchon dral cyst or geode (Fig. 4 1.3 9), wh ich h as been described in fou r disease processes: (1) degenerat ive j oin t disease (mu st h ave jo int space narrow in g, s clero sis, and osteo phytes); (2) rh eumat oid arthritis; (3 ) calcium pyro phosph ate dihydra te crysta l dispo sition disease or pseu dogout ; and (4) avascu lar n ecrosis. The clinician must be certain n o joint patho lo gy that might indica te on e o f these processes is present, or an u nnecessary bio psy of a geode migh t be perform ed o n the basis of th e differential o f an epiphyseal lesio n. A pophyses are identical to epiphyses as far as the differential diagnosis o f lytic lesions, with the exception o f geo des, w hich o nly occu r adjacent to articu lar s urfaces. The carpal bo nes, the t arsal bo nes, a nd t he patella ha ve
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P.10 82 a tenden cy to behave like epiphyses in th eir differential diagnosis of lesion s. Therefo re, a lyt ic lesion in t hese areas h as a similar differential diagnos is as an epiphyseal lesion .
FIGU RE 41 .3 . Geo de. A large, well-defined lytic lesio n in the proximal h umerus is present, wh ich is asso ciat ed with marked degenerative disease o f the gleno hum eral jo in t. Wh en defin ite degenerative jo in t disease is pres en t an d asso ciat ed with a lytic lesio n, the lytic lesio n shou ld be co nsidered to be a geode. A biopsy was perfo rm ed, wh ich co nfirm ed th is to be a geode, or subch ondral cyst; ho wever, t he biopsy c ould h ave been avoided.
Discriminator
1 . M ust be you nger than age 30. 2. Mu st be epiphyseal.
Chondromy oid Fibroma

Ch ondro my oi d fibroma, like osteoblastom a, is such a rare lesion th at failure t o mention it is probably no t go in g to resu lt in m issing mo re t han one in a lifetime. Why include it, then? I recom mend not including it, but it is part o f the c lassic FE GNO MASHI C differential. If it is mention ed, at least kno w what it loo ks like. Basically, chon drom yxoid fibrom as resem ble NOFs. U nlike NOFs, ho wever, t hey can be s een in a patient of an y age. Ch ondromyxoid fibromas often ext end
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int o t he epiphyses (Fig. 41 .40 ), whereas NOFs rarely do. A lso , th ey can present w ith pa in, wh ich w ill no t o ccur with an NOF. Th ey have been repo rted to progress fro m a benign pro cess to an aggressive an d even m alignan t lesio n, but this is extremely rare. Altho ugh cho ndro myxo id fibro mas are cartila gino us lesions, c alcified cartilage matrix is virt ually n ever seen radiographically.
Discriminator
1 . M ention wh en an NOF is m en tioned. 2. No calcified mat rix.
FIGU RE 41 .4 . C on dro my o id Fibroma. A well-defined lytic lesio n in the distal tibia th at extends slightly into th e epiphysis is no ted o n t his an teropo sterior plain film. A non ossifyin g fibroma cou ld certainly ha ve this appearance; ho wever, t his un derwen t biopsy a nd w as fou nd t o be a ch ondromyxoid fibroma. Chon drom yxo id fibro mas o ft en extend in to the epiphysis, as in this exam ple, whereas n ono ssifying fibro mas usually do not .
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S MMA
Tha t, in essence, is the differen tial diagno sis for a ben ign cystic lesio n o f bone. I t is probably 9 8% accurate, w hich is good enou gh for m ost radiologists. To increase th e accu racy t o 99% , it wou ld be necessary to add many unco mmo n o r rare lesion s, an d th e wh ole pro cess w ould beco me t oo confusing fo r most radiolo gists to learn and P.10 83 a pply. I f there is a favorit e lesion th at is not on th is list, by all means add it. L ikew ise, if th e list is already too cum bersom e, forget abou t o steoblastoma and c hondrom yxoid fibrom a. I am un able to make it much simpler t han that an d still be reaso nably accurate.
TABLE 41.
Lesions in atients ears of Age
ounger T an
E osin ophilic granu lo ma An eurysm al bone cyst Non ossifyin g fibroma Cho ndro blast oma So litary bon e cyst
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TABLE 41.
Automatics
You nger than age 30 Infection Eos ino philic granulom a Older than age 40 Infection Metast atic disease and myelo ma
S ome of th e lesio ns I h ave purpo sefu lly om itt ed are intra osseous ganglio n, pseu dotum or of h emoph ilia, hem angioendot heliom a, o ssifying fibro ma, int raosseo us lipoma, glomu s tu mor, n eu ro fibrom a, plasma cell granu lo ma, and s chwan nom a. O thers cou ld be added t o t his list, of co urse, but are best left to t he pat hologistno t t he radio lo gist for th e diagnosis. There are several features th at are so mewh at usefu l in separatin g th e variou s lesions in FE GNOM ASHIC. For instan ce, if the patien t is yo unger th an the a ge of 3 0 years, be sure to co nsider E G c o ndro asto ma NO F so itar one c st, an d A C (Table 41.2 ). If th e patient is over 30 years of a ge, tho se five lesions can be excluded. Not e th at th is is no t a differential diagnosis for lesions in patients u nder age 3 0; it sim ply m eans these en tities shou ld not be m entioned in older pa tient s. Fo r those youn ger t han age 3 0, other lesio ns such as fibrou s dysplasia a nd infection must also be men tio ned. There are a few lytic lesion s th at h ave no go od discriminato rs oth er t han age a nd, t herefore, mus t be mention ed ro utinely. I call t hese lesio ns auto matics because one shou ld auto matically m ention them rega rdless of t he locat io n o r appearance of th e lesio n. Infectio n a nd E G mu st be mention ed for t hose younger th an age 3 0, whereas m et astatic disease an d infect io n m ust be included in an y differential in a patient older t han age 4 0 (Table 41 .3). These lesions have a pro tean radiograph ic appearan ce an d sho uld be m entioned not o nly in t he ben ign cystic differential but also fo r an a ggressive lesion.
TABLE 41.4 Lesions T at Ha e No eriostitis
ain or
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Fibro us dysplasia E ncho ndro ma Non ossifyin g fibroma So litary bon e cyst
TABLE 41.
In fection
Epip yseal Lesions
Giant cell t umo r Cho ndro blast oma Geode
I f periostitis or pain is present (assuming no trauma, wh ich can be a foolhardy a ssumption ), yo u can exclude fi ro s d sp as ia so itar on e c st NO F, an d en c on drom a (Table 41.4 ). If th e lesio n is epiphyseal, th e differential is infection ian t ce t m or c o ndro ast oma (an d do no t forget eodes) (Table 4 1.5 ). If th e patient is over 40 years of age, add m etastatic disease an d m e om a an d remove c ondro astom a from t he epiphyseal list.
The epiph yseal differen tial tends t o apply also to the tarsal bones (especially th e c alcan eus), the carpal bo nes, and t he pat ella. In th e calcaneu s, a unicameral bo ne cyst sho uld also be con sidered and has a ch aract erist ic appearan ce and loca tio n (see Fig. 4 1.3 4). Apo physes are epiphyseal equivalents and h ave t he sa me different ial as epiph ys es. The differen ce between an epiph ysis and an a pophysis is th at epiphyses co ntribut e to th e length of a bone, wh ereas a pophyses serve as ligamento us attachm ents.
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A classic different ial for benign, cys tic rib lesio ns is the mnem onic F AME, in w hich F = fi ro s d sp asia, A = A C, M = m et astatic diseases an d m e oma, a nd E enc ondroma and EG (Table 41 .6). If m ultiple lytic lesion s are presen t, F EEM HI is a useful m nemon ic of th e lesio ns in FEGNOM ASHIC that can be m ultiple: F = fi ro s d sp a sia, E en c on drom a, E E G, M = metast atic disease a nd m e om a, H perparat roidism (bro wn tum or), an d I infect ion (Table 41 .7). A few findings that just do no t seem to narro w the differen tial diagno sis are presence o r absence o f a s oft tissue mass, expan sio n o f the bone (except it must be present in an A BC), sclerotic or non sclerotic bo rder (except it mu st be n onsc lero tic in giant cell tum or), presence o r absence o f bony stru ts o r c ompartment s in the lesion, and size of th e lesio n. I f calc ified matrix is ident ified in a lesion , it is tempting t o n arrow the differen tial to eith er t he o steoid series P.10 84 o r the chon droid series of lesio ns, depen ding on th e character of t he m atrix. B e c arefu l of th is. Very few radio lo gists can reliably different iate chon droid from o steoid m atrix. Rou tin e calcificatio n of a lesion or debris, det ritus, or s equ estration s in osteom yelitis can mimic ch ondroid or o steoid calcification and be misleading. Th e o nly lesion tha t m ust exh ibit ca lcified m atrix is th e en chon drom a (except in t he ph alan ges). Ch ondroblastom as an d ost eoblast omas dem onst rate calcified m atrix abo ut half the tim e, an d cho ndro myxoid fibromas n ever h ave radiographically demo nstrable calcified m atrix.
TABLE 41.
Differential for
ib Lesions
Fibro us dysplasia An eurysm al bone cyst M et astatic disease an d m yeloma E ncho ndro ma and eo sin ophilic granu lo ma
TABLE 41.
Multiple Lesions
FEEMHI
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Fibro us dysplasia E osin ophilic granu lo ma E ncho ndro ma M et astatic disease an d m yeloma Hyperparathyro idism (bro wn tu mors) In fection
DIFFE ENTIAL DIAGNOSIS OF A SCLE OTIC LESION

M any lytic lesio ns spo ntan eously regress an d are no t u sually seen in patients o ver 3 0 yea rs of age. Wh en t hese lesio ns regress, they o ften fill in with new bo ne and h ave a sclerotic o r blastic a ppearance. Th erefo re, when a sclerotic focu s is identified in a 20- t o 4 0-year-o ld patien t, especially if it is an a sym ptoma tic, in ciden tal finding, the P.10 85 following lesions sho uld be c onsidered: NOF (Fig. 4 1.41 ), EG, aneurysm al bone c yst, solitary bo ne cyst, and cho ndro blasto ma. Several ot her lesion s sho uld be included that can also a ppear sclero tic: fibrou s dysplasia, osteoid osteom a, infection, bro wn tum or (h ealing), an d perh aps a gian t bo ne island (Fig. 4 1.4 2). I n any patient older than th e age o f 40 years, the nu mber one possibilit y sho uld be metast atic disease.
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FIGU RE 41 .41. Healin g No nossifyi ng Fibro ma. A plain film of th e knee in th is 25 -year-old patient reveals a sclerotic lesio n in th e pro ximal tibia, w hich is a h ea ling or reso lvin g n ono ssifying fibro ma.
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FIGU RE 41 .4 . Giant Bon e Island. A large sclerotic lesion is presen t in th e right supraacetabular region of t he iliu m (arro ), which represen ts a giant bone is land. The slightly feat hered margins of th e trabeculae, w hich blend in with the no rmal bo ne, and t he lon g axis of t he lesion being in t he direction of prim ary weigh t bearin g are cha racteristic for a bon e islan d.
EFE ENCES
1. David R, O ria R, Kum ar R, et al. Radio lo gic featu res o f eosinoph ilic granu lo ma of bon e. Pictorial ess ay. AJR Am J Roentgen ol 1 989 ;1 53 : 102 1 1 02 6.
2. Dah lin D. Gian t cell tum or of bo ne: highligh ts o f 40 7 cases. AJR Am J Ro entgeno l 19 85;14 4:955 96 0.
3. Go ld R, Hawkins R, Katz R. Pictorial essay. Bacterial o steomyelitis: findings o n plain radiograph y, CT, MR, and scin tigraphy. A JR A m J Ro entgeno l 19 91;15 7:365 37 0.
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Musculo Skeletal Radiology

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Ovid: Fundamentals of Diagnostic Radiology

Chapter 41 Benign Cystic Bone Lesions

Ovid: Fundamentals of Diagnostic Radiology

TABLE 41.1 Discriminators for Benign Lytic Bone LesionsMnemonic: FEGNOMASHIC

Fibrou s dyspla sia

1. Calcifica tio n present (except in phalanges) 2. Painless (no periostitis)

Eo sin ophilic granu lom a

You nger than age 30

Gian t cell tu mor

Nono ssifyin g fibro ma

1. Youn ger than age 3 0 2. Painless (no periostitis) 3. Cortically based

M en tioned when aneu rysmal bo ne

Ovid: Fundamentals of Diagnostic Radiology

Metast atic disea ses and myelo ma

Older than age 40

1. E xpan sile 2. Youn ger than age 3 0

So litary bone cyst

1. Central 2. Youn ger than age 3 0

Hyperparath yroidism (brow n t umo r)

M ust have o ther evidence of h yperpa rath yroidism

1. Youn ger than age 3 0 2. E piphyseal

Chon drom yxo id

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

McCune Albrig t Syndrome

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Enchondroma and Eosinophilic Granuloma

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

FIGU RE 41 .1 . Eosin op il ic G ran ulo ma

EG . A well-defined lytic lesion

is seen involving the midfemu r in th is 20 -year-old patient. Biopsy sh owed th is to be E G.

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

FIGU RE 41 .14. Eosin op il ic G ran ulo ma

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

ch aracteristics of a gian t cell tum or.

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

. Non ossifyin g Fibroma. A well-defined, expan sile lytic

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Ovid: Fundamentals of Diagnostic Radiology

Metastatic Disease and Myeloma

Ovid: Fundamentals of Diagnostic Radiology

. Metastatic Disease. A well-defined lytic lesio n is seen in

Ovid: Fundamentals of Diagnostic Radiology

. Mul tiple Myeloma. A. A diffu se permeative pattern is