Osteoid Osteoma & Osteoblastomas

Albert Leung, HMS IIIGillian Lieberman, M.D.

BIDMC Radiology ClerkshipFebruary 22, 2010

OverviewIndex PatientPeriosteal ReactionsDifferential DiagnosisPrinciples of Osteoid OsteomasBone AnatomyMenu of TestsRadiologic ImagesTreatments

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Learning ObjectivesRecognize the clinical presentation of osteoid osteomaUnderstand the differential diagnosis for this clinical presentationReview the principles of osteoid osteoma and its classification within the context of bone anatomyLearn the menu of appropriate radiologic imaging studies and the indicationsStudy the radiologic presentations and recognize classic findingsKnow how to medically and surgically manage osteoidosteomas

Index Patient: Presenting HistoryChief Complaint

Right wrist painHistory

18 yr old R hand dominant male with persistent R wrist pain for 4 monthsPain is worse at night, waking patient from his sleepPain relief with ibuprofenNo history of trauma or repetitive motions with hand

Review of SystemsDenies numbness/tingling, fevers, chills, night sweats

Past, Family, Social HistoriesNon‐significant

Index Patient: Physical ExamPalpable nodule (3.5 x 3 cm) over the radial aspect of the R distal radius with focal tenderness and swellingNo erythema, discoloring, ecchymosis, or drainageFull range of motion of R shoulder, elbow, wrist, and fingers; no strength deficitsNormal sensation in all distributions+2 pulses bilaterallyNo palpable axillary lymph nodes

Our Patient: Radiograph of cortical osteoid osteoma

in R distal radius

Fusiform

cortical thickening

Ovoid sclerotic lesion with

central radiolucency1.1 x 1.3 cm

AP Radiograph

Image from BIDMC PACS

Our Patient: R distal radius osteoid osteoma

on CT Imaging

Focal areas of radiolucency

surrounded by sclerotic

regions that occupy the cortex and invade the medulla

Axial C‐

CT


Our Patient: Periosteal reaction on CT Imaging

Periosteal reaction: elevated cortex

from bony expansion


Coronal C- CT of R distal radius

Periosteal Reaction: Non‐aggressive Types

Rana RS, Wu JS, and Eisenberg RL. “Periosteal Reaction.” American Journal of Roentgenology. Oct 2009. 193(4): W259-272.

Periosteal Reaction: Aggressive Types

Rana RS, Wu JS, and Eisenberg RL. “Periosteal Reaction.” American Journal of Roentgenology. Oct 2009. 193(4): W259-272.

Partial Differential Diagnosis for Wrist Pain/Bone Mass

MassesBenign Neoplasms

Osteoid OsteomaOsteoblastomaOsteomaEnostosis (bone island)

Ganglion cystInfection

Brodie abscess (subacuteosteomyelitis)Osteomyelitis

InflammationTenosynovitisRheumatoid arthritis

Degenerative ConditionsOsteoarthritisStress fracture

NeurologicalCarpal tunnel syndrome

Our Patient’s Differential Diagnosis

Unlikely given patient’s history and presentation

Distinguishing Characteristics on Radiologic Imaging

MassesBenign Neoplasms

Osteoid Osteoma ‐ < 2 cm; radiolucent nidus with surrounding sclerosis; may spontaneously regressOsteoblastoma – large (> 2 cm); no regression in size over timeOsteoma – cold bone scan; absent periosteal reaction & radiolucent nidusEnostosis – cold bone scan; thorny radiations; low signal on T2w MRI

InfectionBrodie abscess – cortical destruction with a linear, serpentine tract extending away from abscess

Degenerative ConditionsStress fracture – linear radiolucency perpendicular, rather than parallel, to cortex

Background: Osteoid Osteoma

DemographicsMajority of patients are young (< 35 yr old)Males > females (2‐3:1)

Benign skeletal neoplasmConsists of a spherical nidus of osteoid tissue & bony trabeculae superimposed on highly vascularized connective tissueMay initially appear on radiograph as a small sclerotic bone island within a circular lucencyNO malignant potential

SizeRanges from 0.5‐2 cm (avg 1.5 cm)No growth progressionMay regress spontaneously over years

Background: Osteoid

Osteoma (continued)

MechanismUnknown etiologyNidus consists of highly vascular osteoblastic proliferation, surrounded by a secondary zone of sclerosisElevated prostaglandin E2 levels in nidus responsible for bone pain & vasodilationTumor infarction may be involved during cases of spontaneous regression

LocationsTypically affects the appendicular skeleton

Metaphysis/diaphysis of long bones: 70%Femur/tibia: 55%Phalanges of hands/feet: 20%Spine: 10% ‐ Causes painful scoliosis with concavity towards the lesionPosterior elements: 90%Extremely rare in skull & facial bones

Osteoid

osteoma

vs Osteoblastoma

Osteoid

osteoma OsteoblastomaUsually < 2 cm diameterPresents with intense pain, often sharply localized and worse at nightPain characteristically relieved by aspirin/NSAIDsNon‐aggressive behaviorVariable locations: femur, tibia, fibula, humerus, hands/feet, vertebraeNeural staining reveals axons throughout the tumor (may explain bone pain)

Usually > 2cm diameterLack of intense painAggressive behaviorTypically in the vertebrae or major bones of the lower extremityOften affects the spongiosaof the boneAbsence of neural axons upon staining

Review of Bone Anatomy

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tsagalis.net/bones/anatomy.jpg

Classification of Osteoid

OsteomasCortical

Most common location (80%)Radiolucent nidus seen within the bone cortex and surrounded by fusiform cortical thickening/laminated periosteal formation

CancellousIntramedullary lesion; mild reactive sclerosis & difficult to identify, significantly delaying the diagnosisCommon sites: femoral neck, posterior spine, hands & feet

IntraarticularJoint effusion or synovitis

SubperiostealRound mass adjacent to cortexAbsent periosteal reactionVery rare

Gitelis

S, Wilkins R, and Conrad EU, III. “Benign Bone Tumors.”

Journal of Bone & Joint Surgery (Am). 1995; 77: 1756‐1782.

Osteoid Osteomas

Classic Clinical PresentationFocal bone pain that worsens at night & increases with activityPain is relieved by aspirin within 30 minutes (75% of cases)Local swelling and point tendernessExacerbation of pain with alcohol

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http://paddyk.files.wordpress.com/2009/11/5-aspirin.jpg

Menu of Radiologic TestsPlain Radiographs*Computed Tomography*MRIUltrasonographyNuclear Imaging*Angiography

* Usually used for evaluating osteoid

osteomas

Plain RadiographsMain imaging techniqueDiagnostic in 75% of casesClassic Appearance

Well‐defined radiolucent nidus with surrounding zone of sclerosisCentral nidus is typically < 1.5 cm in diameter

Companion Patient #1: Radiograph of L tibial

osteoid

osteoma

21 yr old male with 4 months of atraumatic left calf pain, worse at night; osteoid osteoma eventually removed by percutaneous RF ablation

Periosteal reaction with cortical thickening in posterior tibia

Sagittal Radiograph


CT ImagingBest imaging tool for osteoid osteomaStudy of choice for localizing the nidusGood at evaluating complex anatomy (e.g. – spinal pedicles, laminae, femoral neck, hands, feet)

Companion Patient #1: L tibial osteoid

osteoma

on CT Imaging

Sagittal C- CTAxial C- CT

Mature periosteal reaction and thickening with central radiolucency

Image from BIDMC PACS Image from BIDMC PACS

Back To Our Index Patient: R distal radius osteoid

osteoma

on CT

Central radiolucent nidus

within a sclerotic zone

Osteoid

osteoma

eventually removed by

open surgical curettage


Sagittal C- CT

MRIAdvantages

Easily detects edema in the soft tissues & bone marrowBetter at diagnosing cancellous/intramedullary osteoidosteomasGood for evaluating joint effusion/synovitis for intraarticular lesions

AppearanceT1w: nidus is isointense to muscleT2w: radiolucent areas of nidus with intermediate to high signal intensity

Companion Patient #2: Radiograph of L tibial

osteoid

osteoma

18 yr old male with nocturnal focal pain in L proximal tibia for 2 years; relief with NSAIDs; osteoid osteoma eventually removed by percutaneous RF ablation

Non-aggressive thick periosteal reaction of the L medial tibial metaphysis

AP Radiograph



osteoma

on Axial CT

5 mm radiolucent nidus

Thick periosteal reaction (10 mm)

Axial C- CT



osteoma

on Coronal CT

Oval-shaped radiolucent lesion within the medial tibial cortexDimensions: 4 x 4 x 18 mm

Coronal C- CT



osteoma

on MRI STIR

Edema appears as high signal intensity within the bone marrow

Coronal C- MRI STIR



osteoma

on MRI T1w

Axial C- MRI T1wCoronal C- MRI T1w

Low signal intensity edema in soft tissue structures surrounding the cortical lesion

Image from BIDMC PACS Image from BIDMC PACS

Nuclear Imaging: Bone ScanUses technetium‐99m phosphonatesTumor site demonstrates focal area of intense uptakeDouble density sign: small focus of increased activity (nidus) surrounded by a larger area of less intense activity (reactive sclerosis)Tracer is excreted through kidneys and urinary bladder

Companion Patient #3: Sacrococcygeal osteoid

osteoma

on CT Imaging

19 yr old male with 1 yr hx of pain at coccyx, worse at night pain & relieved with ibuprofen; osteoid osteoma eventually removed by percutaneous RF ablation

Small curvilinear lucency (6 mm) with focal sclerosis in adjacent posterior cortex


Axial C- CT

Companion Patient #3: CT guided biopsy of a sacrococcygeal

osteoid

osteoma

CT guided needle core biopsy of the radiolucent nidus


Axial C- CT

Companion Patient #3: Coronal bone scan of a sacrococcygeal

osteoid

osteoma

Small intense focus of tracer uptake in the coccyx with double density sign

Coronal Bone Scan


Companion Patient #3: Sagittal

bone scan of a sacrococcygeal

osteoid

osteoma

Abnormally increased focal area of intense tracer uptake


Sagittal Bone Scan

UltrasonographyMay be used for guidance of percutaneous biopsiesDoppler U/S detects the highly vascular nidusUseful for detecting intra‐articular osteoid osteomas

AngiographyCentral nidus is highly vascularIntense circumscribed blush that develops during the early arterial phase and persists into venous phase is diagnosticAngiography is useful for distinguishing osteoid osteomafrom a Brodie abscess

TreatmentsMedical Management

NSAIDSSurgical Management

Open surgical curettageCT guided

Percutaneous radio‐frequency (RF) ablation, laser, ethanol, or thermocoagulation therapy

AnesthesiaGeneral or spinal

SummaryOsteoid osteoma (OO) is a latent benign bone tumor that classically presents as focal pain that is worse at night and relieved by NSAIDsCortical osteoid osteomas are often associated with non‐aggressive periosteal reactionsOOs and osteoblastomas are histologically similar but differ in size, pain intensity, location, aggressiveness, and neural staining patternsOOs are classified by their relative position to the bone: cortical, cancellous, intraarticular, and subperiosteal

Summary ContinuedOOs have a classic appearance on plain radiographs and CT imaging: central radiolucent nidus with surrounding zone of sclerosisCT imaging is the best imaging tool for OOs and is the study of choice for localizing the nidusMRI is useful for detecting soft tissue/bone marrow edema and intramedullary OOsNuclear bone scans may localize the tumor and demonstrate focal areas of intense tracer uptake; double density sign is occasionally seenDoppler U/S can detect the highly vascular nidusAngiography may distinguish OOs from a Brodie abscess: intense blush that persists into venous phase is diagnostic of OO

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Gitelis

S, Wilkins R, and Conrad EU, III. “Benign Bone Tumors.”

Journal of Bone & Joint Surgery (Am ed). 1995;77:1756‐

1782.

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F, Ciabattoni

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Dec 1996; 17(12): 1006‐1015.

Rana

RS, Wu JS, and Eisenberg RL. “Periosteal Reaction.”

American Journal of Roentgenology. Oct 2009. 193(4):W259‐

272.

AcknowledgementsDr. Gillian Lieberman

Dr. Jim Wu

Dr. Erica Gupta

Dr. Jay Catena

Special Thanks To:Dr. Corrie Yablon

Dr. Aarti Sekhar

Maria Levantakis

Patients

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Osteoid Osteoma & Osteoblastomas