- 1.Bone Tumor & Tumor-like lesions Sun Yat-sen Memorial
Hospital SYSU
2. Bone Tumor & Tumor like lesions
- Aims of Imaging modalities
- Classification of Bone Tumor
- Steps of Diagnostic Analysis
- Common bone tumor & tumor like lesions
3. When presented with a lesion in a bone, three important
questions require to be answered:
- Is the lesion neoplastic or infective ?
- Is it benign or malignant ?
- Is it a primary or secondary neoplasm ?
yes 4. 1.Aims of Imaging modalities
- normal variant? d eformation
Imaging Anatomy X-ray Signs Clinical Data 5. 2. Classification
of Bone Tumor Tumor-like lesionBone cyst,Fibrous dysplasia Primary
BoneTumor Tumor fromBone Tissue benign Osteochondroma, Giant cell
tumor, Osteoma, Chondroma, Chondroblastoma malignant Osteosarcoma,
Chondrosarcoma, Fibrosarcoma Tumor fromBoneAffiliatedTissue benign
Osteoangioma, Odontogenic tumor (exp. Adamantinoma) malignant
Ewing's sarcoma, Reticulum cell sarcoma of bone, Notochordoma,
Myeloma Metastatic Tumor Carcinoma, Sarcoma, Neuroblastoma
Carcinoma, Sarcoma, Neuroblastoma 6. WHOClassification ofBone Tumor
& Tumor like lesions 2002 1 Cartilaginous tumor 2 Osteogenic
tumor 3 Fibrogenic tumor 4 Fibrohistiocytic tumor 5 Ewing
sarcoma/Primitive neuroectodermal tumor 6 Blood-cell forming tissue
tumor 7 Giant cell tumor 8 Notochord tumor 9 Vascular tumors10
Myogenic tumor 11 Lipogenic tumor 12 Neural tumor 13 Confounding
tumor 14 Other tumor 15 Arthropathy synovial chondromatosis16 Bone
and soft tissue tumor related c ongenital or hereditary syndrome 7.
3,Steps of Diagnostic Analysis---clinical data
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- Skeleton all over the body
8.
exogenousosteochondroma 3,Steps of Diagnostic
Analysis---clinical data 9.
- Age: the distribution of lesion has a relative regularity
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- Infant: neuroblastoma metastasis
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- Childhood, adolescent: Ewing's sarcoma
3,Steps of Diagnostic Analysis---clinical data 10. 3,Steps of
Diagnostic Analysis---clinical data 11.
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- Benign: painful, tenderness is not obvious, general state is
good
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- Malignant: painful, obvious tenderness, quick development,
short course
3,Steps of Diagnostic Analysis---clinical data 12.
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- Benign: blood, urine, marrow are NORMAL
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- Osteosarcoma: Alkali Phosphatase (ALP)
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- metastatic tumor&myeloma: secondary anemia and blood
calcium
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- Myeloma :Bence-Jones protein in urine
3,Steps of Diagnostic Analysis---clinical data 13.
- benign or malignant ->histology
3,Steps of Diagnostic Analysis---imaging data chondroblastoma
14.
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- Giant cell tumor: ending of long bone
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- Osteosarcoma: metaphysis of long bone
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- Myeloma, metastasis tumor: flat bone, irregular bone
3,Steps of Diagnostic Analysis---imaging data 15.
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- Primary tumor: single frequent
Multiple Myeloma Osteogenic metastasis Giant cell tumor 3,Steps
of Diagnostic Analysis---imaging data 16.
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- Benign: expanding, pressure destruction, neighbouring cortex
iscontinuous and integrated
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- Malignant: invasive bone destruction, ill-defined margin,
moth-eaten, spot like bone destruction, mass invading to the soft
tissue, periostealreactive hyperplasia andCodman triangle
3,Steps of Diagnostic Analysis---imaging data benign malignant
17.
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- D.HyperostosisandOsteosclerosis
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- Tumor bone: ground-glass, spindle like, patchy
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- Tumor cartilage: spot, c urve,ring shape
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- Osteogenesis reactionin Neighbouring bone tissue---benign or
low grade malignant tumor
Normal periosteal ossification Tumorcell ossification 3,Steps of
Diagnostic Analysis---imaging data 18. Differential diagnosis
between Benign and Malignant Bone Tumor items Benign Malignant
growth Slow, compressing neightbouring tissue, no metastasis Quick,
neightbouring tissue invading, metastasis Signs of the Lesion
Expansive, well-defined, thin but continue tissueInvading,
ill-defined, irregular destruction of cortex, tumor bone formation
Periosteal reaction most of time (-), can be shown after
pathological fracture, but no bony destruction Different forms of
periosteal reaction, can be destructed by the tumor Surrounding
soft tissue No mass, well-defined if there is Mass formation,
indistinct demarcation with surrounding tissue 19. Principles in
diagnosing Bone Tumors
- Jaffe 3-combined Principles(clinic, radiology, pathology
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- Clinical manifestation (history, symptoms, physical signs),
laboratory tests (routine test, biochemistry )
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- Imaging examination (X-ray, CT, MRI, ultra-sound,nuclear )
-
- Pathology test and other special test (immunology, infrared
ray, flourescence)
20. Osteosarcoma
- Most frequent, primary, malignant bone tumor
- Origin from primitive osteogenic tissue, to form tumor boneand
bone like tissue .
- 3 types according to the X-ray:Osteosclerotic,Osteolytic, Mixed
type
- Age: frequent in teenagers (10-20y), M F
- Favourite Site:metaphysis, surrounding the knee joint (50%),
especially the superior part of humerus
- Clinic:progressive pain, functional disturbance, venous
engorgement
- Laboratory: Alkali Phosphatase (ALP)
- Develop fast, pulmonary metastasis is common
21. Radiological A ppearance
- Periosteal proliferation and periosteal new bone destruction---
Codman triangle
- Soft tissue mass and bone tumor inside ( ivory/marble, cotton,
spiculate, radial, sunburst )
Geographic bone destruction Moth-eatenbone destruction
Permeativebone destruction 22. OsteoscleroticOsteosarcoma
- Mainly with tumor bone formation
- Intact cortex in early stage, cortex destruction in advance
stage.
- Obvious periosteal reaction
- Tumor bone in soft tissue
23. Osteosarcoma in superior part of tibia ( Osteosclerotictype,
ivory tumor bone), obvious tumor bone formation which invading into
soft tissue Osteosclerotic Osteosarcoma 24.
Osteosclerotic Osteosarcoma in Fibula 25. Cotton like tumor
bone, Codman triangle Osteosclerotic Osteosarcoma in Fibula 26.
Osteosclerotic o steosarcoma ininferior femur, obvious tumor bone
formation () and big mass in soft tissue (M) , cortex destruction
and become thinner () OsteoscleroticOsteosarcoma M M 27.
OsteolyticOsteosarcoma
- Periosteal proliferationCodmantriangle ()
- Tumor bone is not common in soft tissue
- Extensive bone destruction with pathologic fracture
28. Osteolytico steosarcoma indistal metaphysis of the femur,
apparentOsteolyticdestruction is seen, associated with soft tissue
mass and Codmantriangle () OsteolyticOsteosarcoma 29. Osteosarcoma
Osteolyticdestructionin sup erior tebia, soft tissue mass
formation, with Codmantriangle () 30. OsteolyticO steosarcoma
inInferior Femur
31.
- Combining the appearance of osteosclerotic type &
osteolytic type
Mixed osteosarcoma O steosarcoma indiaphysis of femur, bone
cortex destruction, thickness decrease and defect of the cortex,
mass formation in soft tissue, flocculent tumor bone inside the
mass 32. Osteosarcoma in superior tibia, obvious bone destruction
and tumor bone formation,periosteum proliferation. Codmantriangle
() Mixed Osteosarcoma 33. Mixed Osteosarcoma 34. Osteosarcoma
- Acute onset, frequent inmetaphysis of tubular bone, tendency of
extensive spreading. Osteoporosis and small quantity of bone
destruction in acute stage,reactive hyperostosis surround the
lesion,periosteal proliferation and sometimes soft tissue mass
.
D.D. 35. Giant Cell Tumor
- Origin from the mesenchyma of connective tissue of bone,its
mainly composed of mononuclear stromal cell and multinucleated
giant cell
- Anaplastic tumor, can divided into benign, active growing and
malignant one.
- Common in 20 40y 80 >20y), knee jointbone and distal end of
radius are favorite sites.
- Clinical symptoms: local pain, varicose veins of skin
- Frequent in boneextremities
36.
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- Site: boneextremities, often reach to the subchondral
region
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- Eccentric, osteolytic, expansive bone destruction, well-defined
, with finebone ridge inside, nocalcification or ossification
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- No reactivehyperostosis nearby, no periosteal reaction if there
is no fracture happened
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- No soft tissue mass generally, spot or moth-eaten bone
destruction in the distal edge of tumor
Giant Cell Tumor 37. Giant cell tumor of fibular 38. Giant cell
tumor of radius Expansive bone destruction in the distal end of
L-radius, reach to the subchondral region of the joint but the bone
surface is still intact, multilocular, well-defined, no
sclerosis,no calcification or ossification inside 39. Giant cell
tumor Expansive bone destruction in distal end of R-radius (), with
in complete bone shell, soft tissue formation extend outside the
bone shell. 40. Bone cyst
- Frequent in long bone, especially femur and upperhumerus
- Originate frommetaphysis, but stay in the diaphysis with
growing, develop along the longitudinal axis of bone shaft
- Asymptomatic, discover by pathologic fracture
41. RadiologicalAppearances
- Expansive,ovoid-shape bone destructiondevelop along the
longitudinal axis of bone shaft, sometimes multi-capsular,
symmetrical thinner of the cortex, no periosteal reaction
- After pathologic fracture, thefracture fragment fall into
thecapsular space ( Falling Fragment Sign). Then the bone cyst can
be heal, the cyst reduced orself-limited
42. (A)Bone cyst of R- Humerus ,develop longitudinally, slight
expansive: (B) Complicate with pathologic fracture; (C): Recheck
after fracture, density increase inside the cyst. A B C 43. Bone
cyst of femur Radiolucent,develop longitudinally, well-defined
margin, no sclerosis.CT show uniform low density inside the cyst.
44. Bone cyst of humerus
45. BoneMetastases
- Most frequent malignant bone tumor, multiple.
- Primary tumor:breast cancer, lung cancer, thyroid cancer,
prostatic carcinoma, renal carcinoma, nasopharyngeal carcinoma
(NPC).
- Route of metastasis: hematogenous
- Frequent site: spongy bone with red marrow
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- vertebral body, rib, superior femur, iliac bone, cranial bones,
humerus
- Seldom involve the distal part of knee and elbow joint.
46. Osteolytic Bone Metastases Nasopharyngeal
Carcinomapatient,osteolytic bone destruction in R- humerus and
clavicle, unclear margin, no ossification or calcification.
Clavicle mass formation M M 47. Osteolytic Bone MetastasesRound
destruction area incranial bones, ill-defined margin, no sclerosis
48. Bone Metastases 49. Prostatic carcinoma. Increase density in
pelvis, lumbosacral vertebrae and bilateral femur . Osteoblstic
Bone Metastases 50. Uniform increased density of L 2 , L 4 , L
5vertebra, sacral vertebrae and iliac bone. Osteoblstic Bone
Metastases 51. Mixed Bone Metastases Small and large patchy bone
destruction area as well as increased density area in pelvis,
lumbosacral vertebrae and bilateral femur. 52. Questions
- How to differentiate benign or malignant bone tumor
- How manytypes of osteosarcoma there are by X-ray signs? What
are they? What is the radiological appearances of them?
- What is the radiological appearance of Giant cell tumor?
- What is the radiological appearances of bone cyst?
53.
