Radiological presentation and staging of MSK tumours

Nor Azman MZ

Radiological presentation

• Plain radiograph very important for bone tumours

• For soft tissue tumour radiographs are useful to identify osseous or mineralising lesions and what is the tumour effect on bone

• MRI is superior in the assessment of a soft tissue mass.

RADIOGRAPHIC EVALUATION

1. What is the age?2. Where is the lesion? location3. What is the lesion doing to the bone? Pattern of

destruction4. How is the bone responding? Periosteal Reaction5. What is in the lesion? Matrix6. How many lesions?

What is the age?

Where is the lesion? location

Location

Location can provides clues to its identity– Medullary

– Medullary eccenteric

– Cortical

– Juxtacortical

LOCATION BENIGN BONE TUMOR

JUXTACORTICAL TUMOR

Location

• Epiphyseal : PGCAT– PVNS– GCT– Chondroblastoma– ABC– Tuberculous & other infections

• Metaphyseal– NOF, UBC, OSC, CSC

• Diaphyseal– ES, EG, Osteoid Osteoma– metastasis

OSTEOID OSTEOMAOSTEOCHONDROMA

Location : Juxtacortical

RADIOGRAPHIC EVALUATION

1. What is the age?2. Where is the lesion? location3. What is the lesion doing to the bone? Pattern of

destruction4. How is the bone responding? Periosteal Reaction5. What is in the lesion? Matrix6. How many lesions?

What is the lesion doing to the bone?

• Pattern of destruction– Geographic

– Moth-eaten

– Permeative

Geographic Bone Destruction

• Destructive lesion with sharply defined border

• Implies a less-aggressive, more slow-growing, benign process

• Narrow transition zone

e.g

– Non-ossifying fibroma

– Chondromyxoid fibroma

– Eosinophilic granuloma

Geographic

Moth-eaten Appearance• Areas of destruction with ragged borders

• Implies more rapid growth

• Probably a malignancy

e.g

Myeloma

Metastasis

Lymphoma

Ewing sarcoma

Permeative Pattern• Ill-defined lesion with multiple

“worm-holes”

• Spreads through marrow space

• Wide transition zone

• Implies an aggressive malignancy

– Round-cell lesions

Leukemia

Lymphoma, leukemia Ewing’s SarcomaMyelomaOsteomyelitisNeuroblastoma

Less malignant More malignant

RADIOGRAPHIC EVALUATION

1. What is the age?2. Where is the lesion? location3. What is the lesion doing to the bone? Pattern of

destruction4. How is the bone responding? Periosteal Reaction5. What is in the lesion? Matrix6. How many lesions?

How is the bone responding ?

Periosteal reaction– Benign

• None

• Solid

– Malignant

• Lamellated

• Sunburst

• Codman’s triangle

SUNBURST

CODMANS

LAMELLATED/ONION PEEL

Periosteal Reaction

SOLID

Less malignant More malignant

RADIOGRAPHIC EVALUATION

1. What is the age?2. Where is the lesion? location3. What is the lesion doing to the bone? Pattern of

destruction4. How is the bone responding? Periosteal Reaction5. What is in the lesion? Matrix6. How many lesions?

WHAT IS THE LESION ?MATRIX

• Osteoblastic– Fluffy, cotton-like or cloud-

like densitiesOsteosarcoma

• Cartilaginous– Comma-shaped, punctate,

annular, popcorn-likeEnchondroma, chondrosarcoma, chondromyxoid fibroma

• Ground glass appearance– Fibrous dysplasia

RADIOGRAPHIC EVALUATION

1. What is the age?2. Where is the lesion? location3. What is the lesion doing to the bone? Pattern of

destruction4. How is the bone responding? Periosteal Reaction5. What is in the lesion? Matrix6. How many lesions?

How many lesions?

• Multiple bony lesion

DD for holes in the bone

• FOGMACHINE– Fibrous dysplasia

– Osteoid osteoma, osteoblastoma, osteosarcoma

– Giant cell tumour

– Myeloma

– Aneurysmal Bone Cyst, adamantimoma

– Chondromyxoid fibroma, chondroblastoma, chondrosarcoma

– Hystiocytosis

– Infection

– Nonossifying fibroma

– Enchondroma, Ewing sarcoma

Staging

Staging

Purpose

• Determine tumor type

• Determine prognosis

• Guide treatment

• Compare results between study groups

• Delineate extent of local and distant disease

Staging Studies

• Plain Radiograph

• MRI

• CT scan

• Chest CT

• Bone Scan

Plain Radiographs

Evaluate:

• Rate of tumor growth

• Tumor interaction with surrounding non-neoplastic tissue

• Internal composition of tumor

MRI

Visualize entire bone and adjacent joint

Best test for intraosseous extent and soft tissue extent

Identify skip metastases

Tumor proximity to neurovascular structures

Occasionally helpful in diagnosis of bone or soft

tissue tumors (experienced radiologist)

CT

• Good for evaluating cortical details and destruction

• Subtle cortical erosions (endosteal;periosteal)

• not detectable on plain x-ray or MRI

• Subtle calcifications / ossification (Visible tumor

matrix mineralization)

Chest CT

• Presence of metastatic disease

Bone Scan

• Whole body bone scan

• Sites of bony mets

• Active lesion??

Staging

• Benign Staging System

• Stage 1: Latent

– Grow slowly with growth of individual and

then stop; tendency to heal spontaneously

(ex. NOF; UBC)

• Stage 2: ActiveProgressive growth

• Stage 3: Aggressive

Grading

G1 G2

LG Chondrosarcoma High Grade Chondrosarcoma

Secondary Chondrosarc Conventional

Osteosarcoma

Parosteal Osteosarcoma Ewing’s

Sarcoma/PNET

Adamantinoma MFH

Angiosarcoma

Staging

Soft Tissue Sarcomas

• Important Prognostic Characteristics

– Tumor Size (>5cm, worse prognosis)

– Tumor Depth (Deep, worse prognosis)

–Grade (High grade, worse prognosis)

–Presence of Mets

Grading

Soft Tissue Sarcomas (Biological Behavior)

• Tumors that are definitionally high grade– Ewing’s Sarcoma

– PNET

– Rhabdomyosarcoma

– Angiosarcoma

– Pleomorphic Liposarcoma

– Soft Tissue Osteosarcoma

– Mesenchymal Chondrosarcoma

Grading

Soft Tissue Sarcomas (Biological Behavior)

– Tumors that are definitionally low grade

• Well Differentiated Liposarcoma

• Dermatofibrosarcoma Protuberans

• Infantile Fibrosarcoma

• Angiomatoid MFH

Evaluating response to chemoRx