schreibman - bone tumors in 1 simple chart
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Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info
page 1 of 31Bone Tumors:In 1 Simple Chart
Ken L Schreibman, PhD/MD 2010 schreibman.info
Bone Tumors
In 1 Simple Chart
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TheChart
Ken L Schreibman, PhD/MD 2010 schreibman.info
NON-aggressiveBlastic
Chondroid:Enchondroma
Osseous:Osteoid OsteomaOsteoblastoma
Osseous & Chondroid:
Osteochondroma
NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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WhyBoneTumorsareIntimidatingBone Tumors are Rare
Dont see enough to be confidentMany types of Bone Tumors
Have Confusing (similar) NamesOsteosarcomaOsteochondromaOccur in children
Essentially only 2bone malignanciesoccur in children
http://seer.cancer.gov/statfacts/html/bones.html
0%
5%
10%
15%
20%
25%
30%
85
Incidence Bone Tumorsby age
Bone Tumors: by Age
20
Bone Tumors: by Age
4020
Ken L Schreibman, PhD/MD 2010 schreibman.info
Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors
1) Patients Age40Multiple Myeloma, Metastases
Ken L Schreibman, PhD/MD 2010 schreibman.info
Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors
1) Patients Age2) Aggressive vs Non-aggressive(NOT Malignantvs Benign)
Zone of TransitionPeriosteal Reaction
Not everything that looks aggressive is malignant(e.g. osteomyelitis)
Aggressive Non-aggressive
Describing
Ken L Schreibman, PhD/MD 2010 schreibman.info
2 Cases: Destructive lesions distal fibulaBenign?
Malignant?Cant tell with radiographs
Thus we use the termAggressive
http://seer.cancer.gov/statfacts/html/bones.htmlhttp://seer.cancer.gov/statfacts/html/bones.html -
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Ken L Schreibman, PhD/MD 2010 schreibman.info
AggressiveAggressive vs Non-aggressiveZone of Transition
Periosteal Reactions
Ken L Schreibman, PhD/MD 2010 schreibman.info
Zone of TransitionAggressive vs Non-aggressive
Grow Slowly Narrow
Geographic Well DefinedCan Outline Lesionwith Sharp Pencil
Sclerotic MarginsGrows VERY Slowly!
Ken L Schreibman, PhD/MD 2010 schreibman.info
Zone of TransitionAggressive vs Non-aggressive
Grow Slowly Narrow Geographic Well Defined
Can Outline Lesionwith Sharp Pencil
Sclerotic Margins
Grows VERY Slowly!Asymptomatic, incidental finding
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grow Slowly Narrow Geographic Well Defined
Can Outline Lesionwith Sharp Pencil
Sclerotic Margins
Grows VERY Slowly!
Zone of TransitionAggressive vs Non-aggressive
Ken L Schreibman, PhD/MD 2010 schreibman.info
Zone of TransitionAggressive vs Non-aggressive
Grow Slowly
Narrow Geographic Well Defined
Can Outline Lesionwith Sharp Pencil
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grow Slowly
Narrow Geographic Well Defined
Can Outline Lesionwith Sharp Pencil
Sclerotic MarginsGrows VERY Slowly!
Grow Rapidly
WidePermeativeIll DefinedMoth Eaten
Cannot tell whereLesion ends and
Normal Bone begins
Zone of TransitionAggressive vs Non-aggressive
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Grow RapidlyWide
PermeativeIll DefinedMoth Eaten
Cannot tell whereLesion ends and
Normal Bone begins
Aggressive vs Non-aggressiveZone of Transition
Cannot tell whereLesion ends and
Normal Bone begins
W,S 16yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows Slowly Narrow
Geographic Well Defined
Can Outline Lesionwith Sharp Pencil
Grows RapidlyWide
PermeativeIll DefinedMoth Eaten
Zone of TransitionAggressive vs Non-aggressive
Cannot tell whereLesion ends and
Normal Bone begins
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows SlowlyGrows RapidlyPeriosteal Reaction
Aggressive vs Non-aggressive
TOOCOMPLI-CATED
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows RapidlyInterrupted
Simplifying Periosteal ReactionAggressive vs Non-aggressive
Grows SlowlySolidSmoothContinuous
Ken L Schreibman, PhD/MD 2010 schreibman.info
Simplifying Periosteal ReactionAggressive vs Non-aggressive
BoneModel
Fx
Grows Slowly
SolidSmoothContinuous
Looks likeHealing Callus
F,A 2moM 1m laterKen L Schreibman, PhD/MD 2010 schreibman.info
Simplifying Periosteal ReactionAggressive vs Non-aggressive
BoneModel
Grows Slowly
SolidSmoothContinuous
V,T 49yoM
HOAHypertrophicOsteo-Arthropathy
HPOAHypertrophicPulmonaryOsteo-Arthropathy Stable over 1y
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Grows RapidlyInterrupted
May grow sorapidly it doesnt
have time toossify
(Unossifiedperiosteum is not
radiopaque)
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows RapidlyInterrupted
LamellatedOnionskin
Grows ossifiesGrows ossifiesGrows ossifies
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Courtesy of James Choi, MD
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows RapidlyInterruptedLamellatedOnionskinSpiculatedHair-on-end
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows RapidlyInterruptedLamellatedOnionskinSpiculatedSunburstCodmans
Triangles(Growing so rapidly,has time to ossifyonly at corners)
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows Rapidly
InterruptedLamellatedOnionskinSpiculatedSunburstCodmans
Triangles(Growing so rapidly,has time to ossifyonly at corners)
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grows Rapidly
InterruptedLamellatedOnionskinSpiculatedSunburstCodmans
Triangles
Aggressive vs Non-aggressiveSimplifying Periosteal Reaction
Grows Slowly
SolidSmoothContinuous
Looks likeHealing Callus
S,C 15yoM
3w post Fx, ORIF=very early callus8w post Fx, ORIF
=more mature callus
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Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors
1) Patients Age
2) Aggressive vs Non-aggressiveZone of TransitionPeriosteal ReactionCortical Destruction
Aggressive Non-aggressive
Describing
Ken L Schreibman, PhD/MD 2010 schreibman.info
Aggressive vs Non-aggressiveCortical Destruction
Cortex Intact =
Non-aggressive
Similar lytic lesionsBoth have well
defined, sclerotic,
medullary borders
Cortex Absent =
Aggressive
IR
Ken L Schreibman, PhD/MD 2010 schreibman.info
Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors
1) Patients Age2) Aggressive vs Non-aggressiveZone of TransitionPeriosteal ReactionCortical DestructionSoft Tissue Extension
Radiographs
MRI
Aggressive Non-aggressive
Describing
Ken L Schreibman, PhD/MD 2010 schreibman.info
2 Cases: Aggressive lesions distal fibula
CorticalDestruction
PeriostealReaction
Benign?Malignant?
Cant tell with radiographs
Thus we use the termAggressive
Ken L Schreibman, PhD/MD 2010 schreibman.info
2 Cases: Aggressive lesions distal fibulaT2 Soft Tissue
Extension
T2
T1
H,M 13yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
TwoYEARSlater
Active Osteomyelitis Chronic Osteo.
Aggressive vs Non-aggressive
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Bone Matrix: 4 TypesChondroidrings&arcs
Osseouscloud-likeamorphous
FibrousGroundGlass
NonePurely LyticNotnecessarilycystic
Calcified Uterine Fibroid Myositis Ossificans
Multiple MyelomaKen L Schreibman, PhD/MD 2010 schreibman.info
Bone Matrix: 4 TypesChondroidrings&arcs
Calcified Uterine FibroidEnchondroma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Bone Matrix: 4 TypesOsseouscloud-likeamorphous
Myositis OssificansF,C 8yoF
Osteogenic SarcomaH,S 15yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
Bone Matrix: 4 TypesFibrous
GroundGlass
Fibrous DysplasiaB,C 53yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
Bone Matrix: 4 TypesNonePurely Lytic
Not necessarily cystic
Multiple MyelomaS,N 62yoMKen L Schreibman, PhD/MD 2010 schreibman.info
Bone Matrix: 4 Types
G,B 18yoF
CTNonePurely Lytic
Not necessarily cystic
T1
Intraosseous Lipoma
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Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors
1) Patients Age
2) Aggressive3) Matrix4) LocationWhich bone?
Some tumors have propensity for certain bonesWhich part of the bone?
MANY tumors characteristically occur at the:Epiphysis / Metaphysis / Diaphysis
Ken L Schreibman, PhD/MD 2010 schreibman.info
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing Sarcoma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Pt Age: 10-20 years(when growth spurt occurs)
Location: Metaphyseal(where growth occurs)Distal FemurProximal Tibia(where mostgrowth occurs)
Matrix: Osseous
osteo-genic: makes boneNeed to eval for skip metsMR entire length of bone
Osteogenic Sarcoma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteogenic Sarcoma
F,C 8yoF
Pt Age: 10-20 years
Location: Metaphyseal
Matrix: Osseous
T1
T1
T2
MRI is useful for stagingthe extentof the tumor
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteogenic Sarcoma
F,C 8yoF
MRI is useful for stagingthe extentof the tumor
Radiographs show us
what we need to know todiagnose type of tumor!
Skeletally immatureAggressive lesionWide zone of trans.Sunburst periost.Osseous matrixMetaphyseal---------------------------------Osteogenic Sarcoma!
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteogenic Sarcoma
R,T 11yoF
Sometimes osteosarc isgrowing SO quickly it
doesnt have time toform an osseous matrixPatient presents
with hair-on-endperiosteal reaction
After 2 months ofchemotherapytumor growth hasslowed enough toform osseous matrix
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Ewing SarcomaPt Age: 5-25 years
Tumor ofBone MarrowLocation: Diaphyseal
Flat BonesMatrix: PermeativeCortical DestructionAggressive
Periosteal Reaction
Soft Tissue Extension>> Bone Extent
Ken L Schreibman, PhD/MD 2010 schreibman.info
Ewing SarcomaT2 Soft Tissue
Extension
T2
T1
H,M 13yoF
>> BoneExtent
Ken L Schreibman, PhD/MD 2010 schreibman.info
Ewing Sarcoma common in pelvis
S,B 6yoM
Things canhide in thepelvis
Air incolon
3 months later
Air incolon?
Ken L Schreibman, PhD/MD 2010 schreibman.info
Ewing Sarcoma common in pelvis
S,B 6yoM
T2fs Things canhide in thepelvisUnlike in the extremitieswhere radiographs are key,
the usefulness ofradiographs in thepelvis is limited.
In the pelvis,cross-sectional
imaging is crucial,preferably with MRI.
Ken L Schreibman, PhD/MD 2010 schreibman.info
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB
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Cortical DesmoidCortical Desmoid: Do Not Touch!
Q,M 17yoM
Just a little periosteal reactionMEDIAL posterior femoral condyle
Tug lesion: Adductor longus insertionMedial gastrocnemius origin
CT
T2fs
Cross-sectional imaging doesnt really help
Ken L Schreibman, PhD/MD 2010 schreibman.info
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
ALWAYS consider Lymphoma!
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 40MetastasesMultiple Myeloma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Cartilage malignancy
Matrix: Chondroid
Location: Ends of bonesPelvis
Soft tissues
Chondrosarcoma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Chondrosarcoma
S,B 39yoM
Chondroidrings&arcs
Radiographs
Cartilage malignancy
Matrix: Chondroid
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ChondrosarcomaCartilage malignancy
Matrix: ChondroidChondroid
rings&arcsRadiographsCT
S,B 39yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaCartilage malignancy
Matrix: ChondroidChondroidMRI
T2: Bright
Gd:peripheralenhancementBulk of tumordoesnt enhance
S,B 39yoM
T2fs T1fs+Gd
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaCartilage malignancy
Matrix: Chondroid
Normal cartilage has no blood supplyInjured cartilage doesnt regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesnt respond to chemotherapy
Treatment: Complete tumor resection
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaCartilage malignancy
Matrix: Chondroid
Normal cartilage has no blood supplyInjured cartilage doesnt regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesnt respond to chemotherapy
Treatment: Complete tumor resectionS,B 39yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
Chondrosarcoma
W,A 30yoF
30yoF 1 year history heal pain
1 week later
other side
Ken L Schreibman, PhD/MD 2010 schreibman.info
Chondrosarcoma
T2fs T1fs+Gd
T1
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Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 20
May involve the bonesSecondarilyPrimarily
Ken L Schreibman, PhD/MD 2010 schreibman.info
Fibrosarcoma
F,B 23yoF
T1 T2fs
MRI is useful for stagingthe extentof the tumor
Ken L Schreibman, PhD/MD 2010 schreibman.info
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if
marrow not involved,can resect tumor.If spreads to marrow,conventional OS.
3) PERIostealLooks like aggressive
periosteal reactionLocation: Long bones
Osteogenic Sarcoma Periosteal Osteosarcoma
Murphey M D et al.Radiology 2004;233:129-138
2004 Radiological Society of North America
tibia 11yoM
AggressivePeriostealReaction
Periosteal Osteosarcoma
Murphey M D et al.Radiology 2004;233:129-138
2004 Radiological Society of North America
tibia 34yoF
AggressivePeriostealReaction
SoftTissueExtension
SparingBoneMarrow
Ken L Schreibman, PhD/MD 2010 schreibman.info
Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if
marrow not involved,can resect tumor
If spreads to marrow,conventional OS.
3) PERIosteal
Looks like aggressiveperiosteal reaction4) PARosteal
Osteogenic Sarcoma
Ken L Schreibman, PhD/MD 2010 schreibman.info
Surface Osteosarcoma4) PARosteal
Pt Age: 20-30 yearsLocation: Back ofFemoral Condyles
Arise from cortex,grow outward
Do NOT containnormal marrow
(As opposed toosteochondroma)
Osteogenic Sarcoma CT
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteogenic Sarcoma CT
T2fs
T1 MRI: No Marrowinvolvement
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Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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B) Unicameral (Simple) Bone CystUni-cameral: Latin one - chamber(in US we have bi-cameral legislature)
Pt Age:< 20
Matrix: None (True Cyst)Location:Metaphyseal>50% Proximal Humerus
20-30% Proximal Femur50% - Incidental Finding50% - Pathologic Fx
Fallen FragmentKen L Schreibman, PhD/MD 2010 schreibman.info
B) Unicameral (Simple) Bone Cyst
D,C 5yoM
Normal Side
Ken L Schreibman, PhD/MD 2010 schreibman.info
B) Unicameral (Simple) Bone Cyst
D,C 5yoM after 1 month
Fractures tend to heal
after 3 months
Fracture healed
Cyst?
Ken L Schreibman, PhD/MD 2010 schreibman.info
B) Unicameral (Simple) Bone CystCysts tend to recur
6m later 12m later 18m later
Although UBCsarise from
metaphysisend of bonegrows awayfrom cyst
so cystbecomes
diaphyseal
Ken L Schreibman, PhD/MD 2010 schreibman.info
MRI shows cyst extentB) Unicameral (Simple) Bone Cyst
18m later
T1 T2fs
T1
T2fs
Simple cystKen L Schreibman, PhD/MD 2010 schreibman.info
B) Unicameral (Simple) Bone Cyst
M,T 4yoM
FallenFragment
after 3 months
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B) Unicameral (Simple) Bone Cyst
P,D 6yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
B) Unicameral (Simple) Bone Cyst
H,T 18yoM
T2fs
Simple cyst with
hemorrhagefluid-fluid level
Ken L Schreibman, PhD/MD 2010 schreibman.info
C) ChondroblastomaPt Age: Skeletally immature
Location: Epiphyseal
Matrix: Chondroid(No matrix if not calcified)
BenignAggressive appearance!Periosteal Reaction
Surrounding EdemaBone MarrowSoft Tissues
Ken L Schreibman, PhD/MD 2010 schreibman.info
C) ChondroblastomaPt Age: 10 30yoLocation: Epiphyseal
Matrix: Chondroid(No matrix if not calcified)
BenignAggressive appearance!Periosteal Reaction
16yoM
Surrounding EdemaBone MarrowSoft Tissues
T2fs
Ken L Schreibman, PhD/MD 2010 schreibman.info
C) Chondroblastoma
16yoM
Cartilage-sensitive sequence
Articular Cartilage
Cartilageunfused physis
Ken L Schreibman, PhD/MD 2010 schreibman.info
C) Chondroblastoma
B,Q 15yoM
T1 IR Cartilage sequence
Epiphyseal mass, skeletally immatureAggressive appearance
Edema in surrounding marrow & tissues
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Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect
THE most common bone lesionOccurs up to 40% ALL children
(75% occur 10
20 years old)Regress after skeletal maturity
Asymptomatic, incidental finding(e.g. on knee MR for ACL tear)
If >50% bone diameter Fx
Location: MetaphysisFemur & Tibia
Ken L Schreibman, PhD/MD 2010 schreibman.info
Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect
Radiographic appearance:
Characteristic& Diagnostic
If asymptomatic, nofurther workup is needed
Eccentric, sub-corticalCortex thinned, expanded
Sclerotic marginScalloped
Multi-loculatedF,M 18yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect
Radiographic appearance:
Characteristic&DiagnosticIf asymptomatic, no
further workup is needed
Eccentric, sub-corticalCortex thinned, expanded
Sclerotic margin
ScallopedMulti-loculatedB,J 19yoM
T1IRNo aggressive characteristics
Ken L Schreibman, PhD/MD 2010 schreibman.info
Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect
G,M 9yoF
9yo 11yo 13yo
Fx HealingCallus
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E) Eosinophilic GranulomaNon-neoplastic proliferation histiocytes
Langerhans Cell HistiocytosisPt Age: typically 3yo)Triad: skull lesions, exophthalmos, DI
Letterer-Siwe (60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB
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Pt Age: 60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB
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ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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Location: SubarticularMatrix: Purely Lytic
Age:< 20 (skeletally immature)
ChondroblastomaAge:20-40 (skeletally mature)
Giant Cell Tumor
Age:> 40MetastasesMultiple Myeloma
Why Age is Important
V,R 21yoM
GCT
Ken L Schreibman, PhD/MD 2010 schreibman.info
Location: SubarticularMatrix: Purely Lytic
Age:< 20 (skeletally immature)
ChondroblastomaAge:20-40 (skeletally mature)
Giant Cell Tumor
Age:> 40MetastasesMultiple Myeloma
Why Age is Important
C,G 61yoM
Met
1LungCancer
Ken L Schreibman, PhD/MD 2010 schreibman.info
ABCUBC
CBFCD/NOF
EGFD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 60)
AGGRESSIVE NON-aggressiveLytic
NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB
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EnchondromaBenign rests of hyaline cartilageCommonOften discovered incidentally
Typically asymptomatic50% small tubular bonesMostly lyticPathologic Fracture
Ken L Schreibman, PhD/MD 2010 schreibman.info
Glomus TumorBenign vascular tumor
(neuromyoarterial apparatus)
Subungual, erodes bone
Dorsal cortex distal phalanxAge: 30 50 ( 3x> )TriadSensitivity to coldLocalized tendernessSevere intermittent
painS,D 37yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
Glomus Tumor
S,D 53yoM
Dorsal cortex distal phalanx
Ken L Schreibman, PhD/MD 2010 schreibman.info
Epidermoid Inclusion CystImplantation of epidermal elementsAmputationPuncture (seamstress)Volar cortex distal phalanx
T2fsT1fs+GdT1fs+GdT1fs
Ken L Schreibman, PhD/MD 2010 schreibman.info
Epidermoid Inclusion Cyst
Ken L Schreibman, PhD/MD 2010 schreibman.info
Gout
M,B 78yoM
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NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB
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NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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Chondrosarcoma
IR T1fs + Gd
Histopathology1: Low Grade2: Intermediate
3: High GradeCellularity:markedlyincreased
Nuclei Size:markedlyincreased
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaHistopathology
1: Low Grade2: Intermediate
3: High GradeCellularity:slightlyincreased
Nuclei Size:slightlyincreased
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaHistopathology
0.5: Borderline1: Low Grade2: Intermediate3: High Grade
Histologically:resemblesenchondroma
Radiologically:aggressive
Enchondroma
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaEnchondroma
T1 T2fs
B,B 42yoF
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaEnchondroma
How do you distinguish between them?Very difficult, sometimes you cantClues:
All ChondrosarcHot on BS
Some EnchonHot on BS
All ChondrosarcPainful (never incidental)
40% EnchonPainful
This pt had painuncontrollable with
oral narcotics
Ken L Schreibman, PhD/MD 2010 schreibman.info
ChondrosarcomaEnchondroma
B,B 42yoF
This pt had painuncontrollable with
oral narcoticsHistopathology:No malignant cells
So was this:
Enchondroma?
0.5 BorderlineChondrosarcoma?
Pt was very happy with outcome!Shes now pain freeShes doesnt have cancer
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NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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Osteoblastoma (= Osteoid Osteoma)Term osteoblastomaused for:Larger lesions
( > 1cm)Lesion in spineposterior elementsPainful scoliosis
(Typicallyscoliosis ispainless)
S,T 16yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteoblastoma (= Osteoid Osteoma)
Bone Scan(Posterior)
SPECT(Sagittal)
S,T 16yoM
SPECT(Axial)
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteoblastoma (= Osteoid Osteoma)CT:Gold StandardDiagnosisLucent NidusCentral Dot Calcium
S,T 16yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
Young womanwith back painFetus is an
incidental finding
Years earlierwith back pain
Osteoblastoma
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NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EG
FD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE NON-aggressiveBlastic
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB
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OsteochondromaMost Common Benign Neoplasm of BoneExostosisPedunculated (stalk)
Sessile (flat)Cartilage Capseen only on MR
Point away from jointContinuity with
underlying boneCortex continuous with cortexMarrow continuous with marrow
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaMost Common Benign Neoplasm of BoneExostosisPedunculated (stalk)
Sessile (flat)Cartilage Capseen only on MR
Point away from jointContinuity with
underlying boneCortex continuous with cortexMarrow continuous with marrow K,J 11yoM
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteochondroma
K,J 11yoM
Cortex continuous with cortexMarrow continuous with marrow
T1
T2fs
No aggressive characteristics
Cartilage Cap
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity
(can grow during childhood)Cartilage cap > 1cm
(can be 2-3cm during childhood)
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaMalignant Transformation to Chondrosarcoma
Funny shaped femursMHE?
Chondroid matrixAggressive appearance
Hot on BSc/w Chondrosarc
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaMalignant Transformation to Chondrosarcoma
CT: Tissue Window CT: Bone Window
T1fs+GdT2fs
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OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%
Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity
(can grow during childhood)Cartilage cap > 1cm
(can be 2-3cm during childhood)
Can cause mechanical problems
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaCan cause mechanical problems
W,M 25yoF
Multiple miscarriagesT1
T2fs
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaCan cause mechanical problems
K,T 18yoM MRA
Mass effect on rightsubclavian artery
Ken L Schreibman, PhD/MD 2010 schreibman.info
OsteochondromaCan cause mechanical problems
H,P 11yoF T1 PDfs
T2fs
Rubbing, causingPes Anserine Bursitis
Ken L Schreibman, PhD/MD 2010 schreibman.info
Osteochondroma T1
vs PARosteal Osteosarcoma
T1 T2fsW,K 17yoM
Cortex continuous with cortexMarrow continuous with marrow
CartilageCap
NO cortex/marrowcontinuity
Ken L Schreibman, PhD/MD 2010 schreibman.info
NON-aggressiveBlastic
Chondroid:Enchondroma
Osseous:Osteoid Osteoma
OsteoblastomaOsseous & Chondroid:Osteochondroma
NON-aggressiveLytic
ABCUBC
CBFCD/NOF
EGFD
Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)
AGGRESSIVE
40
age
OsteosarcomaEwing SarcomaOsteomyelitis (Active)
Mets (NB