tumor tulang - kenneth bucwalter, indiana university (pp)
TRANSCRIPT
![Page 1: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/1.jpg)
Kenneth Buckwalter, M.D.
Indiana University
(317) 274-1837
Radiology of Bone Tumors
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Outline
• Work-up and Radiologic assessment
• Approach
– Normal bone anatomy
– Radiographic Analysis
• Location
• Margins
• Periosteal reaction
• Matrix
• Examples
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Work-up
• History
– Age is critical.
– Smoker?
– Malignancy?
• Physical examination
– Breast mass?
• Good radiographs of affected region
– 2 views minimum
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Multiple vs. Solitary
• Multiple
– metastatic
– congenital
• fibrous dysplasia
– acquired
• Paget
• Solitary
– metastatic
– primary bone tumor, malignant or benign
![Page 5: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/5.jpg)
Multiple
• 50+ y/o
– known malignancy?
– myeloma, get SPEP
– otherwise, do metastatic work-up
• child to early adult
– known malignancy?
– EG?
– polyostotic fibrous dysplasia?
– otherwise, do metastatic work-up
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Solitary
• Aggressive radiographic appearance
– bone scan to stage and verify solitary nature
– metastatic work-up
• baseline CXR
• spiral CT for pulmonary nodules
• Staging for surgery
– cross-sectional imaging: CT or MR
• Need tissue biopsy
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Biopsy
• obvious superficial mass, blind biopsy
• tissue compartments must not be contaminated
– Biopsy should be done in consultation with a tumor surgeon.
• skinny needle most helpful with metastatic disease
• core best for primary tumor
![Page 8: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/8.jpg)
Cross-sectional imaging
• Pictures are pretty, but diagnosis established
at histology
• MRI best for most tumors
– optimal results at sites with experience
• Role of CT limited
– may assist in assessing tumor matrix
– useful in directing biopsy
![Page 9: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/9.jpg)
Normal Anatomy
epiphysis
metaphysis diaphysis
physis
childhood adult
cortex
medullary
space
physeal scar
![Page 10: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/10.jpg)
How are Bone Tumors
Like Real Estate?
Location!
Location!
Location!
![Page 11: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/11.jpg)
Location
• Location and age of patient most important
parameters in classifying a primary bone
tumor.
• Simple to determine from plain radiographs.
![Page 12: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/12.jpg)
Location
Rad Clin N Am,
Dec 1981
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Reaction of bone to tumor
• Limited responses of bone
destruction: lysis (lucency)
reaction: sclerosis
remodeling: periosteal reaction
• Rate of growth determines bone response
– slow progression, sclerosis prevails
– rapid progression, destruction prevails
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Reaction of bone to tumor
• Margin between tumor and native bone is
visible on the plain radiograph.
• Slowly progressive process is “walled-off” by
native bone, producing distinct margins.
• Rapidly progressive process destroys bone,
producing indistinct margins.
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Radiographic Margins
• Margin types 1A, 1B, 1C, 2, and 3
– least aggressive 1A, to most aggressive 3
• Aggressive lesions destroy bone.
• Aggressiveness increases likelihood of
malignancy.
– BUT, not all aggressive processes are malignant.
– AND, not all malignant diseases are aggressive.
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Margins: 1A,1B,1C
increasing aggressiveness Rad Clin N Am,
Dec 1981
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1A: sclerotic margin
• simple cyst (UBC)
• enchondroma
• FD / FX
• chondroblastoma
• GCT
• chondrosarcoma (rare)
• MFH (rare)
Rad Clin N Am,
Dec 1981
![Page 18: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/18.jpg)
1B: well-defined, non-sclerotic
• GCT
• enchondroma
• chondroblastoma
• myeloma, metastatsis
• CMF
• FD
• chondrosarcoma
• MFH
Rad Clin N Am,
Dec 1981
![Page 19: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/19.jpg)
1C: lytic, ill-defined margins
• chondrosarcoma
• MFH
• osteosarcoma
• GCT
• metastasis
• infection
• EG
• lymphoma
Rad Clin N Am,
Dec 1981
![Page 20: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/20.jpg)
2: “motheaten”
• myeloma, metastases
• infection
• EG
• osteosarcoma
• chondrosarcoma
• lymphoma
Rad Clin N Am,
Dec 1981
![Page 21: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/21.jpg)
3: “permeative”
• Ewing
• EG
• infection
• myeloma, metastasis
• lymphoma
• osteosarcoma
Rad Clin N Am,
Dec 1981
![Page 22: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/22.jpg)
Types of
Periosteal
Reaction
Rad Clin N Am,
Dec 1981
![Page 23: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/23.jpg)
Periosteal Reaction
• Limited usefulness
• Thick, uninterrupted
– long standing process, often non-aggressive
• stress fracture
• chronic infection
• osteoid osteoma
• Spiculated, lamellated
– aggressive process
– tumor likely
![Page 24: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/24.jpg)
Codman Triangle
periosteal reaction
tumor
advancing tumor margin
destroys periosteal new
bone before it ossifies
Codman
Triangle
![Page 25: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/25.jpg)
Tumor Matrix
• “Matrix” is the internal tissue of the tumor
• Most tumor matrix is soft tissue in nature.
– Radiolucent (lytic) on x-ray
• Cartilage matrix
– calcified rings, arcs, dots (stippled)
– enchondroma, chondroblastoma, chondrosarcoma
• Ossific matrix
– osteosarcoma
![Page 26: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/26.jpg)
Matrix
Rad Clin N Am,
Dec 1981
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Examples
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AGE 13
Location metadiaphysis
Margins 1A-1B
Periosteal Reaction none
Matrix none
Other trabecular struts
DX UBC
Example 1
![Page 29: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/29.jpg)
Example 2
![Page 30: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/30.jpg)
AGE adult
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other fx
DX ABC
Example 2
![Page 31: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/31.jpg)
Example 3: 13 y/o with knee pain
![Page 32: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/32.jpg)
AGE 13
Location epiphyseal
Margins 1B
Periosteal Reaction none
Matrix none
Other
DX chondroblastoma
Example 3
![Page 33: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/33.jpg)
Example 4: 45 y/o with knee pain
![Page 34: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/34.jpg)
Example 4
AGE 45
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix none
Other epi involvement
DX GCT
![Page 35: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/35.jpg)
Example 4*, 35 y/o F, GCT
![Page 36: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/36.jpg)
AGE 66
Location diaphyseal
Margins 1A
Periosteal Reaction minimal, thick
Matrix none
Other 2nd lesion
DX wait…..
Example 5
![Page 37: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/37.jpg)
Example 5
AGE 66
Location diaphyseal
Margins 2
Periosteal Reaction none
Matrix none
Other
DX wait…..
![Page 38: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/38.jpg)
Example 5
AGE 66
Location flat bone
Margins 1B
Periosteal Reaction none
Matrix none
Other multiple
DX myeloma
![Page 39: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/39.jpg)
Example 6: 14 y/o with claudication
![Page 40: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/40.jpg)
Example 6
![Page 41: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/41.jpg)
Example 6
AGE 14
Location metaphysis
Margins 1B
Periosteal Reaction none
Matrix mature bone
Other claudicat'n
DX exostosis
![Page 42: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/42.jpg)
Example 7: 25 y/o woman with knee pain
![Page 43: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/43.jpg)
Example 7
![Page 44: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/44.jpg)
AGE 25
Location metaphysis
Margins 1A
Periosteal Reaction none
Matrix ?
Other multiple
DX NOF
Example 7
![Page 45: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/45.jpg)
Example 8: 45 y/o with thigh pain
![Page 46: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/46.jpg)
Example 8
AGE 45
Location diaphysis
Margins 1B
Periosteal Reaction thick
Matrix faint
Other
DX osteoid osteoma
![Page 47: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/47.jpg)
AGE 12
Location diaphysis
Margins 3
Periosteal Reaction lamellated
Matrix none
Other
DX Ewing
Example 9
![Page 48: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/48.jpg)
Example 9
“onion-skin”
![Page 49: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/49.jpg)
Example 10
![Page 50: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/50.jpg)
AGE 16
Location diaphysis
Margins 3
Periosteal Reaction spiculated
Matrix bone
Other fx
DX osteosarcoma
Example 10
![Page 51: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/51.jpg)
AGE 20
Location metaphysis
Margins 3
Periosteal Reaction irregular
Matrix bone
Other
DX osteosarcoma
Example 10*, osteosarcoma
![Page 52: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/52.jpg)
AGE 56
Location metaphyseal
Margins 1A
Periosteal Reaction none
Matrix chondroid
Other
DX enchondroma
Example 11
![Page 53: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/53.jpg)
Summary
• Radiographs are essential
• Aggressiveness of process dictates the
response of the bone
• Most helpful information in analysis
– Age
– Location
– Margins
![Page 54: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/54.jpg)
“Don’t Touch Me”
• Fibrous lesions
– fibrous dysplasia
– NOF (non-ossifying fibroma)
• enchondroma
• exostosis
• unicameral (simple) bone cyst
![Page 55: Tumor Tulang - Kenneth Bucwalter, Indiana University (PP)](https://reader031.vdocument.in/reader031/viewer/2022021921/577cc9c61a28aba711a49771/html5/thumbnails/55.jpg)
AGE
Location
Margins
Periosteal Reaction
Matrix
Other
DX
Example