Tumours of the Bone – Dr M Schranz 1

TUMOURS OF BONE

Metastatic Tumours

The most common bony malignancies are metastatic carcinomas.

Metastatic lesions represent the most common cause of pathology fractures due to a neoplasm.
Usually are multiple, but can be solitary. The most common primaries are breast, prostate, lung,
kidney and thyroid, in that order.

Renal metastasis are quite vascular and have cold bone scans.

For example, look at the following plain radiograph of this elderly gentleman with prostatism and
pain in the right hip.

He had a renal carcinoma which was treated by nephrectomy 8 years before and Paget's disease
of the right hemipelvis and proximal right femur known for 20 years.

CT scan of the pelvis (bone window) demonstrates destruction of the anterior cortex with large
soft tissue mass.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 2

A Coronal, gadolinium-enhanced T1-weighted MR-image demonstrates an oval mass in the

trochanteric region with intermediate signal intensity on T1-weighted image and strong
enhancement after Gd-contrast injection.

Subsequently needle biopsy under CT guidance were carried out, showing metastatic renal
carcinoma.

Prostate cancer metastases tend to be blastic, that is, they tend to make the bones around them
thicker and more dense, whereas many other types of cancer metastasis to the bones tend to be
lytic, which means they tend to destroy and remove the bones around them. This means that
pathological fractures are relatively uncommon in prostate cancer, and it is likely that a patient
with prostate cancer in the spine will not suffer a pathological fracture.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 3

AP radiograph of the pelvis and the lumbar spine: Multiple circumscribed hyperdense lesions are
visible in the lumbar vertebrae and the pelvic bones

Note: Wilms’s tumour and neuroblastoma (rosettes) are the most common metastatic lesions in
childhood.

Primary Bone Tumours

Oesteogenic Lesions

Osteoid Osteoma - Usually are intracortical lesions of any bone, especially the femur, tibia, and
vertebra (posterior elements), with a characteristic nidus and associated pain. Th e classic pain is
worse at night, relieved by salicylates, and exacerbated by alcohol.

Treatment ordinarily consists of surgical removal of the nidus with a marginal excision.

The following is a plain radiograph of the leg of a 30-year-old man with a complaint of right leg
pain of one year's duration. The pain was worse at night but was fully relieved by aspirin. There is
no history of trauma.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 4

A plain radiograph of the right tibia and fibula reveals a focally sclerotic expanded area of the
tibial cortex without overlying soft tissue or periosteal abnormalities. A radiolucent nidus is visible
in the center of the focal area of sclerosis.

Radionuclide bone scintigraphy using technetium -99m MDP (methylene diphosphonate) reveals
a very prominent focal uptake of the radiotracer in the same region seen to be sclerotic on plain
radiograph

Three types of osteoid osteomas exist; categories are based on location:

? cortical location is the most common with a dense sclerotic reaction disguising the nidus.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 5

? Medullary locations, often in the femoral neck or bones of the hands or feet, are less common
where osteosclerosis is minimal to moderate.

? Subperiosteal is the rarest form with little or no reactive sclerosis making it a more difficult to
diagnose radiographically

Osteoblastoma

Osteoblastoma is a solitary, benign tumour producing osteoid and bone, with 90% of cases
reported in the second and third decades of life. Cases have however been reported in patients
aged 3-72 years, this patient being at the lower end of this range. There is a male predominance
of 2:1. Clinical symptoms often differ from those of osteoid osteoma, with osteoblastoma
producing an inconsistent, dull localized pain, as opposed to the intense nocturnal pain caused by
osteoid osteoma. Osteoblastoma of the spine accounts for 30-40% of all osteoblastomas, most
frequently involving the posterior vertebral elements (55%), although extension into the vertebral
body is common (42%). Approximately 60-70% of osteoblastomas occur in the metaphyses and
diaphyses of long bones, and rarely in the pelvis.

The following radiograph is of a three year old boy whose mother noticed a reluctance to use his
left arm.

Plain radiograph of the left shoulder shows eccentric two centimetre oval lytic lesion, with
surrounding, well-defined, narrow margin of transition. There is associated lateral metaphyseal
periosteal reaction, with no distinct soft tissue component

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 6

Bone scintigraphy (bone scan) shows a focal region of intensely increased activity in the proximal
left humeral metaphysis. There is normal distribution of activity in the remainder of the skeleton

The patient underwent an intra-lesional curettage with excision fragments demonstrating nidus
formation with islands of osteoid and bone trabeculae lined by osteoblasts, consistent with an
osteoblastoma

Paget’s Disease

This disease, which affects about 3% of men and women, is characterised by increased bony
turnover.

Paget’s disease typically involves the sacrum, spine, femur and cranium of older patients.

Features of Paget’s include deformities (bowing), pain, change in size of bones (increased hat
size), kyphosis, and systemic features like cranial nerve impingement, bruits, and high-output
cardiac failure.

Radiographic features vary with the stage of the disease but include cortical thickening, coarse
trabeculae, sclerotic ivory or enlarged picture frame vertebrae, cotton wool appearance of the
femur and pelvis, and osteoporosis circumscripta of the calvarium.

Paget's disease may result in stress fractures as seen in the tibia below

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 7

Cortical stress fractures as a complication of Paget’s disease are associated with long standing
(inactive) disease. The fractures can be partial or complete. Radiographically, they are seen as
single or multiple horizontal radiolucent areas with a predilection for the convex aspect of bone.
This is in contrast to the Looser’s zones associated with osteomalacia which affect the concave
aspect.

After Tc 99m were injected, there is markedly intense uptake at the sacrum, left hemipelvis, mid
and distal right femur, entire right tibia, proximal and mid left femur. There is expansion of the
right distal femur and entire tibia.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 8

Osteosarcoma

The most common primary bone malignancy in children (boys > girls), occurs most commonly in
the second and third decades of life. It is characterised by the production of osteoid directly from
malignant spindle cell stroma. The knee and proximal humerus are common sites, and early
diagnosis is difficult. A relatively painless mass is a frequent presentation. Osteosarcomas are
classified as primary or secondary (following a preexisting lesion such as Paget’s or a result of
XRT, and usually seen in older patients). Primary tumours are further classified as central or
juxtacortical.

This osteosarcoma is very dense radiographically, a finding that indicates that the tumor is
making bone. The tumor results in the destruction of the adjacent cortex and extends into the
adjacent soft tissue.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 9

Chondrogenic Lesions

Chondromas are benign tumours of mature hyaline cartilage usually located within bone
(enchondroma), but occasionally on the bony surface (periosteal chondroma).

Enchondroma

Benign cartilaginous neoplasm arising in diaphyseal medullary cavities of long bones, possibly
from epiphyseal plate remnants. Can be solitary or multiple (Ollier’s disease [alone] and
Maf fucci’s syndrome [with skin hemangiomata] - both with higher rates of malignant
transformation [up to 30% in Ollier’s]). Enchondromas are asymptomatic and can be located in
any bone, especially in the hands and feet.

The typical x-ray picture of an enchondroma shows a central, or slightly eccentric, well-
circumscribed or bubbly radiolucent lesion, finely or densely stippled with calcification, and
located in the interior of a short or long tubular bone

An example of an enchondroma of the humerus:

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 10

Osteochondroma (Osteocartilaginous Exostosis)

One of the most common benign bone tumours. These lesions represent a disorder of normal
enchondral bone growth, and are usually sessile or pedunculated lesions arising from the cortex
of a long bone adjacent to the epiphyseal plate. Tumour enlargement is common and ceases
after maturity.

The most common location of an osteochondroma is in the region of the knee, particularly the
lower metaphysis of the femur or the upper metaphysis of the tibia.

The next radiograph shows a typical osteochondroma of the femur.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 11

An osteochondroma of a long bone characteristically points away from the o

j int because its
epiphysial site of origin lags behind the advancing growth plate as the bone lengthens

Multiple hereditary exostosis is an autosomal dominant disorder with a mild decrease in stature,
normal intelligence, and multiple osteochondromas. It is commonly accompanied by leg length
discrepancy, knee and elbow angular deformities, and other skeletal abnormalities.
Osteochondromas develop in multiple metaphyses of affected children and they continue to
increase in size and number until skeletalmaturity. Problems include nerve compression
(especially peroneal nerve), ankle diastasis, angular deformities, and malignant transformation
(2%).

Chondromyxoid Fibroma

Chondromyxoid Fibromas are most commonly found in the metaphysis of a large tubular bone of
a lower limb at a variable distance from the frequently open growth plate and often in contact with
it.

The following image shows an eccentric lytic epiphyseal chondromyxoid fibroma with a scalloped
medial internal border.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 12

Chondroblastoma

Chondroblastomas are benign tumors of cartilaginous origin.

A characteristic appearance on routine roentgenograms is that of a small, well-defined, round or

ovoid, eccentric rarefaction most commonly occupying the end of a long bone. Although
predominantly epiphyseal in long bones, the associated growth plate is most commonly open and
may be breached by the lesion with resultant metaphyseal extension.

Chondroblastoma is a rare benign neoplasm occurring in 75% of cases in the second decade of
life, when the growth plates are still open. This is one of two neoplasms of incompletely
differentiated cartilage. The other neoplasm is chondromyxoid fibroma. Most common locations
are the long bones (70% arise in the proximal humerus and at the knee), and flat bones, including
pelvis. In the long bones, the tumor almost invariably occurs in the epiphysis.

Conservative treatment of chondroblastoma is usually effective.

When this type of lesion involves the impact load bearing bones such as the os calcis treatment is
difficult. The tumor, as well as the treatment, weakens the weight bearing integrity of the
calcaneus and threatens to violate the heel pad. This can alter gait at heel strike. These
considerations are particularly important in athletic individuals.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 13

This is seen in the next case, a 18 year old male with a complaint of right heel pain that had
gradually increased over the two months prior to initial evaluation.

Plain radiographs and MRI revealed a well-defined cystic lesion in the posterior inferior aspect of
the os calcis

An incisional biopsy was performed, together with curettage of the wall of the cavity, showing the
presence of a Chondroblastoma.

The cavity was filled with autogenous cancellous bone graft from the right iliac crest; primary
closure followed

Chondrosarcoma

Second to osteosarcoma in prevalence of bony sarcoma’s. Chondrosarcomas can arise from

preexisting lesions (osteochondromas, chondromas) or they can be primary. They are usually
associated with dull, deep pain. Radiographs may show invasiveness and soft tissue extension.

Central chondrosarcoma of femur, shown below, shows a large lesion in the interior of the
diaphysis or metaphysis characterized by irregular or circular ( or bubbly) radiolucencies, granular
or lobular radioopaque areas of calcification, fuzzy or scalloped regions of destruction of the inner
cortex, enlargement of bone contours, focal periosteal reaction, and, most ominously, penetration
of the cortex and extension of the tumor into the soft tissue.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 14

Fibrogenic Lesions

Simple (Unicameral) Bone Cyst - Benign lesions that occur during growth.

The simple bone cyst is a common, benign, fluid-containing lesion, usually occurring in the
metaphysis of long bones

Plain radiography is the examination of choice because of its high diagnostic capability of simple
bone cysts. CT and MRI usually are not required and should only be used for evaluation in
anatomically complex areas such as the spine or pelvis. These areas often are difficult to
evaluate accurately on plain film. Use CT and MRI to determine the extent of the lesion and
whether complications such as a fracture are present. Nuclear medicine scans usually are not
necessary in the evaluation of simple bone cysts.

Radiographs demonstrate simple bone cysts as well-defined, geographic lesions with narrow
transition zones. A thin sclerotic margin is a typical finding. Simple bone cysts usually are situated
in the intramedullary metaphyseal region immediately adjacent to the physis.

A pathologic fracture through a simple bone cyst is a common occurrence. This may lead to the
‘fallen fragment’ sign, which describes the migration of a fragment of bone to a dependent portion
of the fluid-filled cyst. It occurs in only a minority of patients. This sign is an important
differentiating feature between a simple bone cyst and other nonlytic bone lesions. When present,
the ‘fallen fragment’ sign is pathognomonic of a simple bone cyst.

A 10-year -old boy with a simple bone cyst in the upper metaphyseal region of the right humerus.
A pathologic fracture is noted. A ‘fallen fragment’ is observed within the lesion (arrow). This sign
is pathognomonic of a simple bone cyst.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 15

Aneurysmal Bone Cyst (ABC).

Aneurysmal bone cyst is a rare, solitary, expansive vascular lesion most often located in the long
bones, vertebrae, or flat bones and most frequently seen between 5-20 years

Radiographically, aneurysmal bone cyst of a long bone is a radiolucent lesion, usually

eccentrically located in the metaphysis and often with a characteristic subperiosteal "blow out"
appearance.

Radiograph showing an aneurysmal bone cyst of the tibia.

Fibrous Dysplasia

Fibrous dysplasia is also common the in skull, ribs, and tibia. Radiographs also show a typical
ground glass appearance and scalloping from within.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 16

On CT scan an expansile lesion is seen in a right lower rib exhibits several benign features: sharp
margins, no aggressive periosteal reaction, and no associated soft tissue mass. No cartiliginous
tumor matrix is evident.

Nonossifying Fibroma (Fibrous Cortical Defect)

Nonossifying Fibroma is the most common bone lesion (40% children); - it results from defect of
periosteal cortical bone development which leads to failure of ossification. The lesion typically is a
well marginated radiolucent lesion, with a distinct multilocular appearance. The lesion is usually
irregular and is surrounded by a reactive rim of bone. Typically you should see benign cortical
thinning, erosion, slight expansion.

Look at the following CT , it shows a bony lesion that is mostly sclerotic. It has a sharp zone of
transition, no periosteal reaction, no matrix formation, and lies in the medullary portion of the
bone, adjacent to the lateral cortex. This radiographic appearance strongly suggests a benign
lesion. Entities to consider would include a healing fibrous cortical defect and fibrous dysplasia

Haematopoietic Lesions

Eosinophilic granuloma

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 17

Eosinophilic granuloma (EG) is a solitary, non-neoplastic proliferation of histiocytes. EG is part of

a spectrum of Langerhan's cell histiocytosis, formerly known as histiocytosis X. EG is a localized
lesion in bone or lung and occurs most commonly in children aged 5 to 10.

The radiologic appearance of EG is non-specific and differs by location. The skull may have a
lesion with sharp, punched out borders that is uneven across the inner and outer table causing a
"beveled edge". Pelvic lesions are often poorly defined. Spine lesions are normally found in the
vertebral body. EG is found in the diaphysis or metaphysis of long bones in the center of the
medullary cavity. The lesion may cause endosteal scalloping or a periosteal reaction. Bone scan
is not useful in defining EG. CT scan and MRI delineate the extent of the intramedullary and
cortical penetration. The radiologic differential includes Ewing's sarcoma, osteosarcoma,
metastases and osteomyelitis.

lesion in the diaphysis of the tibia showing in the center of the medullary cavity. The lesion may
cause endosteal scalloping

Myeloma

- Uncontrolled proliferation of marrow plasma cells (highly differentiated B lymphocytes) leads to

the development of this tumour, the most common primary malignant tumour in bone. Common
presentations include bone pain, anaemia and raised ESR in a 50-60 year old patient. Histology
demonstrates sheets of plasma cells (clock faced eccentric nuclei, perinuclear clear area, and

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 18

increased RER on electron microscopy). Of note, the lesion lacks any background stroma. X-ray
shows punched out lesions. Treatment is chemotherapy, radiotherapy and surgical stabilisation
impending fractures.

The following shows a vertebral body biopsy of a lesion under CT guidance, performed by Dr
Viktor Serafimov in the Radiology Department. The patient had severe back pain and the lesion
was seen was seen on the plain film. A scintigraphy suprisingly showed an increase in the signal
intensity of this lesion. This turned out to be multiple myeloma on histology.

Lymphoma of Bone (Histiocytic Lymphoma)

Primary lymphoma of bone (PLB) is a rare malignant neoplastic disorder that affects the skeleton.
Most PLB cases result from non– Hodgkin-type lymphoma PLB has been reported in patients as
young as 2 years and as old as 88 years. The incidence of disease is distributed fairly evenly in
the second through eighth decades The most common radiographic features include the following

? Permeative lytic pattern of bone destruction (74%)

? Metadiaphyseal location (69%)

? Periosteal reaction (58%)

? Soft tissue mass

The following shows a lateral radiograph demonstrating a lytic lesion with a moth-eaten
appearance centered in the mid diaphysis of the tibia.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 19

Typical scintigraphic appearance. Whole body image from technetium 99m bone scan reveals a
solitary area of intensely increased tracer uptake suggestive of Paget disease. An old left rib
fracture and degenerative changes in both hands are evident.

Undetermined Etiology

Giant Cell Tumour

The majority of these tumours present between 20 - 40 yrs and only 3% are found in the
immature skeleton. The usual sites are in the bones adjacent to the knee, distal end of radius and
occasionally in the sacrum or pelvis. The probability of a particular bone tumour location is often
related to the relatively greater normal bone growth in that area. With large tumours, the site of
origin is inferred from the centre of radius of the mass. The osteoclastoma is related to an
apophysis or joint margin.

The cyst like lesion is lobulated, which gives a pseudo- multiloculate appearance on a plain
radiograph. The lesion is typically asymmetrically placed in the bone. The endosteal margin is not
usually sclerotic and can often be hazy. A wider endosteal margin usually means a more
aggresive tumour with a greater possibility of recurrence after curetting. There is thinning of the

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 20

overlying cortex from the expanding lesion. The cortex may be so thinned as to be unseen and
this impression of a soft tissue mass is not necessarily an indication of sarcoma. There is no
periosteal reaction associated with this tumour. The tumour has a vascular character and shows
an increased blood pool phase of the bone scan.

The following radiograph shows an osteoclastoma (giant cell tumour) in the distal ulna

Ewing’s Sarcoma

Second (to osteosarcoma) most common malignant bone tumour of childhood. Occurs in young
children in the flat and axial bones (pelvis), and in the diaphyses of long bones (fibula, femur).
Often associated with systemic signs (fever, weight loss) and local tenderness with erythema and
induration, and can be confused with osteomyelitis.

The radiographic findings of Ewing's reflect its pathologic course. Early on, as the lesion
displaces the marrow elements with only modest bone destruction, it appears a splotchy,
permeative, ill-defined radiolucent process with indistinct margins and a rather wide zone of
transition to normal bone

In this magnified view of the proximal humerus with a Ewing's in the metaphysis, there is early
reactive bone about the medial and lateral cortices.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 21

With continued enlargement, the lesion extends through the reactive new bone that the
periosteum is laying down in an attempt to contain the lesion. This extension results in the
development of a large soft-tissue component. This often destroys the periosteal reaction over
the central portion of the lesion leaving Codman's triangles of reactive bone proximally and
distally.

www.e-radiography.org Society of Medical Radiographers (Malta)

Tumours of the Bone – Dr M Schranz 22

The following table indicates the commonest locations of bone tumours.

LOCATION/SITE TYPICAL PATHOLOGY

Chondroblastoma, chondrosarcoma, giant

Epiphyseal
cell tumour, infection

Metaphyseal Any lesion

Osteoblastoma, Ewing’s eosinophilic granuloma, lymphoma,

Diaphyseal
adamantinoma, fibrous dysplasia

Pelvis Mets, myeloma, Ewing’s, chondrosarcoma, Paget’s Disease.

Proximal humerus Chondroid lesions.

Knee Osteosarcoma, adamantinoma, chondromyxoid fibroma

Ribs Mets, myeloma, Ewing’s chondrosarcoma, fibrous dysplasia

Mets, myeloma, eosinophilic granuloma, chondroma, Paget’s,

Spine (Vertebral body)
haemangioma

Spine (Posterior
Aneurysmal bone cyst, osteoid osteoma, osteoblastoma
elements)

Periosteal Myosotis, osteosarcoma, chondrosarcoma, chondroma

Mets, myeloma, haemangioma, fibrous dysplasia, osteochondromas,

Multiple lesions
enchondromas, histiocytosis X

www.e-radiography.org Society of Medical Radiographers (Malta)