HOW TO APPROACH A

BONE TUMOR
dr. Arie Hendarin
WHO CLASSIFICATION OF BONE
TUMOR
INCINDENCE
NON IMAGING BIOPSY DECISION
FACTORS
 HOW TO APPROACH A BONE
TUMOR ?
General Principles
Bone tumor is broad category : benign and malignant neoplasm (primary &
secondary), miscellanous metabolic abnormality and various tumor-like
conditions.
Use term agressive vs non-agressive process instead malignant vs benign
Imaging modality :
Radiograph : inexpensive, easy to perform, excellent assesment of cortical
features
CT scan : origin of lesion, internal matrix, integrity of cortex
MRI : tumor characterization (fat/fluid-fluid levels), degree of tumor extension for
staging
USG : guided biopsy
FACTORS TO CONSIDER WHEN
EVALUATIONG BONE TUMOR
PATIENT AGE
 GREAT MIMICKER
Osteomyelitis
Eosinophilic Granuloma (EG) / Langerhans Histiocytosis : < 30 y.o
Fibrous Dysplasia : Can also look anything, < 30 y.o, no perisoteal
reaction (Except when fractured)
Metastasis : especially > 30 y.o
 SINGLE / MULTIPLE LESION ?
Multiple Lesion : FEEMHI
Fibrous dysplasia (FD)
Enchondroma
Eosinophilic Granuloma (EG)
Mets, Multiple myeloma
Hyperparathyroid brown tumors
Infection (osteomyelitis)
LESION LOCATION : WHICH
BONE ?
LESION LOCATION : WHERE ALONG THE
BONE ?
LONGITUDINAL PLANE
LESION LOCATION : WHERE ALONG THE BONE ?
TRANSVERSE PLANE
LESION DENSITY
 PATTERN OF BONE
DESTRUCTION
AND LESION MARGINS
Pattern of bone destruction : geographic, moth eaten, permeative reflects
the lesion growth rate
Geographric : non agressive, often but not always benign
Moth eaten and permeative : agressive, often but not always malignant
The lesion margin reflects both the lesion growth rate and the response of
the host bone :
Sharply defined :
Without sclerotic margin
With sclerotic margin
Poorly/ill defined
Zone of transition : wide or narrow
LODWICK CLASSIFICATION
 PERIOSTEAL REACTION
Non specific response of the periosteum to underlying iritation as
periosteum is lifted up by an underlying lesion, it lays down a new bone
The density of the new bone depends on whether the underlying process
is expanding slowly (non agressive) or rapidly (agressive)
Remember : non agressive is often but not always benign. Agressive is
often but not always malignant.
MATRIX MINERALIZATION
 CORTEX INTEGRITY
Intact
Endosteal scalloping
Enchondroma : thinning of cortex > 2/3 raises suspicion for malignant
degeneration
Bulge/expand the cortex thinning of cortex, as in lytic expansile lesion
Cortex destruction
 SOFT TISSUE EXTENSION
Soft tissue should be assessed for :
Density (fat, fluid or air)
Calcification, must be differentiated from ossification
Ossification : corticomedullary is well seen, e.g myositis ossificans
Calcification : osseous or cartilagoneus
Secondary changes in the bone
Primary from bone or from soft tissue ?
AGRESSIVE OR NON AGRESSIVE
 SOME MNEMONICS
Non aggressive lytic lesion : FEGNOMASHIC
Multiple lytic lesion : FEEMHI
Multiple ribs lesion : FAME
CONCLUSION
STAGING PRIMARY BONE TUMOR