Imaging Diagnosis

of Bone Tumors:
Beyond Pattern
Recognition

Susan V. Kattapuram, M.D.

Massachusetts General
Hospital
Harvard Medical School
 PATTERN RECOGNITION

If my own Aunt Minnie

walked into the room
would you ask how I
knew her?
Variably attributed to Ben
Felson and E.B.D. Neuhauser

Aunt
Minnie
Aunt Minnies

Aunt
Aunt Minnies
 2 KEYS TO DIAGNOSIS
Grade and Tissue Type
GRADE
Local aggressiveness (margins)
Differentiation (maturity of matrix)
Metabolic activity
Size
TISSUE TYPES:
Bone

Cartilage

Round cells
 BONE MARGINS

TYPE I: TYPE II: TYPE III:

GEOGRAPHIC MOTH-EATEN PERMEATED

 MARGINS
TYPE I TYPE II TYPE III
Geographic Moth-eaten Permeated
 MARGINS
TYPE I TYPE II TYPE III
Geographic Moth-eaten Permeated
SCLEROTIC MARGINS

WALL INFLAMMATORY INVOLUTING

 Sclerotic Margins

CYST N.O.F. F.D. ABSCESS

 SCLEROTIC MARGINS

INVOLUTING INFLAMMATORY

Fibrous Dysplasia Osteoid osteoma

Non-ossifying Chondroblastoma
fibroma
Eosinophilic Abscess/Eosinophilic
granuloma granuloma
 MATRIX:
BONE
MICROSCOPIC
Cloud-like
Fluffy

MACROSCOPIC
Spicules
Cortex

DENSITY
Does not
exceed cortex
 BONE LESION GRADE
LOW :
Small lesion
Densely mineralized

Rare

HIGH:
Sparsely mineralized
Invasive
 OSTEOMA
ADULTS
SLOW GROWTH
SYMPTOMS (if any) DUE TO MASS
MEDULLARY- Bone island
PERIOSTEUM-
SKULL Button osteoma, Sinuses >> LONG
BONES Ivory exostosis
 Bone Islands
(osteopoikilosis
)
Uniform, mature
bone
Oval, long axis
parallel to stress
lines
Serrated, irregular
outlines
 OSTEOMA

BONE ISLAND BUTTON OSTEOMA

 Multiple Osteomas
(Idiopathic, Gardners Syndrome,
Tuberous sclerosis, osteopoikilosis)
 OSTEOID OSTEOMA
CHILDREN, YOUNG ADULTS,
NO GROWTH
MALE>>FEMALE
PAINFUL
CORTEX = PERIOSTEUM, >
MEDULLARY
LONG BONES >> FLAT BONES
 OSTEOID OSTEOMA

medullary
cortica periosteal
 OSTEOBLASTOMA
CHILDREN, YOUNG ADULTS
PROGRESSIVE
PAINFUL
MEDULLARY > PERIOSTEAL
SPINE (blastic) > LONG BONES (lytic)
TRANSITION LESION
AGGRESSIVE, PSEUDOMALIGNANT
FORMS
OSTEOBLASTOMA

6 mths later
OSTEOBLASTO
MA
 Aggressive
osteoblastoma
 Aggressive
osteoblastoma vs OSA
17 male
Osteoblastoma
curettaged,
packed
? recurrence

Osteosarcoma
 OSTEOSARCOMA:
a malignant tumor which
forms bone
CHILDREN, YOUNG ADULTS BUT
LONG TAIL
MOST FREQUENT 1
MALIGNANT BONE TUMOR
PAINFUL
MEDULLARY > PERIOSTEAL >
SOFT TISSUE > CORTEX
LONG BONES > SPINE
 OSTEOSARCOMA
TYPES:
Location in Bone
MEDULLARY most common
INTRACORTICAL least common
SURFACE conventional, parosteal,
periosteal
SOFT TISSUE
SPECIAL SITES:
MANDIBLE, SPINE
OLDER, SOMEWHAT BETTER
PROGNOSIS
OSTEOSARCOMA
Intramedullary
PAROSTEAL OSA
LOW GRADE,
WELL DIFFERENTIATED BONE
 PAROSTEAL
OSTEOSARCOMA:
Marrow invasion
SURFACE OSA:
(conventional)
Intracortical
Osteosarcoma
 OSTEOSARCOMA
TYPES:
PRIMARY ETIOLOGY
SECONDARY
Genetic-
Li Fraumeni syndrome
Familial retinoblastoma

Pre-existing lesions
Paget sarcoma
Fibrous dysplasia

Dedifferentiation

Radiation
 SECONDARY
SARCOMA

Initial 9 mths
 SECONDARY
SARCOMA

Ax Cor T2 T1
postgado
 OSTEOSARCOMA TYPES:

HISTOLOGY
OSTEOBLASTIC
CHONDROBLASTIC
FIBROBLASTIC
TELANGECTATIC

mmary #4: Many lesions contain more than one cell type !
 OSTEOSARCOMA:
Osteobla Chondroblastic Telangiect
stic atic
 OSTEOSARCOMA:
Imaging longitudinal extent

Longitudinal and soft tissue Attenuation differences >

extent best seen on MR 20 HU are abnormal
images
OSTEOSARCOMA:
Special anatomical
situations
 CARTILAGE MATRIX:
WATER CONTENT
LOW ATTENUATION
HIGH T2 SIGNAL

NODULES (HYALINE TYPE)

CALCIFICATION
AMORPHOUS (dense!)
ENDOCHONDRAL BONE FORMATION

AVASCULAR
 CARTILAGE TUMORS:
GRADE
LOW:
NODULES
MINERALIZATION THROUGHOUT
HIGH
UNCOMMON
DEGENERATED vs. DEDIFFERENTIATED
ALL:
INVASIVE IN BONE, PUSHING IN SOFT
TISSUES
 CHONDROMA
ADULTS
MEDULLARY (enchondroma) >>
PERIOSTEAL SOFT TISSUE>> CORTICAL
SYMPTOMS
Medullary - none
Periosteal, Cortical - PAIN
SLOW OSSIFICATION
MULTIPLE LESIONS:
Olliers Disease
Maffuccis Disease
ENCHONDROMA
ENCHONDROMA
 OSTEOCHONDROMA:
A GROWTH DISTURBANCE
CHILDREN, YOUNG ADULTS
Growth ceases at skeletal maturity
May (rarely) regress
SYMPTOMS (if any) DUE TO MASS OR
COMPLICATION:
Fracture
Bursitis
Malignant degeneration
LONG BONES >> FLAT BONES
SUBTYPES
Radiation
Trauma
Multiple hereditary
OSTEOCHONDROMA
OSTEOCHONDROMA
OSTEOCHONDROMA
Cartilage cap
 OSTEOCHONDROMA

Medullary continuity
Cartilage cap

Soft tissue mass

OSTEOCHONDROMA

Points
wrong
PERIOSTEAL
CHONDROMA
PERIOSTEAL
CHONDROMA
 CHONDROBLASTOMA
CHILDREN, YOUNG ADULTS
LONG BONE EPIPHYSIS (humerus,
femur)>> FLAT BONES
PAINFUL (prostaglandin)
GROWTH USUALLY LIMITED
CHONDROBLASTOMA
CHONDROBLASTOM
A
CHONDR
OMYXOID
FIBROMA
Usually resembles
non-ossifying
fibroma
Not usually
calcified
 CHONDROSARCOMA
Third most common primary
malignant bone tumor
Older adults
Some pain
Long bones >> Flat bones
Mostly low, intermediate grade
 CHONDROSARCOMA
SUBTYPES BASED ON
LOCATION

MEDULLARY (CENTRAL) most

common
INTRACORTICAL least common
SURFACE (PERIPHERAL)
SOFT TISSUE (rare)
 CHONDROSARCOMA
SUBTYPES BASED UPON ETIOLOGY:
Primary
Secondary: DEGENERATION of chondroma
SUBTYPES BASED UPON
HISTOLOGY
HYALINE
MYXOID
DEDIFFERENTIATED
MESENCHYMAL (soft tissues)
CLEAR CELL (epiphyseal, slow)
CHONDROSARCOMA:
borderline lesion
CHONDROSARCOMA:
Longitudinal growth
CHONDROSARCOMA
nodular growth
CHONDROSARCOMA:
Arising from osteochondroma
CHONDROSARCOMA:
surface lesion
CHONDROSARCOMA:
Soft Tissue
CHONDROSARCOMA:
Mesenchymal
CHONDROSARCOMA:
High grade
CHONDROSARCOMA:
Dedifferentiation
CHONDROSARCOMA:
Dedifferentiation
ROUND CELL TUMORS
Ewing Family
There is no mature tissue of origin
Histochemistry: 95% express p30/32 MIC2 antigen
Cytogenetics: 85% contain a specific translocation t(11;22)
(Q24;Q12).

Lymphoma
Metastases
 EWING TUMOR
Second most common 1 bone tumor
80% < age 20
Males > females
Survival
before chemotherapy 5-10%
current 70%

Neural origin same as PNET and

ASKIN tumor
EWING / PNET:
Permeated margins

Subperiosteal
spread
Ewing Tumor
ROUND CELL TUMOR:
RAPID GROWTH AFTER
PATHOLOGICAL FRACTURE

2 mths later
 ROUND CELL TUMOR:
RAPID GROWTH AFTER PATHOLOGICAL
FRACTURE
 EWING TUMOR:
PROGNOSIS
GOOD PROGNOSTIC FEATURES:
Distal location
Rib
Good response to chemo (>90%
histological necrosis)*
BAD PROGNOSTIC FEATURES:
Large (>8-10 cm or 100 ml)
Central (especially pelvic tumors)

* Wunder, Jay S.; Paulian, Gabe; Huvos, Andrew G.; Heller, Glenn; Meyers, Paul A., and Healey, John
H. The histological response to chemotherapy as a predictor of the oncological outcome of operative
treatment of Ewing Sarcom. Journal of Bone and Joint Surgery. 1998 Jul; 80-A(7):1020-1033
 EWING FAMILY LYMPHOMA

MEDULLARY > SURFACE OR S.T. MEDULLARY > ST

DIA = METAPHYSIS DIA = METAPHYSIS

LONG BONES > SPINE

TRUNK > LONG BONES

AGE 5-30
AGE 20-60
PAINFUL, OFTEN SYSTEMIC
SYMPTOMS OFTEN NOT VERY SICK

T(11;22) TRANSLOCATION
 EWING / PNET:
Soft tissue primary
Before Chemotherapy: 4/26/00