Concerning Features and Pathologic FracturesSARAH BOLANDER, MMS, PA-C

Objectives1. Discuss critical history and physical exam components for musculoskeletal tumors/lesions

2. Differentiate aggressive and nonaggressive features on imaging

3. Describe most common clinical presentations and imaging features for the following bone tumors/lesions:

Benign:OsteochondromaEnchondromaOsteoid osteomaOsteoblastomaGiant cell tumorUnicameral bone cystAneurysmal bone cystNon-ossifying fibromaFibrous dysplasia

Malignant:Multiple myelomaOsteosarcomaEwing sarcomaChondrosarcoma

Metastatic tumors

Osteomyelitis

Bone TumorsBenign◦ Latent, active, aggressive

◦ Tumor-like: bone cysts

Malignant◦ Primary

◦ Benign bone tumors are 100x more likely then primary malignant tumors

◦ Secondary

◦ > 30-40 yo: always consider metastasis or plasmacytoma (leading to multiple myeloma)

Clinical PresentationPattern of pain◦ Prior to injury◦ Night, rest, exercise

Medication: ◦ Analgesics or NSAIDS and response◦ Steroid use (bone infarcts)

History of trauma◦ Mechanism of injury

Cancer history◦ Metastasis considerations

Benign: majority asymptomatic◦ Localized pain typically correlates

with the aggressive nature of the lesion

Malignant◦ Variable pain and/or swelling for

weeks to months◦ Soft tissue mass

Metastatic ◦ History of cancer◦ >30 yo: ddx of metastatic and

myeloma even with benign featuresPati

ent

His

tory

Age

Radiology Assistant

< 30 yo

> 30 yo

Location, Location, Location

Radiology Assistant

ImagingRadiographic Imaging: first-line for all tumors◦ Entire bone needs to be imaged◦ Reliable resource to follow benign lesions

◦ May be definitive diagnosis for some benign lesions preventing further studies

MRI: preferred with aggressive features on radiographs ◦ Distinguishes activity of lesion

◦ Bone edema, periosteal reaction, soft tissue mass

CT: sensitive for cortical destruction and mineralization◦ Beneficial: osteoid osteomas and differentiating cartilage lesions

Bone Scan (Technetium Tc 99m): Sensitive for new bone formation

Characteristics of Lesions

Benign or Nonaggressive/Early Malignant

Malignant or Aggressive Benign

Border Well-defined, Sclerotic marginNarrow zone of transition

Ill-definedWide zone of transition

Growth Rate Slow Rapid

Bone Destruction ConfinedGeographic

Infiltrative, cortical destructionMoth-eaten, permeative

Periosteal Reaction UnilaminarSolid

MultilaminarInterrupted

Soft Tissue Involvement Absent Present

BorderWELL-DEFINED, NARROW ZONE OF TRANSITION ILL-DEFINED, WIDE ZONE OF TRANSITION

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 7874Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 7473

Bone DestructionCONFINED: GEOGRAPHIC INFILTRATIVE: MOTH-EATEN/PERMEATIVE

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Periosteal Reaction

Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 23796

Onion Skin

Pathology Outlines

Codman Triangle

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 36446

Sunburst

Case courtesy of mehul, Radiopaedia.org, rID: 53960

Soft Tissue Involvement

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 8024

Matrix • Cumulus cloudOsteoblastic

• Arcs and rings

• PopcornCartilage

• Ground glassFibrous

• LyticNot

Appreciated

Bone Matrix

OsteochondromaBenign bone tumor with cartilage cap: most common◦ Developmental anomaly ◦ Typically solitary appearing during rapid growth

LE > UE

Clinical presentation: asymptomatic◦ Mechanical symptoms: nerve/vascular compression,

Imaging: radiographs (MRI malignancy concerns)◦ Sessile or pedunculated

Malignancy risk: growth following skeletal maturity or aggressive features (cartilage cap > 1.5 cm)◦ 1% risk with solitary lesion◦ MHE: Multiple Hereditary Exostosis (5-25% risk)

Case courtesy of Dr Shrikant Nagare, Radiopaedia.org, rID: 35669

EnchondromaIntramedullary cartilage tumor◦ Metaphyseal

Early adulthood

Clinical presentation: asymptomatic◦ Pain with pathologic fracture

Imaging: incidental finding◦ Radiographs: nonaggressive lytic lesion◦ +/- expansile: hands/feet◦ No periosteal reaction or soft tissue involvement

Rare transformation to chondrosarcoma◦ Concerns with pain or if epiphyseal◦ MRI helps with differentiation

Case courtesy of Radswiki, Radiopaedia.org, rID: 11389

Osteoid OsteomaBenign bone forming tumors

◦ Long bones > phalanges > vertebrae

10-35 yo, M > F

Classic presentation: severe, deep night pain◦ Relieved by ASA

Lucent nidus surrounded by fibrovascular rim with surrounding sclerosis◦ Nidus is < 2 cm, releases prostaglandins causing pain

Imaging: Radiographs may be normal or cortical thickening with lucent nidus◦ CT modality of choice

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6131

OsteoblastomaRare, benign bone tumor◦ Histologically similar presentation to osteoid osteoma

◦ Axial skeleton > long bones

Locally aggressive

Middle-age, M>F

Clinical Presentation: dull pain◦ Worse at night

◦ Unresponsive to ASA

Imaging: expansile lytic with sclerotic rim◦ Radiographs, CT, but MRI less beneficial

Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 48855

Giant Cell TumorBenign, Aggressive tumor◦ Following growth plate closure

◦ Metaphysis through epiphysis of long bones

◦ Femur/tibia > radius, sacrum, vertebrae

Early adulthood

Clinical presentation: Insidious bone pain◦ Soft tissue mass

◦ May be found incidentally

Imaging: Well-defined, eccentric, abut articular surface without sclerotic rim◦ Radiographs, MRI

Case courtesy of Radswiki, Radiopaedia.org, rID: 11453

Unicameral Bone Cyst: UBCMost common benign bone lesion◦ “Simple Bone Cyst”◦ Metaphysis long bones: upper humerus > femur

Adolescents

Clinical Presentation: asymptomatic◦ Pathologic fracture presenting sx

Imaging: Geographic, well-defined◦ Radiographs (MRI/CT typically not needed)◦ Nonaggressive, expansile◦ Pathologic fx: fallen leaf (fragment) sign

Aneurysmal Bone Cyst: ABC

Expansile tumor-like lesion◦ Metaphysis of long bones > spine

80% < 20 yo

1/3 secondary to underlying cause

Clinical presentation:◦ Asymptomatic

◦ Pathologic fracture or palpable mass

Imaging: osteolytic with thin cortex◦ Radiographs

◦ MRI: Fluid-Fluid levels

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 14333

Non-Ossifying Fibroma: NOFBenign fibrous lesion◦ Larger cortical defect (>3 cm)

10-15 yo, M>F

Clinical Presentation: asymptomatic◦ Pathologic fracture

Imaging: Incidental finding◦ Radiographs: nonaggressive features

MES: metaphyseal, eccentric, sclerotic

Case courtesy of Dr Erik Ranschaert, Radiopaedia.org, rID: 10862

Fibrous DysplasiaOften asymptomatic and incidental finding on imaging

Symptoms may arise from bone expansion ◦ Cosmetic appearance

◦ Soft tissue compression or displacement

Monostotic > Polyostotic

Imaging: Radiographs and CT◦ “Ground Glass” opacities

◦ Well-defined, no periosteal reaction

Case courtesy of Dr Salman S. Albakheet, Radiopaedia.org, rID: 60893

Multiple MyelomaMultiple Myeloma: Most common primary bone neoplasm in adults◦ Bone marrow: entire skeleton involved

◦ Most common vertebrae

>40 yo, M>F,

Risk: radiation or pesticide exposure, HIV

Clinical Presentation: Fatigue, fever, night sweats, diffuse bone pain

Imaging: Skeletal survey◦ Radiographs: punched out lesions

◦ MRI more sensitive and PET-CT helps with distribution

Labs: Anemia (normochromic/normocytic), hypercalcemia◦ Reverse albumin/globulin ratio

◦ U/A shows Bence-Jones proteins

OsteosarcomaHigh grade malignancy

Most common primary bone tumor in young patients◦ Primary tumor: 10-20 yo

◦ Distal femur > proximal tibia > humerus

◦ Secondary tumors due to malignant degeneration: elderly

2nd and 3rd decades of life

Clinical Presentation (primary):◦ Bone pain, soft tissue mass◦ Pathologic fracture

Imaging: Aggressive features◦ Permeative, sunburst, Codman triangle◦ MRI: Essential tool, soft tissue involvement

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 7529

Ewing SarcomaHighly malignant primary bone tumor◦ Metadiaphysis, diaphysis: Femur > tibia, humerus,

pelvis◦ Large tumors

10-20 yo, M > F

Clinical Presentation: local pain◦ May have soft tissue mass or pathologic fracture◦ +/- fever with elevated ESR

Imaging: Aggressive features◦ Permeative, onion skin◦ Soft tissue extension

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 7844

ChondrosarcomaMalignant cartilaginous tumor

◦ Primary and secondary tumors

◦ Femur > pelvis > UE

Middle age to older adults

Low-immeadiate grade

Clinical presentation:

◦ Pathologic fracture

◦ Palpable mass

Imaging: aggressive, lytic

◦ Calcifications: rings and arcs

◦ Moth eaten, permeative

Case courtesy of Dr Domenico Nicoletti, Radiopaedia.org, rID: 30655

Metastatic TumorsLead Kettle (PB-KTL): Prostate, Breast, Kidney, Thyroid, Lung

Clinical Presentation: Asymptomatic

◦ Pathologic fracture, soft tissue mass, localized pain

Diagnostics:

◦ Labs: anemia

◦ Imaging: vertebrae, proximal femur/humerus, pelvis, skull

◦ Osteolytic bone destruction (KTL), osteoblastic/sclerotic (P), or mixed (B)

◦ Bone Scan

Osteomyelitis Bacterial >> Fungal, TB, Virus

LE > vertebrae, radial styloid, SI joint◦ Neonates: metaphyseal/epiphyseal

◦ Children: metaphysis

◦ Adults: epiphyseal/subchondral regions

Always a differential for aggressive lesions

1. Direct extension: open wound◦ Diabetic foot ulcer, post op infection

2. Hematogenous spread of infection: most common

◦ 80-90%: Staphylococcus aureus◦ Others specific to scenario (i.e. neonates, IVDU, etc)

OsteomyelitisImaging

Earliest Consideration: Soft Tissue swelling

Radiographs:◦ Localized Osteopenia

◦ Lytic lesion with cortical destruction

◦ Periosteal reaction

MRI: most sensitive and specific for soft tissue and joint involvement

Sequestrum: dead bone, it appears dense as it is devitalized bone◦ Late occurrence

◦ CT helpful

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 7651

Correlate FindingsHISTORY, PHYSICAL EXAM, AND DIAGNOSTICS

References and Resources1. Özer, E. Ewing sarcoma / primitive or peripheral neuroectodermal tumor (PNET).

PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/boneewing.html. Accessed December 27th, 2018.

2. Mehta K, McBee MP, Mihal DC, England EB. Radiographic analysis of bone tumors: a systematic approach. Semin Roentgenol. 2017; 52(4): 194-208.

3. Umer M, Hasan OHA, Khan D, Uddin N, Noordin S. Systematic approach to musculoskeletal benign tumors. Int J Surg Oncol. 2017; 2(11): e46.

4. Costelloe CM, Madewell JE. Radiography in the initial diagnosis of primary bone tumors. Am J Roentgenol. 2013; 200: 3–7.

5. Ennecking WF. Musculoskeletal tumor surgery. New York, NY: Churchill Livingstone; 1983.

6. Yildiz C, Erler K, Atesalp AS, Basbozkurt M. Benign bone tumors in children. Curr Opin Pediatr.2003; 15: 58.

7. Cruz AI, Lindskog D. Pathologic fractures through benign bone lesions in children and adolescents. Curr Orthop Pract. 2011; 22(4): 351-361.

8. Miwa S, Otsuka T. Practical use of imaging technique for management of bone and soft tissue tumors. J Orthop Sci. 2017; 22(3): 391-400.

Questions?