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Imaging of Benign and MalignantBone tumors

F.M. Vanhoenacker

Outline

• Introduction

• Benign tumors

• Pseudotumors/ tumor-like lesions

• Malignant tumors

• Conclusion

Where science meets medicine for the benefit of the patient

Introduction

Where science meets medicine for the benefit of the patient

Case 1: 12-y-o female with low back pain

A. Benign tumor

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

Case 2: 22-y-o male with wrist pain

A. Benign tumor

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

Case 3: 14-y-o female with groin pain

A. Benign tumor

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

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Benign tumors

Where science meets medicine for the benefit of the patient

Dense bone island

XR: spicular margins; CT high density (HU); MRI low SI on all pulse sequences

Dense bone island

XR: spicular margins; CT high density; MRI low SI on all pulse sequences

Osteoid Osteoma

MRI shows BME; CT is the preferred technique for demonstration of nidus

Case 1: 12-yo female with low back pain

A. Benign tumor: O.O.

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

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Osteoid Osteoma

MRI shows BME; CT for demonstration of nidus; spine posterior

Osteoblastoma

Larger nidus ≥ 1,5 cm, less typical clinical symptoms

Osteoblastoma Non Ossifying Fibroma (NOF)

XR: well defined, progressive sclerosis; MRI variable SI, no soft tissue mass

Non Ossifying Fibroma (NOF)

XR: well defined, progressive sclerosis; MRI variable SI, no soft tissue mass

Adamantinoma

Young age XR: anterior tibia cortex;lytic-sclerotic; MRI, 2/3 extension axial images

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Osteocartilaginous Exostosis

XR: continuity cortex/medulla; sessile vs stalk away from joint(coathanger)

Osteocartilaginous Exostosis

MRI: thickness of hyaline cartilage cap of high T2 signal; marker for benignity

Osteocartilaginous Exostosis

US: thickness of hyaline cartilage in superficially located lesions Benign complication: fracture at narrow stalk

Osteocartilaginous Exostosis

Osteocartilaginous Exostosis

Benign complication: impingement on adjacent structures

Benign complication: impingement on adjacent structures and bursitis de novo

Osteocartilaginous Exostosis

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Osteocartilaginous Exostosis

Benign complication: local impingement on adjacent structures: muscle tear

Osteo cartilaginous Exostosis

Malignant complication: chondrosarcoma, soft tissue mass-chondroid calcifications

Osteocartilaginous Exostosis

Malignant complication: chondrosarcoma, soft tissue mass, chondroid matrix

Hereditary Multiple Exostosis Syndrome

Hereditary Multiple Exostosis Syndrome

Modeling defects: trumpet-like metadiaphysis and pseudomadelung deformity

Enchondroma

Chondroid calcifications: “Popcorn” – “Ring and Arcs”

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Enchondroma

chondroid calcifications: “Ring and Arcs”, pathological fracture hands/feet

Enchondroma

MRI: Chondroid matrix high on T2-WI – Lobular - “Ring and Arcs” enhancement

Enchondroma

MRI: low SI on T1- and T2-WI? – Lobular - “Ring and Arcs” enhancement

Enchondroma

Dense chondroid calcifications: “Popcorn” – “Ring and Arcs”

MRI: geographical pattern

Bone infarct Chondroblastoma

Young age, epiphysis, high T2 SI, marked BME

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Chondroblastoma

CT: well demarcated, chondroid matrix, (aggressive)

Intra-osseous ganglion cyst

Older age, associated cartilage lesion, BME

Solitary bone cyst

Location (humerus/femur/….) – fallen fragment sign – high SI on T2-WI

Solitary bone cyst

Location (humerus/femur/….) – high SI on T2-WI – rim enhancement

Aneurysmal bone cyst

Location (metaphysis) – expansile – “soap bubble”

Aneurysmal bone cyst

MRI– Fluid-fluid levels- multilocular enhancement (solid variants exists)

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Case 2: 22-y-o male with wrist pain

A. Benign tumor

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

MRI of the same patient. Sagittal FS T2-WI and axial T2-WI. There is lesion extension withinpronator quadratus muscle (arrows). The lesion is of relatively low SI on the T2-WI, in keepingwith hemosiderin deposition, which favors the diagnosis of a giant cell tumor.

Giant Cell Tumor

MRI of the same patient. Axial FS T1-WI after administration of gadolinium contrast. There is markedenhancement of the lesion and its soft tissue extension (arrows). Note also surrounding bonemarrow edema (star).

Giant Cell Tumor Giant Cell Tumor

Pseudotumors/tumor-like

Where science meets medicine for the benefit of the patient

Case 3: 14-y-o female with groin pain

A. Benign tumor

B. Malignant tumor

C. Tumor-like

D. Pseudotumor

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Fibrous Dysplasia

Variable location, fibrous matrix; lytic, mixed (“rind sign”), ground-glass.

Fibrous Dysplasia

MRI: not useful for characterization, but useful for local extent and pediatrics

Fibrous Dysplasia

MRI: Mc Cune Albright syndrome and narrowing orbits

Fibrous Dysplasia

MRI: Polyostotic fibrous dysplasia and Soft tissue myxoma (courtesy B. Daenen)

Fibrous Dysplasia

Scintigraphy for evaluation of polyostotic disease Mc Albright/Mazabraud

Intra-osseous lipoma

Often located in calcaneus, radiolucent on XR, resembles cyst, but fatty content+/-calcification, older age than cyst, potentially evolution of same lesion.

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Paget’s disease

Monostotic Paget cause confusion: osteolytic front, bone expansion, coarsetrabeculae

MRI of a 50-year-old male with a painfull suprapatellar soft tissue swelling. T1-WI and FS T2-WIshow a lesion within the quadriceps with extension within the patella and prepatellar soft tissue(arrows). Note also a bone infarct within the distal femur.

Tophaceous gout

MRI of a 50-year-old male with a painfull suprapatellar soft tissue swelling. Sagittal and axial FST1-WI after gadolinium contrast administration show a lesion within the quadriceps (arrows)with extension within the patella and prepatellar soft tissue (arrows).

Tophaceous gout

Malignant tumors

Where science meets medicine for the benefit of the patient

Osteosarcoma

Two age peaks, osteoid matrix, aggressive periosteal reaction, MRI for local extent and skip metastasis

Ewing’s sarcoma

usually lytic (sclerotic) (mixed)

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Ewing’s sarcoma

Variable periosteal reaction along the growth velocity / aggressive nature

Ewing’s sarcoma

MRI: typical large soft tissue component

(Changing) calcifications – scalloping – cortex destruction – epiphyseal extension

Chondrosarcoma Chondrosarcoma

(Changing) calcifications – scalloping – cortex destruction – epiphyseal extension

Chondrosarcoma

MRI: scalloping – cortex destruction – epiphyseal and ST extension –ring enhancement –role dynamic MRI

Chordoma

Location at sacrococcyx/cervicocranial junction – elderly – multilevel –sparing disc space

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ConclusionBasic principles in diagnosis

Age

Location

Multiplicity

Imaging parameters

Conclusion

• Plain films are the mainstay– Detection– Characterization– CT: complex anatomical regions

• MRI– Local staging– (Characterization)– Follow-up after treatment

Conclusion