39David Sutton

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 39.1 Multiple skeletal metastasis is demonstrated on a whole-body radionuclide bone scan. The primary tumour was carcinoma of the breast in a middle-aged woman. Note the predominantly axial distribution of the lesions, many of which were not apparent on conventional radiographs. (A) PA view. (B) AP view.

• Fig. 39.2 Metastatic carcinoma of the bronchus. Sagittal T1 - weighted (A) and STIR(B) MRI sequences obtained in the body coil demonstrate extensive metastasis throughout the thoracolumbar spine and liver. The primary bronchial carcinoma is also evident.

• Fig. 39.3 Two examples of solitary metastasis producing bone in the adjacent soft tissues. (A) Carcinoma of the colon in a great toe metatarsal. (B) Transitional cell carcinoma of the bladder in the mid tibia.

• Fig. 39.6 Carcinoma of the prostate with expansile lytic metastasis. (A) A view of the pelvis before the onset of symptoms reveals no abnormality in the pubic rings. (B) Five years later the patient was complaining of severe pain in the groin. Note the ill-defined trabecular pattern, expansion of bone and ill definition of cortex that has developed since the previous examination.

• Fig. 39.6 Carcinoma of the prostate with expansile lytic metastasis. ( (C) Blood-pool phase of a bone scan and (D) delayed image reveals a marked increase in activity. Note the abnormality in the lesser trochanter of the right femur. These features could not be distinguished from active aggressive Paget's disease on purely scintigraphic grounds except that the lesion in the right femur has not started at a joint. The diagnosis was established by biopsy and the presence of a very high acid phosphatase level in the blood.

• Fig. 39.7 (A,B) Two examples of solitary metastasis from renal cell carcinoma. In both cases, these metastases were the presenting abnormality. Both are expansile and have crenellated margins, with trabeculation in the lesion.

• Fig. 39.8 Metastasis from carcinoma of thyroid. (A) A localised view of the anterior inferior iliac crest shows a small radiolucent defect with a faint sclerotic margin (arrows). (B) Five years later a very large destructive bone lesion is present with relatively well defined margins and apparent strands of calcification within the lesion

• Fig. 39.8 Metastasis from carcinoma of thyroid. (C) CT confirms the very extensive nature of the tumour and shows the soft-tissue planes to be preserved (arrow). The strands of calcification are shown to be residual bone anteriorly and posteriorly and not new bore in the metastasis.

• Fig. 39.8 Metastasis from carcinoma of thyroid. (D,E) Common iliac arteriography (subtraction images) demonstrates the very vascular nature of this metastasis. Note the increase in number of abnormal vessels with changing calibre, the dense tumour blush and early venous filling.

• Fig. 39.9 Pancoast tumour-carcinoma of the apex of the lung invading and destroying the first and second ribs.

• Fig. 39.10 Bone island-enostosis. (A) A dense area of endosteal sclerosis present in the upper femoral shaft, discovered by chance following injury. (B) A bone scan reveals slight increase in activity localised to the area of sclerosis. Biopsy confirmation. (C) Enostosis, acetabular roof. Uniformly dense circular lesion with characteristic radiating spicules extending into the adjacent bone.

• Fig. 39.11 Ivory osteomas of the frontal sinus. (A) A typical, compact, rounded, dense opacity is demonstrated on the frontal view. (B) In another patient a larger lesion has moulded to the shape of the sinus.

Fig. 39.12 Osteoid osteoma. (A) Involving the ulna in a 13-year-old boy. The appearances are typical, with a well-defined area of radiolucency (arrow) containing a dense nidus. Extensive cortical sclerosis is present around the lesion. (B) Radioisotope bone scan in another patient demonstrating intense focal increased scintigraphic activity in the distal tibia surrounded by a more diffuse area of less intense activity, typical of an osteoid osteoma. (C) CT section of the tibial lesion elegantly demonstrating the cortically located nidus.

• Fig. 39.13 Osteoid osteoma-a young man complaining of groin pain. (A) Initially it was thought the X-rays were normal; however, in retrospect, a small radiolucency (arrow) is present. A bone scan was performed in order to detect any occult cause of pain. (B) A localised focus of increased vascularity is shown on the blood-pool film (arrow).

• Fig. 39.13 Osteoid osteoma-a young man complaining of groin pain. (C) Extensive abnormality on the delayed film. (D) CT demonstrates the radiolucent defect anteriorly (closed arrow) with associated, consolidated periosteal new bone. A nutrient artery is shown posteriorly (open arrow) and is an incidental finding.

• Fig. 39.14 Osteoid osteoma in a young girl complaining of left hip and knee pain, initially thought to be due to juvenile onset rheumatoid arthritis. (A) A subtle radiolucency with a central density is shown in the basi-cervical region of the left femur. (B) Coronal FFE-T 2 MR section demonstrating high signal intensity within the proximal left femur due to considerable bone marrow oedema. A joint effusion is evident also together with some surrounding soft tissue oedema.

• Fig. 39.14 Osteoid osteoma in a young girl complaining of left hip and knee pain, initially thought to be due to juvenile onset rheumatoid arthritis (C) Axial T2 -weighted MRI showing a prominent left hip joint effusion and bone marrow oedema within the femoral neck. The nidus, however, is not evident. (D) Axial T 2 - weighted image through the proximal femur demonstrating more striking bone marrow oedema distal to the joint capsule and level of the osteoid osteoma. Periosteal new bone formation is also shown anteriorly (arrow). (E) Thin section CT showing the anteriorly located calcified nidus within the cortex of the femoral neck and the large joint effusion.

• Fig. 39.15 Osteoid osteoma in the proximal phalanx of the index finger. (A) The AP radiograph shows ill-defined periosteal new bone formation and some sclerosis involving the proximal phalanx. Marked soft-tissue oedema is also evident. (B) The lateral radiograph demonstrates apparent expansion and scalloping of the distal anterior cortex of the proximal phalanx with trabecular sclerosis distal to the radiolucent nidus (arrows).

• Fig. 39.16 Osteoblastoma of the right transverse process and pedicle of L3. An ill-defined radiolucency is shown within a sclerotic and expanded transverse process and pedicle.

• Fig. 39.17 Osteoblastoma of the left transverse process of L3. (A) In this example the central area exhibits calcification. Expansion is present with diffuse sclerosis. (B) Note on the bone scan (which has been reversed for ease of comparison) the extensive area of increased activity corresponding to the whole of the osteoblastoma on the plain film. Note also the scoliosis, with which these patients may present.

• Fig. 39.18 Osteoblastoma of the left pedicle and lamina of L3. (A) Conventional oblique radiograph showing expansion and sclerosis. (B) Radionuclide bone scan demonstrating extensive and marked increase in activity and a scoliosis. (C) CT section showing punctate calcification of the lesion with expansion of the pedicle and lamina and prominent dense sclerosis. Considerable soft-tissue oedema is also evident (arrows).

• Fig. 39.19 Aggressive osteoblastoma. (A) Conventional radiograph demonstrates a large area of ill-defined bone sclerosis extending into the soft tissues above the acetabular roof. This had been previously biopsied. A vague ill-defined zone of radiolucency is demonstrated within the proliferative new bone. (B) A T,-weighted coronal MR image demonstrates extensive low-signal abnormality throughout the whole of the right iliac blade down to the acetabular roof. A soft-tissue component is also evident. This scan also illustrates how difficult it can be to assess sclerotic lesions using MRI

• Fig. 39.20 Osteosarcoma of the distal fibula-predominantly osteoblastic. Amorphous calcification/ossification is present in the soft tissues with cortical destruction and a little periosteal new bone formation.

• Fig. 39.21 Osteosarcoma of the distal femur-predominantly chondroblastic. Note the well-defined soft-tissue mass and radiating spiculation of calcification within it. Sclerosis and lysis are present within the medullary cavity that is slightly expanded.

• Fig. 39.22 Telangiectatic osteosarcoma of the distal femur. (A) A predominantly radiolucent defect is shown on conventional radiograph which angiographically (B) is shown to contain large, tortuous, pathological vessels. Well-marked Codman's triangles are present together with sclerosis in the shaft of the bone, surrounding the lesion.

• Fig. 39.23 An advanced osteosarcoma of the proximal humerus presents with a pathological fracture. A large well-defined soft-tissue mass contains calcification and ossification. Codman's triangles are present. Extensive tumour in the medulla has caused both bone destruction and bone formation.

• Fig: 39.25 Osteosarcoma- metastasis in the lung present with a pneumothorax.

• Fig. 39.24 Osteosarcoma of the spine. (A) A conventional radiograph of the upper lumbar spine shows a extensive area of tumour new bone formation arising from the lamina of Ll and extending into the paravertebral soft tissues. (B) The CT section demonstrates the origin and extent of the tumour. Marked compression of the dural sac results from extension onto the spinal canal.

• Fig. 39.26 (A) Metastasis from osteosarcoma presents with an encysted pleural effusion on the right after several months apparently disease free after amputation. (B) A CT scan demonstrates the encysted effusion in the horizontal fissure with calcification dorsally due to metastasis. This feature had not been appreciated on conventional tomography. A second metastasis is shown in the right lower lobe, again not obvious on conventional radiographs.

• Fig. 39.27 Osteoblastic osteosarcoma of the proximal tibia. (A) The conventional radiograph reveals patchy increased density in much of the upper tibia. Note a little new bone laterally.

• Fig. 39.27 Osteoblastic osteosarcoma of the proximal tibia. (B) A scan in the early blood-pool (left) and delayed phases (right) demonstrates an extensive abnormality. Note the activity is more uniform and extensive than the apparent involvement shown on the plain film. The distal extent of the tumour is confirmed however by (C), a CT scan which shows a subtle change in marrow attenuation below the level of the apparent tumour on plain film, an example of how CT may be used to gauge the extent of marrow involvement.

• Fig. 39.28 Osteosarcoma of the distal femur of a young woman. (A) The full intraosseous extent is difficult to assess on the plain film. (B) An arteriogram demonstrates a very extensive pathological circulation and on the late capillary phase (C) note that the tumour extends into the epiphysis, almost to the articular surface, and that there is a satellite or 'skip' lesion in the proximal femoral shaft (arrow).

• Fig. 39.28 Osteosarcoma of the distal femur of a young woman. (C) note that the tumour extends into the epiphysis, almost to the articular surface, and that there is a satellite or 'skip' lesion in the proximal femoral shaft (arrow). This latter lesion is confirmed by CT (D), and is shown to be bone forming (the upper image shows an attenuation of 188 HU in the lesion).

• Fig. 39.29 Osteoblastic osteosarcoma. A middle-aged woman presented with pain and swelling in the mid ulna. (A) A radiograph shows ill-defined sclerosis and cortical destruction. (B) An angiogram demonstrates an egg-shaped soft-tissue mass with displacement of both the ulnar and interosseous arteries. The extraosseous extent of the tumour was thereby delineated.

• Fig. 39.30 Osteosarcoma. Coronal T,-weighted (A) and STIR (B) sequences demonstrate an extensive osteosarcoma of the lateral femoral condyle. The pleomorphic nature of the tumour can be appreciated by the more superficial main neoplasm with subadjacent marrow oedema. Note the overlying abnormal vessels shown as a signal void and the joint effusion on the STIR sequence. Clear extension across the metaphysis is also shown. These features confirm an extracompartmental osteosarcoma.

• Fig. 39.31 Osteosarcoma of the proximal humerus. (A) Conventional radiograph showing permeative bone destruction and focal areas of intramedullary sclerosis. A spiculated periosteal reaction is also evident. Axial T 1 -weighted (B) and coronal STIR (C) images demonstrate the longitudinal extent of the tumour within the medullary canal and the extraosseous involvement, including extension into the shoulder joint (arrows).

• Fig. 39.32 Osteosarcoma of the proximal tibia. (A) Conventional radiograph demonstrating an osteosclerotic lesion with Codman's triangles and a pretibial soft-tissue mass. (B) Sagittal T1 –weighted image showing intramedullary involvement throughout the whole of the tibia included in the illustration and extension into the proximal epiphysis. Both posterior and anterior extraosseous involvement is evident. (C) Axial turbo T 2 -weighted image demonstrating circumferential soft-tissue involvement with radiating spicules of new bone within the soft-tissue component.

• Fig. 39.33 Osteosarcoma of the proximal tibia. (A) Conventional radiograph showing an osteoblastic lesion with periosteal new bone medially. (B) Sagittal turbo T 2 -weighted image with fat suppression. (C) Axial T,-weighted image with fat suppression. (D) Axial turbo T 2 -weighted image with fat suppression. The MR images elegantly demonstrate the heterogeneity of the tumour, the intramedullary involvement (note the normal fatty marrow within the distal femur and proximal fibula), periosteal new bone and involvement of the tibia origin of the patellar tendon. Perilesional oedema and a joint effusion are also evident.

• Fig. 39.33 Osteosarcoma of the proximal tibia. (A) Conventional radiograph showing an osteoblastic lesion with periosteal new bone medially. (B) Sagittal turbo T 2 -weighted image with fat suppression. (C) Axial T,-weighted image with fat suppression. (D) Axial turbo T 2 -weighted image with fat suppression. The MR images elegantly demonstrate the heterogeneity of the tumour, the intramedullary involvement (note the normal fatty marrow within the distal femur and proximal fibula), periosteal new bone and involvement of the tibia origin of the patellar tendon. Perilesional oedema and a joint effusion are also evident.

• Fig. 39.35 Diaphyseal osteosarcoma of the midshaft of the femur. Note the radiating spiculation of bone, Codman's triangles and well-defined soft tissue mass.

• Fig. 39.36 Diaphyseal osteosarcoma. A pathological fracture is present in the mid humerus with extensive endosteal sclerosis and cortical destruction from the medullary aspect. Tumour is present to the neck of the humerus with areas of dense sclerosis and surrounding faint radiolucency. These 'skip' lesions do not represent isolated tumour; the shaft was involved continuously. This variety carries a poor prognosis.

• Fig. 39.37 Central osteosarcoma of the distal femoral metaphysis presenting as a dense area of sclerosis with ill-defined margins.

• Fig. 39.38 Soft-tissue osteosarcoma. An elderly vicar complained of an enlarging soft-tissue mass adjacent to the medial malleolus of his right ankle. Note the amorphous soft-tissue ossification and calcification and normal bone underlying the lesion.

• Fig. 39.39 Radiation sarcoma arising in the posterior iliac crest on the left, in an elderly woman treated 6 years previously for carcinoma of the cervix. The lesion is purely osteolytic with ill-defined surrounding

• Fig. 39.40 Parosteal osteosarcoma of the proximal humerus. A well-defined mass of dense tumour bone surrounds the humeral shaft. A typical radiolucent line is present between the tumour bone and the proximal shaft inferomedially (arrow). The underlying bone appears normal.

• Fig. 39.41 Parosteal osteosarcoma arising from the anterior aspect of the femur (A) is shown angiographically (B) to be unremarkable apart from a slight increase in the number of branches going into the tumour. The lesion was found at biopsy to be of very low-grade malignancy.

• Fig. 39.42 Paget's sarcoma of the body of the pubis. (A) No malignancy was seen in this man at initial presentation with polyostotic Paget's disease. (B) Three years later, however, he complained of local pain with the development of a purely lytic destructive lesion involving the body of the pubis.

• Fig. 39.43 Multiple chondromas in the hand. This child presented with painless swelling. Note the cortical expansion and thinning, well-defined defects, patchy amorphous calcification and moulding abnormalities indicating slow growth

Fig. 39.44 Cartilage tumour. This patient presented with a longstanding ache in the thigh. Coronal T 1 -weighted (A) and STIR (B) sequences demonstrate a mixed lesion within the femoral shaft. Note that the cartilage has high signal on the STIR sequence. A surrounding rim of sclerosis is shown by deficient signal on both images. Histologically, this tumour was considered benign, in spite of giving rise to symptoms and to increased activity on a radionuclide scan and showing a high water content on MRI. In a different patient, presenting with signs of internal derangement, a similar lesion is shown on coronal T,-weighted (C) and

• Fig. 39.44 Cartilage tumour. In a different patient, presenting with signs of internal derangement, a similar lesion is shown on coronal T,-weighted (C) and STIR (D) images.

• Fig. 39.45 J uxtacortical chondromas arising on the volar aspect of the proximal and middle phalanges of the index finger. Obvious pressure defects are present with new bone formation at the margins. Punctate calcification is present in the middle of the proximal lesion.

39.46 Maffucci's syndrome (woman aged 23). Numerous chondromas In this case of dyschondroplasia are accompanied by soft-tissue swelling which contains phleboliths indicating haemangiomas. These skeletal lesions are more liable than ordinary chondromas to undergo malignant transformation.

• Fig. 39.47 Chondroblastoma in the proximal epiphysis of the tibia. The tumour has thinned the overlying cortex and extends across the growth plate into the upper metaphysis.

• Fig. 39.48 Chondroblastoma. (A) A lytic lesion with a thin rim of sclerosis is shown in the distal femoral epiphysis. Axial gradient echo-image (B) and sagittal T2 -weighted image (C) showing speckled areas of high-signal intensity within the subchondral lesion.

• Fig. 39.49 Chondroblastoma of the femoral head. The CT image demonstrates a destructive subchondral lesion containing areas of calcification within it and bordered by a sclerotic rim.

• Fig. 39.50 Chondromyxoid fibroma of the proximal tibia. Note the extremely well defined radiolucent defect with a sclerotic margin on the endosteal aspect. (A) Ap view (B) Lateral view.

• Fig. 39.51 (A, B) Chondromyxoid fibroma-great toe metatarsal. The tumour is eccentric in position with extreme cortical expansion and thinning. The endosteal margin is well defined and faintly sclerotic. No calcification is present.

• Fig. 39.52 Osteochondroma of the distal femur. The cortex is continuous with that of the underlying bone and trabecular bone merges with that of the femur. A well-defined cartilage cap contains calcification and is directed away from the joint.

• Fig. 39.53 (A,B) A pedunculated osteochondroma exhibits growth over a 2-year period in the humerus of a child. Such growth is common and stops usually at, or soon after, puberty.

• Fig. 39.54 (A,B) Osteochondromas may rarely be shown to regress, remodelling resulting in normal appearances. Here an osteochondroma of the proximal humerus cannot be visualised 6 years later.

• Fig. 39.55 Diaphyseal aclasia. (A) Multiple osteochondromas are present in the proximal tibia and fibula. A large sessile lesion of the proximal tibia has caused widening of the interosseous space and secondary moulding abnormalities of both the tibia and fibula. In another patient (B), similar modelling abnormalities are shown.

• On MRI, following ligamentous injury, only a minimal cartilage cap can be identified on the medial osteochondroma, and a slightly thicker cap on the laterally projecting osteochondroma: (C) coronal T 1 - weighted, (D) coronal FFE-T2 and (E) axial T,-weighted images.

• Fig. 39.56 Chondrosarcoma arising from the superior public ramus on the left. A huge mass is present containing extensive calcification. The femoral artery is displaced by the mass but note the absence of any pathological circulation. This is typical of a low-grade chondrosarcoma.

Fig. 39.57 Central chondrosarcoma. The destructive lesion in the femoral shaft has smooth well-defined margins, but in the upper portion, some characteristic punctate calcification is visible. The tumour is of a slow- growing type because organised periosteal new bone has thickened the minor cortex around the lesion.

• Fig. 39.58 Central chondrosarcoma. (A) The tumour is more aggressive than that in Fig. 39.57, and has extended into soft tissues. This is confirmed by CT (B), showing extension anterior to the femoral shaft. Calcification is seen both in the soft tissue mass and within the shaft lesion.

• Fig. 39.58 Central chondrosarcoma. (A) The tumour is more aggressive than that in Fig. 39.57, and has extended into soft tissues. This is confirmed by CT (B), showing extension anterior to the femoral shaft. Calcification is seen both in the soft tissue mass and within the shaft lesion.

• Fig. 39.59 Chondrosarcoma arising in the acetabulum of a 45-year-old man. (A) The tumour is purely lytic. Cortical thickening is shown medially. (B) CT demonstrates disruption of the cortex posteriorly, with a localised soft-tissue mass beneath the glutei and faint calcification within the lesion.

• Fig. 39.60 Chondrosarcoma. Arising primarily in the region of the acetabulum. A coronal T 1 -weighted (A) and axial STIR (B) sequences demonstrate a large lobulated mass occupying the floor of the acetabulum and extending through into the pelvis and the obturator foramen. Note the high signal on STIR, suggesting aggressive tumour, with also some increased signal surrounding the lesion due to oedema (secondary response). There is obvious involvement of the hip joint.

• Fig. 39.61 Chondrosarcoma arising in the sphenoid bone of an adult woman. A large soft-tissue tumour extends from the nasal cavity to the middle fossa. A thin sclerotic margin outlines the mass, which contains faint punctate calcification. Note the displacement of the globe.

Fig. 39.62 Dedifferentiated chondrosarcoma. A chondrosarcoma is present centrally within the distal femoral shaft, characterized by slight expansion and amorphous calcification. In addition, an area of osteolysis is present with cortical destruction around the lower half of the tumour. The latter represents a high-grade malignancy arising in conjunction with a preexisting relatively low-grade tumour.

• 1284 A TEXTBOOK OF RADIOLOGY AND IMAGING Fig. 39.63 Mesenchymal chondrosarcoma. A hard mass had been present in this middle-aged man's calf for 8 years. Recently it had increased in size. (A) Soft-tissue radiography shows extensive calcification in a well-defined tumour mass. (B) The blood-pool phase of a bone scan reveals a marked increase in vascularity throughout the lesion that is intensely active on the delayed images ((C) top right). Note also the presence of multiple metastasis, particularly in vertebrae and the pelvis

• Fig. 39.63 Mesenchymal chondrosarcoma (D) A femoral arteriogram confirms the markedly abnormal vascularity with pathological vessels throughout the tumour mass. The similarity between the extent of the abnormality shown angiographically and on the blood-pool phase of the bone scan is striking.