Bone tumor radiological approach

RADIOLOGIAL APPROACH TO BONE TUMORS

DR. C. K.VASU, M.D

THERAPEUTIC GOALS

DO NOT OVERTREAT A BENIGN TUMOR

DO NOT UNDERTREAT A MALIGNANT TUMOR

DO NOT MISDIRECT BIOPSY

RADIOLOGIST CAN SEE THE THREE DIMENSIONAL GROSS PATHOLOGY

IF RADIOLOGIC FINDINGS ARE NOT CORRELATING WITH THE PATHOLOGY FINDINGS:SPECIAL STAINS, ADDITIONAL IMAGES WILL HELP

TUMOR MAY HAVE VARYING HISTOLOGY AND REPRESENTATIVE SAMPLE FROM EPICENTRE OF THE LESION HAS TO BE TAKEN

ROLE OF PLAIN RADIOGRAPH

INITIAL EXAMINATION –STARTS THE DIAGNOSTIC ALGORITHM

SCREENING, DETECTION,DIAGNOSIS,FOLLOWUP

IN THIS COST-CONSCIOUS ERA

SYSTEMATIC APPROACH

AGE

SITE

ZONE OF TRANSITION

MATRIX

CORTEX

PERIOSTEAL REACTION

SOFT TISSUE COMPONENT

SINGLE - MULTIPLE

AGE AT PRESENTATION

DIFFERENTIAL DIAGNOSIS CAN BE NARROWED

1 ST DECADE : NEUROBLASTOMA,LEUKEMIA2 ND DECADE : OSTEOSARCOMA, EWINGS SARCOMA3RD DECADE: GIANT CELL TUMORELDERLY : METASTASIS, CHONDROSARCOMA

CLUE TO AGE : FROM EPIPHYSEAL FUSION

OSTEOSARCOMA@

CHONDRO BLASTOMA

GCT@

LOCATION

EPIPHYSEAL :

CHONDROBLASTOMA, GIANT CELL TUMOUR

METAPHYSEAL :

OSTEOSARCOMA, ANEURYSMAL BONE CYST

DIAPHYSEAL :

EWINGS SARCOMA

CHONDRO BLASTOMA@

GCT / ABC

EWINGS SARCOMA

EWINGS SARCOMA

ZONE OF TRANSITION IT IS AN ASSESSMENT OF THE

BIOLOGICAL ACTIVITY GEOGRAPHIC OR TYPE 1 (LODWIG) 1A----WITH SCLEROSIS: BONE DEPOSITION

TO REDIRECT TRANSMITTED FORCES IN TYPE 1A LESIONS IDEAL POSTOP

RADIOGRAPH SHOULD SHOW COMPLETE REMOVAL OF NOT ONLY SCLEROTIC RIM BUT ALSO SEVERAL MMS “NORMAL BONE”

IF SCLEROTIC RIM REMAINS HIGHER RECURRENCE CHANCE

EX: CHONDROBLASTOMA, BONE CYST

TYPE 1B:

BIOLOGIC ACTIVITY IS SLIGHTLY MORE: NO SCLEROTIC RIM

EX: GIANT CELL TUMOR

TYPE 1C LESION

LYTIC LESION WITH ILL DEFINED MARGIN: THEY ARE MALIGNANT UNLESS PROVED OTHERWISE:

EX: CHONDROSARCOMA,

FIBROSARCOMA

MULTIPLE CLUSTERED SMALL HOLES(<5MM)

(TYPE 3) PERMEATIVE PATTERN

LUCENT LINEAR STREAKS DD IS SIMILAR: OSTEOSARCOMA,

EWINGS SARCOMA

(TYPE 2)MOTH EATEN

LYTIC LESION WITH SCLEROTIC RING

GCT

CHONDROSARCOMA RADIUS

OSTEOGENIC SARCOMA

PERMEATIVE PATTERN

CORTICAL BREAK

MALIGNANT LESIONS

:OSTEOSARCOMA,EWINGS SARCOMA

BENIGN LESIONS: NO CORTICAL BREAK USUALLY:

EX: GCT,ABC

GIANT CELL TUMOUR PATELLA

DESMOPLAS-TIC FIBROMA

OSTEOCHONDROMA@

OSTEOCHONDROMA

PERIOSTEAL REACTION

OUTER FIBROUS LAYER AND INNER CELLULAR LAYER.

10-21DAYS : SEEN EARLIER IN YOUNGER PATIENTS

INDICATION OF BIOLOGICAL ACTIVITY

TYPES OF PERIOSTEAL REACTION

CONTINUOUS: LAMELLATED (ONION –PEEL)

DISCONTINUOUS : CODMAN ANGLES COMPLEX: LAMELLATED + CODMAN MORE EXTENSIVE AND COMPLEX

THE PERIOSTEAL REACTION GREATER BIOLOGICAL ACTIVITY

EWINGS SARCOMA@

LAMELLAR APPEARENCE

SUN RAY

OSTEOSARCOMA

PAROSTEAL OSTEOSARCOMA

EWINS SARCOMA

MATRIX OSSEUS MATRIX: OSTEOMA,OSTEOID

OSTEOMA---CLOUD LIKE RELATIVELY HOMOGENOUS AREA OF BLASTIC CHANGE

CARTILAGE MATRIX: STIPLLED, CURVILINEAR CALCIFICATION(RINGS AND ARCS)---ENCHONDROMA,CHONDROSARCOMA

NON-MINERALIZED MATRIX: GIANT CELL TUMOR, OSTEOLYTIC OSTEOSARCOMA

OSTEOID OSTEOMA

D/D:GARRE’S OSTEOMYELITIS

OSTEOSARCOMA@

CHONDRO SARCOMA@

MEDULLARY NECROSIS

NO MATRIX--FIBROSARCOMA

SOFT TISSUE COMPONENT

DETECTED ON PLAIN XRAY-DISPLACED FAT PLANE

ROLE OF CT AND MRI

FIBROSARCOMA@

EWINGS SARCOMA

LESION MULTIPLICITY

KEY DIAGNOSTIC SIGN

PRIMARY BONE TUMORS USUALLY SINGLE

PRIMARY : SECONDARY --1: 500

MULTIPLE EXOSTOSIS

OLLIERS DISEASE

METASTASIS-from bronchus@

QUIZ

OSTEOCHONDROMA

OSTEOCHONDROMA

METAPHYSEAL

GROWS AWAY FROM THE JOINT

ANY AGE

NO CORTICAL BREAK

NORMAL CORTEX WITH WHICH IT IS CONTINUOUS

CHONDRO BLASTOMA@

CHONDROBLASTOMACARTILAGINOUS

MATRIXBEFORE EPIPHYSEAL

FUSIONNARROW ZONE OF

TRANSITIONEPIPHYSEAL

GCT

GIANT CELL TUMOUR

EPIPHYSEAL20-45 YEARSMATRIX NOT

MINERALIZEDNARROW ZONE OF

TRANSITION

OSTEOSARCOMA

OSTEOSARCOMA

15-25 YEARS2 ND PEAK AT 40+METAPHYSEALOSTEOID MATRIXCODMAN,SUNBURSTZONE OF TRANSITION

CHONDROSARCOMA

CHONDROSARCOMA 40 + AGE GROUP

MATRIX CALCIFIED

DISPROPORTIONATE SOFT TISSUE

ENDOSTEAL SCALLOPING

EWINGS SARCOMA AGE GROUP—5-30 YEARS ONION PEEL PERIOSTEAL

REACTION DD OSTEOMYELITIS WIDE ZONE OF TRANSITION DIAPHYSEAL

NO MATRIX--FIBROSARCOMA

FIBROSARCOMA

NO MINERALIZED MATRIX

LARGE SOFT TISSUE

DIAPHYSEAL

CORTICAL BREAK

OSTEOID OSTEOMA

OSTEOID OSTEOMA

SCLEROTIC

NIDUS

WELL DEFINED

NO CORTICAL BREAK

HEMANGIOMA SPINE

EWING’S SARCOMA

HEMANGIOMA

IVORY VERTEBRA

OSTEOCHONDROMA

OSTEOCHONDROMA