Schreibman - Bone Tumors in 1 Simple Chart

7/28/2019 Schreibman - Bone Tumors in 1 Simple Chart

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Ken L Schreibman, PhD/MD 01/10/10 www.schreibman.info

page 1 of 31Bone Tumors:In 1 Simple Chart

Ken L Schreibman, PhD/MD 2010 schreibman.info

Bone Tumors

In 1 Simple Chart

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TheChart


NON-aggressiveBlastic

Chondroid:Enchondroma

Osseous:Osteoid OsteomaOsteoblastoma

Osseous & Chondroid:

Osteochondroma

NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EG

FD

Mets/Mult MyelomaOsteomyelitis (Active)2Osteosarc (>60)

AGGRESSIVE

40

age

OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB


2/31




WhyBoneTumorsareIntimidatingBone Tumors are Rare

Dont see enough to be confidentMany types of Bone Tumors

Have Confusing (similar) NamesOsteosarcomaOsteochondromaOccur in children

Essentially only 2bone malignanciesoccur in children

http://seer.cancer.gov/statfacts/html/bones.html

0%

5%

10%

15%

20%

25%

30%

85

Incidence Bone Tumorsby age

Bone Tumors: by Age

20

Bone Tumors: by Age

4020


Overview of this PresentationWhy Bone Tumors are IntimidatingDescribing Bone Tumors

1) Patients Age40Multiple Myeloma, Metastases



1) Patients Age2) Aggressive vs Non-aggressive(NOT Malignantvs Benign)

Zone of TransitionPeriosteal Reaction

Not everything that looks aggressive is malignant(e.g. osteomyelitis)

Aggressive Non-aggressive

Describing


2 Cases: Destructive lesions distal fibulaBenign?

Malignant?Cant tell with radiographs

Thus we use the termAggressive
http://seer.cancer.gov/statfacts/html/bones.htmlhttp://seer.cancer.gov/statfacts/html/bones.html


3/31




AggressiveAggressive vs Non-aggressiveZone of Transition

Periosteal Reactions


Zone of TransitionAggressive vs Non-aggressive

Grow Slowly Narrow

Geographic Well DefinedCan Outline Lesionwith Sharp Pencil

Sclerotic MarginsGrows VERY Slowly!



Grow Slowly Narrow Geographic Well Defined

Can Outline Lesionwith Sharp Pencil

Sclerotic Margins

Grows VERY Slowly!Asymptomatic, incidental finding


Grow Slowly Narrow Geographic Well Defined


Sclerotic Margins

Grows VERY Slowly!




Grow Slowly

Narrow Geographic Well Defined



Grow Slowly

Narrow Geographic Well Defined


Sclerotic MarginsGrows VERY Slowly!

Grow Rapidly

WidePermeativeIll DefinedMoth Eaten

Cannot tell whereLesion ends and

Normal Bone begins



4/31




Grow RapidlyWide

PermeativeIll DefinedMoth Eaten


Normal Bone begins

Aggressive vs Non-aggressiveZone of Transition


Normal Bone begins

W,S 16yoF


Grows Slowly Narrow

Geographic Well Defined


Grows RapidlyWide

PermeativeIll DefinedMoth Eaten



Normal Bone begins


Grows SlowlyGrows RapidlyPeriosteal Reaction

Aggressive vs Non-aggressive

TOOCOMPLI-CATED


Grows RapidlyInterrupted

Simplifying Periosteal ReactionAggressive vs Non-aggressive

Grows SlowlySolidSmoothContinuous



BoneModel

Fx

Grows Slowly

SolidSmoothContinuous

Looks likeHealing Callus

F,A 2moM 1m laterKen L Schreibman, PhD/MD 2010 schreibman.info


BoneModel

Grows Slowly


V,T 49yoM

HOAHypertrophicOsteo-Arthropathy

HPOAHypertrophicPulmonaryOsteo-Arthropathy Stable over 1y


5/31





May grow sorapidly it doesnt

have time toossify

(Unossifiedperiosteum is not

radiopaque)

Aggressive vs Non-aggressiveSimplifying Periosteal Reaction



LamellatedOnionskin

Grows ossifiesGrows ossifiesGrows ossifies


Courtesy of James Choi, MD


Grows RapidlyInterruptedLamellatedOnionskinSpiculatedHair-on-end



Grows RapidlyInterruptedLamellatedOnionskinSpiculatedSunburstCodmans

Triangles(Growing so rapidly,has time to ossifyonly at corners)



Grows Rapidly

InterruptedLamellatedOnionskinSpiculatedSunburstCodmans

Triangles(Growing so rapidly,has time to ossifyonly at corners)



Grows Rapidly

InterruptedLamellatedOnionskinSpiculatedSunburstCodmans

Triangles


Grows Slowly


Looks likeHealing Callus

S,C 15yoM

3w post Fx, ORIF=very early callus8w post Fx, ORIF

=more mature callus


6/31





1) Patients Age

2) Aggressive vs Non-aggressiveZone of TransitionPeriosteal ReactionCortical Destruction


Describing


Aggressive vs Non-aggressiveCortical Destruction

Cortex Intact =

Non-aggressive

Similar lytic lesionsBoth have well

defined, sclerotic,

medullary borders

Cortex Absent =

Aggressive

IR



1) Patients Age2) Aggressive vs Non-aggressiveZone of TransitionPeriosteal ReactionCortical DestructionSoft Tissue Extension

Radiographs

MRI


Describing


2 Cases: Aggressive lesions distal fibula

CorticalDestruction

PeriostealReaction

Benign?Malignant?

Cant tell with radiographs

Thus we use the termAggressive


2 Cases: Aggressive lesions distal fibulaT2 Soft Tissue

Extension

T2

T1

H,M 13yoF


TwoYEARSlater

Active Osteomyelitis Chronic Osteo.

Aggressive vs Non-aggressive


7/31




Bone Matrix: 4 TypesChondroidrings&arcs

Osseouscloud-likeamorphous

FibrousGroundGlass

NonePurely LyticNotnecessarilycystic

Calcified Uterine Fibroid Myositis Ossificans

Multiple MyelomaKen L Schreibman, PhD/MD 2010 schreibman.info

Bone Matrix: 4 TypesChondroidrings&arcs

Calcified Uterine FibroidEnchondroma


Bone Matrix: 4 TypesOsseouscloud-likeamorphous

Myositis OssificansF,C 8yoF

Osteogenic SarcomaH,S 15yoM


Bone Matrix: 4 TypesFibrous

GroundGlass

Fibrous DysplasiaB,C 53yoF


Bone Matrix: 4 TypesNonePurely Lytic

Not necessarily cystic

Multiple MyelomaS,N 62yoMKen L Schreibman, PhD/MD 2010 schreibman.info

Bone Matrix: 4 Types

G,B 18yoF

CTNonePurely Lytic

Not necessarily cystic

T1

Intraosseous Lipoma


8/31





1) Patients Age

2) Aggressive3) Matrix4) LocationWhich bone?

Some tumors have propensity for certain bonesWhich part of the bone?

MANY tumors characteristically occur at the:Epiphysis / Metaphysis / Diaphysis


AGGRESSIVE NON-aggressiveLytic


40

age

OsteosarcomaEwing Sarcoma


Pt Age: 10-20 years(when growth spurt occurs)

Location: Metaphyseal(where growth occurs)Distal FemurProximal Tibia(where mostgrowth occurs)

Matrix: Osseous

osteo-genic: makes boneNeed to eval for skip metsMR entire length of bone

Osteogenic Sarcoma


Osteogenic Sarcoma

F,C 8yoF

Pt Age: 10-20 years

Location: Metaphyseal

Matrix: Osseous

T1

T1

T2

MRI is useful for stagingthe extentof the tumor


Osteogenic Sarcoma

F,C 8yoF


Radiographs show us

what we need to know todiagnose type of tumor!

Skeletally immatureAggressive lesionWide zone of trans.Sunburst periost.Osseous matrixMetaphyseal---------------------------------Osteogenic Sarcoma!


Osteogenic Sarcoma

R,T 11yoF

Sometimes osteosarc isgrowing SO quickly it

doesnt have time toform an osseous matrixPatient presents

with hair-on-endperiosteal reaction

After 2 months ofchemotherapytumor growth hasslowed enough toform osseous matrix


9/31




Ewing SarcomaPt Age: 5-25 years

Tumor ofBone MarrowLocation: Diaphyseal

Flat BonesMatrix: PermeativeCortical DestructionAggressive

Periosteal Reaction

Soft Tissue Extension>> Bone Extent


Ewing SarcomaT2 Soft Tissue

Extension

T2

T1

H,M 13yoF

>> BoneExtent


Ewing Sarcoma common in pelvis

S,B 6yoM

Things canhide in thepelvis

Air incolon

3 months later

Air incolon?


Ewing Sarcoma common in pelvis

S,B 6yoM

T2fs Things canhide in thepelvisUnlike in the extremitieswhere radiographs are key,

the usefulness ofradiographs in thepelvis is limited.

In the pelvis,cross-sectional

imaging is crucial,preferably with MRI.




40

age

OsteosarcomaEwing SarcomaOsteomyelitis (Active)

Mets (NB


10/31




Cortical DesmoidCortical Desmoid: Do Not Touch!

Q,M 17yoM

Just a little periosteal reactionMEDIAL posterior femoral condyle

Tug lesion: Adductor longus insertionMedial gastrocnemius origin

CT

T2fs

Cross-sectional imaging doesnt really help



ALWAYS consider Lymphoma!



40

age

OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 40MetastasesMultiple Myeloma


Cartilage malignancy

Matrix: Chondroid

Location: Ends of bonesPelvis

Soft tissues

Chondrosarcoma


Chondrosarcoma

S,B 39yoM

Chondroidrings&arcs

Radiographs

Cartilage malignancy

Matrix: Chondroid


11/31




ChondrosarcomaCartilage malignancy

Matrix: ChondroidChondroid

rings&arcsRadiographsCT

S,B 39yoM



Matrix: ChondroidChondroidMRI

T2: Bright

Gd:peripheralenhancementBulk of tumordoesnt enhance

S,B 39yoM

T2fs T1fs+Gd



Matrix: Chondroid

Normal cartilage has no blood supplyInjured cartilage doesnt regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesnt respond to chemotherapy

Treatment: Complete tumor resection



Matrix: Chondroid

Normal cartilage has no blood supplyInjured cartilage doesnt regrowChondrosarcoma: poor blood supplyShows very little Gd enhancementDoesnt respond to chemotherapy

Treatment: Complete tumor resectionS,B 39yoM


Chondrosarcoma

W,A 30yoF

30yoF 1 year history heal pain

1 week later

other side


Chondrosarcoma

T2fs T1fs+Gd

T1


12/31







40

age

OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 20

May involve the bonesSecondarilyPrimarily


Fibrosarcoma

F,B 23yoF

T1 T2fs






40

age



13/31




Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if

marrow not involved,can resect tumor.If spreads to marrow,conventional OS.

3) PERIostealLooks like aggressive

periosteal reactionLocation: Long bones

Osteogenic Sarcoma Periosteal Osteosarcoma

Murphey M D et al.Radiology 2004;233:129-138

2004 Radiological Society of North America

tibia 11yoM

AggressivePeriostealReaction

Periosteal Osteosarcoma

Murphey M D et al.Radiology 2004;233:129-138

2004 Radiological Society of North America

tibia 34yoF

AggressivePeriostealReaction

SoftTissueExtension

SparingBoneMarrow


Surface OsteosarcomaPt Age: 20-30 yearsGood prognosis if

marrow not involved,can resect tumor

If spreads to marrow,conventional OS.

3) PERIosteal

Looks like aggressiveperiosteal reaction4) PARosteal

Osteogenic Sarcoma


Surface Osteosarcoma4) PARosteal

Pt Age: 20-30 yearsLocation: Back ofFemoral Condyles

Arise from cortex,grow outward

Do NOT containnormal marrow

(As opposed toosteochondroma)

Osteogenic Sarcoma CT


Osteogenic Sarcoma CT

T2fs

T1 MRI: No Marrowinvolvement


14/31







40

age



15/31







40

age



16/31




B) Unicameral (Simple) Bone CystUni-cameral: Latin one - chamber(in US we have bi-cameral legislature)

Pt Age:< 20

Matrix: None (True Cyst)Location:Metaphyseal>50% Proximal Humerus

20-30% Proximal Femur50% - Incidental Finding50% - Pathologic Fx

Fallen FragmentKen L Schreibman, PhD/MD 2010 schreibman.info

B) Unicameral (Simple) Bone Cyst

D,C 5yoM

Normal Side



D,C 5yoM after 1 month

Fractures tend to heal

after 3 months

Fracture healed

Cyst?


B) Unicameral (Simple) Bone CystCysts tend to recur

6m later 12m later 18m later

Although UBCsarise from

metaphysisend of bonegrows awayfrom cyst

so cystbecomes

diaphyseal


MRI shows cyst extentB) Unicameral (Simple) Bone Cyst

18m later

T1 T2fs

T1

T2fs

Simple cystKen L Schreibman, PhD/MD 2010 schreibman.info


M,T 4yoM

FallenFragment

after 3 months


17/31





P,D 6yoM



H,T 18yoM

T2fs

Simple cyst with

hemorrhagefluid-fluid level


C) ChondroblastomaPt Age: Skeletally immature

Location: Epiphyseal

Matrix: Chondroid(No matrix if not calcified)

BenignAggressive appearance!Periosteal Reaction

Surrounding EdemaBone MarrowSoft Tissues


C) ChondroblastomaPt Age: 10 30yoLocation: Epiphyseal

Matrix: Chondroid(No matrix if not calcified)

BenignAggressive appearance!Periosteal Reaction

16yoM

Surrounding EdemaBone MarrowSoft Tissues

T2fs


C) Chondroblastoma

16yoM

Cartilage-sensitive sequence

Articular Cartilage

Cartilageunfused physis


C) Chondroblastoma

B,Q 15yoM

T1 IR Cartilage sequence

Epiphyseal mass, skeletally immatureAggressive appearance

Edema in surrounding marrow & tissues


18/31




Non-Ossifying Fibroma (NOF)D) Fibrous Cortical Defect

THE most common bone lesionOccurs up to 40% ALL children

(75% occur 10

20 years old)Regress after skeletal maturity

Asymptomatic, incidental finding(e.g. on knee MR for ACL tear)

If >50% bone diameter Fx

Location: MetaphysisFemur & Tibia



Radiographic appearance:

Characteristic& Diagnostic

If asymptomatic, nofurther workup is needed

Eccentric, sub-corticalCortex thinned, expanded

Sclerotic marginScalloped

Multi-loculatedF,M 18yoF



Radiographic appearance:

Characteristic&DiagnosticIf asymptomatic, no

further workup is needed

Eccentric, sub-corticalCortex thinned, expanded

Sclerotic margin

ScallopedMulti-loculatedB,J 19yoM

T1IRNo aggressive characteristics



G,M 9yoF

9yo 11yo 13yo

Fx HealingCallus


19/31




E) Eosinophilic GranulomaNon-neoplastic proliferation histiocytes

Langerhans Cell HistiocytosisPt Age: typically 3yo)Triad: skull lesions, exophthalmos, DI

Letterer-Siwe (60)



40

age


Mets (NB


20/31




Pt Age: 60)



40

age


Mets (NB


21/31




ABCUBC

CBFCD/NOF

EG

FD




40

age



22/31




Location: SubarticularMatrix: Purely Lytic

Age:< 20 (skeletally immature)

ChondroblastomaAge:20-40 (skeletally mature)

Giant Cell Tumor

Age:> 40MetastasesMultiple Myeloma

Why Age is Important

V,R 21yoM

GCT


Location: SubarticularMatrix: Purely Lytic

Age:< 20 (skeletally immature)

ChondroblastomaAge:20-40 (skeletally mature)

Giant Cell Tumor

Age:> 40MetastasesMultiple Myeloma

Why Age is Important

C,G 61yoM

Met

1LungCancer


ABCUBC

CBFCD/NOF

EGFD




40

age

OsteosarcomaEwing SarcomaOsteomyelitis (Active)Mets (NB 60)



40

age


Mets (NB


23/31




EnchondromaBenign rests of hyaline cartilageCommonOften discovered incidentally

Typically asymptomatic50% small tubular bonesMostly lyticPathologic Fracture


Glomus TumorBenign vascular tumor

(neuromyoarterial apparatus)

Subungual, erodes bone

Dorsal cortex distal phalanxAge: 30 50 ( 3x> )TriadSensitivity to coldLocalized tendernessSevere intermittent

painS,D 37yoF


Glomus Tumor

S,D 53yoM

Dorsal cortex distal phalanx


Epidermoid Inclusion CystImplantation of epidermal elementsAmputationPuncture (seamstress)Volar cortex distal phalanx

T2fsT1fs+GdT1fs+GdT1fs


Epidermoid Inclusion Cyst


Gout

M,B 78yoM


24/31




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EG

FD


AGGRESSIVE NON-aggressiveBlastic

40

age



40

age



40

age


Mets (NB


25/31




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EG

FD



40

age



26/31




Chondrosarcoma

IR T1fs + Gd

Histopathology1: Low Grade2: Intermediate

3: High GradeCellularity:markedlyincreased

Nuclei Size:markedlyincreased


ChondrosarcomaHistopathology

1: Low Grade2: Intermediate

3: High GradeCellularity:slightlyincreased

Nuclei Size:slightlyincreased


ChondrosarcomaHistopathology

0.5: Borderline1: Low Grade2: Intermediate3: High Grade

Histologically:resemblesenchondroma

Radiologically:aggressive

Enchondroma


ChondrosarcomaEnchondroma

T1 T2fs

B,B 42yoF



How do you distinguish between them?Very difficult, sometimes you cantClues:

All ChondrosarcHot on BS

Some EnchonHot on BS

All ChondrosarcPainful (never incidental)

40% EnchonPainful

This pt had painuncontrollable with

oral narcotics



B,B 42yoF

This pt had painuncontrollable with

oral narcoticsHistopathology:No malignant cells

So was this:

Enchondroma?

0.5 BorderlineChondrosarcoma?

Pt was very happy with outcome!Shes now pain freeShes doesnt have cancer


27/31




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EG

FD



40

age



40

age



28/31




Osteoblastoma (= Osteoid Osteoma)Term osteoblastomaused for:Larger lesions

( > 1cm)Lesion in spineposterior elementsPainful scoliosis

(Typicallyscoliosis ispainless)

S,T 16yoM


Osteoblastoma (= Osteoid Osteoma)

Bone Scan(Posterior)

SPECT(Sagittal)

S,T 16yoM

SPECT(Axial)


Osteoblastoma (= Osteoid Osteoma)CT:Gold StandardDiagnosisLucent NidusCentral Dot Calcium

S,T 16yoM


Young womanwith back painFetus is an

incidental finding

Years earlierwith back pain

Osteoblastoma


29/31




NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EG

FD



40

age



30/31




OsteochondromaMost Common Benign Neoplasm of BoneExostosisPedunculated (stalk)

Sessile (flat)Cartilage Capseen only on MR

Point away from jointContinuity with

underlying boneCortex continuous with cortexMarrow continuous with marrow


OsteochondromaMost Common Benign Neoplasm of BoneExostosisPedunculated (stalk)

Sessile (flat)Cartilage Capseen only on MR

Point away from jointContinuity with

underlying boneCortex continuous with cortexMarrow continuous with marrow K,J 11yoM


Osteochondroma

K,J 11yoM

Cortex continuous with cortexMarrow continuous with marrow

T1

T2fs

No aggressive characteristics

Cartilage Cap


OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity

(can grow during childhood)Cartilage cap > 1cm

(can be 2-3cm during childhood)


OsteochondromaMalignant Transformation to Chondrosarcoma

Funny shaped femursMHE?

Chondroid matrixAggressive appearance

Hot on BSc/w Chondrosarc


OsteochondromaMalignant Transformation to Chondrosarcoma

CT: Tissue Window CT: Bone Window

T1fs+GdT2fs


31/31



OsteochondromaMost Common Benign Neoplasm of BoneMalignant Transformation to ChondrosarcomaSolitary: 1%

Multiple Hereditary Exostoses (MHE):10-30%Signs of malignant transformation:Growth of lesion after skeletal maturity

(can grow during childhood)Cartilage cap > 1cm

(can be 2-3cm during childhood)

Can cause mechanical problems


OsteochondromaCan cause mechanical problems

W,M 25yoF

Multiple miscarriagesT1

T2fs



K,T 18yoM MRA

Mass effect on rightsubclavian artery



H,P 11yoF T1 PDfs

T2fs

Rubbing, causingPes Anserine Bursitis


Osteochondroma T1

vs PARosteal Osteosarcoma

T1 T2fsW,K 17yoM

Cortex continuous with cortexMarrow continuous with marrow

CartilageCap

NO cortex/marrowcontinuity



Chondroid:Enchondroma

Osseous:Osteoid Osteoma

OsteoblastomaOsseous & Chondroid:Osteochondroma

NON-aggressiveLytic

ABCUBC

CBFCD/NOF

EGFD


AGGRESSIVE

40

age


Mets (NB

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Schreibman - Bone Tumors in 1 Simple Chart