IntroBone tumors are very diverse in morphology and biological potential (can be no big deal or rapidly fatal)MOST bone tumors are benign lesionsMost benign lesions are seen

Bone neoplasms are very difficult to diagnose specifically on radiologic testing aloneSo why is radiology important?Exact location of lesionExtent of growth/metastasisAggressivenessBest test for Dx= X-rayBest test for staging= CT or MRIQuick shout out to the pathologists histologic grade is the most important prognostic feature of bone sarcomas and essential for staging most of the bone tumor types.

CasesFind the lesionExample:

CasesFind the lesionExample:RIGHT THERE!

Case I16 yr old white male with pain in his left upper arm.Mild swelling and tendernessPain progressively getting worse for ~ 3 monthsRecent onset of mild fever

Imaging:

Imaging:**

Biopsy material showed a highly cellular, infiltrative neoplasm consisting of sheets of tightly packed, round cells with very scant cytoplasm ("round blue cell tumor"). Occasional Homer-Wright rosettes were identified. Other fields showed extensive necrosis.

Dx: Ewings Sarcoma (or PNET)#2 primary bone malignancy in kids (5-15 is most common age groupMuch more common in CaucasiansTypically in the diaphysis of long tubular bones or in large flat boneLytic tumor w/ permeative margins extending into the soft tissuePeriostial rxn creates sheets of reactive bone in an onion-skin fashion

Another most excellent example of onion-skinning

Case II33 yr old black female with sudden severe hand pain after very minor trauma.Completely healthy otherwise.All labs normal

Dx: EnchondromaBenign cartilagenous tumors but hard to distinguish from a low grade chondrosarcomaAcral bones-- the most common primary hand tumorUsually solitary, usually incidental finding (non-painful unless associated with fracture)Get hand films and look for dec. lucency but not so much as a cyst (more ground-glass) w/ or w/o areas of stippled calcifications or rings

For boards and wards:Multiple enchondromas = ____________Multiple enchondromas + hemanigiomas of soft tissue = _____________

For boards and wards:Multiple enchondromas = Olliers DzMultiple enchondromas + hemangiomas of soft tissue = Maffucci syndrome

Case III50 yr old white male with back pain Mainly lower spine/sacral pain, progressive ~ 8 monthsNew onset rectal pain and constipation

CT guided FNA confirmed

Dx: ChordomaArises from notochord remnants. Thus is typically midline along the spine and usually at the ends (Sacrococc or occ/cervical jxn)Males>Females, middle age+ staining w/ S-100 and epithelial markersLocally invasive until very late in disease where mets can go to the lungs, LN, skin.

Case IV21 yr old male with new onset chest pain today, worse on inhalation. ROS significant for an ongoing aching leg pain for the past 6 months which he has put off seeing a doctor for.

Dx: The dreaded Osteosarcoma#1 primary bone malignancyAssociated with RB1 and p53 gene mutations1000x greater risk w/ Hx of hereditary retinoblastomaMember of the Li-Fraumeni Syndrome familyBimodal age spike: young and elderly75%

Metaphysial tumor60% at the knee (distal femur or prox tibia)Radiographic terms to know:Codmans Triangle:

Sunburst periostial formation:AKA Hair on end

For the future Surgeons:Rotationplasty is a new solution to disfiguring surgical resections of lower limb sarcomas:

Quick Hits:Gout

Incidental finding on knee xrayFabella = posterior sesmoids or little confused knee caps

13 yr old boy with superior tibial pain, r/o neoplasm w/ xray shows:Osgood Schlatter

Metastatic DiseaseMost common malignant lesion of boneBone is # 3 on the list of favorite places for mobile cancers to goMalignant lesions are more likely to be in axial bonesTypically multifocal BUT renal and thyroid carcinomas are notorious for producing only a solitary lesionCan be lytic, blastic, or both:Lung is Lytic, Prostate Produces, Breast does Both

Mets (cont)AdultsLungProstateBreastKidneyKidsNBWilmsOSEwingsRhabdomyosarcoma

The EndThanks for your attention and good luck on applications!

BibliographyRobbins and Cotran, Pathological Basis of Disease, 7th EditionMD Murphey, MR Robbin, GA McRae, DJ Flemming, HT Temple, and MJ Kransdorf The Many Faces of Osteosarcoma RadioGraphics 1997; 17: 1205 William R. Reinus, Louis A. Gilula IESS Committee Radiology of Ewing's sarcoma: Intergroup Ewing's Sarcoma Study (IESS) RadioGraphics 1984; 4: 929-944. Washington Univ. in St. Louis (website)Harvard Medical School (website)Learning Radiology.com (website duh)Bonetumor.org (Youre not even reading this are you?)