Approach to Bone Tumors

www.frcrtutorials.com

Dr Sameer
Shamshuddin

MBBS, DMRD, FRCR

West of Scotland
 Bone Tumours FRCR 2B
Test of Observation and Systematic Approach
 Do not jump to a diagnosis

 Start as a Year 1 trainee and finish the case as a Consultant MSK Radiologist

 Basics First

 Build a case

 Come to a logical set of differentials

 Assert with confidence if it is Benign or Malignant

 Diagnosis and Further management

 What to focus on ?
What to do ?
 Radiograph: AP and Lateral
( if not given say single view and would always interpret with a
conjunctional orthogonal view)

 Age: Skeletally mature / Immature

 Abnormality: Focal / Diffuse

 Where is it: which bone, which part of a bone?

 Epiphysis / Metaphysis / Diaphysis

 Very Basics First
 Type of the lesion: Lucent, Sclerotic or Mixed

 Epicentre of the lesion: Medullary / Cortical / Parosteal / Soft tissue

 Margins: Geographic/Moth eaten/permeative

 Zone of transition: Narrow / wide

 Expansile/non-expansile

 Matrix (Osteoid, Cartillaginous, Fibrous or mixed)

 Effect on endosteum, cortex and periosteum

 Periosteal reaction: Aggressive or Non-aggressive (forget sunburst , onion peel etc……)

 Soft tissue extension

 Last but not the least: How many??? ( solitory or multiple)

 Next Level: definite pass
Characteristic feature of a lesion

 SBC: Fallen fragment sign

 ABC: Septated
 Osteoid osteoma: calcific nidus
 Fibrous dysplasia: ground glass matrix
 Myeloma: punched out lesion

Makeup your mind: Aggressive or Non-aggressive

Primary Dx and a few reasonable differentials:

Osteoid, Chondroid, Fibrous, Sarcomatous , Mets or a Weird one !

 What Next: Consultant Stuff
 This is a no touch lesion or

 This needs a bone tumor centre referral

Further characterization :
MRI: extent of marrow involvement
soft tissue involvement
relationship to neurovascular bundle
planning biopsy

Bone Scan: multiplicity of the lesion

Biopsy

CT chest for staging

Some Teaching
 DDX: Solitory Lucent Lx
FEGNOMASCHIC / FOGMACHINES
 Fibrous Dysplasia

 Eosinophilic Granuloma / Enchondroma

 Giant Cell Tumor

 Non-ossifying Fibroma

 Osteoblastoma

 Metastasis / Myeloma

 Aneurysmal Bone Cyst

 Solitary Bone Cyst

 Chondroblastoma / Chondromyxoid Fibroma

 Hyperparathyroidism (brown tumors) / Hemangioma

 Multiple Lucent Bone Lesions

 Metastasis / Myeloma
 Lymphoma
 LCH, Leukemia, Neuroblastoma mets – Kids

 Fibrous Dysplasia
 Hyperparathyroidism (brown tumors)
 Multiple enchondroma
 HME (diaphyseal aclasia)
 Infection
 Don’t touch lesions
 NOF

 Bone infarction

 Fibroxanthoma

 Periosteal desmoid

 Intraosseous ganglion
 Role of Modalities
 Characterization of a lesion: Radiograph best

 Anatomic localization: CT / MRI

 Characterization of the calcification: CT>>MRI

 Cystic from solid – US or MRI + contrast

 Demonstration of vascular supply: MRI

 Planning biopsy: MR

 Performing a Biopsy: CT

 Nuclear medicine: Number of lesions

Let the fun begin now 

Enchondroma
SBC
ABC
ABC
ABC
OSTEOCHONDROMA
Osteochondroma
HME
Bn vs Malg ?
Bn vs Malg ?
Ollier’s
Ollier’s
Maffuci: calcific phleboliths
OSTEOID OSTEOMA
NOF / FCD 2cm
Ganglion
EPIDERMOID
INCLUSION CYST

GLOMUS TUMOR
FB GRANULOMA
ENCHONDROMA
SARCOIDOSIS
Osteomyelitis: never forget
OSTEOPOIKILOSIS
OSTEOPOIKILOSIS
OSTEOPOIKILOSIS
osteosarcoma
Role of MR

Skip lesions

Marrow

Soft tissue involvement

Paroteal OS
Periosteal osteosarcoma: typical spiculated periosteal
reaction arising from the femur.
Telangiectatic OS
Ewing’s Sarcoma
Ewing’s Sarcoma
GCT: after fusion of
growth plate, sub-
articular, multi-
septated, geographical
Chondrosarcoma: Cortical thickening/Lesion larger
than 4 CM and marked endosteal scalloping with
presence of pain: All features favour chondrosarcoma
Aggressive tx
Septation ,fluid levels and solid
components – aggressive sarcoma
Chordoma
Mets: Breast
Mets
LCH
LCH
Fib Dysplasia
Polyostotic FD
FD: Look for complications: path #
Paget’s with Sarcoma
MMLLL
Osteomyelitis: don’t forget in kids
across the growth plate
Thank You

Dr Sameer Shamshuddin
MBBS, DMRD, FRCR,
STR5, Glasgow, UK