COMMON MALIGNANT BONETUMORS

1.METASTASES

2.OSTEOID ORIGIN:OSTEOSARCOMA

3.CHONDROID ORIGIN:CHONDROSARCOMA

4.FIBROUS ORIGIN:.MALIGANT FIBROUSHISTIOCYTOMA

5.MARROW TUMORS:1.EWINGS SARCOMA2.PRIMARY BONE LYMPHOMA

6.NOTOCHORD ORIGIN:CHORDOMA

METASTASESMOST COMMON BONE TUMORS – SOLITARYSECONDARIES

BONE METASTASES MOST COMMON WITH BREAST ,BRONCHUS , PROSTATE , KIDNEY AND THYROID

INCIDENCE VERY HIGH – BREAST CANCER – 73% - 80%

MOST COMMON SITES : VERTEBRAE , PELVIS ,PROXIMAL FEMORA , HUMERI , SKULL AND RIBS RADIOLOGICAL FEATURES :

XRAYS – LYTIC AND MULTIPLE , OCCURS IN THEMEDULLARY CAVITY OF THE BONE

POORLY DEFINES MEDULLARY DESTRUCTIONONLY LESION OF APPROXIMATELY 20 MM CAN BEVISUALIZEDIN OSTEOPOROSIS EVEN LARGER LESIONS CANNOT BEVISUALIZED.HYPERNEPHROMA – ALWAYS CAUSES LYTICMETASTASES

PELVIC XRAY SHOWING EXPANSILELYTIC METASTASIS

XRAY SPINE SHOWING OSTEOBLASTIC METASTASIS

BREAST CARCINOMA – MIXED APPEARANCEOSTEOBLASTIC CHANGE SEEN IN OSTEOSARCOMAMETS

PROSTATE – ALWAYS CAUSESOSTEOBLASTICMETASTASES

IDENTIFICATION OF MULTIPLE METASTASES1.TC – MDP BONE SCINTIGRAPHYMOST COST EFFECTIVE METHOD THOUGH WHOLEBODY MRI IS SENSITIVE BUT NOT COST EFECTIVE.

SCINTIGRAPHY FINDINGS:

“HOT SPOT”- MULTIPLE SITES OF INCREASEDSKELETAL ACTIVITY -IF BLOOD SUPPLY IS INTACT /OSTEOBLASTIC

“COLD SPOT” - WHICH INFARCTS OR SHOWS NOOSTEOBLASTIC RESPONSE - MOST COMMONLY SEENWITH RENAL METASTASES

OCCASIONALLY A COMBINATION OF BOTH HOT ANDCOLD LESIONS OCCUR

“SUPER SCAN” - DIFFUSE OSTEOBLASTIC METASTATICDISEASE – GENERALIZED INCREASE IN SKELETALACTIVITY WITH REDUCED OR ABSENT RENALACTIVITY

MRI :

ANY AREA OF UNEXPLAINED NCREASED UPTAKESHOULD BE EXAMINED WITH MRI.

T1W – REDUCED SIGNAL INTENSITY

T2W /FSFSE– INCREASED SIGNAL INTENSITY – APPEARSAS A HYPERINTENSE 'HALO' AROUND A LESION –HIGHLY SPECIFIC FEATURE OF METASTASES.

SOURCE OF PRIMARY TUMOR CAN BE DETECTED BYNON INVASIVE AND COST EFFECTIVE TECHNIQUESLIKE USG AND X-RAY EXAMINATION.FEATURES FOR DIFFERENTIATING BETWEENMETASTASES AND NON-METASTATIC LESION:

POSITIVE FEATURE FOR IDENTIFYING METASTASES:1.DIAPHYSEAL INVOLVEMENT2.VERTEBRAL BODY INVOLVEMENT3.PEDICLES INVOLVEMENT

FEATURES SUGGESTIVE OF NON METASTATIC LESION1.ABSENCE OF BONE EXPANSION2.ABSENCE OF FLORID PERIOSTEAL REACTION3.ABSENCE OF TUMOR BONE FORMATION4.ABSENCE OF LARGE SOFT TISSUE MASS

PRIMARY MALIGNANT TUMOR OFOSTEOID ORIGIN

OSTEOSARCOMAMOST COMMON PRIMARY MALIGNANT BONETUMOR

CLASSIFICATION :PRIMARY AND SECONDARY

PRIMARY OSTEOSARCOMA:1.CENTRAL – CONVENTIONAL HIGH GRADE ANDLOW GRADE 2.INTRACORTICAL OR SURFACE – PAROSTEAL ,PERIOSTEAL OR HIGH GRADE3.MULTICENTRIC – OSTEOSARCOMATOSIS4.EXTRA SKELETAL OR SOFT TISSUE

SECONDARY OSTEOSARCOMA :

CAUSES – 1.PAGETS DISEASE2.RADIOTHERAPY3.DE- DIFFERENTIATED PART OFCHONDROSARCOMA

ALSO ASSOCIATED WITH 1.LIFRAUMENI SYNDROME

2.FAMILIAL RETINOBLASTOMA3.ROTHMUND -THOMPSON SYNDROME

RADIOLOGICAL FEATURES:

SURFACE OSTEOSARCOMA

SHOWING COTICAL DESTRUCTION ANDEXTRAOSSEUS MASS LOCATED INMETAPHYSEAL REGIONCORTICAL DESTRUCTION IS COMMON RESULTS IN EXTRA OSSEUS MASS WHICHCOMMONLY SHOWS TYPICAL OSSEUS “CLOUDLIKE” MATRIX MINERALIZATIONMETAPHYSEAL LESION WITH MOTH EATEN OR

PERMEATIVE PATTERN OF BONE DESTRUCTION

INTENSELYSCLEROTIC INTRAMEDULLARY OSTEOSARCOMAALSO SHOWS CODMAN'S TRIANGLE ANDEXTRAOSSEUS MASS IN THE DISTAL FEMUR

MEDULLARY LESION IS PREDOMINANTLY LYTIC

MEDULLARY SCLEROSIS OCCURS DUE TOMINERALIZATION OF TUMOR OSTEOID

INTRAMEDULLARY LESION SHOWS DENSESCLEROSIS

SUN-BURST APPEARANCE – PERIOSTEALREACTION USUALLY DISORGANIZED ORPERPENDICULAR TO THE CORTEX

CODMAN'S TRIANGLE – PERIOSTEAL REACTIONLEADING TO SEPARATION AND LIFTING UP OFPERIOSTIUM .

VARIATIONS:ENTIRELY LYTICPSEUDO CYSTIC FORM

MRI – STAGING , SHOWS EXTENT OF TUMORCLEARLY

METASTASIS :HEMATOGENOUS METASTASIS : LUNG ,SUBPLEURAL , RARELY CAUSE PNEUMOTHORAX.SCINTIGRAPHY: INCREASED UPTAKEPLAIN FILM AND CT : CALCIFIED MASS

SKIP METASTASIS :RARE BUT ESSENTIAL TOIMAGE ENTIRE BONE IF DETECTION IS TO BEMADE.

CHONDROID MALIGNANT TUMOR– CHONDROSARCOMA

CLASSIFICATION:PRIMARY OR SECONDARYCENTRAL OR PERIPHERAL

HISTOLOGICAL GRADINGHIGH , MYXOID , LOW ,DEDIFFERENTIATED-DEVELOPMENT OF HIGH GRADE NONCHONDROID NEOPLASM

AGE : 50 YRS C/F : PAIN ,PALPABLE MASS , PATHOLOGICALFRACTURE

COMMON SITES: PELVIS , PROXIMAL FEMURAND PROXIMAL HUMERUS

RADIOLOGICAL FEATURES:

PLAIN RADIOGRAPH:

RADIOLOGICALLY OCCULT LARGE PELVICMASS

LOW GRADE TUMORS – MATRIXMINERALIZATION AND ENDOSTEALSCALLOPING .PERIOSTEAL REACTION ISPRESENT

CALCIFIED MASS -CHONDROSARCOMA ARISING FROM THE ILIUM

CALCIFIC CHONDROSARCOMA ARISING FROMTHE LOWER FEMUR METAPHYSES SHOWINGCORTICAL DESTRUCTION , NO PERIOSTEALREACTION AND CALCIFIED TUMOUR MATRIX

MYXOID GRADE : BONE EXPANSION ALSO

JUXTACORTICAL MASS WITH 1.CALCIFICATION(ARROWS) 2.ENDOSTEAL SCALLOPING 3.PERIOSTEAL REACTION 4.MOTHEATENAPPEARANCE ALSO SEEN

HIGH GRADE : CORTICAL DESTRUCTION ,PERIOSTEAL REACTION , BONE EXPANSIONDEDIFFERENTIATED – UNUSUALLYAGGRESSIVE RADIOLOGICAL FEATURES

INSPITE OF CORTICAL SCALLOPING THEPERIOSTEAL REACTION RESULTS ININCREASED CORTICAL THICKNESS.

MRI: DEFINES THE EXTENT OF SOFT TISSUEEXTENSION WITH GREAT ACCURACY

T2W- INCREASED SIGNAL MASSINTERMEDIATE SI ADJACENT TOHYPERINTENSE TUMOR MASS INDICATESDEDIFFERENTIATED TUMOR

T2WIMAGE SHOWING INCRESED SIGNAL INTENSITY WITHTHE TUMOUR SURROUNDING THE BONE IN THIS CASEOF PERIOSTEAL OSTEOSARCOMA

T1W – SLIGHTLY HYPOINTENSE TO MUSCLESAND HYPERINTENSESIGNAL FOCALLY FOR MARROW

MATRIX MINERALIZATION – FOCAL AREAS OFSIGNAL VOID

POST CONTRAST ENHANCEMENT IS MINIMALAND SHOWS PERIPHERL OR SEPTAL PATTERNDUE TO DECREASED VASCULARIZATION

IDENTIFICATION OF MALIG CHANGE INOSTEOCHONDROMA DESTRUCTION OF PART OF CARTILAGE CAPUSG MEAUREMENT OF CARTILAGE CAP SIZEOF > 20 MM INDICATES MALIGNANT CHANGE INOSTEOCHONDROMA

MALIGANANT FIBROUSTUMORS

MALIGNANT FIBROUSHISTIOCYTOMA

MOST COMMON PRIMARY MALIGANANTFIBROUS TUMOR

25 – 30% ARISE FROM PAGET'S DISEASE , POSTRADIOTHERAPY, BONE INFARCTION

LOCATION:METAPHYSES OF LONG BONES AREPREDOMINANTLY INVOLVEDAROUND KNEE , HUMERUS and PELVISAGE : 4TH DECADE , 6 – 80 YEARSRADIOLOGICAL FEATURES:PRIMARY – LYTIC AND DESTRUCTIVE ,

METAPHYSEAL PERIOSTEAL REACTION UNCOMMONSOFT TISSUE MASS MAY BE SEENMIMICS GCT BY EXTENDING TOSUBARTICULAR SURFACE

NO SPECIFIC DIAGNOSTIC FEATURES FOUNDON MRI

MARROW TUMORSEWINGS TUMOR

PRIMARY LYMPHOMA OF BONE

EWING'S SARCOMA

AGE GROUP -< 20 YRS – 75% < 30 YRS – 95%

SYSTEMIC SYMPTOMS – PYREXIA ,ELEVATED ESR , SIMULATES INFECTIONAND SIGNIFIES DISEMINATED DISEASEWITH POOR PROGNOSIS

SITE OF OCCURANCE:DIAPHYSEAL TUMOROCCURING IN FEMUR, HUMERUS ,PELVICBONES AND RIBS.

LESIONS MOSTLY SINGLE , BUT MULTIPLE

LESIONS ALSO SEEN

READILY METASTASIZES TO BONE

RADIOGRAPHIC APPEARANCE:

PERMEATIVE PATTERN OF LYTIC BONEDESTRUCTION WITH A WIDE ZONE OFTRANSITION.

CORTICAL DESTRUCTION PRESENT EXTRAOSSEUS SOFT TISSUE/SUBPERIOSTEAL MASS PRESENT

SUBPERIOSTEAL LESION CAN ERODE OUTERCORTEX AND CAUSE SAUCERIZATION

CODMAN TRIANGLE AND HAIR ON ENDAPPEARANCE DUE TO PERIOSTEAL REACTIONPRESENT .CORTICAL THICKENING , BONEEXPANSION and PATHOLOGICAL FRACTURES RARE

EWING'S SARCOMA ARISING FROM PROXIMALHUMERAL METAPHYSES AND DIAPHYSESSHOWING LYTIC MOTH-EATEN BONEDESTRUCTION , CODMAN'S TRIANGLE ANDCORTICAL DESTRUCTION .BONE EXPANSIONSEEN .NO SCLEROSIS AS SEEN WITHOSTEOSARCOMA ,NO CALCIFICATION AS SEENWITH CHONDROSARCOMA

XRAY SHOWS LAMELLAR ONION SKINPERIOSTEAL REACTION SEEN IN EWING'S

SARCOMA.PERMEATIVE BONE DESTRUCTIONSEEN.

OCCASIONALLY SPINAL AND FLAT BONELESIONS CAN CAUSE SCLEROTIC APPEARNCERESEMBLING OSTEOSARCOMA

CT/MRI SHOWS LARGE EXTRA OSSEUSCOMPONENT . INTRAOSSEUS COMPONENT ISACCURATELY DEMOSTRATED

DIFFERENTIAL DIAGNOSIS:OSTEOMYELITISTRAUMALYTIC OSTEOSARCOMAPRIMARY BONE LYMPHOMA IN PATIENTSMORE THAN 30 YRS OF AGE

PRIMARY BONE LYMPHOMAAKA 1. RETICULUM CELL SARCOMA 2.LYMPHSARCOMA OF BONEINVOLVEMENT OF SINGLE SITE IN BONE WITHNO OTHER SITE INVOLVED FOR SIX MONTHSAFTER DIAGNOSIS

USUALLY A NON HODGKIN'S B-CELLLYMPHOMA

RADIOLOGICAL FEATURES :SIMILAIR TO EWING'S SARCOMA

PERMEATIVE LYTIC DESTRUCTIVE LESIONREPORTED IN 74% RELATIVE ABSENCE OF CORTICALDESTRUCTION IS A CHARACTERISTIC FEATURE

SEQUESTRA AS SEEN IN OSTEOMYELITIS AREALSO CHARACTERISTICALLY SEEN

MRI : EXTENSIVE INVOLVEMENT OFMEDUALLY CANAL WITH LARGEEXTRAOSSEUS MASS AND LITTLE CORTICALBONE DESTRUCTION

NOTOCHORD ORIGIN TUMORCHORDOMA

MIDLINE TUMOR , AXIAL LOCATIONAGE : 50 - 70YRSSITE : SACROCOCCYGEAL (50%) , CLIVALTUMOR (40%)

SYMPTOMS : CONSTIPATION , BLADDERDYSFUNCTION ,CRANIAL NERVE PALSIES ANDPELVIC MASS .

RADIOLOGICAL FEATURES:SACRAL MASS , DESTRUCTIVE , SOMETIMESOCCULT FEW CASES – EXTRAOSSEOUS MASSCALCIFICATIONIN CLIVUS LESION – SELLA AND CLIVUS MAY

BE DESTROYED

MRI :T1W – LOW SI MASS WITH EXTRAOSSEUSEXTENSION , HIGH SI occur BECAUSE OFHEMORRHAGE AND HIGH PROTEIN CONTENT

T2W – HIGH SI LESION MASS WITH LOW SIINTERNAL SEPTATIONS AND WELL DEFINEDMARGINS

MRI T1WIMAGE SHOWING “THUMB SIGN”(ARROWS) OFPONS DUE TO IMPINGEMENT OF THE TUMOURWHICH APPEARS ANTERIOR AND HYPODENSETO PONS