Dr.
Vineel Bezawada
M.S (orthopaedics)
When you see lytic bone lesion think of
FOGMACHINE.
Diagnosis (Mnemonic
=
Differential
C = Chondroblastoma
F = Fibrous Dysplasia
FOGMACHINES)
O = Osteoblastoma
G = Giant Cell Tumour
H=
Hyperparathyroidism(brown
tumours)/ Hemangioma
I = Infection
M = Metastasis /
Myeloma
A = Aneurysmal Bone
Cyst
N = Non-ossifying Fibroma
E = Eosinophilic Granuloma /
Enchondroma
S = Solitary Bone Cyst
The most important
determinants to analyse the
The morphology
of the are:
bone lesion on a plain radiograph
bone
lesion
Well-defined osteolytic
ill-defined osteolytic
Sclerotic
The age of the patient
It is important to realize that the plain radiograph is the
most useful examination for differentiating these
lesions.
CT and MRI are only helpful in selected cases.
Most bone tumors are osteolytic.
The most reliable indicator in determining whether
these lesions are benign or malignant is the zone of
transition between the lesion and the adjacent
normal bone .
Once we have decided whether a bone lesion is
sclerotic or osteolytic and whether it has a welldefined or ill-defined margins, the next question
should be: how old is the patient?
Age is the most important clinical clue.
Finally other clues need to be considered, such as a
lesion localization within the skeleton and within the
bone, any periosteal reaction, cortical destruction,
matrix calcifications, etc.
Notice the following:
Infections, a common tumor mimic, are seen in any age
group.
Infection may be well-defined or ill-defined osteolytic,
and even sclerotic.
EG and infections should be mentioned in the
differential diagnosis of almost any bone lesion in
patients < 30 years.
Many sclerotic lesions in patients > 20 years are healed,
previously osteolytic lesions which have ossified, such
as: NOF, EG, SBC, ABC and chondroblastoma.
Zone of transition
In order to classify osteolytic lesions as well-defined
or ill-defined, we need to look at the zone of
transition between the lesion and the adjacent
normal bone.
The zone of transition is the most reliable indicator
in determining whether an osteolytic lesion is
benign or malignant.
The zone of transition only applies to osteolytic
lesions since sclerotic lesions usually have a narrow
transition zone.
Small zone of transition
A small zone of transition results in a sharp, well-
defined border and is a sign of slow growth.
A sclerotic border especially indicates poor
biological activity.
In patients < 30 years a
well-defined border
means that we are
dealing with a benign
lesion.
In patients > 30years,
and particularly over 40
years, despite benign
radiographic features,
metastasis or
plasmacytoma also have
Wide zone of transition
An ill-defined border with a broad zone of
transition is a sign of aggressive growth.
It is a feature of malignant bone tumors.
There are two tumor-
like lesions which may
mimic a malignancy
and have to be
included in the
differential diagnosis.
These are infections
and eosinophilic
granuloma.
Both of these entities
may have an
aggressive growth
Periosteal reaction
A periosteal reaction is a non-specific reaction and will occur
whenever the periosteum is irritated by a malignant tumor,
benign tumor, infection or trauma.
The benign type is seen in benign lesions such as benign
tumors and following trauma.
An aggressive type is seen in malignant tumors, but also in
benign lesions with aggressive behavior, such as infections
and eosinophilic granuloma.
Cortical destruction
Cortical destruction is a common finding, and not very useful in
distinguishing between malignant and benign lesions.
Complete destruction may be seen in high-grade malignant lesions,
but also in locally aggressive benign lesions like EG and
osteomyelitis.
More uniform cortical bone destruction can be found in benign and
low-grade malignant lesions.
Endosteal scalloping of the cortical bone can be seen in benign
lesions like FD and low-grade chondrosarcoma.
Ballooning is a special type of cortical destruction.
In ballooning the destruction of endosteal cortical bone and the
addition of new bone on the outside occur at the same rate,
resulting in expansion.
This 'neocortex' can be smooth and uninterrupted, but may also be
focally interrupted in more aggressive lesions like GCT.
Location within the
skeleton
Location: epiphysis - metaphysis diaphysis
Epiphysis
Only a few lesions are located in the epiphysis, so this could be an
important finding.
In young patients it is likely to be either a chondroblastoma or an infection.
In patients over 20, a giant cell tumor has to be included in the differential
diagnosis.
In older patients a geode, i.e. degenerative subchondral bone cyst must be
added to the differential diagnosis.
Look carefully for any signs of arthrosis.
Metaphysis
NOF, SBC, CMF, Osteosarcoma, Chondrosarcoma, Enchondroma and
infections.
Diaphysis
Ewing's sarcoma, SBC, ABC, Enchondroma, Fibrous dysplasia and
Osteoblastoma.
Location: epiphysis - metaphysis diaphysis
Location: centric - eccentric juxtacortical
Centric in long bone
SBC, eosinophilic granuloma, fibrous dysplasia, ABC
and enchondroma are lesions that are located centrally
within long bones.
Eccentric in long bone
Osteosarcoma, NOF, chondroblastoma, chondromyxoid
fibroma, GCT and osteoblastoma are located
eccentrically in long bones.
Cortical
Osteoid osteoma is located within the cortex and
needs to be differentiated from osteomyelitis.
Juxtacortical
Osteochondroma. The cortex must extend into the
stalk of the lesion.
Parosteal osteosarcoma arises from the periosteum.
Matrix
Calcifications or mineralization within a bone
lesion may be an important clue in the
differential diagnosis.
There are two kinds of mineralization: a
chondroid matrix in cartilaginous tumors like
enchondromas and chondrosarcomsa and an
osteoid matrix in osseus tumors like osteoid
osteomas and osteosarcomas.
Chondroid matrix
Calcifications in chondroid tumors have many
descriptions: rings-and-arcs, popcorn, focal
stippled or flocculent.
Osteoid matrix
Mineralization in osteoid tumors can be
described as a trabecular ossification pattern
in benign bone-forming lesions and as a
cloud-like or ill-defined amorphous pattern in
osteosarcomas.
Polyostotic or multiple lesions
Most bone tumors are solitary lesions.
If there are multiple or polyostotic lesions, the differential diagnosis
must be adjusted.
Polyostotic lesions < 30 years
NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas,
osteochondoma, leukemia and metastatic Ewing' s sarcoma.
Multiple enchondromas are seen in Morbus Ollier disease.
Multiple enchondromas and hemangiomas are seen in Maffucci's
syndrome.
Polyostotic lesions > 30 years
Common: Metastases, multiple myeloma, multiple enchondromas.
Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism,
bone infarcts.
Thank You !!!
