BONE TUMOURS
Introduction
• Malignant bone tumors are not very common.
• To recognize a malignant tumor and
differentiate it from benign can be difficult and
often impossible.
• Processes such as infection and eosinophilic
granuloma can mimic malignant tumors.
• They will often be included in the differential
diagnosis of an aggressive lesion along with
malignant tumors.
Factors to consider
1. Determine aggressiveness (pattern of
destruction and repair)
2. Tissue characterization by matrix (usually by
CT)
3. Location of lesion
4. Age of patient
Pattern of bone destruction
• Most important factor in determining the rate of
growth or aggressiveness of the tumor.
• Cortical penetration is indicative of an aggressive
lesion.
• Pattern types include:
Geographic lytic pattern
• Well-delineated, circumscribed hole in the bone
• Sclerotic rim indicates relatively slow growth.
• An ill-defined or wide transition zone indicates a
moderately aggressive process.
Moth-eaten pattern
• Numerous small holes of varying size in cortical and
trabecular bone
• Reflects aggressive behavior
Permeative pattern
• Numerous elongated holes along the cortex
• Occasionally, only a decrease in cortical bone density is
visible.
• Reflects aggressive behavior
In order of increasing aggressiveness:
Ia: Geographic lucency, well-defined sclerotic
margin
Ib: Geographic lucency, well-defined
nonsclerotic margin
Ic: Geographic lucency, ill-defined margin
II: Moth-eaten
III: Permeative
Pattern of Bone Repair
• New bone (osteoblastic activity) is formed in response
to destruction:
Periosteal response
• Buttressing (wavy periostitis; benign lesion)
Thick, single layer of periosteal reaction
Indicates slow growth or benignity
Nonspecific: hypertrophic pulmonary osteoarthropathy
(HPO), atherosclerosis, benign tumors
• Aggressive patterns
Seen with rapidly progressive lesions such as malignancy or
osteomyelitis
Lamination (onion-peel). Periosteum appears in layers.
Codman's triangle. Periosteum forms bone only at the margin
of the tumor.
Spiculations
Sunburst pattern is seen in aggressive malignant lesions;
spiculations commonlypoint to the center of the lesion.
Hair-on-end pattern is seen with lesions that invade the
marrow cavity in long bones.
• Endosteal response
Thick rim of new bone indicates benign, slow growth (e.g.,
nonossifying fibroma [NOF],osteoma, Brodie abscess,
fibrous dysplasia).
Thin rim or no rim indicates a more active lesion.
• Mottled appearance
Results from bone intermingled with a permeative or moth-
eaten pattern of destruction
• Indicates invasiveness (malignant and nonmalignant
causes)
Tissue Characterization
• Tumor matrix refers to the neoplastic
intercellular substance produced by tumor
cells.
• CT is often required to adequately define the
matrix.
• For example, an increased tumor density on
plain film may be due to osteoid matrix or
periosteal/endosteal response.
• Chondral calcifications: linear, curvilinear, ring-like, punctuate or
nodular
• Osseous mineralization: cloud-like and poorly defined, whereas
diffuse matrix mineralization in benign fibrous tumours
produces the characteristic ‘ground-glass’ appearance (e.g.
fibrous dysplasia)
• Chondroid or osteoid matrix mineralization: this is often central
It is often peripheral in benign lesions such as a bone infarct or
myositis ossificans
Location of the tumour
Location of a Lesion in the Skeleton
• As a general rule, most primary tumors arise in areas of rapid
growth (distal femur, proximal tibia, humerus),
• Metastases occur in well-vascularized red bone marrow (spine, iliac
wings).
• The following tumors have a predilection for typical locations:
Enchondromas: phalanges
Osteosarcoma, giant cell tumor: around the knee
Hemangioma: skull and spine
Chondrosarcoma: innominate bone
Chordoma: sacrum and clivus
Adamantinoma: mid tibia
Location within Anatomic Regions
• Epiphysis: typical are cartilaginous and articular
lesions such as chondroblastoma or eosinophilic
granuloma (EG)
• Metaphysis: lesions of different causes (e.g.
neoplastic, inflammatory, metabolic) have a
predilection for the metaphysis (rich blood supply)
• Epiphyseal/metaphyseal region: giant cell tumors
• Diaphysis: after the 4th decade of life, most solitary
diaphyseal bone lesions involve the bone marrow.
Axial Location within a Bone
Refers to the position of the lesion with respect to the long axis of the bone.
• Central lesions (usually benign); Enchondroma, Unicameral bone cysts,
Eosinophilic granuloma (EG)
• Eccentric lesions; Aneurysmal bone cyst (ABC), Osteosarcomam, NOF,
Giant cell tumor (GCT), Chondromyxoid fibroma
• Cortical lesions (most commonly benign); Cortical defect, Cortical
desmoid, Osteoid osteoma, Periosteal chondroma
• Parosteal lesions; All osseous, cartilaginous, and fibrous malignancies
Osteochondroma, Myositis ossificans (should be separate from bone)
Age at presentation
• Metastases are the commonest malignant bone
tumours in patients that are > 45 years of age
• Primary malignant bone tumours are rare
before 5 years of age
• 1st decade: these are commonly disseminated
bone lesions of leukaemia and neuroblastoma
• 2nd decade: it is usually an osteosarcoma or
Ewing’s sarcoma
