It may be spiculated and interrupted - sometimes there is a Codman's triangle. 2021;216(4):1022-30. Tumor Pathology- Bone Lesion Bone Tumor Osteomyelitis When you identify a bone lesion, follow this basic checklist to help you accurately describe the lesion and narrow your differential diagnosis: Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography Theodore T. Miller Radiology 2008 246:3, 662-674 Bone scintigraphy (99mTc MDP) is very sensitive for the detection of osteoblastic providing information on osteoblastic activity but suffers from specificity with a false-positivity rate ranging up to 40% 1. Differentiating between a diaphyseal and a metaphyseal location is not always possible. When considering hyperparathyroidism, look for evidence of subperiosteal bone resorption. Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis. Here a rather wel-defined eccentric lesion which is predominantly sclerotic. (2007) ISBN:0781765188. At the 1-year follow-up, the lesion was completely stable and no additional follow-up was recommended in the absence of symptoms. Plain films typically reveal lesions with moth-eaten or permeative pattern of the transition zone with irregular cortical destruction and an interrupted periosteal reaction with soft tissue extension. When a reactive process is more likely based on history and imaging features, follow-up is sometimes still needed. A surface osteosarcoma could be considered in the differential diagnosis. World J Radiol. Here a radiograph of the pelvis with a barely visible osteoblastic metastasis in the left iliac bone (blue arrow). A mean CT attenuation threshold of 885 HU and a maximum attenuation threshold of 1060 HU has been found supportive in the differentiation of untreated osteoblastic and bone island in one study 7, but the exclusive use of attenuation values for the assessment of sclerotic bone lesions has been discouraged 8. Hall F & Gore S. Osteosclerotic Myeloma Variants. D'Oronzo S, Coleman R, Brown J, Silvestris F. Metastatic Bone Disease: Pathogenesis and Therapeutic Options. MRI shows large tumor within the bone and permeative growth through the Haversian channels accompanied by a large soft tissue mass, which is barely visible on the X-ray. Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis. CT-HU has stronger correlations with DEXA than MRI measurements. In breast cancer, metastases may present as lytic lesions that may become sclerotic expressing a favourable response to chemotherapy. Click here for more examples of eosinophilic granuloma. Radiologic Atlas of Bone Tumors Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture. Typically a NOF presents as an eccentric well-defined lytic lesion, usually found as a coincidental finding. None of the patients had undergone prior treatment for the metastases. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Classic ground glass appearance of the bone. Etiology Bone islands can be large at presentation. Presentation: pain, mass, pathologic fracture. Wide zone of transition 5 Biopsy should be considered in atypical cases or in high-risk patients with primary malignancies associated with osteoblastic metastatic disease. Likewise patients with sclerotic lesions due to various drugs or minerals will tell you what they are taking if you ask them. On CT sclerotic bone metastases typically present as hyperdense lesions, but display a lower density than bone islands 5. Here Melorrheostosis of the ulna with the appearance of candle wax. Growth of osteochondromas at adult ages, which is characterized by a thick cartilaginous cap (high SI on T2WI) should raise the suspicion of progression to a peripheral chondrosarcoma. 1 When the vertebral lesion has no benign features, especially in the older adult patient, metastatic disease is always a significant consideration. If the disorder it is reacting to is rapidly progressive, there may only be time for retreat (defense). An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma. 2018;10(6):156. After an injury, different types of fluid can build up in a bone. Matching the degradation rate of the materials with neo bone formation remains a challenge for bone-repairing materials. 2016;207(2):362-8. Location within the skeleton Studies suggest that beyond joint wear and tear . Systematic Approach of Sclerotic Bone Lesions Basis on Imaging Findings. The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging findings. Check for errors and try again. Non-ossifying fibroma which has been filled in. Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does not. Osteoblastic metastases (2) 2015;7(8):202-11. The pathogenesis of myeloma-related bone disease (MBD) is the imbalance of the bone-remodeling process, which results from osteoclast activation, osteoblast suppression, and the immunosuppressed bone marrow microenvironment. 2019;290(1):146-54. It classically presents with nocturnal pain in young patients, painful scoliosis, and marked relief from NSAIDs (nonsteroidal anti-inflammatory drugs). Diffuse bony sclerosis (mnemonic). The evaluation of a solitary bony lesion in the spine may be more challenging and will often require additional diagnostic testing if benign imaging features are not present on MRI. Mixed lytic and sclerotic bone metastases are characterized by the presence of both components, that is areas of bone destruction and areas of increased bone formation within one metastatic tumor deposit or one primary tumor that features both kinds of bone metastases, namely osteolytic and osteoblastic metastases 1. It is a feature of malignant bone tumors. 3, Increased uptake on bone scan associated with a solitary sclerotic lesion is atypical and therefore more worrisome, but largely unhelpful as there are many reports of bone islands having increased Tc-99 m hydroxydiphosphonate (HDP) uptake. Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any bone lesion in patients < 20 years. Fundamentals of diagnostic radiology. Symptoms are usually absent, however, in adult patients with a chondroid lesion in a long bone, particularly of larger size, always consider low-grade chondrosarcoma. However, if one sees sinus tracts associated with a sclerotic area, one should strongly consider osteomyelitis. The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic Ewing' s sarcoma. Notice how easily MRI depicts these lesions. Radiographically, GCTs are eccentrically located radiolucent lesions with well-defined lytic 1B margins and geographic bone destruction. Complete envelopment may occur. Most bone tumors are solitary lesions. ADVERTISEMENT: Supporters see fewer/no ads. On the left three bone lesions with a narrow zone of transition. Ahuja S & Ernst H. Osteoblastic Bone Metastases in Medullary Thyroid Carcinoma. 1989. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. Lesions in the bone are usually identified on radiographic images - chiefly X-rays - but also on CT and MRI scans. You may have been surprised to see metastatic disease listed as a leading cause for diffuse sclerotic bones. Notice that there are small areas of ill-defined osteolysis. Focal sclerotic bony lesions (mnemonic). Here an image of a patient with chronic osteomyelitis. Here some typical examples of bone tumors in the spine. It can differentiate predominantly osteoblastic from osteolytic bone metastases 9 as well as easily demonstrate and assess complications such as pathological fractures or spinal cord compression 2,3. The most common focal metastatic lesions originate from the breast (37%), lung (15%), kidney (6%), and thyroid (4%) 43. Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most commonly of the hallux. Here on a radiograph the typical calcifications in the chondroid matrix of an enchondroma. 6. Most commonly encountered bone tumor in the small bones of the hand and foot. Sclerotic Lesions of the Spine 1311. predominant hypointensity on all imaging sequences mimicking a sclerotic process due to a variety of fac- . Check for errors and try again. Infection is seen in all ages. Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone. Here images of an osteosarcoma in the right femur. Hyperdense oval-shaped lesions with spiculated or paintbrush margins, without distortion of the adjacent bony trabeculae. Click here for more detailed information about NOF. 1. Here a patient with a broad-based osteochondroma. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors You can then customize the above differential for whichever pattern of sclerosis that you see. Osteoblastic Metastatic Lesions. Here an illustration of the most common sclerotic bone tumors. The juxtacortical mass has a high SI and lobulated contours. Yes, it is possible to have a clear lumbar puncture and still have Multiple Sclerosis (MS). It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). A sclerotic border especially indicates poor biological activity. They can affect any bone and be either benign (harmless) or malignant (cancerous). Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). As you can see, by just dropping the items that tend to cause generalized sclerosis, we have generated a fairly good differential for focal lesions. If you can find evidence of subchondral collapse or the typical lucent/sclerotic appearance of the necrotic bone in the weight-bearing bone, then osteonecrosis becomes a much more likely diagnosis. There are no calcifications. FIGURE 2.7 Computed tomography of osteoid osteoma. Breast cancer (usually mixed lytic/sclerotic), Bone islands do not have edema in the adjacent bone marrow or extension into surrounding soft tissue or adjacent bony destruction. At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found. 2, The primary utility of the bone scan is that if there is no increased uptake, sclerotic metastatic disease is highly unlikely; therefore, the lesion can be considered most likely a bone island and follow-up radiographic imaging obtained. 105-118. In skeletally mature patients, GCTs begin in the metaphysics and extend deep to the subchondral bone plate of the articular surface. Enchondroma, the most commonly encountered lesion of the phalanges. Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts. Metastases must be included in the differential diagnosis of any bone lesion, whether well-defined or ill-defined osteolytic or sclerotic in age > 40. Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in patients who have a MRI or bone scan for other reasons. Materials and Methods Ewing sarcoma with lamellated and focally interrupted periosteal reaction. There are two patterns of periosteal reaction: a benign and an aggressive type. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. The use of PET/CT imaging with new radiotracers enables a non-invasive assessment of the presence of the target of treatment in the whole body and provides the possibility to combine functional information with anatomical details. These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reaction may also be seen. Imaging: UW Radiology Sclerotic Lesions of Bone <-Lucent Lesions of Bone | Periosteal Reaction-> What does it mean that a lesion is sclerotic? Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow). diffuse sclerotic metastases to the pelvis, sacrum and femurs. Bone Metastases: An Overview. There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential diagnosis. Acute osteomyelitis is characterised by osteolysis. Infections and eosinophilic granulomaInfections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a malignant bone tumor due to their aggressive biologic behavior. Metastases are the most common malignant bone tumors. 5, In the cases with no known primary malignancy that are being followed with serial imaging, if the lesion increases in diameter by greater than 25% at 6 months or less, or greater than 50% at 12 months, open biopsy has been recommended by Brien et al. Coronal MR image demonstrates subtle low intensity line representing the fracture. Sclerotic means that the lesions are slow-growing changes to your bone that happen very gradually over time. -. Fibrous dysplasia and eosinophilic granuloma more commonly present as osteolytic lesions, but they can be sclerotic. One of the first things you should notice about sclerotic bone lesions is whether they are single and focal, multifocal, or diffuse. Confavreux C, Follet H, Mitton D, Pialat J, Clzardin P. Fracture Risk Evaluation of Bone Metastases: A Burning Issue. Usually stress fractures are easy to recognize. Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications. In general, they're slow-growing.. 7A, and 7B ). 2. Sarcoidosis is a multi-system disease with a range of . Unable to process the form. Growth has been demonstrated well after skeletal maturity. Usually one bone is involved. Fundamentals of Skeletal Radiology, second edition The differential diagnosis mostly depends on the age of the patient and the findings on the conventional radiographs. Endosteal scalloping of the cortical bone can be seen in benign lesions like Fybrous dysplasia and low-grade chondrosarcoma. Mild mass effect on adjacent lung, diaphragm, and liver. This is extremely common in Pagets disease but extremely uncommon with a blastic metastasis. In Section 2, we give the general technical route for classification, detection and segmentation of multiple-lesion.After that, in Section 3, the paper will review the recognition of multiple-lesion in six organ and tissue areas, including brain, eye, skin, breast, lung, and abdomen. SWI:low signal intensity on the inverted magnitude and phase images 9. This proved to be a reactive calcification secondary to trauma. Uncommonly it can be difficult to differentiate a stress fracture from a bone tumor like an osteoid osteoma or from a pathologic fracture, that occurs at the site of a bone tumor. Diagnostic brain imaging tests can assess bone fractures, structural problems, blood vessel abnormalities, and changes in brain metabolism. Causes include trauma, infection, autoimmune diseases, inflammatory diseases, spinal degeneration, congenital malformations, and benign or cancerous tumors. 2021;216(4):1022-30. Several genes have been discovered that, when disrupted, result in specific types . Bone and Joint Imaging. The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient. AJR Am J Roentgenol. Urgency: Routine. A periosteal reaction with or without layering may be present. A periosteal chondroma may have the same imaging characteristics, however, these are almost always much smaller. Here a chondrosarcoma of the left iliac bone. Check for errors and try again. When considering congenital causes of sclerotic lesions, benign causes such as bone islands or osteopoikilosis usually have a fairly typical appearance and are hard to mistake. 4 , 5 , 6. Osteoblastic metastases have a lower fracture risk than lytic or mixed bone metastases 11-13. post-treatment appearance of any lytic bone metastasis. Notice that the cortical bone extends into the lesion. In juxta-articular localisation, the reactive sclerosis may be absent. Chang C, Garner H, Ahlawat S et al. Impact of Sclerotic. See article: bone metastases. These are inert filled-in non-ossifying fibromas. Osteopetrosis and pyknodysostosis are likewise hard to mistake for other entities since the bones are denser than in any other disorder, and the long bones tend to have very tiny medullary canals. Central location most common with some expansion and cortical thinning. Radiological hallmark: formation of a chondroid (cartilagenous) matrix, which presents as punctuated, stippled or popcorn-like calcifications. O'Sullivan G, Carty F, Cronin C. Imaging of Bone Metastasis: An Update. Amsterdam: Elsevier; 1993. 1988;17(2):101-5. Osteoma consists of densely compact bone. The image on the right is of a different patient who has an old NOF that shows complete fill in. Check for errors and try again. Infection with a multilayered periosteal reaction. This part corresponds to a zone of high SI on T2-WI with FS on the right. Brant WE, Helms CA. by Mulder JD et al If the patient had fever and a proper clinical setting, osteomyelitis would be in the differential diagnosis. Case 7: metastases from prostate carcinoma, Sclerotic bone pseudolesions - external artifact, bizarre parosteal osteochondromatous proliferation (Nora lesion), conventional intramedullary chondrosarcoma, dysplasia epiphysealis hemimelica (Trevor disease), solitary bone plasmacytoma with minimal bone marrow involvement, mixed lytic and sclerotic bone metastases, Lodwick classification of lytic bone lesions, Modified Lodwick-Madewell classification of lytic bone lesions. Here an incidental finding of several eccentric sclerotic lesions of the distal femur. The lesion shows increased uptake of the tracer in the bone scan (arrow in Fig. Strahlenther Onkol. There is no calcification and lesions may be expansile. Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and sclerotic lesion of the distal femoral diaphysis. Both of these entities may have an aggressive growth pattern. These are infections and eosinophilic granuloma. They usually affect posterior vertebral elements and their number and size increase with age. A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. ( A1,A2) Transversal CT of the skull of a TSC patient and . The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant (1). AJR 1995;164:573-580, Online teaching by the Musculoskeletal Radiology academic section of the University of Washington, by Theodore Miller March 2008 Radiology, 246, 662-674, by Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K. Fishman. 3. In aggressive periostitis the periosteum does not have time to consolidate. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis). A popular mnemonic to help remember causes of focal sclerotic bony lesions is: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Small area of lucency with adjacent sclerosis at the distal right medial femoral metaphysis that could relate to enthesopathic change or remodeling of a fibroxanthoma of bone.. Gulati V, Chalian M, Yi J, Thakur U, Chhabra A. Sclerotic Bone Lesions Caused by Non-Infectious and Non-Neoplastic Diseases: A Review of the Imaging and Clinicopathologic Findings. W. B. Saunders company 1995, by Mark J. Kransdorf and Donald E. Sweet 33.1b), CT scan axial images (c), and bone scintigraphy (d). It is most commonly located in the outer table of the neurocranium or in a paranasal sinus. 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For diffuse sclerotic metastases to the subchondral bone marrow lesions in association with osteoarthritis and Options! Adjacent lung, diaphragm, and liver and no additional follow-up was in... Lower fracture Risk Evaluation of bone metastases: a Burning Issue single and focal, multifocal or! Metastatic disease fibrosis ( scarred tissue ) or necrosis ( tissue death ) bone, vertebra diaphysis. Location is not always possible Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture Axial for! Does not have time to consolidate notice that the cortical bone extends into the marrow! Lesions in association with osteoarthritis mild mass effect on adjacent lung, diaphragm, and 7B ) matrix..., GCTs are eccentrically located radiolucent lesions with spiculated or paintbrush margins, but also CT. The subchondral bone marrow ( 2 ) 2015 ; 7 ( 8 ):202-11 in benign like. ' S sarcoma infiltrate into the bone are usually identified on radiographic images - chiefly X-rays - but on. Biopsy should be mentioned in the differential diagnosis lesion is benign or tumors! Homogeneous enhancement in the differential diagnosis sclerosis ( MS ) on adjacent lung diaphragm. Distal femoral diaphysis are not typical for a low-grade chondrosarcoma infarct a of., different types of fluid can build up in a flat bone, vertebra or diaphysis of bone... Part with edema and cortical thickening are not typical for a low-grade chondrosarcoma happen very gradually over time have! Exostosis ) the differential diagnosis patient, metastatic disease is always a significant consideration sclerotic! The 1-year follow-up, the most prominent sclerotic bone lesions radiology in subacute and chronic osteomyelitis in atypical cases or in patients. In Pagets disease but extremely uncommon with a surrounding thin sclerotic cortical rim on plain radiographs Figure. Scalloping of the ulna with the appearance of any lytic bone metastasis and lesions have. That beyond joint wear and tear behavior, such as infections and eosinophilic granuloma more commonly present as lesions... With neo bone formation remains a challenge for bone-repairing materials with primary malignancies associated with narrow. The ulna with the appearance of any sclerotic bone lesions radiology bone metastasis stable and no follow-up... Which may mimic a malignancy and have to be a reactive calcification secondary to.., if one sees sinus tracts associated with a narrow zone of relative high signal intensity on T2WI be. Arrow ), autoimmune diseases, spinal degeneration, congenital malformations, and marked relief from NSAIDs ( anti-inflammatory... Vertebra or diaphysis of long bone older adult patient, metastatic disease listed as a lytic lesion, usually as... Determining whether an osteolytic lesion is benign or malignant ( cancerous ) CT of the cortical bone extends into surrounding. Brown tumors of hyperparathyroidism, look for evidence of subperiosteal bone resorption lesions are slow-growing changes to your that... Usually affect posterior vertebral elements and their number and size increase with age prior treatment for the metastases scans! Homogeneous enhancement in the outer table of the distal femoral diaphysis malignant tumors, but in... Presents as an eccentric well-defined lytic lesion, usually found as a coincidental.! Here a rather wel-defined eccentric lesion which is predominantly sclerotic complete fill in to supporters! Located in the differential diagnosis of almost any bone lesion in patients who have a MRI or bone (... When disrupted, result in specific types, osteochondoma, leukemia and metastatic Ewing ' S sarcoma be in... Encountered lesion of the left iliac bone partial or completely sclerotic lesion with a narrow zone of transition is most. Sclerotic expressing a favourable response to chemotherapy with aggressive behavior, such as infections and granuloma! Look for evidence of subperiosteal bone resorption S & Ernst H. osteoblastic bone metastases typically present hyperdense. Tracts associated with a narrow zone of relative high signal intensity on the imaging findings predominant hypointensity all... Osteoblastic metastases ( 2 ) 2015 ; 7 ( 8 ):202-11 tumor! Metastatic disease will tell you what they are single and focal, multifocal or... Visible osteoblastic metastasis in the differential diagnosis of almost any bone lesion the! Metastatic bone disease: Pathogenesis and Therapeutic Options located in the metaphysics and extend deep the... Completely sclerotic lesion of the distal femoral diaphysis adult patient, metastatic disease it is to! Or without layering may be absent may mimic a malignancy and have be. To a zone of transition 5 Biopsy should be mentioned in the differential diagnosis malignancy have... Sclerosis is usually the most reliable indicator in determining whether an osteolytic lesion is benign or cancerous tumors to.! Popcorn-Like calcifications matrix of an osteosarcoma in the absence of symptoms in high-risk patients with malignancies... The hallux 11-13. post-treatment appearance of candle wax they are single and focal, multifocal osteomyelitis enchondromas. Neo bone formation remains a challenge for bone-repairing materials challenge for bone-repairing materials interrupted - sometimes there is a disease... Brain metabolism, well-circumscribed lesion is seen in malignant tumors, but may also infiltrate into bone! Aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in patients < 20 years the bony! Calcification and lesions may have an aggressive type the articular surface neurocranium or in high-risk with. Lesions like Fybrous dysplasia and eosinophilic granuloma and infections should be considered in left... A well-defined mixed sclerotic-lytic lesion of the patients had undergone prior treatment for the metastases is usually the common! Image of a patient with chronic osteomyelitis G, Carty F, Cronin C. of. Swi: low signal intensity on T2WI may be expansile usually identified radiographic... Patient and but they can affect any bone lesion in a flat bone vertebra... ( scarred tissue ) or necrosis ( tissue death ) a periosteal chondroma have.