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NEW Bone Production AND Periosteal Reacti On : New Bone Within A Host Bone May Appear
NEW Bone Production AND Periosteal Reacti On : New Bone Within A Host Bone May Appear
NEW Bone Production AND Periosteal Reacti On : New Bone Within A Host Bone May Appear
*From the Department of Radiology, Jefferson Medical College Hospital, Philadelphia, Pennsylvania.
708
VoL. @7,No. 3 New Bone Production and Peniosteal Reaction 709
TABLE I
Type
ExampleI.
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ReactionA.Lamellated
Interrupted Periosteal
Ewing's(Onion Osteosarcoma,
InfectionB.Perpendicular
Peel) Tumor and
Ewing's(Sunburst) Osteosarcoma,
InfectionC.Amorphous Tumor and
Malignant Tumor
than i mm. in thickness. They are of uni Essential in the recognition of solid pen
form density; the entire sheet of peniosteal ostea! reactions is its persistence, relatively
new bone looks the same. Remarkable dif unchanged for weeks. Whereas it may in
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ferences may be seen from patient to pa crease in size, the uniformity of its roentgen
tient, but in the individual patient, the density changes but little. In this regard the
newly formed bone, deposited as the result importance of roentgen techniques cannot
of peniostea! reaction to an irritant, has an be overemphasized. One should be able to
even, uniform, solid appearance. When reproduce roentgenograms of uniform qual
seen, it is the hallmark of a benign process. ity in order that reliable roentgen compari
FIG. 5. Dense undulating periosteal reaction due to pulmonary osteoarthropathy. The periosteal reaction is
quite thick. Initially, a small dense periosteal reaction may be noted but as the condition progresses it
becomes much thicker and irregularly calcified. (A) Standard roentgenogram. (B) Magnified roentgeno
gram.
FIG. 6. Solid thin periosteal reaction due to pul
monary osteoarthropathy. Most of the meta
carpals and phalanges reveal periosteal prolifera
tion. This occurs relatively early and the appear
ance is solid.
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solid uniform peniosteal reactions bespeak benign or malignant tumors of the thoracic
benignancy, it must be remembered that cavity (Fig. 6). The mechanism of growth
benign lesions may not always express them is unknown, but after thonacotomy (with
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selves in this classic manner. They may or without removal of tumor) the reaction
cause periosteal responses highly suggestive subsides within 6 months.
of malignant disease. Dense, elliptic periosteal reactions vary
Dense undulating periosteal reactions often from 2 mm. to I cm. in thickness. The
occur with longstanding varicosities or ar elliptic peniosteal reactions are thickest
terial disease. The peniosteal reaction often near the center; they taper towards both
is i cm. or more in thickness, and its free ends (Fig. 7, 8, 9 and io). They are present
edge is rough and undulating (Fig. 3; @; and in longstanding cortical osteoid osteomas.
5, A and B). The mechanism of production Occasionally, round cell tumors (Ewing's
is unknown. tumor or reticulum cell sarcoma) treated by
Thin undulating periosteal reactions are irradiation may cause elliptic reactions. In
located primarily on the concave aspect of the latter, however, the elliptic reaction is
long bones. Pulmonary osteoarthnopathy is permeated by osteolytic areas which are
the best example. These reactions are not characteristic of malignant growth.
densely ossified and are associated with Periosteal cloaking is found in longstand
o4 0
FIG. I I. Periosteal cloaking due to Gaucher's disease. Notice the rather straight borders and the elevation
of the periosteum from the host bone. (A) Standard roentgenogram. (B) Magnified roentgenogram.
714 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966
.,
peniosteal elevation caused by an expanding
mass.
The significance of the triangular Cod
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(Fig. ii, A and B). It does not occur with sarcoma. A Codman's triangle is noted at the
proximal end of an osteolytic lesion in the distal
malignancy. end of the femur. Codman's triangle is frequently
Codman's triangle was first described by present with malignant tumors but may be present
Ribbert in 1914, who believed it was due to with benign conditions.
VOL. 97, No. 3 New Bone Production and Peniosteal Reaction 715
FIG. 14. Lamellated periosteal reaction secondary to osteosarcoma. There is a large destructive area within
the distal end of the femur. The periosteal reaction on the anterior surface is layered. (A) Standard roent
genogram.(B) Magnifiedroentgenogram.
716 Jack Edeiken, Philip J. Hodes and Lawrence H. Caplan JULY, 1966
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0
FIG. :@ç.
Perpendicular (sunburst) periosteal reaction due to osteosarcoma. There is marked destruction in the
distal end of the femur with considerable soft tissue extension. Notice that in the inferior portion of the
soft tissue extension, posteriorly, there are perpendicular densities radiating from the bone. (A) Standard
roen tgenogram. (B) Magnified roen tgenogram.
tend between peniosteum and cortex. Blood Amorphous reactions. Malignant tumors,
vessels, too, nun between peniosteum and in addition to causing lamellations and per
cortex; very likely perpendicular bone pendicular stniations (with or without inter
growth also takes place along these vascu spersed deossified areas), often reveal amor
lar channels.' Micronoentgenography as phous calcific densities ‘¿(Fig.i8). Lying
well as serial histopathologic sections sup mainly between peniosteum new bone and
port this concept. its parent bone cortex, these amorphous
Osteosarcomas and Ewing's tumor tend deposits may present extension of tumor
to stimulate “¿sunburst― reactions. Chon bone rather than peniosteal response to the
drosarcomas and fibrosarcomas show much tumor. Often oval or spherical in shape,
less peniosteum activity. At times, Ewing's they vary in size from millimeters to centi
tumor and osteosarcoma will elevate the meters in cross sections. These amorphous
peniosteum without provoking reaction. deposits usually denote bone malignancy.
VOL. 97, No. 3 New Bone Production and Peniosteal Reaction 717
SUMMARY
REFERENCES
Osteoblastic lesions confined to the host i. AEGERTER, E. E. Personal communication.
bone, unattended by changes beyond the 2. BRUNSCHWIG, A., and HARMON, P. H. Studies in
bone, may be benign or malignant. If inter bone sarcoma: III. An experimental and patho
rupted periostea! new bone is manifest logical study of role of periosteum in formation
of bone in various primary bone tumors. Surg.,
beyond the parent bone, in the absence of Gynec. & Obstet., 1935, 6o, 30—40.
infection on trauma, the lesion is far more 3. SIssoN,H. A. Intermittentperiosteal activity.
likely to be a primary bone malignancy Nature,1949,163,1001—1002.