European Journal of Radiology 82 (2013) 2140–2148

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European Journal of Radiology

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Imaging tumors of the patella

R. Casadei a , J. Kreshak a,c , R. Rinaldi b , E. Rimondi b , G. Bianchi a , M. Alberghini c , P. Ruggieri a , D. Vanel b,c,∗
a
Department of Orthopaedic Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
b
Department of Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
c
Department of Pathology, Istituto Ortopedico Rizzoli, Bologna, Italy

a r t i c l e i n f o a b s t r a c t

Keywords: Background: Patellar tumors are rare; only a few series have been described in the literature and radio-
Patella graphic diagnosis can be challenging. We reviewed all patellar tumors at one institution and reviewed
Tumor the literature.
Lesion
Materials and methods: In an evaluation of the database at one institution from 1916 to 2009, 23,000 bone
Imaging
tumors were found. Of these, 41 involved the patella. All had imaging studies and microscopic diagnostic
Radiology
Knee confirmation. All medical records, imaging studies, and pathology were reviewed.
Results: There were 15 females and 26 males, ranging from 8 to 68 years old (average 30). There were 30
benign tumors; eight giant cell tumors, eight chondroblastomas, seven osteoid osteomas, two aneurysmal
bone cysts, two ganglions, one each of chondroma, exostosis, and hemangioma. There were 11 malignant
tumors: five hemangioendotheliomas, three metastases, one lymphoma, one plasmacytoma, and one
angiosarcoma.
Conclusion: Patellar tumors are rare and usually benign. As the patella is an apophysis, the most frequent
lesions are giant cell tumor in the adult and chondroblastoma in children. Osteoid osteomas were frequent
in our series and easily diagnosed. Metastases are the most frequent malignant diagnoses in the literature;
in our series malignant vascular tumors were more common. These lesions are often easily analyzed
on radiographs. CT and MR define better the cortex, soft tissue extension, and fluid levels. This study
presents the imaging patterns of the more common patellar tumors in order to help the radiologist when
confronted with a lesion in this location.
© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Tumors of the patella are very rare and often present with knee
pain and/or swelling, or may be found as incidental lesions. Only
a handful of studies report a series of patella tumors [1–12]; most
are case reports [8]. While most authors report a high percentage of
tumors in this location to be benign (the most frequent diagnoses
being giant cell tumor, chondroblastoma, and aneurysmal bone
cyst), the differential diagnosis for a solitary lesion of the patella is
broad and contains several sinister entities (most frequently metas-
tases).
Patellar tumors are usually not studied with the full comple-
ment of imaging modalities that are otherwise used for staging
of lesions and for preoperative planning. Radiographic diagnosis
of patellar tumors can be challenging, however, radiographs alone
∗ Corresponding author at: Department of Radiology, Istituto Ortopedico Rizzoli,
Bologna, Italy. Tel.: +39 051 6366931.
E-mail addresses: roberto.casadei@ior.it (R. Casadei), j.kreshak@yahoo.com
(J. Kreshak), eugenio.rimondi@ior.it (E. Rimondi), giuseppe.bianchi@ior.it
(G. Bianchi), marco.alberghini@ior.it (M. Alberghini), daniel.vanel@ior.it (D. Vanel).
are usually sufficient to make the correct diagnosis. When radio-
graphic appearance leaves doubt as to the diagnosis, confirmation
by biopsy is always necessary to avoid overtreatment of benign
tumors or inadequate surgery for malignant lesions.
We present our single-institution series of patellar tumors.
Pathologic diagnoses, age, gender, relative incidence, and our imag-
ing findings are presented in conjunction with those imaging
findings described in the literature.
2. Materials and methods
From 1916 to 2009, 23,000 bone tumors were evaluated at
our institution; only 41 were located in the patella. All cases had
imaging studies and microscopic confirmation of the diagnosis.
Medical records were reviewed for all cases. For 10 patients only
radiographs were available. One patient had radiographs and a
computed tomography (CT) scan, another had radiographs, bone
scans, and angiography. In 28 cases, radiographs, CT, and bone scans
were available for evaluation. MRI was used in only 7 cases. Two
musculoskeletal radiologists each reviewed all cases. Imaging char-
acteristics evaluated included: appearance of lesion (lytic, blastic,
mixed, matrix production), location in the patella, portion of patella

0720-048X/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2011.11.040
 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148
Fig. 1. Giant cell tumors of the patella. a: Involvement of the entire patella. Margins are often ill-defined and pathologic fracture frequently occurs. b: CT demonstrates the
cortical expansion and destruction. c–e: MRI reveals intra-articular fluid as well as any ligament, tendon, and/or joint involvement.
affected, nature of cortex, presence of a periosteal shell or reaction,
bone expansion, soft tissue involvement, septae, and/or pathologic
fracture, and whether or not there was joint involvement. The lit-
erature was reviewed from 1900 to 2009.
3. Results
Twenty-six patients were male, 15 female, with an average age
at presentation of 30 years (range, 8–68). There were 30 benign
(73%) and 11 malignant tumors (27%) with a prevalence for males
in both groups (60% and 72%, respectively). Patients with benign
tumors were younger than patients with malignant tumors (aver-
age age 26 years versus 39 years, respectively).
Of the benign lesions, there were eight giant cell tumors (19.5%
of all patellar tumors in our series), eight chondroblastomas, seven
osteoid osteomas, two aneuyrsmal bone cysts, two intraosseous
ganglion cysts, and one chondroma, osteochondroma, and heman-
gioma each. Of the malignant tumors, there were six vascular
tumors (14.6%), two hematologic tumors, and three metastases.
3.1. Radiographic findings of specific tumor types
3.1.1. Benign tumors
3.1.1.1. Giant cell tumors. We found 8 cases of giant cell tumor
(GCT) in our series of patellar tumors (19.5%, Fig. 1). Five patients
(62.5%) were female, three male, with an average age of 32 years
(range 17–54). In four cases, tumor involved the entire patella, in
two patients two-thirds was involved, and in two patients half was
affected by tumor. Margins of these lytic lesions were ill-defined in
2141
five patients, and sharp in the other three. The cortex was expanded
in five patients, nearly completely destroyed in two, and signifi-
cantly thinned in one. Reactive sclerotic rims were absent in all
cases. Mineralization was not present in any of the lesions. Septa-
tions were observed in four cases. For patients where CT or MRI
was used, fluid levels were not observed. Two patients (25%) had a
pathologic fracture; in only one case there was there joint contam-
ination.
3.1.1.2. Chondroblastoma. Eight cases were observed in the patella
(19.5%, Fig. 2). Six patients (75%) were male, two female (25%), with
an average age of 19 years (range 8–27). All patients had a geo-
graphic lesion of the patella, encompassing more than half of the
bone in six cases. The margins of the lesion were well-defined in all
patients; the cortex was thinned in seven and unaffected in one. A
periosteal shell was seen in one case and a sclerotic rim in four oth-
ers. No periosteal reactions or septations were seen in our series. In
four cases small, diffuse calcifications were observed, but no ossifi-
cation. Fluid levels were observed in one case. Pathologic fracture
was observed in six cases. None of the cases had joint involvement.
3.1.1.3. Osteoid osteoma. Seven cases occurred in the patella (17%,
Fig. 3). Four patients (57%) were female, 3 (43%) male, with an aver-
age age of 19 years (range 11–34). The nidus was evident on imaging
studies for all patients and was located in different sites: one cen-
tral, two lateral, two medial, one anterior, one posterior. Four were
intra-cortical, one sub-periosteal, and two in cancellous bone. A dif-
fuse, ill-defined sclerotic reaction around the nidus was observed
in four cases. An ossified nucleus of varying extent was observed
2142 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148

Fig. 2. a and b: Chondroblastomas appear as geographic lesions with lobulated margins. They are frequently located in the distal pole of the patella. Thinned cortices are
common, often with a partial thin sclerotic rim of reactive bone. c: Calcifications inside the lesion are well-demonstrated on CT.

Fig. 3. Osteoid osteoma of the patella. a: The nidus is often clearly seen on radiographs. b: CT demonstrates the sclerosis surrounding the nidus. A small velvet periosteal
reaction is observed. c: The nidus is also well seen on MRI.

in all cases. In lesions close to or involving the cortex, a spicular,
velvet periosteal reaction was found. In most cases, a small, sharp,
round spot of increased uptake was seen on bone scan, however,
in one posteriorly located lesion near the joint surface, the uptake
was more diffuse.
3.1.1.4. Aneurysmal bone cyst. Two patients had an aneurysmal
bone cyst (ABC) of the patella (4.9%, Fig. 4). Both patients were
male, ages 25 and 56 years (average 40). A geographic lytic lesion
that involved most of the patella was observed in both cases. The
margins were well-defined, the cortex thin and expanded. Calcifica-
tions and ossifications were not seen. Thin septations were seen on
radiographs. Fluid levels, characteristic of ABCs in other locations,
were not seen in these two cases because MRI were not performed.
There were no pathologic fractures or joint involvement.
3.1.1.5. Intraosseous ganglion cysts. Two cases were observed in the
patella (4.9%, Fig. 5). Both patients were male, ages 14 and 45 years
old (average age 29). The lesions were found incidentally. Both were
geographic lesions involving less than an half of the patella. Sharp,
rounded margins with a thin cortex and a thin sclerotic rim were
observed in both patients. Calcifications and ossifications were not
observed. Broad septae were seen in one case. Fluid levels, patho-
logic fracture, and joint involvement were all absent.
3.1.1.6. Chondroma. One 56-year-old male had a chondroma of the
patella (2.4%). This radiographically mixed lesion was located in
the distal pole of the patella. The margins were well-defined and
the cortex normal. Small calcifications were present, without any
periosteal shell or reaction, sclerotic rim, septations, fluid levels,
pathologic fracture, or joint involvement.

Fig. 4. a: Lytic bone destruction with sharp and rounded margins, coarse septae and thin, expanded cortices are observed in aneurysmal bone cysts. b: MRI of this aneurysmal
bone cyst (in a giant cell tumor) reveals the fluid levels that are frequently found in this lesion.
 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148 2143

Fig. 5. a and b: An intraosseous ganglion appears as a lytic lesion with well-defined and rounded margins, thick septae, a sclerotic rim, and thin cortex.

3.1.1.7. Osteochondroma. One 54-year-old female had a solitary
osteochondroma of the patella, located at the distal pole of the
patella. The cauliflower-like mass protruded anteriorly, toward the
joint.
3.1.1.8. Hemangioma. An 18-year-old male had a hemangioma,
an unusual lesion of the patella (2.4%, Fig. 6). A geographic lytic
lesion of the anterior cortex with clear margins and a sclerotic
rim was observed. The cortex was thinned. Periosteal reaction, cal-
cifications, fluid levels, septations, pathologic fracture and joint
involvement were not observed.
3.1.2. Malignant tumors
3.1.2.1. Vascular tumors. Six cases (five hemangioendotheliomas
and one angiosarcoma) were found in the patella (14.6%, Fig. 7).
One patient was male, five female, with an average age of 40 years
(range 13–68). Two patients had a stage IA lesion, three a stage
IB lesion, and one a stage III lesion. All radiographic features of
malignant tumors were seen in these tumors. The lesions were
all lytic; the pattern was geographic in four cases and permeative
in two. The entire patella was involved in three cases and the
distal pole only in the other three. The margins were sharp and
rounded in four patients, ill-defined two. The cortex was thinned
in two cases, and eroded or completely destroyed in the other four
patients. Sclerotic rims were not observed. In one patient there was
a thin periosteal shell remaining on the articular side of the lesion.
Periosteal reactions, ossifications, and calcifications were not seen
in these patients. In two cases, thin septations were observed. A
pathologic fracture with joint invasion was observed in four cases.
(Fig. 11). All lesions were stage III by definition; two involved the
entire patella. The third was a small metastatic skip lesion from
an osteosarcoma. In two cases the lesion had a permeative radio-
graphic pattern, with ill-defined margins and a broken cortex. A
spicular periosteal reaction and ossification were present in one of
the osteosarcoma metastases. Sclerotic rims, periosteal shells, and
fluid levels were not observed in these tumors. In the adenocarci-
noma metastasis, an irregular, coarse septation was seen. In the last
case joint involvement was present without an evident pathologic
fracture.
4. Discussion
Primary patellar lesions are very rare. Combining those cases
found in a review of the literature from 1900 to 2009 with the
cases in our series resulted in 536 cases. Of these, 390 were benign
tumors, with giant cell tumor (42%) and chondroblastoma (22%)
being the most common diagnoses [1,12]. 146 were malignant
tumors, with metastases (44%) being the most frequent type. The
total incidence of benign and malignant tumors of the patella are
reported in Tables 1 and 2.
There were a total of 165 giant cell tumors (GCT), represent-
ing 31% of all patellar neoplasms. Diagnosis of these tumors is
often delayed when they occur in the patella. The most common
Table 1
Benign bone tumors of the patella: 390 cases.
Number of % of benign % of total
cases tumors cases

GCT 165 42 31
3.1.2.2. Hematologic tumors. Two cases were observed in the Chondroblastoma 85 22 16
patella (4.9%). One patient had non-Hodgkins lymphoma, stage III ABC 29 7 5
(Fig. 8), and the other a plasmacytoma, stage IIB (Fig. 9). In both Osteoid osteoma 25 6 5
cases the lesion involved the entire patella. The lymphoma was a Osteoblastoma 10 3 2
Simple bone cyst 20 5 4
permeative lesion with ill-defined margins, a destroyed cortex, and
Ganglion 8 2 1
a large soft tissue mass. Small, diffuse ossifications were present. Chondroma 21 5 4
The plasmacytoma was a large lytic lesion that had thick septations. Osteochondroma 10 3 2
A pathologic fracture with joint involvement was observed in both Hemangioma 10 3 2
cases. Lipoma 3 <1 <1
NOF 1 <1 <1
Osteoma 1 <1 <1
3.1.2.3. Metastasis. We had three patients with metastatic lesions Chondromyxoidfibroma 1 <1 <1
of the patella in our series (7.3%). Two lesions were metastases from Dysplasia epiphysealis 1 <1 <1
hemimelica
osteosarcoma (Fig. 10) and one from adenocarcinoma of the lung
2144 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148

symptom, anterior knee pain, is often mistaken for an arthritic

pain, chondromalacia, or patellofemoral syndrome and it is only
when radiographs are obtained that the lesion is found. GCT of the
patella usually has radiographic features similar to this lesion in
other sites [12]. As such, for GCTs in the patella, standard radio-
graphs are sufficient for initial diagnosis and to evaluate the degree
of aggressiveness of the lesion. This tumor frequently presents as a
lytic lesion, involving nearly all of the patella, with an ill-defined,
narrow zone of transition to normal cancellous bone. The cortex is
usually expanded and permeated or thinned [12], with a periph-
eral periosteal shell in 65% of cases. A sclerotic rim is very rare
and a periosteal reaction is usually absent. Septations are frequent,
occurring in approximately 65% of cases; these septae are usually
thin and extend throughout the entire tumor [12]. Mineralization
is not seen in this tumor. Bone scan, CT, and MRI are necessary for
adequate staging of patellar GCTs and for preoperative planning,
but only rarely are they are required to make a correct diagnosis.
On CT scan, a uniform lesion with density akin to muscles replaces
the marrow cavity. On MRI a homogeneous signal (low signal on
T1-weighted images and high signal on T2-weighted images) is
frequently observed. MRI is also useful to evaluate extraosseous
extension of the tumor and any ligament, quadricep, or patellar ten-
don involvement [12]. When a pathologic fracture occurs (30% of
cases) or when swelling occurs about the knee, images are obtained
earlier than they might otherwise be, leading to earlier diagnosis. A
chest CT and lymph node examination are recommended to evalu-
ate for occult metastatic lesions in patients with GCT of the patella
[13]. Lung metastases from GCT in this location are rare: only six
cases are reported in the literature [4,14]. Lymph node involve-
ment is similarly very rare with only a handful of cases described
[13]. Local recurrence of GCT always has an aggressive radiographic
appearance and may occur in bone and in the soft tissues [8,13].
When knee pain and signs of joint inflammation (as might be
seen with a septic arthritis) are seen in a young male patient with
a patellar lesion, chondroblastoma should be high on the differen-
tial diagnosis. Eighty-five chondroblastomas have been described,
representing 16% of all patellar tumors. The patella is a sesamoid
bone found in the quadriceps tendon, appearing in the third month
of gestation from a cartilaginous precursor that ossifies at approx-
imately three years of age. Ossification of the patella is similar to
that of an epiphysis or apophysis of a long bone; given that chon-
droblastomas tend to occur in the epiphyses of long bones, this
helps to explain the high incidence of chondroblastoma in this loca-
tion. In most patients, a chondroblastoma of the patella is a stage 2
lesion (53%) and radiographic features are the same as those for
chondroblastoma in other sites [12]. Eccentric, geographic bone
destruction, with lobulated margins, and thinned cortices are com-
Fig. 6. An intracortical hemangioma of the patella is shown. a and b: On radiographs, mon radiographic findings. A periosteal shell may be present in
the margins are sharp, cortex is thinned, and a small sclerotic rim is observed around 13% of cases, but a sclerotic rim, partial or complete, regular or
this lytic lesion. c: CT confirms the radiographic results.
irregular, is seen in 90% of patients. Periosteal reaction is absent
in the patella, despite being observed in 44% of chondroblastomas
in other locations [15]; fluid levels are observed only when sec-
ondary aneurysmal bone cysts are found in association with the
Table 2
Malignant bone tumors of the patella: 146 cases. chondroblastoma in this bone [12,16]. Septations are rare (13%)
and are usually described as broad and only present through part
Number of % of malignant % of total
of the lesion. Calcifications are observed in 19% of cases, less than
cases tumors cases
in other sites (50%) [15], and ossifications are not seen. Pathologic
Metastases 64 44 12 fracture has been described in up to 35% of cases [17]; in our series
Osteosarcoma 30 20 6
Chondrosarcoma 2 1 <1
it was found in 75% of the cases. CT may be useful to display the
Lymphoma 18 12 3 small, diffuse, spotty calcifications inside the lesion. MRI is useful to
Vascular tumors 19 12 3 demonstrate the typical cartilaginous pattern and the perilesional
MFH of bone 7 5 1 bone and soft tissue edema distinctive for this tumor [15].
Myeloma 4 3 <1
Twenty-five cases of osteoid osteoma have been described rep-
Leiomyosarcoma 1 1 <1
Clear cell chondrosarcoma 1 1 <1 resenting 5% of all patellar tumors; seven of 41 of our patellar
tumors were osteoid osteoma. To suspect an osteoid osteoma of
the patella, a clinician must carefully consider the patient’s history,
 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148
Fig. 7. Hemangioendothelioma of the patella. a: Septation and a thinned cortex. b: CT reveals multiple lesions of the patella and femur.
which is often that of well-localized pain during the night, relieved
with anti-inflammatory drugs, but not with rest [18]. According to
previously published reports, only 28% these lesions will have a
demonstrable nidus on radiographs, however the nidus was visible
on imaging for all of our patients. Margins of this lesion are sharp
and the nidus includes a small central ossification. Varying degrees
of sclerosis are observed in more than 40% of cases and a velvet,
spicular periosteal reaction is observed in intracortical and sub-
periosteal cases. In intracortical lesions the cortex may be slightly
expanded. When radiographs are negative, the search for the sus-
pected nidus should be continued with bone scan and CT. In 85% of
cases, bone scan reveals a small isolated spot of increased uptake
surrounded by less intense uptake, the “double density” sign, a fea-
ture typical for osteoid osteoma [18]. Diffuse uptake in the knee is
a not a feature specific for osteoid osteoma [19]. When radiographs
are normal and the patient has non-specific knee complaints,
a delay in diagnosis is possible if imaging other than standard
Fig. 8. Plasmacytoma of the patella: multiple lytic lesions separated by thick septae.
2145
radiographs is not obtained [19]. The nidus and its location in
the patella are very well demonstrated on CT. With these imag-
ing modalities, the diagnosis is sure and biopsy is not necessary. As
in our series, the most frequent subtype described in the literature
is intracortical (40%), followed by the cancellous and subperiosteal
subtypes. MRI is less useful than CT because the reaction of the
normal tissue to the presence of the osteoid osteoma often hides
the nidus. However, in those cases where edema and sclerosis
around the nidus are absent, osteoid osteoma can be very clear on
MRI [19]. Non-surgical treatment of this lesion includes minimally
invasive radiographically guided techniques, including CT-guided
radiofrequency ablation, removal of the lesion with arthroscopic
CT-guided en bloc retrograde resection, or with percutaneous CT-
guided resection using a cannulated skin punch biopsy needle, all
with high success rates and minimal complications.
Only 29 cases of aneurysmal bone cyst (ABC) are described, 5%
of all patellar tumors. When a bulging of the patella is observed,
ABC is high on the differential diagnosis. This clinical sign is due
to the expansive growth of the lesion that thins and expands the
cortex. Geographic bone destruction with rounded margins and
a periosteal shell are observed in 91% of cases. The lesion is fre-
quently surrounded by a sclerotic rim (64%), but it does not display
a periosteal reaction or mineralization. Septations are very com-
mon (82%) and are usually broad, extending throughout the lesion.
Rarely, ABC of the patella occurs with a pathologic fracture or
involves the joint (9%), because almost all of these lesions are
stage 2. MRI is very useful to show the fluid levels that are char-
acteristic sign of this lesion. On T1 weighted images, the lesion
demonstrates intermediate-to-low signal with enhancement of the
sepatations post-gadolinium administration; T2 weighted images
reveal intermediate signal intensity in dependant fluid layers [12].
CT scan demonstrates the typical honeycomb septation feature of
this lesion very well. In these patients a biopsy is always necessary
even if the radiographic features are typical, because this tumor
may have a radiographic appearance very similar to teleangectatic
osteosarcoma (despite this malignant tumor being very rare in the
patella) [20,21]. Areas of secondary ABC are frequently observed in
GCT and chondroblastoma [16].
When a patient presents with hard, painless mass on the patella
(which may limit knee range of motion), osteochondroma is a possi-
ble option. Radiographs alone are sufficient for diagnosis given the
characteristic radiographic features of this lesion: a cauliflower-like
2146 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148

Fig. 9. a: A pathologic fracture in a patient with lymphoma of the patella is shown. Radiographs reveal a sclerotic proximal portion and lytic distal portion. b: CT: permeative
bone destruction, hazy margins, destroyed cortex, large soft tissue mass surrounding the patella, and joint involvement.

Fig. 10. a: Metastasis of osteosarcoma caused permeative bone destruction with ill-defined margins, ossification, permeation of the cortex with a spicular periosteal reaction
anteriorly. b: CT scan of another patient reveals an osteosarcoma skip metastasis in the patella.

mass with both cortex and marrow cavity in continuity with the
cortex of origin, and a cartilaginous cap. A peripheral chondrosar-
coma, a malignant tumor with which an osteochondroma may be
confused, has never been reported in the patella. Nonetheless, MRI
may be useful to differentiate between these tumors by evaluating
the cartilage cap. Another very rare lesion of the patella that appears
as a swelling or mass, usually in a young man, is dysplasia epiphy-
sealis hemimelica. This lesion also has typical radiographic features,
including an ill-defined, enlarged patella with extensive osseous
proliferation. On CT, an ostechondral tumor is seen expanding from

Fig. 11. a: Metastasis of the lung in the patella: a permeative bone destruction with ill-defined margins, destruction of the cortex and soft tissue involvement. b: CT
demonstrates anterior soft tissue involvement, with a broken cortex, without any periosteal reaction.
 R. Casadei et al. / European Journal of Radiology 82 (2013) 2140–2148
an ossification center of the patella. MRI reveals a mass arising from
one of the ossification centers with heterogeneous signal inten-
sity on all MRI sequences. In patients with characteristic imaging
findings, a biopsy is not necessary.
In adults, many benign lesions are discovered by chance. Geo-
graphic bone destruction with clear margins is common in benign
lesions of the patella, but in intraosseous ganglion cysts, chon-
dromas, and hemangiomas, the margins may be more rounded
or lobulated with thinned cortices. Of these lesions, a periosteal
shell is observed only in hemangioma (65%). A sclerotic rim around
the lesion is observed in varying amounts: 75% of ganglions, 45%
of chondromas, and 35% of hemangiomas. Broad septations are
usually only found in ganglions (80%) and in hemangioma (90%),
whereas punctate calcifications are observed in chondroma (70%).
Pathologic fracture and joint involvement are very rare, although
they have been found to occur in osteoblastomas (2%) and heman-
giomas (5%).
We agree with Saglik et al. and Hughes and Spencer, who suggest
that a radiograph of the knee is sufficient to detect an aggres-
sive lesion of the patella [11,22]. However, we do not agree with
Kransdorf et al. that benign and malignant tumors are indistin-
guishable radiographically [6]. The most frequent malignant lesions
in this location have a permeative or moth-eaten radiographic
appearance; only low-grade vascular tumors may have features
that mimic a benign lesion. For example, low-grade hemangioen-
dotheliomas of the patella often involve only a portion of the patella
and are eccentrically located. Their margins are sharp and some-
times rounded. The cortex is usually thinned, and some cases may
be expanded. A periosteal shell is observed in 20% of cases; sclerotic
rims or periosteal reactions are absent. Thin septations are found
in 60% of cases, but calcifications, ossifications or fluid levels are
not observed in these lesions. Pathologic fracture occurs in 40% of
these patients but joint involvement is rare (15%).
Imaging of malignant tumors is less specific than for benign
lesions; radiographic diagnosis of a particular histotype is more
difficult. Malignant tumors often involve the entire patella and mar-
gins of the lesion are almost always ill-defined. The cortex is often
permeated or destroyed by the tumor as these lesions are often
Stage II or III; this is best appreciated on CT. A periosteal reac-
tion with spicular aspects is frequently observed in osteosarcoma
(75%) and in metastases (30%). Broad septations may be observed
in approximately 12% of metastatic lesions whereas thin, irregu-
lar septations are often found in myeloma (50%). A plasmacytoma
may be mistaken for an aggressive GCT. Rings and small spot cal-
cifications, features typical for chondrosarcomas in long bones, are
rarely observed with this tumor in the patella [23]. Irregular, cloudy
ossifications are found in osteosarcoma (80%), whereas they may
be small and diffuse in lymphoma (65%). The fluid levels character-
istic of ABC are rarely observed in teleangectatic osteosarcomas of
the patella, and not in other malignant tumors. The general pattern
of malignant lesions on MRI is low signal on T1-weighed images,
with high signal on T2-weighted images [11]. Post-gadolinium,
diffuse and intense enhancement of the lesion is often observed
on T1-weighted images [12]. Pathologic fractures are frequent
in lymphoma (60%), myeloma (50%), vascular tumors (40%), and,
more rarely, in metastasis (2%). Joint involvement, which is well-
demonstrated on MRI, is often seen in cases of angiosarcoma and
lymphoma, in up to 75% of osteosarcomas, 50% of myelomas, 30%
of metastases, and only 15% of hemangioendotheliomas.
Sixty-four total metastases were found for this location, repre-
senting the most frequent malignant lesion and 12% of all patellar
tumors; although 7.3% of our patellar lesions were metastases, the
most common malignant tumors in our series were vascular malig-
nant primary tumors. Overall, 35% of patients with a metastasis
to the patella have primary lung carcinoma, 10% have breast or
renal cell carcinoma, and 7% have esophageal carcinoma [10,24]. In
2147
7% of patients, the metastasis is undifferentiated and the primary
carcinoma unknown [3,10]. Metastasis from other primary
tumors/sites are rarely reported in the literature [2,10,12].
On radiographs, many non-neoplastic processes such as tuber-
culous osteomyelitis [5], pyogenic osteomyelitis [3,5,6], brown
tumors of hyperparathyroidism [2,5,9,12], gouty tophi [12], dorsal
defect of the patella [3], and Paget’s disease [3,6] can be mistaken
for tumors of the patella.
As has been reported in the literature, we found that lesions
in this location tend to be benign, and occur more frequently in
males. Consistent with previous studies, the benign lesions tend
to occur more frequently in younger patients. The most common
lesions encountered were chondroblastoma and giant cell tumor,
with eight cases each, reflecting previous reports. We also had a
relatively high number of osteoid osteomas, seven of the forty-one
cases. Of our 11 malignant tumors, three were metastases, as have
been reported by other authors. However, we found six malignant
vascular tumors in this location, five of which were hemangioen-
dotheliomas.
5. Conclusions
Tumors of the patella are rare entities. Benign lesions are more
frequent than malignant tumors. Younger patients are more likely
to have a benign neoplasm, older patients a malignant tumor. As
the patella is an apophysis, the most frequent lesions are giant cell
tumor in the adult, chondroblastoma in children. Standard radio-
graphs are the most useful imaging modality for diagnosis. CT and
MR better define the cortex, soft tissue extension, and fluid lev-
els. When radiographic findings are typical for a particular process,
such as an osteochondroma, metastasis in the setting of a known
primary, or osteoid osteoma, biopsy may be avoided. However, as
always, if there is any doubt, biopsy should be performed. This study
presents the imaging patterns of the more common patellar tumors
in order to help the radiologist when confronted with a lesion in
this location.
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