Author’s Accepted Manuscript

Radiographic analysis of Bone Tumors: A

systematic approach

Kaushal Mehta, Morgan P. McBee, David C.

Mihal, Eric B. England

www.elsevier.com/locate/ro

PII: S0037-198X(17)30011-1
DOI: http://dx.doi.org/10.1053/j.ro.2017.04.002
Reference: YSROE50585
To appear in: Seminars in Roentgenology
Cite this article as: Kaushal Mehta, Morgan P. McBee, David C. Mihal and Eric
B. England, Radiographic analysis of Bone Tumors: A systematic approach,
Seminars in Roentgenology, http://dx.doi.org/10.1053/j.ro.2017.04.002
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 Title Page

Authors:

1. Kaushal Mehta, MD
Assistant Professor of Radiology
Fellowship Director, Musculoskeletal Radiology
Department of Radiology
University of Cincinnati Medical Center, Cincinnati, OH 45219

2. Morgan P. McBee, MD
Radiology Resident, PGY-5
Department of Radiology
University of Cincinnati Medical Center, Cincinnati, OH 45219

3. David C. Mihal, MD
Radiology Resident, PGY-5
Department of Radiology
University of Cincinnati Medical Center, Cincinnati, OH 45219

4. Eric B. England, MD
Assistant Professor of Radiology
Program Director, Radiology Residency
Department of Radiology
University of Cincinnati Medical Center, Cincinnati, OH 45219

Institution of work:

Department of Radiology
University of Cincinnati Medical Center, Cincinnati, OH 45219

Corresponding author:

Kaushal Mehta, MD
Assistant Professor of Radiology
Department of Radiology, ML 0761
University of Cincinnati Medical Center, Cincinnati, OH 45219
Telephone number: 513-584-2146
Email: kaushal.mehta@uc.edu
Radiographic analysis of Bone Tumors: A systematic approach

Introduction

Bone tumors are a commonly encountered diagnostic dilemma for radiologists. Benign and

malignant neoplasms, metabolic abnormalities, and tumor-like conditions (reactive focal

abnormalities often related to developmental or inflammatory causes) all fall under the purview

of bone tumors.1 Primary bone tumors are rare; tumor-like conditions, metastatic disease, and

lympho-hematological malignancies outnumber primary bone tumors by far.2 Conventional

radiography is recommended as the initial imaging modality of suspected bone tumors 1-5

Radiography provides excellent resolution and yields the most useful information about the

morphological characteristics of a lesion providing important diagnostic information regarding

aggressive or non-aggressive characteristics of the lesion.1-5 The combination of radiographic

imaging findings, clinical information such as the age of the patient, and in some cases histology

is also essential. Rather than discussing an in depth analysis of every bone tumor, we will instead

focus on a systematic approach to the radiographic analysis of bone tumors. The figures and

tables in this article will help readers become familiar with specific radiographic appearances,

location, and age predilection of common bone tumors and help to organize a differential

diagnosis when analyzing a bone lesion.

Systematic approach

The two most important features in the analysis and differential diagnosis of a bone tumor are the

age of the patient and the morphological features of the lesion on plain radiographs. When

combined with the location, the differential diagnosis can be narrowed even further and can often

times lead to a single correct diagnosis. The specific features that need to be evaluated are

margins and zone of transition, periosteal reaction, mineralization, tumor location, number and

size of the lesions, and the presence of a soft-tissue component (Fig.1).1-3, 5-8 While these features

were originally described on plain radiography, they can also be applied to computed

tomography (CT) in majority of cases.9 Magnetic resonance imaging (MRI) cannot be used to

assess these features due to its inherent sensitivity, which usually overestimates the

aggressiveness of a lesion.10 For example, a radiographically non-aggressive, benign lesion such

as chondroblastoma can show significant marrow and periosteal edema on MRI making its

appearance aggressive.

Clinical information

Age is the most important clinical clue that can help narrow the differential diagnosis when

encountering a bone tumor. Although there is significant overlap between age groups and

exceptions do occur, the typical age range of different bone tumors is summarized (Table 1).1-3

Primary osteosarcoma and Ewing sarcoma are tumors of children and young adults. Occurrence

of chondrosarcoma in children or Ewing sarcoma in middle-aged patients is extremely unusual.

In individuals older than 40 years, the most common form of skeletal malignancy is metastatic

cancer and myeloma. Osteosarcomas in this age group are often secondary malignancies, which

develop at the osseous sites of Paget’s disease or previous radiation. Giant cell tumor, a locally

aggressive lesion, almost exclusively occurs in skeletally mature patients (20 to 50 years of age)

with closed epiphyses while a chondroblastoma and unicameral bone cyst occur in skeletally

immature patients (< 20 years old) with open epiphyses. In general, solitary bone lesions

identified in adult patients have a much higher likelihood of being malignant than those found in

pediatric patients.

The gender of the patient usually plays no significant role in narrowing the differential diagnosis

of a bone tumor. The race of the patient can occasionally be helpful in the diagnosis of a bone

tumor, most commonly in Ewing sarcoma, which occurs overwhelmingly in white patients and is

rarely seen in African Americans.11

Pain, is the second most important clinical factor after age in differential diagnosis of a bone

lesion. Pain could be a symptom of growing lesions, which include locally aggressive lesions

like osteoblastoma, giant cell tumors, and malignancies. It is also seen with pathological

fractures and neurovascular involvement of the tumor. Osteoid osteoma, typically causes intense

night pain relieved by non-steroidal anti-inflammatory drugs and can be a cause of severe

inflammatory synovitis if it is intra-articular.12 Pain can be an important distinguishing factor in

radiographically similar appearing chondroid lesions like low-grade chondrosarcoma (which can

be painful) and enchondromas, which are typically asymptomatic unless complicated by a

pathological fracture.13
Margin and zone of transition

The margin of the lesion and zone of transition between lesion and the adjacent bone are key

factors in determining if a lesion is aggressive. A lesion with sharp margins and a narrow

transition zone is radiographically considered non-aggressive, particularly when the margins

have a sclerotic border. Analysis of the margins is readily performed on radiographs, which are

inexpensive, easily accessible, and provide a concise assessment of lesion behavior on a limited

number of images. A radiographic classification of bone tumor margins has been developed that

identifies three main types.6 Patterns of bone destruction includes geographic, moth-eaten, or

permeative. These patterns reflect the growth rate of lesions, rather than their potential to

represent a malignant tumor.14

A focal, discrete, round or oval shaped lesion is termed geographic (Type I), and shows complete

bony destruction within the lesion with well-defined margins. The borders of geographic bone

destruction are sub-classified into three categories based on their aggressiveness. Type IA

margins are the least aggressive, exhibiting a sclerotic rim (e.g. non-ossifying fibroma (Fig. 2),

fibrous dysplasia, or chondromyxoid fibroma). Type IB margins have no sclerotic rim, while

remaining well defined with a narrow zone of transition, the so-called “punched out” lesion.

These margins indicate indeterminate growth potential and may be seen with benign or

malignant lesions (e.g., giant cell tumor (Fig. 3), aneurysmal bone cyst, multiple myeloma, or

low-grade chondrosarcoma). Type IC margins are poorly defined, with a wide zone of transition,

suggestive of a locally aggressive lesion. Most tumors with type IC margins are malignant (e.g.

early chondrosarcoma or osteosarcoma (Fig. 4)).

Type II and III margins are non-geographic, representing an infiltrative lesion with broad zone of

transition and a more aggressive pattern. The moth-eaten (Type II) pattern manifests as multiple

ill-defined areas of bony destruction with ragged borders and usually indicates malignancy (e.g.

myeloma, metastases, lymphoma, Ewing sarcoma (Fig.5)). Permeative (Type III) manifests as an

ill-defined lesion with multiple “worm-holes” with a very broad zone of transition, spreading

through marrow space. It is the most highly aggressive pattern of bone destruction and

characteristic of a lesion that is growing rapidly. This usually implies an aggressive malignancy

(e.g. small round blue cell lesions such as lymphoma, leukemia, Ewing sarcoma, or multiple

myeloma (Fig.6)). Caveats include entities such as osteomyelitis, eosinophilic granuloma and

rapidly developing osteoporosis, which may have a permeative pattern as well.

Although there are some exceptions, these features are a good guideline for categorizing lesions

as non-aggressive which would suggest a benign process or as aggressive which would suggest a

malignant process.

Periosteal reaction

Periosteal reaction can be an important radiographic feature that can help characterize a bone

lesion. It often develops because of cortical involvement in response to direct tumor spread,

vascularity, inflammatory response, or as a result of a complication such as fracture or infection.

This reflects the biologic potential of the lesion even though it is less specific than other

radiographic signs.7 Periosteal reaction can be broadly classified as continuous/uninterrupted,

interrupted, or complex, depending on its morphology.

The uninterrupted pattern is characterized by a continuous mineralized periosteal reaction over

the whole bone. This pattern can manifest as a unilamellated, solid, smooth appearance which is

typical of a slow growing, indolent processes such as osteoid osteoma (Fig.7), osteoblastoma,

hypertrophic osteoarthropathy, or venous stasis. The uninterrupted pattern can manifest as a

multilamellated or ‘‘onion-skin’’ appearance in more active processes and represents an

intermediate aggressive reaction such as that seen in Ewing sarcoma (Fig.8).7 This form can also

be seen in non-neoplastic processes such as eosinophilic granuloma, osteomyelitis and healing

fractures.

The interrupted pattern is characterized by interrupted mineralized periosteal reaction caused by

the lesion breaking through the cortex and growing into the adjacent soft tissues typically

manifesting as a “spiculated”, or “hair-on-end” (perpendicular to the cortex) or “sunburst”

pattern, which is the most aggressive appearance, highly suggestive of malignancy, such as

osteosarcoma (Fig. 9) or Ewing sarcoma. Codman's triangle is the visible portion of the elevated

periosteum (from tumor) where it joins the cortex, acquiring a triangular shape (Fig. 10).1-3, 7

Typically, the Codman triangle is often associated with osteosarcoma, but any aggressive process

that lifts the periosteum can produce this appearance, including benign entities such as sub-

periosteal hematoma and abscess. Complex patterns include a mix of continuous and interrupted

types. In general, a solid periosteal reaction is suggestive of a benign process, while the more

interrupted and complex pattern is suggestive of a greater biologic activity and a more aggressive

lesion. As with many rules in medicine, there are caveats, such as when benign and malignant

processes coexist. This most commonly occurs when there is a fracture or infection in the same

area as the bone tumor.

Patterns of matrix mineralization

Matrix is found in benign and malignant tumors and does not closely correlate to malignant

potential, but matrix mineralization at radiography has been found to be helpful in distinguishing

different histologic types of primary bone tumors.15 Each type of matrix mineralization shows a

spectrum of radiographic appearances.

Mature osteoid, or organized bone, shows more orderly, trabecular pattern of ossification and is

characteristic of the benign bone-forming lesions such as osteoblastoma (Fig. 11A). Osteoid

matrix can be fluffy, cloud-like, or demonstrate ill-defined amorphous densities suggestive of

haphazard mineralization, and this pattern is seen in malignant bone-forming tumors like

osteosarcoma (Fig.11B).

Cartilaginous matrix is classically described as stippled, flocculent, or as a ‘‘ring and arc’’

configuration that forms around globular cartilage lobules, as seen in cartilaginous tumors like

enchondroma (Fig.12) and chondrosarcoma. This pattern is usually easier to recognize

radiographically and only suggests the histologic nature of the tissue (cartilage) but does not

reliably differentiate between benign and malignant processes.

Fibrous matrix demonstrates a “ground-glass” radiographic density as a result of small,

abnormally arranged trabeculae of immature woven bone appearance, or dense mature

mineralization that can be uniform or heterogeneous and is classically seen in fibrous dysplasia

(Fig.13).

The gradual increase in mineralization with time is termed “maturation” and can be seen in

tumors such as fibrous dysplasia, non-ossifying fibroma, fibrous cortical defect, osteoid osteoma,
and bone islands.16 This should not be confused with the post-therapeutic response of aggressive

lesions that have responded well to therapy which is usually evident peripherally in lesions. It

should be remembered that the margin classification system discussed in this article applies only

to untreated bone tumors.6 Many lesions of varying cell types do not show any type of internal

matrix, and this is also the case with highly dedifferentiated osteoid or chondroid malignancies.18

Location

The majority of bone tumors have a propensity to occur in characteristic locations in the skeleton

and specific locations within long bones (Table 2). 1-3, 19 Hence, the differential diagnosis can be

refined based on the location, which at times can lead to a specific diagnosis. A well-defined

lucent lesion in the proximal humerus in a young individual, for example, will most likely be a

unicameral bone cyst. The differential diagnosis of a lesion in the calcaneus would be different

from one in the sternum. Most lesions arising in the calcaneus are benign, whereas most lesions

arising in sternum are malignant. Some of the lesions have a strong predilection for specific

locations, such as adamantinoma for the anterior cortex of tibia (Fig. 14), osteoblastoma for the

posterior elements of the spine, or periosteal desmoid for the posterior distal femoral

metaphysis.2

Whether the lesion arises in the axial or appendicular skeleton is also important. Certain tumors

predominate in the region of red marrow as a result of being derived from the cells of marrow or

being transported to this location by vascularity. Multiple myeloma, metastatic disease, Ewing

sarcoma, and lymphoma are some of the tumors that primarily localize to the hematopoietic

marrow.1-3 The distribution of Ewing sarcoma follows the hemopoietically active red marrow,
which is in long bone diaphysis in the skeletally immature patient and subsequently shifts to the

flat bones such as the pelvis and skull when skeletally mature.1-2,19

The majority of the primary bone tumors develop in the region of fastest bone growth

(metaphysis), particularly in the distal femur and proximal tibia. This region has the richest blood

supply and the unique vascular anatomy of looped vessels which promotes slow flow, and

predisposes to metastatic seeding of tumor and infection.2 A lesion in the long bone can show

propensity to develop in a specific anatomic location in the longitudinal plane (epiphysis,

diaphysis or metaphysis) and in the transverse plane based on the center of the lesion (medullary

process-central versus eccentric, cortical or juxtacortical) (Fig. 15).1-3 For example, aneurysmal

bone cyst, unicameral bone cyst, non-ossifying fibroma, and osteochondroma are all metaphyseal

lesions, but aneurysmal bone cyst is an eccentric medullary lesion (Fig.16A), unicameral bone

cyst is a central medullary lesion (Fig.16B), non-ossifying fibroma is a cortically based lesion,

and osteochondroma is juxtacortical (Fig. 17A). Ewing sarcoma and adamantinoma are both

diaphyseal lesions, but Ewing sarcoma originates in the central medullary cavity while

adamantinoma is cortically based. However, in thin tubular bones such as the fibula and smaller

bones of the hands and feet, the entire diameter of the bone may be involved and it may not be

possible to determine the center of the lesion. Given that the majority of the tumors arise in the

metaphysis or in the diaphysis, the epiphyseal lesions have a limited differential. For example, a

well-defined lucent lesion in the epiphysis of a skeletally immature patient would likely be a

chondroblastoma (Fig. 18A), while in a skeletally mature patient it would likely be a giant cell

tumor. An apophysis is considered as an equivalent of epiphysis and thus we should use the

epiphyseal differential for lesions in sites such as the greater trochanter and tibial tuberosity. In

flat bones, epiphyseal-equivalent areas exist beneath the articular cartilage in bones of the pelvis
and shoulder girdle. Similar “epiphyseal” lesions may develop in the patella and small bones of

the wrist and foot (Fig.19).2 In the spine, hemangioma is the most common benign tumor which

localizes to the vertebral body.20 Other tumors that localize to the vertebral body are myeloma,

lymphoma, metastasis (Fig. 20A), and these are commonly multiple. Paget’s disease is a

common differential consideration when evaluating a sclerotic vertebral body lesion and is

commonly solitary (Fig. 20B). The posterior vertebral elements are mostly affected by benign

lesions, such as osteoblastoma, osteoid osteoma, and aneurysmal bone cyst.2,3,20

Cortical involvement

The cortex can serve as a barrier to expansion of tumors. In addition to lesions that arise in the

cortex, the cortex may be affected by medullary and juxta-cortical lesions. When a slow growing

medullary lesion expands, it can cause lobulated erosion along the inner wall of the cortex

termed endosteal scalloping (Fig. 21).2 With continued growth, medullary lesions may show

cortical expansion and thinning with a resultant ballooned appearance, usually seen with benign

processes that grow slowly enough to let the cortex remain intact such as aneurysmal bone cyst

(Fig. 16A). Lesions that produce a large degree of cortical expansion and thinning predispose to

complications such as pathological fracture, limb length discrepancy, and destruction of the

articular surface as can be seen in some cases of giant cell tumor, predisposing to osteoarthritis.

Malignancies are more likely to progress rapidly and result in cortical destruction. Juxta-cortical

lesions such as parosteal osteosarcoma (Fig. 17B), periosteal chondroma, and juxta-cortical

chondrosarcoma may erode through the outer margin of the cortex and result in saucerization

(Fig.22).2, 8 A cortical lesion like osteoid osteoma can result in proliferation of cortical bone and
thickening, while cortical lesions like lung metastasis, osteofibrous dysplasia, and adamantinoma

can result in destruction or remodeling of cortical bone.21

Soft tissue extension

The presence of a soft tissue mass associated with a bone lesion increases the likelihood that the

lesion is malignant. Exceptions include giant cell tumor, which can be locally aggressive but is

considered benign, and osteomyelitis. Tumors that commonly show a soft tissue component

include lymphoma (Fig. 23), metastases, and primary bone sarcomas.22-23 Cross-sectional

imaging may help differentiate neoplasm from infection, because infection would be expected to

show associated inflammatory changes which are generally more prominent than seen with a

neoplastic process.5,24

Size of the lesion, multiplicity and growth rate

In general, primary malignant bone tumors are larger than benign tumors. As a rule, lesions

larger than 6 cm are statistically more likely to be malignant, although size alone is not an

adequate predictor of malignancy or benignity and additional radiographic features such as rate

of growth and cortical destruction have to be taken into account.8, 24 Several of the lesions have

size criteria that help in differentiation. A lesion size can help differentiate osteoid osteoma from

osteoblastoma. The lucent nidus of osteoid osteoma will rarely measure greater than 2 cm in

diameter. It has been suggested that lesions less than 1.5 cm are usually osteoid osteoma, while
larger than 1.5 cm are usually osteoblastoma.25-26 Benign lesions like fibroxanthomas can be sub-

categorized by the length of the lesion, with lesion less than 3 cm termed as fibrous cortical

defect and longer than 3 cm termed as non-ossifying fibroma.2, 27 A chondroid lesion measuring

less than 2 cm in size in the appendicular skeleton is most likely an enchondroma, while the risk

of it being chondrosarcoma increases if if the lesion measures greater than 5 cm.13,27 Periosteal

chondroma and chondrosarcoma may appear similar on radiographs. Statistically, however,

lesions less than 3 cm at pathology are mostly benign, whereas lesions greater than 5 cm are

malignant.19

Primary bone tumors are solitary occurrences, while other abnormalities may be multiple (Table

3).1-3 Although both benign and malignant tumors can be multifocal, benign lesions tend to have

a symmetrical distribution.

The growth rate of a lesion is of paramount importance in assessing the aggressiveness of the

lesion. Benign tumors usually grow slower than malignancies, or remain stable over a long

period of time. Growth rate can be used to distinguish a slow growing benign bone forming

tumor like osteoblastoma from a rapidly growing osteosarcoma, which at times can be difficult

to distinguish histologically.8 Another example where growth rate is helpful is in distinguishing

enchondroma from low-grade chondrosarcoma in the long bones which otherwise appear similar

radiographically and histologically. Additional features which can be used to distinguish these

two tumors are change in the morphology specifically endosteal scalloping involving more than

two-third of the cortical thickness, change in mineralization pattern, and soft tissue extension

which will favor chondrosarcoma.13

Advanced Imaging
Plain radiography is usually the first imaging technique for a suspected bone tumor since it is

inexpensive, easily available, and best for assessment of morphological characteristics of the

tumor. The margin classification system described in this article is designed primarily for use

with radiography. Limitations of radiography include anatomic overlap that can obscure

abnormalities, limited capacity to evaluate soft tissues and limited contrast for lesion detection in

the trabecular bone. It is estimated that about 40-50% of the trabecular bone must be lost before a

lesion can be detected on the radiograph.6 MRI and CT imaging may provide additional

information by virtue of their multi-planar capability and better soft tissue characterization.

CT in particular is useful for assessing faint matrix mineralization, periosteal reaction, cortical

involvement or cortically based lesions such as osteoid osteoma, detection of lesions in the flat

bones and cystic and fatty components of the lesion.28 MRI is superior to CT for evaluating the

extent of tumor in the medullary cavity and extra-osseous tumor volume, including relationship

with surrounding neurovascular structures and is the modality of choice for staging and assessing

post-treatment response.4, 29-30 However, it should be remembered that the MRI appearance of the

majority of bone tumors is non-specific and should always be assessed concurrently with plain

radiography for better characterization.31

Bone scintigraphy is a highly sensitive but relatively non-specific technique. Its main role is in

detection of suspected metastases in the whole skeleton. It may also be helpful in the detection of

osteoid osteomas ("double density sign" is present in about 50% of cases and is highly

suggestive of this tumor).12

Conclusion

Radiography remains the most important imaging modality in the characterization of bone

tumors despite the availability of advanced imaging techniques. CT and MRI can provide useful

complementary information but should always be interpreted in conjunction with radiographs. If

a systematic approach is followed, correlating patient age with a careful assessment of imaging

features including such as location and margin characterization, the differential diagnosis can be

narrowed and, at times a specific diagnosis can be made.

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16. Yanagawa T, Watanabe H, Shinozaki T, et al. The natural history of disappearing bone
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the spine: what to do and say. Radiographics Jul-Aug;28(4):1019-41, 2008
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Tables
Table 1. Age Distribution of Common Bone Lesions

Age (In Benign Malignant

years)
0-10 Simple bone cyst Ewing sarcoma
Eosinophilic granuloma Leukemia
Infection Metastasis (neuroblastoma)
10-20 Non-ossifying Osteosarcoma
fibroma/fibroxanthoma
Ewing sarcoma
Fibrous dysplasia
Simple bone cyst
Aneurysmal bone cyst
Osteochondroma
Osteoid osteoma
Osteoblastoma
Chondroblastoma
Chondromyxoid Fibroma
Infection
20-40 Enchondroma Parosteal osteosarcoma
Giant cell tumor Adamantinoma
Osteoid osteoma
Osteoblastoma
Fibrous dysplasia
Brown tumor (hyperparathyroidism)
40+ Fibrous dysplasia Metastasis (most common)
Paget’s disease Multiple myeloma
Osteoma Chondrosarcoma
Geode Osteosarcoma (secondary to Paget’s or post-
radiation)
Table 2. Most Common Locations for Bone Lesions

Lesion Locations

Aneurysmal Bone Cyst Tibia, femur, fibula, spine

Adamantinoma Tibia, mandible
Chondroblastoma Femur, humerus, tibia, calcaneus
Chondromyxoid fibroma Tibia, femur, tarsal bones, phalanges of foot
Chondrosarcoma Pelvis, femur, humerus, rib

Eosinophilic Granuloma Femur, skull, iliac bone, rib

Enchondroma Phalanges of hands and feet, femur, humerus, metacarpals
Ewing sarcoma Femur, pelvis, humerus, rib
Fibrous dysplasia Femur, tibia, craniofacial region, rib
Giant cell tumor Femur, tibia, radius, humerus
Hemangioma Spine, rib, craniofacial bones, femur
Lymphoma Femur, pelvis, humerus, tibia

Metastasis Spine, rib, pelvis, femur

Myeloma Spine, rib, pelvis, femur

Non-ossifying fibroma Femur, tibia, fibula, humerus
Osteoid osteoma Femur, tibia, spine, tarsal bone
Osteoblastoma Spine, tarsal bone (calcaneus), femur, tibia
Osteochondroma Femur, tibia, humerus, fibula
Osteomyelitis Femur, tibia, humerus, fibula
Osteosarcoma Femur, tibia, humerus, fibula
Unicameral bone cyst Proximal humerus, proximal femur, tibia, calcaneus
Table 3. Multiple Bone Lesions

Lytic Brown tumor (hyperparathyroidism)

Enchondroma
Eosinophilic granuloma
Fibrous dysplasia
Infection
Metastatic disease
Multiple myeloma
Sclerotic Bone islands
Hemangiomas
Infarct
Infection
Metastasis (prostate, breast)
Osteoid osteoma
Osteopoikilosis
Osteosarcoma
Paget’s disease
Stress fracture
Figure 1 Analysis of bone tumors. Systematic approach to analysis of bone tumors must include
knowledge about patient age, multiplicity of the lesion, morphological characteristics, location
and location within that bone in both longitudinal and transverse planes.
Figure 2 Type 1A geographic lesion (A) Diagram shows a well-defined lucent lesion with narrow
zone of transition and a sclerotic border. (B) Radiograph shows a geographic lytic lesion with
sclerotic borders (arrows) in the meta-diaphysis of distal femur in a 14-year-old female patient
with non-ossifying fibroma.
Figure 3 Type 1B geographic lesion (A) Diagram shows a well-defined lucent lesion with narrow zone of
transition but no sclerotic border. (B) Radiograph shows a geographic lytic lesion without a sclerotic
border (arrows) in the epiphysis of lateral humeral condyle in a 30-year-old male patient with giant cell
tumor.

Figure 4 Type 1C geographic lesion (A) Diagram shows an ill-defined lucent lesion. (B)
Radiograph shows an ill-defined lytic lesion with wide zone of transition (white arrows) in the
meta-diaphysis of distal femur in a 18-year-old male with osteosarcoma. Also note extension to
the cortex (white arrowhead) and associated lamellated periosteal reaction (black arrows).
Figure 5 Type II moth-eaten lytic lesion (A) Diagram shows ill-defined patchy lucent areas in the
medullary cavity. (B) Radiograph shows an ill-defined patchy lytic lesion in the proximal fibula
with poorly defined wide zone of transition (white arrows) in a 20-year-old male with Ewing
sarcoma. Also note the multilamellated periosteal reaction (black arrows) which extends distal
to the identifiable extent of the lesion in the medullary cavity suggesting a possible longer
segment involvement.
Figure 6 Type III permeative lytic lesion (A) Diagram shows numerous ill-defined tiny patchy
lucencies in the medullary cavity. B: Radiograph shows a permeative pattern lytic lesion
involving the medullary cavity and cortex with wide zone of transition (white arrows) in the
diaphysis of humerus in a 52-year-old female with multiple myeloma. Note the pathologic
fracture of the distal humerus (black arrows).
Figure 7 Solid periosteal reaction (A) Diagram shows a solid periosteal reaction (black arrow).
(B) Radiograph shows a solid, smooth periosteal reaction (white arrow) which manifests as
cortical thickening in the diaphysis of tibia in a 16-year-old male with osteoid osteoma. Also
note the small lucent nidus (black hollow arrow).
Figure 8 Multilamellated periosteal reaction (A) Diagram shows a multilamellated periosteal
reaction (black arrow) (B) Radiograph shows a multilamellated, onion skin type periosteal
reaction (white arrow) in the diaphysis of fibula in a 14-year-old male with Ewing sarcoma. See
also Figure 5.
Figure 9 Sunburst or spiculated periosteal reaction (A) Diagram shows a sunburst periosteal
reaction (black arrow) (B) Radiograph shows a severe sunburst periosteal reaction (white
arrows) in the distal femur of a 12-year-old male with osteosarcoma. Also note the large cloud-
like osteoid matrix (white arrowheads)
Figure 10 Codman triangle (A) Diagram shows an elevated periosteum forming an angle with
the cortex (black arrows). B: Radiograph shows elevated periosteum forming a codman triangle
(white arrows) in the mid femoral diaphysis of a 9-year-old female with Ewing sarcoma. Note
the cortical destruction and large soft tissue mass (white arrowheads).
Figure 11 Osteoid matrix. (A) Radiograph shows a homogeneous area of sclerosis (white
arrowhead) suggestive of a mature osteoid in the distal phalanx of the thumb in a 15-year-old-
female with osteoblastoma. Also note the radiolucent nidus (black hollow arrow) (B) Radiograph
shows fluffy, ill-defined amorphous osteoid matrix (white arrow) in the distal femur of a 15-
year-old-male with osteosarcoma. Note the large soft tissue mass (black arrow). Please also
refer to image 9.
Figure 12 Chondroid matrix. Radiograph shows ring-and-arc type chondroid matrix (white
arrows) in the humeral diaphysis of a 30-year-old-male with enchondroma.
Figure 13 Groundglass matrix. Radiograph shows groundglass matrix (arrows) in a geographic
Type1A lesion in the proximal femoral diaphysis of a 40-year-old-male with fibrous dysplasia.
Figure 14 Cortical lesion: Radiograph shows an ill-defined cortically-based lesion in the anterior
tibia diaphysis with patchy areas of sclerosis and lysis in a 30-year-old-male with
adamantinoma. This lesion has a strong predilection for anterior tibial cortex location.
Figure 15 Diagram showing location of common bone tumors and some tumor-like conditions in
long bones in both transverse and longitudinal planes in < 30 years and > 30 years age groups.
AA= adamantinoma, ABC= aneurysmal bone cyst, CB=chondroblastoma, CMF=chondromyxoid
fibroma, CS=chondrosarcoma, EC=enchondroma, EG= eosinophilic granuloma, ES=Ewing
sarcoma, FCD=fibrous cortical defect, FD=fibrous dysplasia, G=geode, GCT=giant cell tumor, M=
metastasis, MM=multiple myeloma, NOF= nonossifying fibroma, OM= osteomyelitis,
OO=osteoid osteoma, OC= osteochondroma, OS= osteosarcoma, RCT=round cell tumors,
SF=stress fracture.
Figure 16 Eccentric versus Central lesions: A. Aneurysmal bone cyst: Radiograph shows an
eccentrically located, expansile, multiloculated, lytic lesion with cortical thinning (white arrows)
in the proximal tibial metaphysis extending to the epiphysis of a 20-year-old female. B.
Unicameral bone cyst: Radiograph shows a centrally located, expansile, lytic lesion (black
arrows) in the proximal humerus meta-diaphysis in a 14-year-old-male. Note also the
pathological fracture (white arrowhead) and fallen fragment sign (black hollow arrow),
classically seen with this lesion.
Figure 17 Juxta-cortical lesions. (A) Osteochondroma: Radiograph shows a pedunculated lesion arising
from the proximal tibial metaphysis which is pointed away from the epiphysis and has a calcified
chondral cap (white arrow) in a 14-year-old-male with osteochondroma. Note remodeling of the fibular
shaft due to long-standing pressure effect from the osteochondroma (black arrow). (B) Parosteal
osteosarcoma: Radiograph shows an ill-defined juxta-cortical osteoid forming lesion (white arrowheads)
causing saucerization ( black hollow arrow) of the posterior cortex of distal femoral metaphysis in a 24-
year-old-male with parosteal osteosarcoma (white arrowheads).This is the most common location of
parosteal osteosarcoma.

Figure 18 Epiphyseal lesion. (A) Chondroblastoma: Radiograph shows a geographic lesion with
thin peripheral sclerosis in the proximal humeral epiphysis of a 14-year-old-female (white
arrows). (B) Clear cell chondrosarcoma: Radiograph shows a geographic lesion with peripheral
sclerosis and central calcifications in femoral head epiphysis of a 50-year-old-male (black
arrows).
Figure 19 Epiphyseal equivalent location: Radiograph shows a geographic, slightly expansile
lesion in the talus of a 16-year-old male with chondroblastoma (white arrows).
Figure 20 Spine lesion. (A) Radiograph demonstrates multifocal ill-defined sclerotic lesions
throughout the spine in a 60-year-old-male with osteoblastic metastasis from prostate
carcinoma. (B) Radiograph demonstrates diffuse sclerosis and enlargement of the L1 vertebral
body which has a picture frame appearance in a 55-year-old-male with Paget’s disease (white
arrows).
Figure 21 Endosteal scalloping. Radiograph shows multiple geographic lytic lesions in the ulnar
shaft causing endosteal scalloping in a 50-year-old-female with multiple myeloma (white
arrows).
Figure 22 Saucerization. Radiograph shows a soft tissue mass (white arrowheads) with foci of
ring-and-arc chondral matrix calcification (blackarrow) causing saucerization of the femoral
cortex (white arrows) in a 27-year-old-female with Juxta-cortical chondrosarcoma.
Figure 23 Soft tissue mass. Radiograph shows a soft tissue mass superior to the shoulder (white
arrows) and moth eaten appearance of the acromion (black arrows) in a 28-year-old male with
lymphoma. Please also refer to Figures 10-11.