Benign Bone Tumor Part I

Dr.Hussain AbuAli

Introduction


Secondary bone tumor is much more common than primary. Approach to bone lesions:
Is the lesion neoplastic or infective?  Is it a primary or secondary neoplasm?  Is it benign or malignant?


Introduction


Approach to tumors:
 Determine

aggressiveness (D & R)  Determine the matrix (CT)  Location of lesion  Age of patient

Destruction pattern


Geographic lytic pattern

Sclerotic rim  Wide transition


Benign Intermediated

MothMoth-eaten pattern


Numerous small holes

Malignant

Permeative pattern


Elongated holes in the cortex

Malignant

Repair pattern


Buttressing (Benign lesion)

 Thick

single layer of periosteal reaction

/ atherosclerosis/ Benign tumor

 HPO

Aggressive
 Lamination

(onion(onion-peal)  Codmans triangle (bony margin) Codman  Sunburst (Malignant lesion)  Hair-on-end (lesion invading the marrow) Hair-on6

Buttressing

Codmans triangle

Sunburst

Hair-on-end

Lamination
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Location


Primary tumor arise in area of rapid growth



Distal femur/proximal tibia/humerus

Metastases occur in well-vascularized red bone wellmarrow



Spine/iliac wings

Typical location:
Enchondroma phalanges  Giant cell tumor around knee  Chordoma sacrum and clivus  Adamantinoma mid tibia


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Location


Location within anatomical region:



Epiphysis


Cartilaginous lesion and eosinophilic granuloma (EG) Nonspecific Giant cell tumor Bone marrow lesion
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Metaphysis


Epi/meta region


Diaphysis


Location


Axial location within a bone:

 

Central lesions


Echondroma/ Unicameral bone cyst/ EG

Eccentric lesions
Aneurysmal bone cyst/ NOF/ Giant cell tumor  Chondromyxoid fibroma/ osteosarcoma


Cortical lesion
Cortical defect/ cortical desmoid/ osteoid osteoma  Periosteal chondroma


Parosteal lesions


Osteochondroma/ malignancies/ Myositis ossificans

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Classification of Benign Bone Tumors

Bone forming tumor: Bone island (Enostosis) Osteoma Osteoid osteoma Osteoblastoma Fibrous tumor: Fibrous cortical defect Non-ossifying fibroma Fibrous dysplasia Ossifying fibroma Desmoplastic fibroma Cartilage forming tumor: Chondroma Osteochondroma Chondroblastoma Chondromyxoid fibroma Other Bone tumor: Giant cell tumor Unicameral bone cyst Aneurysmal bone cyst Eosinophilic granuloma
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Bone forming tumor



Bone island (Enostosis):

    

Neoplasm? Single/ multiple Normal compact lamellar bone usually not more 1.5cm Pelvis, long bones, ribs, and spine. Xray and CT:
  

Uniform dense round/oval intramedullary lesion Radiating thorn-like spicules with narrow transition zone. thornNo periosteal reaction or new bone formation

 

Growing Vs. regress? MRI hypointense on T1 and T2WI T1 T2

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Bone forming tumor



Osteoma:
True osteomas are rare  Skull, paranasal sinuses and mandible  Two types:


Dense variety (Ivory osteoma)  Spongy variety (fibrous tissue)



Asymptomatic Vs. pressure symptoms  X-ray and CT:



Broad base with smooth well-defined margin well Dense endo/periosteal surface of cortex


Gardners syndrome Gardner

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Bone forming tumor



Osteoid osteoma:
Typical history: male 19 y/o complaining from pain history: increased at night and improved with aspirin.  Osteoid osteoma is classified as Cortical, Medullary, or Cortical, Subperiosteal  Site: Site:



Diaphysis of the long bone (30% femur) (25% tibia) (30% (25%


Limb overgrowth in children Lesion on concave side. Joint deformities

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If the spine is involved Neural arch painfull scoliosis



Hand and foot 20% 20%



Bone forming tumor



Osteoid osteoma:


Radiological features:


Radiological nidus <2cm in diameter surrounded by sclerosis <2



Sclerosis may obscure the detection of the nidus

   

CT Nidus # and locations Bone scan hot spot Angiography nidus has dense blush MRI Bone marrow edema Many modalities Preferred treatment currently is PCRFA Failure to remove entire lesion may lead to recurrence
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Management:
  

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Bone forming tumor



Osteoblastoma:
History the same as osteoid osteoma but Aspirin relief is not a feature. Rare.  Spine (post elements) and flat bone



Scoliosis 50% 50%

Two appearance:
Giant osteoid osteoma >2cm and rapidly increasing in >2 size.  Expansile lytic.


Treatment: curettage
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Bone forming tumor



Osteoblastoma:


Radiological findings:
Dense sclerotic bone reaction >2cm >2  Expansile well circumscribed lesion  Variable central calcification or soft tissue component.  MRI is often superior to CT scanning with regard to the detection of a soft-tissue mass soft May mimic osteosarcoma because it may disrupt the cortex (malignant osteoblastoma)


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Osteoblastoma

Osteoid osteoma

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Cartilage forming tumor



Benign cartilage forming tumors:

 Central:
 Chondroma  Chondroblastoma  Chondromyxoid

fibroma

 Peripheral:
 Osteochondroma

(Cartilage(Cartilage-capped Exostosis)  Multiple Exostosis (Diaphyseal aclasis)

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Cartilage forming tumor



Chondroma (enchondroma):
The age of onset is later than bone forming tumors (30). (30).  Asymptomatic but may present as pathological fracture.



Painfull chondroma-fracture=malignant transformation chondroma-

Medullary tumor


Hand 40%, feet 10% and long bones 20% 40%, 10% 20%

Most common tumor of the hand.  Treatment: curettage



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Cartilage forming tumor



Chondroma (enchondroma):


Radiological Findings:Findings: Lytic lesion in bones of the hand and feet.  Chondroid calcifications


Ring (O) and arcs (C) pattern

endosteum with expansion of the cortex but no cortical breakthrough unless fracture  No periosteal reaction or soft tissue mass
 Scalloped

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Cartilage forming tumor



Chondroma (enchondroma):


Usually solitary but if multiple sydromatic



Ollier Olliers disease (multiple enchondromatosis):

  

Multiple radiolucent expansile masses in hand and feet Hand and foot deformity Tendency for unilaterality Multiple enchondromatosis + soft tissue hemangiomas Tendency for unilaterality Malignant transformation is more than olliers disease ollier

Maffucci Maffuccis syndrome:

  

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Cartilage forming tumor



Chondroblastoma (Codman Tumor):

Uncommon neoplasm that occurs almost exclusively in the epiphysis (GCT)  Location around the knee /proximal humerus  Children in second decade  Pain around the joint with some limitation.  Radiological features:


Oval lytic lesion with thin marginal sclerosis in epiphysis  Matrix calcification and periosteal reaction  MRI?  ABC may develop in chondroblastoma


Treatment: curettage

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Cartilage forming tumor



Chondromyxoid fibroma:
    

Very rare tumors Contains myxomatous tissue and giant cells 20-30Y peak incidence M=F 20-30Y Around the knee 2/3 Radiological feature:
  

Lobulated lytic lesion with surrounding sclerosis in metaphysis Calcifications rare CT may be necessary delineate a cortical margin in the expanded soft tissue mass

Treatment: Curettage
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Cartilage forming tumor



Osteochondroma (exostosis):
It is very common benign neoplasm.  Keep growing on & stop growing with skeletal maturity  Age <20 years in 80% (10 to 35 years) M:F 2:1. <20 80% (10  Location any bone but 85% tibia, femur and humerus. 85%  Treatment: en-bloc resection en

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Cartilage forming tumor

 Osteochondroma  Radiological findings:


(exostosis):

CartilageCartilage-covered bony projection (metaphyseal location)  Two types: pedunculated & sessile  Continuous with parent bone & Lesions grows away from joint
 

Uninterrupted cortex Continuous medullary bone.

Calcification in the chondrous portion of cap  MRI:


  

Continuity with parent bone Cartilagous cap Effect of the lesion on the surrounding structure
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Cartilage forming tumor



Osteochondroma (exostosis):


Complications:
Pressure on the nerves and blood vessels  Pressure on the adjacent bone

 

Deformities Fracture

Overlying bursitis  Malignant transformation <1% <1


    

Pain (fracture - bursitis - nerve compression) Growth of the lesion after skeletal maturation >1cm cartilage cap Dispersed calcification in the cap Increase uptake in bone scan

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Cartilage forming tumor



Multiple osteocartilagous exostosis:

     

Diaphyseal eclasis: multiple exostosis Autosomal dominant Short stature Knee, ankle and shoulder Sessile and metaphyseal in location Complications:
 

Growth abnormalities Malignant transformation is higher than the solitary



chondrosarcoma

Dysplasia epiphysealis hemimelica

 

IntraIntra-articular epiphyseal osteochondromas Unilateral

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