Skeletal Radiology IV: Benign Bone Tumors and Tumor Like-Conditions Part 1 – Flashcards
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What is a bone island?
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A circumscribed focus of cortical bone wtihin cancellous bone. It is usually small and under *1cm* in diameter. Can have a brush border. Is very common. Not symptom producing.
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You find what appears to be a bone island. What else could it be?
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*Blastic Metastasis* Also, prostate cancer metastatic to bone, sesamoid bones, bowel contents (like swallowed pills)
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Bone Island
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Bone Island
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Bone Island (Note the brush border)
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Either an accessory sesamoid or a bone island on the 2nd toe. It really doesn't matter which. The other 2 on the first toe are both sesamoid bones.
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Bone Island (On MRI - Note it looks black)
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What is Osteopoikilosis?
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Spotted bone disease. It is an autosomal dominant condition characterized by hundreds of bone islands which tend to cluster around large joints.
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Osteopoikilosis
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Fill this out for Osteopoikilosis. *Number of Lesions*: *Size and Uniformity of Lesions*: *Symptoms*: *MRI Findings*: *Lab Findings*: *Change over Time*:
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*Number of Lesions*: Hundreds *Size and Uniformity of Lesions*: Uniformly small (1cm or less) *Symptoms*: None *MRI Findings*: MRI has no signal *Lab Findings*: None *Change over Time*: No change with serial films!!!!
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Fill this out for Blastic Mets. *Number of Lesions*: *Size and Uniformity of Lesions*: *Symptoms*: *MRI Findings*: *Lab Findings*: *Change over Time*:
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*Number of Lesions*: Usually multiple *Size and Uniformity of Lesions*: Varying sizes *Symptoms*: Bone pain, increasing in severeity *MRI Findings*: MRI findings with it being very high on T2 *Lab Findings*: Present (High PSA) *Change over Time*: Growth, additional lesions over time
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Osteoblastic Metatasis
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We see Osteopoikilosis. Before we make out diagnosis we must rule out what condition?
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Osteoblastic Metastasis
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What is a Hamartoma?
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A *benign* growth made up of an abnormal mixture of cells and tissues normally found in the area of the body where the growth occurs.
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What are osteoma?
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Comprised of normal bone constituents that grow only on skull or sinuses (because they undergo intramembranous bone formation as opposed to endochondral)
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Osteomas are insignificant except for when....
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They may be palpable, can block a sinus outflow, or Gardner's Syndrome.
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What are the symptoms of Gardner's syndrome
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*1.* Osteomas (Palpable) *2.* Colon Polyps (Which can undergo metastatic change) *3.* Skin Lesions
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Osteoma
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Osteoma
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Osteoma
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Osteoid Osteoma
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What is an osteoid Osteoma?
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A small vascular tumor which is *benign*. However, tumor is quite painful (especially at night). Can affect any bone including the spine. When affecting spine, it loves the posterior elements. *Dramatically relieved by NSAIDS*
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What is the prognosis of Osteoid Osteomas?
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Self limiting. May go away on its own.
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What age range is affected by Osteoid Osteoma?
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Age 10-25
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What do Osteoid Osteomas look like radiographically?
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Small radiolucency (called a *nidus*) which can have central calcification. Nidus can be intracortical or intramedullary. Solid reactive new bone may be more noticeable than the tumor itself.
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Is a lucent nidus or a calcified nidus more associated with an older tumor?
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Calcified
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Osteoid Osteoma
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Osteoid Osteoma
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Osteoid Osteoma
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Osteoid Osteoma (Notice it is surrounded by the bodys reaction to it)
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How do we treat Osteoid Osteoma
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*1.* Do nothing... may go away on their own. *2.* If painful, use percutaneous radiofrequency Ablation. Under CT guidance, a needle is inserted into nidus for biopsy. Nidus replaced with probe. Tumor is heated to kill the tumor cells.
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Osteoid Osteomas tend to occur in the (anterior/posterior) segment of the spine.
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Posterior
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Osteoid Osteomas take approximately how long to go away on their own?
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2 years
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What is the differential diagnosis for an osteoid osteoma?
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*1.* Healing Stress fracture (will also have pain and reactive sclerosis. No nidus and might see a fracture line) *2.* Brodie's Abscess (will also have pain, a small lucency, but no reactive sclerosis)
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Healing Stress Fracture
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Brodie's Abscess
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Fibrous Cortical Defect
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Painful tiny benign tumors with big reactive sclerosis are called....
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Osteoid Osteomas
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A giant osteoid osteoma is called...
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Osteoblastoma
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What is an Osteoblastoma?
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Histologically related to osteoid osteoma. These are larger and expansile. Pain is less intense but is *not* worse at night and *not* dramatically relieved by nsaids.
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What age group is most affected as osteoid osteomas
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10-25
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Are osteoblastomas or osteoid osteomas more likely to affect the spine?
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Osteoblastomas. 40% of them affect the spine (most in posterior elements)
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Neurological complications are more common in (osteoblastomas/osteoid osteomas).
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Osteoblastomas (because they are more expansile)
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What percentage of Osteoblastomas affect the spine?
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40%
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Fill this out for Osteoid Osteomas *Age Affected*: *Size of Lesion*: *Expansile*: *Soap Bubbly*: *Bones Affected*:
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*Age Affected*: 10-25 *Size of Lesion*: small (less than 1cm) *Expansile*: No *Soap Bubbly*: No *Bones Affected*: Any
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Fill this out for Osteoblastomas *Age Affected*: *Size of Lesion*: *Expansile*: *Soap Bubbly*: *Bones Affected*:
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*Age Affected*: 10-25 *Size of Lesion*: Larger (larger than 2cm) *Expansile*: Yes *Soap Bubbly*: Yes *Bones Affected*: Any, but 40% are in the spine (mostly posterior elements)
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Osteoblastoma (Appears aggressive)
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In the spinal canal, where is the cord? What is the significance?
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It is more anterior. So tumors which fill in posterior spaces tend to not cause neurological conditions.
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What is the most common benign bone tumor?
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Osteochondroma
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What are osteochondromas?
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Benign growths at the corner of the growth plates. They are encapsulated by a cartilage cap. Osteochondromas have both a bone and cartilage component.
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Osteochondromal lesions (farther from/closer to) the axial skeleton are more likely to become malignant.
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Closer to
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When do Osteochondromas develop?
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Develop early in childhood and are caused by trauma to epiphyseal plate.
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Osteochondromas grow until when?
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Until the child stops growing.
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Osteochondromas do/do not affect the spine.
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*Do*
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Osteochondromas tend to point (towards/away) from the closest joint.
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Away from
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Osteochondroma?
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Osteochondromas are typically (symptomatic/asymptomatic)
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Asymptomatic
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What are the two types of osteochondromas?
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Sessile (flat base) and pedunculated (stalked)
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Pedunculated Osteochondroma
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Sessile Osteochondroma
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What arethe "nicknames" for the two types of Osteochondromas?
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*Sessile*: Cauliflower Exostosis *Pedunculated*: Coat Hanger Exostosis
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Osteochondroma of the C1. Sorry. This is a cheapshot. There is no way for you to determine what this could be. Could be ligament or muscle ossification. Just be aware it could be this.
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Osteochondromas are asymptomatic unless...
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Cosmetic/palpable, mechanical irritation, or fracture *1% of them turn into malignant change*. Its the same as a mole on your skin. Could become cancerous sure. But unlikely.
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Osteochondroma Sessile
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Pedunculated Osteochondroma causing mechanical irritation. It formed a pseudo-joint (adventitious joint) which underwent degenerative joint disease. Note presence of osteophytes.
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How many osteochondromas become malignant?
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Less than 1%. Like the chances of a mole.
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When do we worry about osteochondromas becoming malignant? (symptoms)
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Osteochondroma continues growing after he has stopped growing and has developed pain.
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What is one way to tell the malignant potential of Osteochondromas?
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MRI assessing the cartilage cap. Cartilage is the main offender in this condition. Cartilage cap more than ; 2cm thick is considered for malignancy.
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MRI hallmark of malignant degeneration for osteochondromas is thickening of cartilage cap. What thickness indicates malignant change?
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;2cm
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Normal. That mass on the humerus is the deltoid process.
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Supracondylar process/spur. Not to be confused with osteochondromas. We know this because the spur is facing towards the joint.
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What is another word for osteochondroma?
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Exostosis
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What is HME?
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Hereditary Multiple Exostosis (or Hereditary Multiple Osteochondroma) Autosomal dominant condition characterized by dozens of exostosis lesions.
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Regarding Fibroxanthomas, what is the name for one that is small and one that is large.
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*Small*: Fibrous Cortical Defect *Large*: Non-Ossifying fibroma
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Compare and contrast Fibrous cortical defects and nonossifying fibromas. *Size*: *Soap Bubbly?*: *Path Fx?*: *Clin Significance*: *Spinal?*:
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*Size*: FCD is 3cm *Soap Bubbly?*: No to FCD and yes to NOF *Path Fx?*: No to FCD and Yes to NOF *Clin Significance*: No big deal for FCD. Path Fx possible in NOF *Spinal?*: No for both.
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Where are you more likely to see monostotic fibrous dysplasia?
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Proximal Femur and Rib
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HME/HMO Hereditary Multiple Exostosis
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HME/HMO
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HME/HMO
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What is the chance of malignant change with HME?
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5-25%
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HME/HMO. Notice the only sign is widened femoral necks.
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In osteochondroma, malignant transformation occurs in what portion of? What will it turn into?
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Cartilage. Chondrosarcoma.
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What is the MC benign bone tumor of the small, tubular bones of the hands and feet?
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Enchondroma
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Enchondroma is the MC bengin bone tumor of...
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Small tubular bones of hands and feet
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Tell me about Enchondromas.
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Potentially expansile with a cartilage matrix which can calcify. *Does not affect spine and usually symptomatic*.
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Under what conditions are enchondromas potentially symptomatic?
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Path fracture or malignant transformation
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Enchondroma
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Enchondroma
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Enchondroma (Popcorn calcification)
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Enchondroma (Popcorn calficiation and path fracture)
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Enchondroma (Notice popcorn calcification) This patient has an osteophyte on the inferior of the humeral head. Probably why they came into get an xray.
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Any time you see an enchondroma, what two things must you consider for your differential diagnosis?
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*1.* Medullary Bone Infarct *2.* Low grade chondrosarcoma
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Multiple Enchondroma is called...
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Ollier Disease
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Ollier Disease
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How do you get Ollier disease?
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You are born with it but it is *not hereditary*.
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What is a quick way to assess a child's age if you have an x-ray of their hand?
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children *generally* gain one new ossified carpal bone per year. This should tell you imprecisely what their bone age should be. Can help you assess development.
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Ollier Disease. Note the many enchondromas. This disease has caused deformity in the proximal limb.
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What is Maffucci Syndrome?
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Ollier disease combined with soft tissue hemangiomas. Soft tissue is usually difficult to see on x-ray but these hemangiomas are calcified into phleboliths. In addition to endochondromas, phleboliths are pathognomonic for Maffucci syndrome. (Usually if phleboliths are anywhere other than pelvis)
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Maffucci Syndrome
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What is this?
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Phleboliths. Small calcifications in the veins.
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What is the most common benign bone tumor of the hands and feet?
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Enchondromas
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What is the cancer risk with patients who have enchondromas?
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*Rare* Enchondromas have a 1-5% chance. However, Ollier is 25% and Maffucci is 50%. Don't get too focused on memorizing.
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There is a higher chance for enchondroma lesions the closer you get to....
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Axial skeleton.
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What is the ddx for enchondromas?
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*1.* Medullary infarct *2.* Low grade chondrosarcoma.
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What are Chondroblastomas?
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Rare cartilage tumors affecting children and young adults. (Mean age is 20) Arises in the epiphysis. *Only tumor to do this*. Usually affects lower extremity.
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The only tumor to arise in the epiphysis is the...
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Chondroblastoma.
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Chondroblastomas typically affect what?
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Lower extremities. Half are around the knees.
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Chondroblastoma
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Chondroblastoma
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What are the symptoms of Chondroblastomas?
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Joint pain
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What is the only true epiphyseal tumor
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Chondroblastoma. Only one that starts there.
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T/F: Cartilage tumors do not like the spine?
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True.
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Clinically, patients with HME presence how physically?
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Short stature and visible palpable limb deformities.
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T/F: Fibrous Cortical Defects can sometimes have pain.
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False. No pain. This is unlike osteoid osteomas.
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Majority of Fibrous Cortical Defect is seen in.....
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Metaphyseal *cortex* of long bones
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Patient has no pain.
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Fibrous Cortical Defect
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Fibrous Cortical Defects are under ___ cm.
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3 cm
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Fibrous Cortical Defect
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T/F: Fibrous Cortical defects never affect the spine.
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False. They typically do not affect the spine.
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How many cm's (generally) are 1 inch?
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2.5 (2.54 specifically) is 1 inch. You need to know this for patients. "Your tumor is 2.5cm in length" tells little to most patients.
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Non-Ossifying Fibroma are most clinically significant due to...
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Pathological fractures.
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How large are non-ossifying fibroma?
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Over 3cm in length.
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Non-ossifying Fibroma
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Tell me about the physical appearance of non-ossifying fibroma.
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Soap bubbly and surrounded by a sclerotic rim. It is slightly expansile and is over 3cm in length.
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Non-Ossifying Fibroma
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Is ESR accelerated in heart failure?
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No
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Compare and contrast the size, age range, prevalence, location, expansile nature, cortical involvement, and clinical significance of FCD vs NOF and then look at the picture to see if you got it right.
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Yay
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Where do we often find Non-ossifying Fibromas?
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Metaphysis of long bones
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Non-Ossifying Fibromas are generally (painful/not painful)
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Not painful
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T/F: Fibrous Dysplasia MUST develop in childhood. If it doesn't, you will never get it.
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True
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What are the 4 forms of Fibrous Dysplasia?
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*1.* Monostotic - most common *2.* Polyostotic (With endocrinopathy you get diabetes myellitus, cushing syndrome, and precocious puberty-McCune-Albright) *3.* Craniofascial *4.* Cherubism
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Tell me about Monostotic Fibrous Dysplasia
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Very common, painless, affects ribs mostly (but also long bones), and develops during childhood.
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What do monostotic Fibrous Dysplasia look like radiographically?
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Lesions range from lucent to opaque or in-between. (Ground glass or frosted mug appearance). Often have thick rim of sclerosis called a "rind" sign. Can be expansile.
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Rind sign, ground glass, and location tell us this is likely *Fibrous Dysplasia*
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Great example of Rind sign. Fibrous Dysplasia.
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What classification system can we use to assess fracture risk?
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Mirel
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Ignore humerus for now.
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Right 2nd rib and posterior portion of left 4th rib shows a monostotic Fibrous Dysplasia that is expansile.
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Tell me about Polyostotic Fibrous Dysplasia
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Many tumors of fibrous dysplasia. Can happen with or without endocrinopathy. Asymmetrical and 50% of patients have cafe-au-lait spots that look like the Coast of Maine (Small islands).
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What do the cafe-au-lait spots look like in Polyostotic Fibrous Dysplasia?
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"Coast of maine". Large "landmass" with many "islands"
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Shepherd's crook deformity
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What is a Shepherd's crook deformity?
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Proximal femur deformity due to fibrous dysplasia. Usually coxa vara and less than 120. (normal femoral neck angle is 120-130)
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Normal femoral neck angle is how many degrees?
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120-130
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Shephard's Crook
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Cherubism
