Henk Jan van der Woude and Robin Smithuis
Radiological Abteilung im Onze Lieve Vrouwe Gasthuis, Amsterdam und Alrijne Hospitalet in Leiderdorp, Holland
release date
In this article, we discuss a systematic approach to differential diagnosis of bone tumors and tumor-like lesions.
The differential diagnosis depends primarily on the review of conventional radiographs and the age of the patient.
Used abbreviations:
- ABC = Aneurysmatische Knorglezyste
- CMF = Chondromyxoidfibrom
- EG = Eosinofilt-Granulom
- GCT = giant cell tumor
- FD = Fibrous Dysplasia
- HPT = hyperparathyroidism with brown tumor
- NOF = non-ossifying fibroma
- SBC = Simple Bone Cyst
Systematic access
The most important determinants when analyzing a potential bone tumor are:
- The morphology of the bone lesion on a plain radiograph
- Well defined osteolysis
- ill-defined osteolytic disease
- sclerotic
- age of the patient
It is important to realize that plain x-ray is the most useful examination to distinguish these lesions.
CT and MRI are only useful in selected cases.
Here are links to other articles on bone tumors:
- Bone tumors in alphabetical order
- Well-defined osteolytic bone tumors
- ill-defined osteolytic bone tumors
- Sclerotic bone tumors
- Bone tumors A-G
- Bone tumors H-O
- Bone tumors P-Z
Approach
Most bone tumors are osteolytic.
The most reliable indicator for determining whether these lesions are benign or malignant is the transition zone between the lesion and the adjacent normal bone (1).
Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has well-defined or ill-defined margins, the next question should be: how old is the patient?
Age is the most important clinical clue.
Finally, other indicators must be taken into account, such as B. the localization of a lesion in the skeleton and in the bone, any periosteal reactions, cortical destruction, matrix calcifications, etc.
bee
Age is the most important clinical clue to distinguish possible bone tumors.
There are many ways to subdivide age groups, as illustrated in the table combining the morphology of a bone lesion with the age of the patient.
Some prefer to divide patients into two age groups: 30 years.
Most primary bone tumors occur in patients. Metastases and myeloma must be included in the differential diagnosis in patients > 30 years of age.
Note the following:
- Infections, a common tumor mimic, occur in every age group.
- Infection can be well-defined or ill-defined osteolytic and even sclerotic.
- Eosinophilic granulomas and infections should be included in the differential diagnosis of almost all bone lesions in patients < 20 years.
- Many sclerotic lesions in patients > 20 years are healed, previously osteolytic lesions that are ossified, such as: NOF, EG, SBC, ABC, and chondroblastoma.
transition zone
To classify osteolytic lesions as well-defined or ill-defined, we need to look at the transition zone between the lesion and the adjacent normal bone.
The transition zone is the most reliable indicator for determining whether an osteolytic lesion is benign or malignant (1).
The transition zone only applies to osteolytic lesions, since sclerotic lesions usually have a narrow transition zone.
Narrow transition zone: NOF, SBC and ABC
Small transition zone
A small transition zone leads to a sharp, well-defined border and is a sign of slow growth.
A sclerotic rim indicates particularly low biological activity.
In patients > 30 years and especially > 40 years, metastasis or a plasmacytoma should also be considered despite benign radiological features
On the left three bone lesions with a narrow transition zone.
Based on the morphology and age of the patients, these lesions are benign.
Note that the growth plates have not yet closed in all three patients.
Pictures
- Non-ossifying fibroma
- Solitary bone cyst
- Aneurysmal bone cysts
Metastases and Multiple Myeloma
In patients > 40 years, metastases and multiple myeloma are the most common bone tumors.
Metastases under the age of 40 are extremely rare unless the patient has a known primary malignancy.
Metastases can be included in the differential diagnosis when a younger patient is known to have a malignancy such as neuroblastoma, rhabdomyosarcoma, or retinoblastoma.
A broad transitional zone suggests malignancy or infection or an eosinophilic granuloma
Wide transition zone
A poorly defined border with a wide transition zone is a sign of aggressive growth (1).
It is a feature of malignant bone tumors.
There are two tumor-like lesions that can mimic malignancy and must be included in the differential diagnosis.
These are infections and eosinophilic granulomas.
Both companies can exhibit an aggressive growth pattern.
Pictures
- Osteosarcoma
- Osteomyelitis
- Granular eosinophils
Infections and eosinophilic granulomas
Infections and eosinophilic granulomas are uncommon because they are benign lesions that can mimic a malignant bone tumor due to their aggressive biological behavior.
The edges of these lesions may be poorly defined, but cortical destruction and an aggressive periosteal response can also be seen.
periosteal reaction
A periosteal reaction is a nonspecific reaction and occurs when the periosteum is irritated by a malignant tumor, benign tumor, infection, or trauma.
There are two patterns of periosteal reactions: benign and aggressive.
The benign type occurs with benign lesions such as benign tumors and after trauma.
An aggressive type occurs in malignant tumors, but also in benign lesions with aggressive behavior, such as B. infections and eosinophilic granulomas.
Fibrous dysplasia, enchondroma, NOF, and SBC are common bone lesions.
They show no periosteal reaction unless there is a fracture.
If there is no fracture, these bone tumors can be ruled out.
Benign periosteal reaction
It can be very useful to recognize a benign periosteal reaction as a malignant lesionnever causea benign periosteal reaction.
A benign periosteal reaction is thick, wavy, and uniform callus formation resulting from chronic irritation.
In benign, slow-growing lesions, the periosteum has time to grow thick new bone and convert it into a more normal-looking cortex.
Bild
Benign periosteal reaction and osteoid osteoma.
The large arrow indicates a solid periosteal response.
Small arrow indicates Nidus.
Aggressive periosteal reaction
This type of periostitis is layered, lamellar, or shows bone formation perpendicular to the cortex.
It can be pointed and discontinuous - sometimes there is a Codman triangle.
A Codman's triangle refers to an elevation of the peritoneum away from the cortex, which forms an angle where the elevated periosteum and bone meet.
With aggressive periostitis, the peritoneum does not have time to consolidate.
Aggressive periosteal reaction
Aggressive periosteal reaction (2)
- Osteosarcoma with interrupted periosteal rectification and Codman's triangle proximally (red arrow).
There is periosteal bone formation perpendicular to the cortex and extensive bone matrix formation of the tumor itself. - Ewing's sarcoma with lamellar and focally interrupted periosteal reaction. (white arrows)
- Infection with multi-layered periosteal reaction.
Note that the periostitis is aggressive, but not as aggressive as in the other two cases.
Osteosarcoma (left) and Ewing's sarcoma (right)
cortical destruction
Cortical destruction is a common finding and not particularly helpful in distinguishing between malignant and benign lesions.
Complete destruction can be seen in high grade malignant lesions but also in locally aggressive benign lesions such as EG and osteomyelitis.
More uniform cortical bone destruction can be seen in benign and low-grade malignant lesions.
Endosteal cortical bulges can be seen in benign lesions such as fibrous dysplasia and low-grade chondrosarcoma.
Pictures
- Osteosarcoma
Irregular cortical destruction - Ewing Sarcoma
Cortical destruction (green arrow) and aggressive periosteal reaction (arrowheads).
Chondromyxoid fibroma (left), giant cell tumor (right)
balloon flight
Ballooning is a special form of cortical destruction.
During ballooning, the destruction of the endosteal cortical bone and the addition of new bone on the outside occur at the same rate, resulting in expansion.
This "neocortex" can be smooth and continuous, but can also be focally disrupted in more aggressive lesions such as GCT.
Pictures
- Chondromyxoides Fibrom
A benign, well-defined, extensive lesion with regular cortical bone destruction and a peripheral layer of new bone. - Riesenzelltumor
A locally aggressive lesion with cortical destruction, expansion, and a thin, disrupted peripheral layer of new bone.
Note the wide transition zone to the medullary cavity, which is a sign of aggressive behavior (red arrow).
Ewing's sarcoma with permeative growth through the Haversian ducts accompanied by a large soft-tissue mass
Cortical Destruction (3)
In the group of malignant small round cell tumors, which include Ewing's sarcoma, bone lymphoma, and small cell osteosarcoma, the cortex may appear almost normal on radiographs, while permeative growth occurs in the Haversian canals.
These tumors can be accompanied by a large soft tissue mass while there is almost no visible bone destruction.
Pictures
- Ewing Sarcoma
X-ray shows no signs of cortical destruction. - MRI shows a large tumor in the bone and permeative growth through the Haversian canals, accompanied by a large soft-tissue mass that is barely visible on the x-ray.
location in the skeleton
The location of a bone lesion in the skeleton can provide an indication of the differential diagnosis.
The figure on the left shows the preferred locations of the most common bone tumors.
Almost all bone tumors can be found in some places, for example in the humerus or around the knee.
Top 5 bone tumor ranking in alphabetical order:
Aneurysmal bone cysts-Tibia, femur, fibula, spine, humerus
Adamantin-skinnebensskaft, lower jaw
Chondroblastom-In- Femur, humerus, tibia, tarsal bone (calcium), patella
Chondromyxoides Fibrom- Shin bone, femur, tarsal bone, phalanx foot, fibula
Kondrosarcoma- Femur, rib, hipbone, shoulder, shin
chord- sacrococcygeal, spheno-occipital, zervikal, lumbal, Thorax
Granular eosinophils -Femur, skull, hip bone, rib, vertebra
Enchondrom -Phalanges of hands and feet, femur, humerus, metacarpal, ribs
Ewing Sarcoma- Femur, Hip Bone, Fibula, Rib, Tibia
Fibrous Dysplasia- Femur, tibia, rib, skull, humerus
Riesenzelltumor- Femur, Tibia, Wadenbein, Humerus, Distal Radius
Hemangioma- Spine, ribs, cranial-facial bones, femur, tibia
lymphoma- Femur, tibia, humerus, hip bone, vertebrae
metastases- Vertebrae, ribs, pelvis, femur, humerus
Non-ossifying fibroma- Shin, femur, fibula, shoulder
Osteoid-Osteom- Femur, tibia, spine, tarsal bones, phalanx
Osteoblastom- Spine, tarsal bones (calcium), femur, tibia, humerus
Osteochondroma- Thigh, shoulder, shin, hip, pelvis
Osteomyelitis- Femur, tibia, shoulder, fibula, radius
Osteosarcoma- Femur, tibia, shoulder, fibula, hip bone
Solitary bone cyst-Proximal Humerus, Proximal Femur, Heel Bone, Pelvic Bone
Lage: Epiphyse – Metaphyse – Diaphyse
- Epiphyse
Since there are few lesions in the epiphysis, this could be an important finding.
In young patients, it is likely a chondroblastoma or an infection.
A giant cell tumor must be included in the differential diagnosis in patients over 20 years of age.
In elderly patients, a geode, i.e. a degenerative subchondral bone cyst is added to the differential diagnosis.
Watch carefully for signs of osteoarthritis. - Metaphyse
NOF, SBC, CMF, osteosarcoma, chondrosarcoma, enchondroma and infections. - Diaphyse
Ewing's sarcoma, SBC, ABC, enchondroma, fibrous dysplasia and osteoblastoma.
It is not always possible to distinguish between a diaphyseal and a metaphyseal location.
Many lesions may be in either organ or migrate from the metaphysis to the diaphysis during growth.
Large lesions tend to spread to both areas.
Position: centric - eccentric - juxtacortical
- Central in the long bone
SBC, eosinophilic granuloma, fibrous dysplasia, ABC, and enchondroma are lesions centrally located in long bones. - Eccentric in the long bone
Osteosarcoma, NOF, chondroblastoma, chondromyxoid fibroma, GCT and osteoblastoma are localized eccentrically in long bones. - Cortical
Osteoid osteoma is located in the cortex and must be distinguished from osteomyelitis. - subcortical
osteochondroma. The cortex must reach the pedicle of the lesion.
Parosteal osteosarcoma arises from the periosteum.
- SBC: central dialysis
- NOF: eccentric metaphysis
- SBC: central dialysis
- Osteoidosteoma: cortical
- Degenerative subchondral cyst: epiphysis
- ABC: centric diaphyseal
Chondroide Matrix
Matrix
Calcifications or mineralizations in a bone lesion can be an important clue in the differential diagnosis.
There are two types of mineralization:
- Chondroid matrix in cartilage tumors such as enchondromas and chondrosarcomas
- Osteoid matrix in bone tumors such as osteoid osteomas and osteosarcomas.
Chondroide Matrix
Calcifications in chondroid tumors have many descriptions: ring-shaped, popcorn-shaped, focally punctured, or flaky.
Pictures
- Enchondroma, the most common lesion of the phalanges.
- Peripheral chondrosarcoma arising from an osteochondroma (exostosis).
- Chondrosarcoma of the rib.
Osteoid matrix in osteosarcoma (left) and osteoid osteoma (right).
Osteoidmatrix
Mineralization in osteoid tumors can be described as a trabecular ossification pattern in benign osteogenic lesions and as a cloudy or ill-defined amorphous pattern in osteosarcoma.
Sclerosis can also be reactive, e.g. in Ewing's sarcoma or lymphoma.
- links
Cloud-like bone formation in osteosarcoma.
Note the aggressive, disrupted periosteal reaction (arrows). - To the right
Trabecular ossification pattern in osteoid osteomas.
Note the osteolytic nidus (arrow).
LEFT: Polyostotic fibrous dysplasia. RIGHT: Multiple osteolytic lesions in the femoral shaft
Polyostotic or multiple lesions
Most bone tumors are solitary lesions.
If multiple or polyostotic lesions are present, the differential diagnosis must be adjusted.
Polyostotic lesions
NOF, fibrous dysplasia, multifocal osteomyelitis, enchondroma, osteochondroma, leukemia and metastatic Ewing's sarcoma.
Many enchondromeres are Ollier disease.
Multiple enchondromas and hemangiomas occur in Maffucci syndrome.
Polyostotic lesions > 30 years
Common: Metastases, multiple myeloma, multiple enchondromas.
Uncommon: Fibrous dysplasia, brown tumors of hyperparathyroidism, bone infarcts.
Memory aid for multiple oseolytic lesions: FEEMHI:
Fibrous dysplasia, enchondromas, EG, mets and myeloma, hyperparathyroidism, infection.
spinal lesions
Here are some typical examples of bone tumors in the spine.
- Hemangioma.
- metastases.
- Myelomatosis.
- Plasmacytoma: vertebra plana.
This "mini-brain" appearance of a plasmacytoma in the spine is sufficiently pathognomonic to avoid biopsy (9).
More examples
- ABC
- Kondrosarcoma
- metastasis of breast cancer
- Osteoblastom
foot lesions
Here are some typical examples of bone tumors on the foot:
- Geode or subchondral cyst in the navicular bone
- Geode or subchondral cyst in the tarsal bone
- Chondroblastoma of the tarsal bone
- X-ray and MRI of a chondroblastoma in the tarsal bone
- Chondroblastoma of the tarsal bone
- Aneurysmal cartilage cyst and tarsalbenet
- Chondroblastoma of the tarsal bone
- Chondromyxoides Fibrom (CMF) im Kalkaneus
- Same patient MR
- CMF in the second metatarsal
- Ewing's sarcoma and calcaneus
- Glomus-Tumor
- Same patient MR
FAQs
What is the best imaging for bone tumors? ›
Metastatic bone lesions are typically hyperintense on DWI. MRI provides good contrast resolution of bone and soft tissue and therefore has good sensitivity and specificity for detection for bone metastases.
What is the most common benign bone tumor? ›Osteochondroma represents 20–50% of benign tumors [59], being the most common bone benign tumor, and 10–15% of all tumors in general. It typically develops in growing bones. For this reason, according to some studies, they probably arise from the epiphyseal growth plate. They affect males more often than females.
What is the mnemonic for the site of bone tumor? ›Remember the Site of origin of Bone Tumors using the mnemonic GEOMED. Another mnemonic that can be used to remember the Site of origin of Bone Tumours is DEMO ECG. Hope that mnemonic helped.
Can an MRI tell if a bone tumor is cancerous? ›MRI scan. An MRI scan uses a strong magnetic field and radio waves to produce detailed pictures of the bones and soft tissues. An MRI scan is an effective way of assessing the size and spread of any cancerous tumour in or around the bones.
What is the most common primary bone tumor radiology? ›In patients > 40 years metastases and multiple myeloma are the most common bone tumors. Metastases under the age of 40 are extremely rare, unless a patient is known to have a primary malignancy.
What percent of bone tumors are cancerous? ›Most bone tumors are benign (not cancerous), but a few are cancerous. Known as primary bone cancers, these are quite rare, accounting for less than 0.2 percent of all cancers.
How do you know if a bone tumor is benign or malignant? ›How are benign and malignant lesions diagnosed? Lesions in the bone are usually identified on radiographic images – chiefly X-rays – but also on CT and MRI scans. For those that are possibly cancerous, a biopsy is conducted to identify it.
What is the first most common malignant bone tumor? ›Osteosarcoma is the most common form of bone cancer. In this tumor, the cancerous cells produce bone. This variety of bone cancer occurs most often in children and young adults, in the bones of the leg or arm.
Which bone tumor has poorest prognosis? ›Patients with metastatic disease at diagnosis have a poor prognosis with a 5-year event-free survival of 30%. Among this group, the prognosis of patients with multifocal osteosarcoma7, 8, 9 or with axial metastases6 is the most severe.
How long can you live with a bone tumor? ›If the cancer is diagnosed at the localized stage, the 5-year relative survival rate is 82%. If the cancer has spread to surrounding tissues or organs and/or the regional lymph nodes, the 5-year relative survival rate is 70%.
What is the most common bone tumor in adults? ›
Multiple myeloma is the most common primary bone cancer. It is a malignant tumor of bone marrow — the soft tissue in the center of many bones that produces blood cells. Any bone can be affected by this cancer. Multiple myeloma affects approximately seven people per 100,000 each year.
What is the most common site for bone tumor? ›The most common locations include the femur (42%, with 75% of tumors in the distal portion of the bone), the tibia (19%, with 80% of tumors in the proximal portion of the bone), and the humerus (10%, with 90% of tumors in the proximal portion of the bone).
Where does bone tumor metastasis to? ›Bone metastasis can occur in any bone but more commonly occurs in the spine, pelvis and thigh. Bone metastasis may be the first sign that you have cancer, or bone metastasis may occur years after cancer treatment.
Where do bone tumors spread? ›The bone is one of the most common sites cancer may spread to, along with the lymph nodes, liver, lungs and brain. Cancer can spread to any bone in the body. Bones commonly affected include the spine, ribs, pelvis and upper bones of the arms and legs.
What can be mistaken for bone tumor? ›Some of the more common benign and nonneoplastic entities that can sometimes be confused with tumors are the following: cortical desmoid, Brodie abscess, synovial herniation pit, pseudocyst, enostosis, intraosseous ganglion cyst, fibrous dysplasia, stress fracture, avulsion fracture (healing stage), bone infarct, ...
Can a doctor tell if a tumor is cancerous by looking at it? ›You may be able to see a growth. Certain things about the image might even suggest that it's likely to be cancerous. But there are many benign (noncancerous) tumors that look very much like cancerous growths. That's why, if your doctor suspects cancer from imaging, they will almost always follow up with a biopsy.
How painful is a bone biopsy? ›Your doctor takes the biopsy once you are asleep. Your doctor injects local anaesthetic into the area. This means the area is numb and it shouldn't be painful. You may also have a drug to make you drowsy and more relaxed (sedation).
What are the three types of bone tumor? ›The three most common forms of primary bone cancers are osteosarcoma, Ewing sarcoma family of tumors, and chondrosarcoma.
What is the average age of diagnosis for malignant bone tumor? ›It is most often diagnosed between the ages of 10 and 30, with most of these diagnoses occurring in teens. However, osteosarcoma can be diagnosed at any age, including in older adults. Around 10% of osteosarcoma is diagnosed in people over age 60.
Can bone tumors be removed? ›The aim of surgery is to completely remove the tumour. Sometimes cancer is in a bone or part of a bone that the surgeon can remove and don't have to replace. These are called expendable bones because they do not need to be replaced (reconstruction) and there is no or little loss of function.
Does bone tumor cause death? ›
Bones: If cancer is in the bones, too much calcium may go into the bloodstream, which can cause unconsciousness and death. Bones with tumors may also break and not heal.
Can you live with a bone tumor? ›Generally, bone cancer is much easier to cure in otherwise healthy people whose cancer hasn't spread. Overall, around 6 in every 10 people with bone cancer will live for at least 5 years from the time of their diagnosis, and many of these may be cured completely.
What are the early stages of bone tumors? ›The earliest symptoms of bone sarcoma are pain and swelling where the tumor is located. The pain may come and go at first. Then it can become more severe and steady later. The pain may get worse with movement, and there may be swelling in nearby soft tissue.
Should benign bone tumors be removed? ›But they can cause problems if they grow too much or damage healthy bone. Most bone tumours are benign. Many benign bone tumours may not need to be treated. But if the tumour causes pain, weakens the bone, or keeps you from moving a part of your body, it may need to be removed.
Do you see an oncologist for benign tumors? ›Even benign tumors can be uncomfortable. If you feel or see a lump, visit an oncologist for an examination. If the doctor confirms that you have a malignant tumor, you will likely feel some uncertainty and fear. However, you can have peace of mind that the doctor will develop an effective treatment plan.
Which bone tumor is more common in female? ›Females are slightly more likely to develop giant cell tumors. Treatment is almost always surgery. Chondromyxoid fibroma: This very rare type of tumor begins in the bone marrow. Treatment is almost always surgery.
Can an MRI tell if a tumor is benign? ›MRI is very good at zeroing in on some kinds of cancers. By looking at your body with MRI, doctors may be able to see if a tumor is benign or cancerous. According to the World Health Organization, survival rates for many types of cancer are significantly higher with early detection.
Is CT or MRI better for bone? ›CT scans create images of bones and soft tissues. However, they aren't as effective as MRIs at exposing subtle differences between types of tissue.
Does MRI or CT show bone better? ›MRI gives better contrast than CT, making it possible to study the relationship to the soft tissues, bone marrow and joints more accurately. On the other hand, CT gives a better picture of the destruction of cortical bone.
Which is more accurate bone scan or MRI? ›MRI is often preferred by doctors when deciding between a bone scan and an MRI for cancer screening. In comparison to standard bone scans, MRIs are more successful in detecting cancer of the bone because they may show an aberrant look or actual abscesses in bones.
Does CT scan show bone tumors? ›
CT scans aren't usually as helpful as MRIs in showing the detail in and around bone tumors. But they are often done to look for possible cancer spread in other parts of the body, such as the lungs, liver, or other organs. CT scans can also be used to guide a biopsy needle into a tumor (a CT-guided needle biopsy).
What is the best imaging for bone pain? ›A bone scan might help determine the cause of unexplained bone pain. The test is sensitive to differences in bone metabolism, which are highlighted in the body by the radioactive tracer. Scanning the whole skeleton helps in diagnosing a wide range of bone disorders, including: Fractures.
Does an MRI show bone issues? ›An MRI scan may be used to look at bones, joints, and soft tissues such as cartilage, muscles, and tendons for things like: Injuries, such as fractures or tears to a tendon, ligament, or cartilage. Structural abnormalities due to aging. Infection like osteomyelitis.
Will a radiologist tell you if something is wrong? ›“Your test needs to be read by a diagnostic radiologist, and the results go back to your physician. Your physician reads the report and then discusses it with you,” Edwards said. The biggest reason for that policy is that only a medical doctor has the training and experience to make a diagnosis.
Does a bone scan show all cancers? ›Bone scans show changes in your bones, but they don't tell you if it's because of cancer or not. You may have to have other tests to figure out what the changes mean. These extra tests will tell you if the spots are cancerous or related to another problem, like arthritis.
What results can you get from a bone CT scan? ›What do the results mean? Test results are considered normal when the radioactive substance is spread evenly throughout the body. This means that you likely don't have a major bone problem. Results are considered abnormal when the scan shows darker “hot spots” or lighter “cold spots” in the bones.