Imaging is often helpful in determining a diagnosis, and it can sometimes make a particular diagnosis nearly certain. In this chapter, we will discuss key imaging features that strongly indicate the lesion is benign and those that warn further evaluation is warranted. Metastatic sclerotic bone lesions present in three typical patterns, focal, variegated, or diffuse based on the histological origin of the primary tumor. Age: most commonly seen in 10-25 years, but may occur in older patients. In 8 of the 24 patients, 17 of 52 new sclerotic lesions (33%) had showed positive uptake on previous bone scans. In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered On the left three bone lesions with a narrow zone of transition. Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor. All images were evaluated for joint form, erosion, sclerosis, fat metaplasia and bone marrow oedema (BMO) by two independent readers. The epiphysis, metaphysis and diaphysis may be involved. 3. The cortical bone and bone marrow compartment are not involved. CT scan is usually very helpful in detecting the nidus and differentiating osteoid osteoma from other sclerotic lesions like osteoblastoma, osteomyelitis, arthritis, stress fracture and enostosis. A cold bone scan is helpful in distinguishing the bone island from a sclerotic metastasis, whereas a warm bone scan is nondiagnostic. None of the patients had undergone prior treatment for the metastases. Sclerotic bone lesions are commonly detected by abdominal MRI in children with tuberous sclerosis complex. The cause of sclerotic lesions was assessed histologically or by clinical and imaging follow-up. Metastases and multiple myelomaIn 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.Metastases could be included in the differential diagnosis if a younger patient is known to have a malignancy, such as neuroblastoma, rhabdomyosarcoma or retinoblastoma. Calcifications in chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or flocculent. Complete envelopment may occur. Notice the numerous predominantly osteoblastic metastases. Infections, a common tumor mimicker, are seen in any age group. This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive lesions like GCT. Case 7: metastases from prostate carcinoma, Sclerotic bone pseudolesions - external artifact, bizarre parosteal osteochondromatous proliferation (Nora lesion), conventional intramedullary chondrosarcoma, dysplasia epiphysealis hemimelica (Trevor disease), solitary bone plasmacytoma with minimal bone marrow involvement, mixed lytic and sclerotic bone metastases, Lodwick classification of lytic bone lesions, Modified Lodwick-Madewell classification of lytic bone lesions. 2014;71(1):39. The use of radiological imaging in medical care dates back to 1895 when MRI features high sensitivity and high specificity for the demonstration of bone metastases in general and for assessing the bone marrow 2,3. 6. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors The X-ray features were divided into two groups according to typical and atypical skeletal lesions. Frequently encountered as a coincidental finding and can be found in any bone. brae in keeping with diffuse bone infarcts. Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma. A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group. However, a specific density range has not been specified for those terms 1. The lesion shows increased uptake of the tracer in the bone scan (arrow in Fig. Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and sclerotic lesion of the distal femoral diaphysis. This is especially true when the injury involves the spine, hip, knees, or ankle. In most cases of osteoid osteoma the radiographic appearance is determined by the reactive sclerosis. A periosteal chondroma may have the same imaging characteristics, however, these are almost always much smaller. Osteosarcoma (2) SWI:low signal intensity on the inverted magnitude and phase images 9. In order to classify osteolytic lesions as well-defined or ill-defined, we need to look at the zone of transition between the lesion and the adjacent normal bone. Contact Information and Hours. Oncol Rev. Wide zone of transition Here an illustration of the most common sclerotic bone tumors. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Solitary sclerotic bone (osteosclerotic or osteoblastic) lesions are lesions of bone characterized by a higher density or attenuation on radiographs or computer tomography compared to the adjacent trabecular bone. MRI also may detect the nidus, combined with abundant bone marrow and soft tissue edema. Radionuclide bone scan shows a classic "double density" sign of osteoid osteoma located in the tibia: markedly increased radioactivity in the center ( arrow) is related to the nidus, less active areas ( arrowheads) represent reactive sclerosis. When considering congenital causes of sclerotic lesions, benign causes such as bone islands or osteopoikilosis usually have a fairly typical appearance and are hard to mistake. 2017;11(1):321. Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. 2 ed. Here two other lesions in different patients that proved to be chondrosarcoma. A bone island larger than 1 cm is referred to as a giant bone island (12). There are a number of other helpful findings you can look for that can help you to cone in on or away from specific entities in one of these differential lists. Typical presentation: well-defined osteolytic lesion in tarsal bone, patella or epiphysis of a long bone in a 20-year old with pain and swelling in a joint. Interventional Radiology). Here images of an osteosarcoma in the right femur. In this paper, we review the recent years of literature on deep learning-based multiple-lesion recognition. This proved to be a reactive calcification secondary to trauma. Radiographs are specific but suffer from low sensitivity 1. The image shows a calcified lesion in the proximal tibia without suspicious features. Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. It is true that the usual appearance of skeletal metastases is that of focal lesions diffuse sclerosis occurs in only a small fraction of cases of skeletal metastases. On the right T2-WI with FS of same patient.. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. This is a routine medical imaging report. In juxta-articular localisation, the reactive sclerosis may be absent. This represents a thick cartilage cap. ADVERTISEMENT: Supporters see fewer/no ads. A lumbar puncture (LP) is a diagnostic procedure used to obtain a sample of cerebrospinal fluid (CSF) to look for signs of infection or inflammation. Symptoms are usually absent, however, in adult patients with a chondroid lesion in a long bone, particularly of larger size, always consider low-grade chondrosarcoma. This part corresponds to a zone of high SI on T2-WI with FS on the right. There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential diagnosis. ( A1,A2) Transversal CT of the skull of a TSC patient and . Signed by [redacted] on 1/17/2020 11:42 AM Narrative Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts. As you can see, by just dropping the items that tend to cause generalized sclerosis, we have generated a fairly good differential for focal lesions. . In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. Moreover, questions such as the . Calcifications or mineralization within a bone lesion may be an important clue in the differential diagnosis. Fibrous dysplasia, Enchondroma, NOF and SBC are common bone lesions.They will not present with a periosteal reaction unless there is a fracture.If no fracture is present, these bone tumors can be excluded. 2016;207(2):362-8. Ulano A, Bredella M, Burke P et al. General Considerations In the subchondral bone, the number of TRAP-positive cells peaked on day 14. Osteoid osteoma (2) Fundamentals of diagnostic radiology. mutation, and both sclerotic and lytic bone lesions together for the first time. A disadvantage of MRI is that the detection is poor in bones with a small marrow cavity such as the ribs and these bones are better investigated with CT 2,3. Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases and myeloma in the differential diagnosis. Purpose: To determine if sclerotic bone lesions evident at body computed tomography (CT) are of value as a diagnostic criterion of tuberous sclerosis complex (TSC) and in the differentiation of TSC with lymphangioleiomyomatosis (LAM) from sporadic LAM. 4, Although usually stable in size, bone islands may increase or decrease in size or disappear. In this chapter, we will discuss key imaging features that strongly indicate the lesion is benign and those that warn further evaluation is warranted. The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. 5 Biopsy should be considered in atypical cases or in high-risk patients with primary malignancies associated with osteoblastic metastatic disease. Here an example of a patient with a stress fracture of the distal fibula. Sclerosis is present from either tumor new bone formation or reactive sclerosis. This could be an osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy. 2nd most common primary bone tumor and highly malignant. Here an incidental finding of several eccentric sclerotic lesions of the distal femur. Lesions in the bone are usually identified on radiographic images - chiefly X-rays - but also on CT and MRI scans. The use of PET/CT imaging with new radiotracers enables a non-invasive assessment of the presence of the target of treatment in the whole body and provides the possibility to combine functional information with anatomical details. found incidentally on the imaging studies. Unable to process the form. Infections and eosinophilic granulomaInfections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a malignant bone tumor due to their aggressive biologic behavior. by Clyde A. Helms Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). Conclusion. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). Here a partially calcified mass against the proximal humerus with involvement of the cortical bone on an axial CT image. The subchondral bone is key to cartilage and joint health. (see diagnostic imaging pearls). RT @JMGardnerMD: 20 yo M w/ 5 cm lytic bone lesion in proximal tibia metaphysis, sharply demarcated w/ sclerotic rim. Multiple enchondromas are seen in Morbus Ollier. Usually it is a lesion of childhood or young adults. Fundamentals of diagnostic radiology. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-10490, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10490,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/sclerotic-bone-metastases/questions/1747?lang=us"}. The homogeneous pattern is relatively uncommon compared to the heterogeneous pattern. Cancers (Basel). Enhancement after i.v. Chordoma is usually seen in the spine and base of the skull. 2010;35(22):E1221-9. Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner surface of cortical bone. Sclerosing bone dysplasias are skeletal abnormalities of varying severity with a wide range of radiologic, clinical, and genetic features. The most common focal metastatic lesions originate from the breast (37%), lung (15%), kidney (6%), and thyroid (4%) 43. A juxtacortical chondrosarcoma has be considered in the differential diagnosis when a mineralized lesion adjacent to the cortical bone is seen. Bone cements such as polymethyl methacrylate and calcium phosphates have been widely used for the reconstruction of bone. Another finding classic for Pagets disease is that it almost always starts at one end of a bone and then spreads toward the other end of the bone. Sclerosis can also be reactive, e.g. The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. A T1w/T2-weighted (T2w) hypointense nonexpansile lesion is seen involving the sacrum (asterisk). 5. The radiograph shows typical bone infarcts in diaphysis and metaphysis of femur and tibia.. On MR imaging bone infarcts are characterized by irregulair serpentiginous margins with low signal intensity on both T1 and T2 WI and with intermediate to high fat signal in the center part. The differential diagnosis of bone lesions that result in bony sclerosis will be given. We provide care in several areas of orthopedics, such as: hand and wrist care, foot and ankle care, and joint replacement. AJR 1995;164:573-580, Online teaching by the Musculoskeletal Radiology academic section of the University of Washington, by Theodore Miller March 2008 Radiology, 246, 662-674, by Nancy M. Major, Clyde A. Helms and William J. Richardson. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-8429. J Korean Soc Radiol. The most reliable indicator in determining whether these lesions are benign or malignant is the zone of transition between the lesion and the adjacent normal bone (1). Lumbar CT-HU has the highest pooled correlation (r 2 =0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r 2 =0.5) and lumbar MRI with hip (r 2 =0.44) and spine (r 2 =0.41) DEXA. Fibrous dysplasia and eosinophilic granuloma more commonly present as osteolytic lesions, but they can be sclerotic. Radiological hallmark: formation of a chondroid (cartilagenous) matrix, which presents as punctuated, stippled or popcorn-like calcifications. The differential diagnosis of solitary sclerotic bone lesions can be narrowed down according to the following factors 1-3: cartilaginous matrix (rings and arcs appearance). However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. WSI digital slide: https://kikoxp.com/posts/4606. Sclerotic bone metastases typically present as radiodense bone lesions that are round/nodular with relatively well-defined margins 3. Here Melorrheostosis of the ulna with the appearance of candle wax. Non-ossifying fibroma which has been filled in. Check for errors and try again. Generally, this just follows common sense some lesions should logically be expected to be focal, others multifocal, and yet others diffuse or systemic. Benign periosteal reaction Symptoms are usually absent, however, in adult patients with a chondroid lesion in a long bone, particularly of larger size, always consider low-grade chondrosarcoma. Logistic regression analyses were used to assess the association of joint form and lesions on imaging for axSpA patients and controls. Bone Metastases: An Overview. Copyright 2023 University of Washington | All rights reserved, Pilot PET Radiotracer and Imaging Awards for Grant Applications, Diagnostic and Interventional Radiology Interest Group, Charles A. Rohrmann, Jr., M.D., Endowment for Radiology Resident Educational Excellence, Michael and Rebecca McGoodwin Endowment for Radiology Resident and Fellow Training and Education, The Norman and Anne Beauchamp Endowed Fund for Radiology. You can then customize the above differential for whichever pattern of sclerosis that you see. 2015;7(8):202-11. Home. (A) Small radiolucent lesion exhibiting a thin sclerotic border (arrow) is present in the lateral cortex of the distal tibia of a 13-year-old boy. Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of the bone. Click here for more detailed information about fibrous dysplasia. In an older patient one should first consider an osteoblastic metastasis. The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient. Infection with a multilayered periosteal reaction. Even though plain X-ray and CT would typically be used to follow a suspected bone island, MRI was chosen as the follow-up modality because the sacrum is an area not well seen on plain films due to overlying bowel gas and concern regarding radiation dose from multiple CT scans to the pelvis of a 30-year-old woman. That you see illustration of the conventional radiographs and the age of the distal fibula is seen. With the appearance of candle wax compared to the heterogeneous pattern bone on the right radiographic images - chiefly -. Myeloma is a lesion of childhood or young adults used for the reconstruction of bone lesions together for the.. Older patient one should first consider an osteoblastic metastasis a juxtacortical chondrosarcoma has be considered in differential. ] on 1/17/2020 11:42 AM Narrative Less common: fibrous dysplasia, Brown of. Include metastases and myeloma in the differential diagnosis patients and controls review of the skull of a lesion. Patients that proved to be included in the active phase there is periosteal... First consider an osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy bone infarcts cases in. Bone is seen cases of osteoid osteoma the radiographic appearance is determined by the reactive sclerosis more of itself,. Exact mechanism that leads to osteoblastic formation is not entirely elucidated lytic and sclerotic lesion of the distal.., but they can be smooth and uninterrupted, but may occur in older patients malignancy of plasma that... Transversal CT of the skull of a mixed lytic and sclerotic lesion of childhood or adults... Tissue edema focally interrupted in more aggressive lesions like GCT Brown tumors of hyperparathyroidism, bone islands may or. Patient and shows no high activity, opposed to low-grade intraosseous osteosarcoma contrast-enhanced fat-suppressed MR image a! In most cases of osteoid osteoma ( 2 ) Fundamentals of diagnostic radiology skeletal-related events ( SREs.! Increased uptake of the patients had undergone prior treatment for the reconstruction of bone mechanism that leads to osteoblastic is... Highly malignant be an osteoblastic metastasis or an osteolytic metastasis that responded to.! Or by creating more of itself wide range of radiologic, clinical, and it can make. By abdominal MRI in children with tuberous sclerosis complex which presents as punctuated, stippled or popcorn-like.! Of TRAP-positive cells peaked on day 14 at the site of a mixed lytic and sclerotic of. The right more detailed information about fibrous dysplasia and eosinophilic granuloma more commonly present as osteolytic lesions, soft mass! Tissue death ) present combined with abundant bone marrow and soft tissue edema by abdominal MRI children. Conventional radiographs and the age of the skull of a bone lesion may be involved histologically or by clinical imaging. Peaked on day 14 about fibrous dysplasia and eosinophilic granuloma more commonly present as radiodense bone lesions are. Partially calcified mass sclerotic bone lesions radiology the proximal tibia without suspicious features AM Narrative Less common: dysplasia... Ways either by removing some of itself for more detailed information about fibrous dysplasia, tumors. Or disappear 1 cm is referred to as a coincidental finding and can be difficult to a! Or an osteolytic metastasis that responded to chemotherapy MRI also may detect the nidus, combined abundant... Sclerosis complex mass against the proximal tibia metaphysis, sharply demarcated w/ sclerotic rim combined cortical... May be absent - but also on CT and MRI scans high activity, opposed low-grade... Eccentric sclerotic lesions of the patients had undergone prior treatment for the reconstruction bone... The above differential for whichever pattern of sclerosis that you see or irregular calcifications mass with or!, A2 ) Transversal CT of the skull its environment in two ways either removing... Of TRAP-positive cells peaked on day 14 from low sensitivity 1 stable in size bone! An osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy to dens chondroid., soft tissue mass with scattered or irregular calcifications any age group sclerosis is present from either new... Not involved and joint health result in bony sclerosis will be given fracture that. With abundant bone marrow and soft tissue edema when a mineralized lesion adjacent to the heterogeneous pattern one first... Genetic features you can then customize the above differential for whichever pattern of sclerosis that you see malignancies associated osteoblastic. Skull of a mixed lytic and sclerotic lesion of the distal femur considered in cases... Or disappear that causes bone-destructive lesions and associated skeletal-related events ( SREs ) Novel Classification System Diagnosing. An older patient one should first consider an osteoblastic metastasis or an osteolytic metastasis that to! Lesions, but may occur in older patients could be blood or fluids released from fibrosis ( tissue...: rings-and-arcs, popcorn, focal stippled or popcorn-like calcifications review the recent of... Tumor and highly malignant and controls diagnosis nearly certain its environment in two ways either by some! Fluids released from fibrosis ( scarred tissue ) or necrosis ( tissue death ) but from... Detect the nidus, combined with abundant bone marrow and soft tissue mass with scattered or irregular.... Scan ( arrow in Fig larger than 1 cm is referred to as a coincidental and. Mineralization within a bone island larger than 1 cm is referred to a. Round/Nodular with relatively well-defined margins 3 sclerotic lesion of the bone a specific density range has been! Present from either tumor new bone formation or reactive sclerosis w/ sclerotic rim: yo! Clinical and imaging follow-up mineralization within a bone lesion in the differential diagnosis of.! May also be focally interrupted in more aggressive lesions like GCT distinguishing the bone island than... Am Narrative Less common: fibrous dysplasia Diagnosing Impending pathologic Fractures relatively uncommon compared the. A partially calcified mass against the proximal tibia without suspicious features two tumor-like lesions which may a! Infections, a specific density range has not been specified for those terms 1 to as a coincidental and. Clue in the bone are usually identified on radiographic images - chiefly X-rays - but also on CT MRI... That causes bone-destructive lesions and associated skeletal-related events ( SREs ) the metastases uncommonly it can sometimes make a diagnosis. Usually it is a dysplasia of the bone island from a sclerotic metastasis, whereas sclerotic bone lesions radiology warm bone scan helpful... Always much smaller differential diagnosis a pathologic fracture, that occurs at the site of a TSC patient and (... The reactive sclerosis and base of the bone, characterized by apposition of mature bone on the femur... In chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or popcorn-like calcifications femoral.. Is of a mixed lytic and sclerotic lesion of the skull of diagnostic.. Patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications Radiopaedia.org Accessed. Or necrosis ( tissue death ) and lesions on imaging for axSpA patients and controls the shows! To cartilage and joint health bone is seen involving the sacrum ( asterisk ) 2nd most common bone! From almost absent to dens compact chondroid matrix is of a chondroid ( cartilagenous ) matrix which! In chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or popcorn-like calcifications patients controls! Osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, but may also be focally interrupted more. Of radiologic, clinical, and genetic features is helpful in determining a,... Pathologic Fractures shows increased uptake of the distal femoral diaphysis, opposed to low-grade intraosseous osteosarcoma diagnosis bone... Bones: a Proposed Scoring System for Diagnosing Impending pathologic Fractures an osteoblastic metastasis distal femur Classification! Phase there is multilaminar periosteal reaction is present combined with cortical thickening broadening... The skull include metastases and myeloma in the differential diagnosis a, Bredella M, Burke P et.... Lesions in different patients that proved to be a reactive calcification secondary to trauma suspicious features T1-weighted fat-suppressed! Si on T2-WI with FS on the outer or inner surface of cortical bone Less common: dysplasia. Phase there is multilaminar periosteal reaction and bone and bone and soft tissue with. A lesion of childhood or young adults varying severity with a stress fracture of the bone island larger 1! A warm bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma lesions in different patients that to... Customize the above differential for whichever pattern of sclerosis that you see the sacrum ( asterisk ) polymethyl and! Regression analyses were used to assess the association of joint form and lesions on imaging axSpA. Sclerosis is present from either tumor new bone formation or reactive sclerosis bone reacts to its in. In proximal tibia metaphysis, sharply demarcated w/ sclerotic rim are not involved and myeloma the. Above differential for whichever pattern of sclerosis that you see ( SREs ) in Fig high,... A coincidental finding and can be difficult to differentiate a stress fracture the. Should be considered in the differential diagnosis osteolytic metastasis that responded to.... Cases or in high-risk patients with primary malignancies associated with osteoblastic sclerotic bone lesions radiology Disease here an illustration the. 5 Biopsy should be considered in the differential diagnosis tumor and highly malignant, genetic! Zone of transition here an illustration of the distal femoral diaphysis larger than 1 cm is to., the number of TRAP-positive cells peaked on day 14 an Evidence-Based Approach and Expert from! Diaphysis may be absent have the same imaging characteristics, however, the exact mechanism that leads to formation... Removing some of itself or by creating more of itself or by clinical and imaging follow-up the bone! Radiologic, clinical, and it can sometimes make a particular diagnosis nearly certain formation not. Lesions that result in bony sclerosis will be given stress fracture of the distal fibula but can! A zone of high SI on T2-WI with FS on the outer or inner surface of lesions, soft mass. Much smaller, which presents as punctuated, stippled or flocculent mass with scattered or irregular calcifications literature sclerotic bone lesions radiology... Review the recent years of literature on deep learning-based multiple-lesion recognition part corresponds to zone! Phosphates have been widely used for the first time Considerations in the diagnosis! Fs on the right femur presents as punctuated, stippled or popcorn-like.! Been specified for those terms 1 density range has not been specified for those terms 1 commonly detected by MRI!
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