BENIGN BONE TUMOR

Radiological approach
Dr. edwin J. L
 BENIGN BONE TUMOURS
• The generally are
– Solitary
– Localised
– Slow growing
– Enlarges by pressure and expansion
– Do not metastasize (though benign tumours like GCT and
chondroblastoma have been known to metastasize)

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 BENIGN BONE TUMOURS
• CHONDROID ORIGIN
• OSTEOID ORIGIN
• CYSTS OF BONE
• FIBROUS ORIGIN
• OTHER TUMOURS
• TUMOUR-LIKE DISORDERS

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 CHONDROID ORIGIN
• Chondroma
• Osteochondroma
• Chondroblastoma
• Chondromyxoid fibroma

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 CHONDROMA
• Commonly central in situation, whence it is
referred to as enchondroma, but may be
eccentric e.g subperiosteal location –
periosteal chondroma
• Multiple enchondromas are found Ollier’s dse
& Maffucci’s syndrome
• Affect tubular bones of the hands & feet in
>50%.
• If it becomes painful in absence of fracture, it
should be biopsied.

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 CHONDROMA
 Age range of 10-80 yrs, most being in 2 nd
to 4th decades

 40%
occur in the hands, being x5 more
common here than in the feet

 Are
extremely rare in the spine and almost
unknown in the skull

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 CHONDROMA - radiology

• Most arise in the medulla of the

phalanges

• Often eccentric and 75% are solitary

• Well circumscribed, round lytic lesions

which expand the cortex
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CHONDROMA, radiology
• Features of benignity
include:
– <20 yrs
– Purely medullary with
well formed Calcification
– Well-defined round
margin
– Cortex intact
– Slow growth

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CHONDROMA, rare types
Multiple chondromas
(Ollier’s disease,
enchondromatosis)
• Not genetically
inherited
• Predominatly unilateral,
in respect to the side of
the body and location
within each bone
• Malignant change
uncommon 12
CHONDROMA, rare types
• Enchondromatosis
with haemangiomas
(Maffucci’s
syndrome)
• Incidence of
chondrosarcomatous
change in uncertain
due to rarity

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 OSTEOCHONDROMA
• Cartilage-capped exostosis

• It is the cartilage cap that is actively growing

• Is a developmental anomaly

• Radiotherapy in childhood reported to cause it

• Peaks in the 2nd decade, but can occur from 2 to 60

yrs

• M:F ratio is 1.4:1 16

OSTEOCHONDROMA • Long bones
commonly affected,
esp. around the knee
• The lesions are
metaphyseal but
migrate to the diaphysis
as normal metaphyseal
growth occurs
• This gives ‘coat-
hanger’ variety,
pointing away from
adjacent joint
• May be single or several
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OSTEOCHONDROMA
• Multiple cartilaginous exostoses
(diaphyseal aclasis) are inherited
in an AD fashion
• They may be larger than the
solitary variety & may lead to
shortening or deformity of the
affected limbs
• MRI is highly accurate in the
assessment of symptomatic
osteochondromas

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OSTEOCHONDROMA
• Presentation tends to relate to
mechanical problems, an
enlarging mass, pressure on
adjoining structures, or
accasionally fracture
• As the lesion grows, the marrow
cavity extends into the exostosis
• Actively growing cartilage is not
visible radiologically, but shown
on US, CT or MRI
• Become Ca+ with age in a
punctate nodular fashion

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OSTEOCHONDROMA
• Small exostoses (not cartilage-
capped) may follow trauma
• These tend to remain static or
regress
• Complete resection of a
solitary osteochondroma
cures the patient
• Malignant transformation of
solitary osteochondroma is
rare. When it occurs, it is
usually chondrosarcoma,
although a rare osteosarcoma
has been reported
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OSTEOCHONDROMA, differential
• Bizarre parosteal osteochondromatous
proliferation (BPOP)
– Are benign lesions arising from surface of
underlying cortex
– Arises in relashionship to small tubular bones of
the hands or feet
– M:F ratio 1:1, with cases from puberty to old age
– Local excision has to be complete as recurrence is
reported in up to 50%

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 CHONDROBLASTOMA
• Rare, usually presenting in a child with pain in
the region of a joint
• Typically found in epiphysis of a long bone
• Though generally benign, cases of localized
aggressive spread associated with distant mets
reported
• 80% occur in the second decade
• M:F ratio is 2:1

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CHONDROBLASTOMA
• Usually eccentric in the
epiphyses but may
straddle the growth
plate if closure is partial

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CHONDROBLASTOMA
• The plain film is usually
sufficient for diagnosis.
• Treatment is curettage, but
there is a 15% recurrence rate.
• To decrease this recurrence
rate, CT is used to further
evaluate extent of the lesion.
• In this case, there is in fact a
small finger of the lesion
extending anteriorly into the
lateral portion of the tibial
epiphysis

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CHONDROBLASTOMA, radiology
• Is spherical & well defined
• Fine sclerotic margin
• May be destructive thereby
suggesting malignancy
• Central ounctate ca+ seen in
10% on plain films
• Secondary ABC change may
be confirmed by fluid-fluid
levels

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CHONDROBLASTOMA, differential
• Subchondral cyst
• GCT, which are rare in children.
When they occur, they tend to
be metaphyseal
• Chondrosarcoma, clear-cell
variety
• Brodies abscess considered if
involves both epiphysis and
metaphysis, including simple &
ABC

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CHONDROMYXOID FIBROMA
• Accounts for <0.5% of biopsied 1º bone
tumours
• Presentation is with local pain & tenderness
• Lesion consists of chondroid, myxoid & fibrous
elements in almost any proportion
• 75% of cases seen btwn 10-30 yrs, peaking in
the 2nd decade
• There is a slight male preponderance

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CHONDROMYXOID FIBROMA
• Most lesions are metaphyseal and eccentric
within the medulla

• It results in thinning and expansion of the

cortex

• Prox 1/3 of tibia contributes to 25% of all cases

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CHONDROMYXOID FIBROMA, radiology
• Margins are well
demarcated and lobulated
with focal histological Ca+ in
a 1/3 of cases
• Involves cortex & medulla
• A sclerotic endosteal border
is characteristic
• Demonstrable ca+ only in
13%

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CHONDROMYXOID FIBROMA, radiology
• It may show a trabeculated
or ‘soap-bubble’
appearance due to
endosteal ridging
• MRI does not offer
information to distinguish it
from other tumours
• Recurrence of 25% following
curretage
• Malignant transformtion
virtually unknown

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CHONDROMYXOID FIBROMA, differential

• Outside its classical

location, less typical
features may resemble
those of other benign
tumours:
– ABC
– Enchondroma
– Chondroblastoma
– Chondrosarcoma
– Fibrous dysplasia

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 OSTEOID ORIGIN
• ENOSTOSIS
• OSTEOMA
• OSTEOID OSTEOMA
• OSTEOBLASTOMA

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ENOSTOSIS
• Bone island
• Is a focus of mature
compact bone located
within the medulla
• Is probably congenital or
developmental
• Tend to be incedental
commonly seen in the
pelvis, femur & other long
bones
• Dense sclerotic focus of the
compact bone within the
cancellous bone of the
proximal tibia is seen

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ENOSTOSIS, radiology
• The features are classical:
– Dense sclerotic focus
– Spiculated margin that
blends with trabeculae of
host bone
• CT section demonstrates
its typical thorn-like
projections

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OSTEOMA
• Predominantly have cortical or
cancellous bone.
• Benign osteoma is the most
frequent primary tumour to
involve the calvarium. It presents
as a very dense, rounded,
homogeneous knob arising from
the outer or inner table

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 OSTEOID OSTEOMA
• A small benign tumour
• Is essentially a harmatoma
• Patients complain of significant, often severe
pain, worse at night, which is usually
dramatically improved with NSAIDs
• Pain at night due to elevated prostaglandin E2

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 OSTEOID OSTEOMA
• Most pts are in the 2nd & 3rd decade
• M:F ratio is 2.5:1
• Insignificance of the plain film changes in the
early stages often results in dx being delayed
for 6m & several yrs after onset of symptoms
• Spinal lesions commonly manifest as painful
scoliosis
• No skeletal site is exempt

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OSTEOID OSTEOMA
• The lesion may also affect the
medullary cavity, cortex or
subperiosteal region
• Is commoner in the appendicular sys,
particularly the diaphyses or
metaphyses of tubular bones

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OSTEOID OSTEOMA,radiology
• Bone scintigraphy is a
valuable confirmatory
investigation giving a
characteristic ‘double
density’ sign
• The nidus is focally
intense while the
surrounding reactive
sclerosis has lesser
intensity
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OSTEOID OSTEOMA, differential
• Bone abscess
• Bone island
• When a nidus is subarticular,
the extent of juxta-articular
osteoporosis can be so
striking that it is mistaken for
a rheumatoid arthritis or
tuberculosis

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 OSTEOBLASTOMA
• Osteoblastoma is a richly vascular tumour
characterized by an abundance of osteoblasts
• Although the histopathology is similar to osteoid
osteoma, clinically and radiographically the two
lesions differ
• Over 80% are in pts <30 yrs, peaking in the 2nd decade
• M:F ratio is 2:1
• Pain in usually present over few months to over a year

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OSTEOBLASTOMA
• The spine is commonly
affected (cf OO), where 45-
50% of osteoblastomas are
found.
• Majority involve the
vertebral arch eccentrically,
leading to a painful
scoliosis. Primary
involvement of the
vertebral body is rare
• Metaphyses & diaphyses of
long bones are also affected

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OSTEOBLASTOMA
• There is a bubbly lytic
expansile lesion involving
the right transverse process
of L1.
• This lesion is geographic,
shows no evidence of
cortical breakthrough or
other aggressive feature,
and appears localized only
to the transverse process.
The remainder of the
vertebral body and
posterior elements are
completely normal.

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OSTEOBLASTOMA
• As it grows, it expands the
bone & shows irregular
margins, well-defined by a
shell of reactive bone
• It fequently produce an extra-
cortical mass which may be
reactive or due to tumour
extension
• This behavoiur is not seen in
the other benign tumours. So
it is possible for it to involve
an adjoining bone or compress
the spinal cord

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 CYSTS OF BONE
• SIMPLE BONE CYST (unicameral cyst)
• ABC
• GCT

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SIMPLE BONE CYST
• Unicameral cyst
• Perhaps the only true
primary cyst of bone
• Aet. is unknown
• Usually solitary
• 70% btwn 4-10 yrs with
90% being <20 yrs

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SIMPLE BONE CYST
 M:F ratio is 2:1
 Rarely symptomatic
 Pathological fracture is
common in pre-
adolescent, esp when
the humerus is involved
 The prox 1/3 humerus
is the commonest site
then the prox 1/3. This
gives 80% btwn the two
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SIMPLE BONE CYST
• Other sites of predilection
iclude the calcaneous &
ilium, which tend to be
affected in the older age
range
• Treatment is by steroid
injection, observation of
minimally symptomatic
lesions, or by curettage and
bone grafting

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 Radiographic Features
• Well defined geographic lucent lesions
• Narrow zone of transition
• Centrally located
• There is a thin sclerotic margin in the majority
of cases
• No periosteal reaction or soft tissue
component.
 Other radiographical features
• Usually unilocular
• Fallen fragment sign.
• Rising bubble sign - Pathognomic
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ANEURYSMAL BONE CYST
• The concept that many
ABCs are secondary to
preceding benign or
malignant lesions is
now generally accepted
• Most pts in the 2nd
decade
• Sex incidence is equal

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ANEURYSMAL BONE CYST

• Majority present with pain

& local swelling
• Spinal lesions may result in
scoliosis or neurological
symptoms
• At surgery, the cyst-like
lesion is found. Curretage
mayresult in brisk bleeding
• Any site is affected

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GIANT CELL TUMOUR
• Is the 5th commonest
primary tumour of bone
• Its behaviour in
unpredictable: most lesions
are locally aggressive while
a few are overtly malignant
& metastasize
• Local recurrence after
curretage may occur in up
to 50%

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GIANT CELL TUMOUR
• In GCT, the smaller stromal
cells are actually the
tumourous cells (which are
thought to be derived from
osteoblasts)
• 80% are in pts btwn 18-
45yrs, rare before skeletal
maturity
• M:F ratio 2:3
• Pathological fracture may
be found in 10%

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GIANT CELL TUMOUR
• About 50% are found on
either side of the knee joint,
distal end of femur being
the commonest single site
• When in an immature pt, it
involves the metaphysis &
may rarely cross the growth
plate
• In the spine, the sacrum is
most commonly affected, to
lie adjacent to the sacro-
iliac joint

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 GIANT CELL TUMOUR
• The lesion is highly vascular, but forms neither
osteoid nor cartilage
• Occasional blood-filled spaces mimic ABC under the
microscope.
• Tumours with giant cell will be part of the
histopathologist ddx, and include:
– Chondroblastoma,
– Brown tumour of hyperparathyroidism
– ABC
– Osteoid-rich osteosarcoma
– Benign fibrous histiocytoma

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 FIBROUS ORIGIN
• FIBROUS CORTICAL DEFECT (metaphyseal
fibrous defect)
• NONOSSIFYING FIBROMA (fibroxanthoma)
• BENIGN FRBROUS HISTIOCYTOMA
• DESMOPLASTIC FIBROMA
• POST-TRAUMATIC CORTICAL DESMOID

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NONOSSIFYING FIBROMA
Fibroxanthoma
• Large
• Symptoms arise only when
large enough to cause
pathological fracture
• Mostly seen in 2nd decade
• Slight male preponderance
is observed

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NONOSSIFYING FIBROMA
• About 90% affect lower
limb, particularly the tibia &
distal end of femur
• Characteristic appearance
caused by lipid and red
flecks of fresh
haemnorrhage
• When bone of a small
diameter is affected, it
crosses the shaft readily &
its characteristic radio
features become less
obvious

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SUMMARY
 SOLITARY LYTIC BONE LESION: When you see lytic bone
lesion think of FOGMACHINE
Differential Diagnosis (Mnemonic
= FOGMACHINES)
• F = Fibrous Dysplasia • H=Hyperparathyroidism/brown
tumors /Hemangioma
• O = Osteoblastoma
• I = Infection
• G = Giant Cell Tumor
• N = Non-ossifying Fibroma
• M = Metastasis / Myeloma

• E = Eosinophilic Granuloma /
• A = Aneurysmal Bone Cyst
Enchondroma

• C = Chondroblastoma
• S = Solitary Bone Cyst
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A radiograph of a (A: Age) skeletally immature individual
(black triangle) with a lesion in (B: Bone: which bone and
which part) Femur involving metaphyseal and diaphyseal
region which was (C: Characteristics and Composition)
osteosclerotic with osteoid matrix (white triangle) and was
(D: Distinctiveness) ill-defined (black arrow), (E: Exterior of
bone) with periosteal reaction of Codman's type and sunray
pattern (black line with two arrow heads), with Pathological
fracture (white arrow) and (Z: Zone of transition) wide zone
of transition (black arrow). The radiological features were
suggestive of malignant bone tumour and MRI was
performed, followed by bone biopsy showing it as
Osteosarcoma.

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A radiograph of a (A: Age) skeletally mature
individual with a lesion in (B: Bone: which bone
and which part) proximal femur involving
metaphyseal region which was (C:
Characteristics and Composition) osteolytic
with no matrix and was (D: Distinctiveness:
black arrow) well defined and had (Z: Zone of
transition) narrow zone of transition. The
radiological features were suggestive of benign
bone tumour and MRI was performed,
followed by bone biopsy showing it as Giant
cell tumour. 74
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A radiograph of a (A: Age) skeletally immature individual
(black arrow) with a lesion in (B: Bone: which bone and
which part) proximal humerus involving metaphyseal and
diaphyseal region which was (C: Characteristics and
Composition) osteosclerotic with osteoid matrix (white
arrow) and was (D: Distinctiveness) ill-defined (black
triangle), (E: Exterior of bone) with periosteal reaction of
Codman's type and sunray pattern (white triangle) and (Z:
Zone of transition) wide zone of transition (black triangle).
The radiological features were suggestive of malignant
bone tumour and MRI was performed, followed by bone
biopsy showing it as Osteosarcoma.

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YES…YOU CAN

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..
• Bone lytic/lucent at the
neck of femur
• unilocular
• Well define margin
• Geographical type I
• Narrow zone of
transition
• No fracture
• No periosteal reaction
Type of bone:
Immature bone
Proximal meta diaphysis
- Expensile lytic bone lesion
- Multilocular
- Well defined margin
- Geographical type I
- Narrow zone of
transition-
- No periosteal reaction
- Pathological fracture

Fallen fragment sign

Rising bubble sign

Dx: UBC with Pathological

fracture
• There is an expansile,
lytic lesion of the 5th
metacarpal (red arrow)
• With amorphous
matrix calcifications
(white arrow)
• There is no pathologic
fracture.
Distal femoral metaphysis – AP/LAT VIEWS

• A well-defined eccentric, multi-

septated radiolucent lesion
• A narrow zone of transition
• Sclerotic margins
• Mild endosteal scalloping is
noted.
• No internal chondroid/ossific
matrix, periosteal reaction,
obvious fracture, or associated
soft tissue abnormality
A few possible differentials:
• ABC, fibrous dysplasia, or GCT.

• NOF
 AT LEAST YOU HAVE TRIED!

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