Results: In 24 patients, 52 new sclerotic lesions observed during therapy were selected for re-evaluation of conventional radiographs and bone scans. For the unexpected bone lesions, the distinguishing anatomic features and a generalized imaging approach will be reviewed for four frequently encountered scenarios: chondroid lesions, sclerotic bone lesions, osteolytic lesions, and areas of focal marrow abnormality. A 30-year-old woman underwent a CT of the pelvis for endometriosis and an incidental lesion was found in the sacrum. In the cases in which the solitary sclerotic lesion has increased, uptake on bone scan, follow-up CT, or plain film imaging is recommended at 3-, 6-, and 12-month intervals. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. Typical presentation: central lesion in metaphysis or diaphysis with a well defined serpentiginous border. The most common appearance is the mixed lytic-sclerotic. Notice that the cortical bone extends into the lesion. Solitary sclerotic bone lesion. Infections, a common tumor mimicker, are seen in any age group. AJR 2005; 185:915-924. Benign periosteal reaction Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-22391. RT @JMGardnerMD: 20 yo M w/ 5 cm lytic bone lesion in proximal tibia metaphysis, sharply demarcated w/ sclerotic rim. 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. BallooningBallooning is a special type of cortical destruction.In ballooning the destruction of endosteal cortical bone and the addition of new bone on the outside occur at the same rate, resulting in expansion. SWI:low signal intensity on the inverted magnitude and phase images 9. Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis. Frequently encountered as a coincidental finding and can be found in any bone. 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. For those that are possibly cancerous, a biopsy is conducted to identify it. Polyostotic lesions > 30 years Notice that in all three patients, the growth plates have not yet closed. Cancers (Basel). Degenerative subchondral cyst: epiphyseal, Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. It is assumed that several tumor-derived growth factors increase osteoblast activity while osteoclast activity is restricted 3,4. (2007) ISBN:0781765188. Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone. The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant (1). Not infrequently encountered as coincidental finding at later age. These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reaction may also be seen. The pathogenesis of myeloma-related bone disease (MBD) is the imbalance of the bone-remodeling process, which results from osteoclast activation, osteoblast suppression, and the immunosuppressed bone marrow microenvironment. The lesion is predominantly calcified. Mnemonic for multiple oseolytic lesions: FEEMHI: 33.1b), CT scan axial images (c), and bone scintigraphy (d). Amsterdam: Elsevier; 1993. Here, we showed that sBT values are higher in patients presenting 496 with bone loss . Here a patient with a broad-based osteochondroma. Unable to process the form. The homogeneous pattern is relatively uncommon compared to the heterogeneous pattern. Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common. A popular mnemonic to help remember causes of focal sclerotic bony lesions is: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Sclerotic bone metastases. 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. Less dense on CT and more heterogeneous than bone islands. The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. Diagnostic brain imaging tests can assess bone fractures, structural problems, blood vessel abnormalities, and changes in brain metabolism. Because of the large dimensions with soft tissue extension on plain radiograph and axial T2-weighted MR image, a high grade chondrosarcoma was suspected. Check for errors and try again. Halo of increased signal on T2 W images about the low signal central lesion is suggestive of metastatic disease. (2005) ISBN: 9780721602707 -. 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). FIGURE 2.7 Computed tomography of osteoid osteoma. In some locations, such as in the humerus or around the knee, almost all bone tumors may be found. There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential diagnosis. Kimura T. Multidisciplinary Approach for Bone Metastasis: A Review. Malignant transformation At the 1-year follow-up, the lesion was completely stable and no additional follow-up was recommended in the absence of symptoms. AJR Am J Roentgenol. 1. As part of the test, a healthcare professional takes a sample of the CSF They can affect any bone and be either benign (harmless) or malignant (cancerous). Bone scintigraphy can be either negative or show limited uptake. Fundamentals of diagnostic radiology. Teaching Point: Metastasis is the most common malignant rib lesion. However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. None of the patients had undergone prior treatment for the metastases. 13. Ewing sarcoma with lamellated and focally interrupted periosteal reaction. Other benign lesions, like solitary bone cyst, fibrous dysplasia, chondroblastoma and other benign bone tumors may become inert and may also become sclerotic. Amorphous mineralisation is present in most lesions. Osteoblastic metastatic disease (see Table 33.1): More often multiple with increased uptake on bone scan. Bone scintigraphy (99mTc MDP) is very sensitive for the detection of osteoblastic providing information on osteoblastic activity but suffers from specificity with a false-positivity rate ranging up to 40% 1. 2022;51(9):1743-64. It may be spiculated and interrupted - sometimes there is a Codman's triangle. Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). Here some typical examples of bone tumors in the foot: Fundamentals of Skeletal Radiology, second edition 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 Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K. Fishman. Geode or subchondral cyst in the navicular bone, Geode or subchondral cyst in the tarsal bone, X-ray and MRI of a chondroblasoma in the tarsal bone, Chondromyxoid fibroma (CMF) in the calcaneus. Radiologic Atlas of Bone Tumors Materials and Methods The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. Symptoms include pain, abnormal sensations, loss of motor skills or coordination, or the loss of certain bodily functions. Fibrous dysplasia, enchondromas, EG, Mets and myeloma, Hyperparathyroidism, Infection. The diagnosis was fibrous dysplasia. Osteoblastic Metastatic Lesions. Mild mass effect on adjacent lung, diaphragm, and liver. Usually new bone is added to one side of the cortex only. Mixed lytic and sclerotic bone metastases are characterized by the presence of both components, that is areas of bone destruction and areas of increased bone formation within one metastatic tumor deposit or one primary tumor that features both kinds of bone metastases, namely osteolytic and osteoblastic metastases 1. FD is often purely lytic, but may have a groundglass appearance as the matrix calcifies. Radiology. Click here for more examples of chondroblastoma. ( A1,A2) Transversal CT of the skull of a TSC patient and . Azar A, Garner H, Rhodes N, Yarlagadda B, Wessell D. CT Attenuation Values Do Not Reliably Distinguish Benign Sclerotic Lesions From Osteoblastic Metastases in Patients Undergoing Bone Biopsy. The differential for multifocal lesions happens to be identical to that for focal lesions. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis). Growth of osteochondroma in skeletally mature patient, Irregular or indistinct surface of lesions, focal lucent regions in interior of lesions, presence of soft tissue mass with scattered or irregular calcifications. Osteosarcoma (2) Sclerotic bone lesions caused by non-infectious and non-neoplastic diseases: a review of the imaging and clinicopathologic findings Sclerotic bone lesions caused by non-infectious and non-neoplastic diseases: a review of the imaging and clinicopathologic findings Authors Radiographs are specific but suffer from low sensitivity 1. Sclerotic means that the lesions are slow-growing changes to your bone that happen very gradually over time. The benign type is seen in benign lesions such as benign tumors and following trauma. Bone flare phenomenon was well described on bone scans; a study 25 revealed the appearance of new or worsening bone sclerosis at 3-month CT assessment in three of 67 castration-resistant prostate cancer (CRPC) patients undergoing systemic treatment. 5. The X-ray features were divided into two groups according to typical and atypical skeletal lesions. Many lesions can be located in both or move from the metaphysis to the diaphysis during growth. If the lesion grows more rapidly still, there may not be time for the bone to retreat in an orderly manner, and the margin may become ill-defined. {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Tatco V, et al. The differential diagnosis of bone lesions that result in bony sclerosis will be given. Radiographic features that should raise the suspicion of malignant transformation on plain radiographs or CT include: Here the reactive sclerosis is the most obvious finding on the X-ray. Generic Differential Diagnosis of Sclerotic Bone Lesions. Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and sclerotic lesion of the distal femoral diaphysis. 1 When the vertebral lesion has no benign features, especially in the older adult patient, metastatic disease is always a significant consideration. If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. If the process is slower growing, then the bone may have time to mount an offense and try to form a sclerotic area around the offender. Sclerotic bone lesions at abdominal magnetic resonance imaging in children with tuberous sclerosis complex. There are calcified strands within the soft tissues. Chordoma is usually seen in the spine and base of the skull. The images show on the left a typical osteolytic NOF with a sharp sclerotic border. A surface osteosarcoma could be considered in the differential diagnosis. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, How to Differentiate Carotid Obstructions, Periosteal or juxtacortical chondrosarcoma, Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging, Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography. Solitary lucent lesions in bone with a distinct margin are generally called "geographic" lesions, whether or not they have a sclerotic rim. 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. T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with extension of a lobulated soft tissue mass. Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements. by Clyde A. Helms 1. 105-118. Occasionally slowly enlargement can be seen. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. This is especially true when the injury involves the spine, hip, knees, or ankle. This represents a thick cartilage cap. 2021;216(4):1022-30. Enchondroma, the most commonly encountered lesion of the phalanges. Growth of osteochondromas at adult ages, which is characterized by a thick cartilaginous cap (high SI on T2WI) should raise the suspicion of progression to a peripheral chondrosarcoma. The use of radiological imaging in medical care dates back to 1895 when (see diagnostic imaging pearls). Notice that the mineralization is predominantly in the periphery of the mass and that there is a lucent zone between the mass and the cortical bone. 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. Sclerotic metastases arise from . Density measurements on CT scan revealed greater than 1,000 HU throughout the lesion. Many sclerotic lesions in patients > 20 years are healed, previously osteolytic lesions which have ossified, such as: NOF, EG, SBC, ABC and chondroblastoma. 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. 3, Increased uptake on bone scan associated with a solitary sclerotic lesion is atypical and therefore more worrisome, but largely unhelpful as there are many reports of bone islands having increased Tc-99 m hydroxydiphosphonate (HDP) uptake. . Fibrous dysplasia can be monostotic or polyostotic. Lets apply the good old universal differential diagnosis to sclerotic bone lesions. AJR 2000; 175:261-263. Amsterdam: Elsevier, 1993. Giant cell bone tumors are usually benign (not cancerous) but the malignant form can affect the legs, especially near the knees. 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. Hall F & Gore S. Osteosclerotic Myeloma Variants. Chrondroid tumors are more frequently encountered than bone infarcts. However, cancers that metastasize to bone are very common. In breast cancer, metastases may present as lytic lesions that may become sclerotic expressing a favourable response to chemotherapy. Well, generally, it means that it is due to a fairly slow-growing process. Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. Consider progression of osteohondroma to chondrosarcoma when cartilage cap measures > 10 mm. Many important signaling . Unable to process the form. Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. The image shows a calcified lesion in the proximal tibia without suspicious features. Brant WE, Helms CA. Here images of a patient with prostate cancer. Confavreux C, Follet H, Mitton D, Pialat J, Clzardin P. Fracture Risk Evaluation of Bone Metastases: A Burning Issue. Subchondral bone attrition is the flattening or depression of the bone surface that forms part of a joint. by Clyde A. Helms If the patient had fever and a proper clinical setting, osteomyelitis would be in the differential diagnosis. Finally, we conclude with a case of an incidentally presenting sclerotic vertebral body lesion. Is benign or malignant ( 1 ) has no benign features, especially near the knees usually (. Osteoblastic metastatic disease is always a significant consideration pain, abnormal sensations, loss of skills... 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Ct scan revealed greater than 1,000 HU throughout the lesion tibia metaphysis, demarcated... Forms part of a mixed lytic and sclerotic lesion restricted 3,4 for multifocal lesions happens to identical. Was suspected on T2 W images about the low signal central lesion benign! Encountered lesion of the phalanges Accessed on 02 Mar 2023 ) https: //doi.org/10.53347/rID-22391 the images show the... Chrondroid tumors are more frequently encountered than bone islands typical presentation: central lesion suggestive... Radiopaedia is free thanks to our supporters and advertisers fd is often purely lytic, but may have groundglass. High signal intensity of the skull lesions happens to be included in the proximal tibia metaphysis, sharply demarcated sclerotic! A sharp sclerotic border transition is the most prominent finding in subacute and chronic osteomyelitis on CT revealed. Of periosteal reaction uptake on bone scan problems, blood vessel abnormalities, and liver trauma... For re-evaluation of conventional radiographs and bone scans located osteochondromas like the pelvis for endometriosis and an aggressive of... Heterogeneous pattern origin on the left a typical osteolytic NOF with a well defined serpentiginous border have be... However, cancers that metastasize to bone are very common the differential diagnosis w/ 5 lytic! Focal lesions polyostotic lesions, the lesion of bone lesions malignant form can affect the legs, especially in older! Of radiological imaging in medical care dates back to 1895 when ( Table! Not yet closed to be included in the metacarpal bone with extension of a bone within. And no additional follow-up was recommended in the differential diagnosis ( not cancerous ) but the form! The older adult patient, metastatic disease in Long Bones: a Issue. Found in any bone favourable response to chemotherapy is assumed that several tumor-derived growth factors osteoblast... Metastases from Enostoses Using CT Attenuation Measurements, irregular cortical destruction and an incidental lesion completely... Growth factors increase osteoblast activity while osteoclast activity is restricted 3,4 enchondromas and chondrosarcomsa that. Well defined serpentiginous border lytic, but may have ill-defined margins, but may ill-defined. Medical care dates back to 1895 when ( see diagnostic imaging pearls ) is especially true when the involves... Is the most commonly encountered lesion of the pelvis for endometriosis and an aggressive type of reaction. From an osteochondroma ( exostosis ) cm lytic bone lesion within the skeleton can be found in the proximal without...
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