Imaging Pearls ❯ Musculoskeletal ❯ Bone Tumors
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- “Malignant peripheral nerve sheath tumors (MPNST), which arise as a result of associations with a peripheral nerve, account for approximately 5%-10% of all soft tissue sarcomas. While an estimated 50% of all MPNSTs originate sporadically, the other half develop in the context of neurofibromatosis type 1 (NF-1), an autosomal-dominant genetic disorder characterized by mutations in the neurofibromin 1 gene (NF1). Affecting 1 in 3000 live births, NF-1 is characterized by distinct neurofibromas and various areas of cutaneous hyperpigmentation, also known as café-au-lait macules. Patients have a 60% risk of developing cancer throughout their lifetime, with MPNSTs being the leading cause of death.”
CT of malignant peripheral nerve sheath tumor
Elias Lugo-Fagundo, Carolina Lugo-Fagundo, Edmund Weisberg, Elliot K. Fishman
R a d i o l o g y Case R e p o r t s 1 8 ( 2 0 2 3 ) 6 2 0 – 6 2 3 - “Computed tomography (CT) imaging may be utilized to de- termine the size, invasiveness, and relationship with adjacent structures of an MPNST, as well as the presence of distant metastatic disease. MPNSTs may calcify, hemorrhage, or erode into adjacent osseous structures, and may show peripheral or irregular enhancement in both CT and MRI . MRI has long been the preferred imaging technique for MPNSTs, since it provides abundant information regarding tumor characterization and the topographical relationship with neighboring structures. However, cinematic rendering (CR) 3-D post-processing serves as a complementary tool to CT enhancing the value of multidetector CT in evaluation and treatment planning of MPNSTs .”
CT of malignant peripheral nerve sheath tumor
Elias Lugo-Fagundo, Carolina Lugo-Fagundo, Edmund Weisberg, Elliot K. Fishman
R a d i o l o g y Case R e p o r t s 1 8 ( 2 0 2 3 ) 6 2 0 – 6 2 3
- Myxopapillary ependymoma (MPE) is a rare variant of conventional ependymoma which arises from the ependymal cells lining the subarachnoid space. It most commonly affects young adults and children. The male-female ratio of this tumor is 2.2:1.2.
It is categorized by the World Health Organization as a Grade 1 lesion and is found predominantly in the sacrococcygeal region most often near the filum terminale or conus medullaris.
The tumor is usually slow growing, is often intradural although local extension into paravertebral soft tissue and adjacent bone is occasionally seen.
Myxopapillary ependymoma: Lesser known cytomorphologic features.
Choudhury M, Rautela A, Nain M.J Cytol. 2015 Jan-Mar;32(1):42-5. - Plain radiograph and CT scan can reveal scalloping of the vertebral bodies secondary to the expansion of the spinal canal caused by the presence of a large myxopapillary ependymoma.
The differential diagnosis of a large myxopapillary ependymoma that is responsible for sacral destruction includes:
Aneurysmal bone cyst
Chondrosarcoma
Chordoma
Giant cell tumor
Metastatic carcinoma
- “Chordomas are most common in individuals aged 40–70 years, and occur twice as often in males as in females. They are the most common primary tumour of the sacrum, arising from notochordal rests. 50–60% of chordomas occur in the sacrococcygeal region. Chordoma is a low-grade tumour but can cause significant morbidity and mortality with local recurrence. Metastatic disease is uncommon but is seen more frequently in sacral chordomas than in skull base chordomas.”
Imaging features of primary and secondary malignant tumours of the sacrum
E Thornton et al.
The British Journal of Radiology 2012 85:1011, 279-284 - "Sacral chordoma usually arises from the third, fourth or fifth sacral vertebra in the midline or paramedian location, and is often seen as a large destructive osteolytic lesion with extraosseous extension When there is extraosseous extension, the tumour can be seen to extend exophytically into the pre-sacral region or sacral canal, resulting in a "mushroom" or "dumbbell" shape Internal calcifications are frequently seen on plain radiographs and CT.”
Imaging features of primary and secondary malignant tumours of the sacrum
E Thornton et al.
The British Journal of Radiology 2012 85:1011, 279-284 - "The tumour can spread over several segments, with or without involvement of the intervertebral discs. In >50% of cases, there are areas of decreased attenuation within the tumour on CT, which reflect myxoid-type tissue presented pathologically. A fibrous pseudocapsule is common, which is of increased attenuation relative to the rest of the tumour.”
Imaging features of primary and secondary malignant tumours of the sacrum
E Thornton et al.
The British Journal of Radiology 2012 85:1011, 279-284 - "Chordomas lie predominantly in the midline, unlike chondrosarcomas which lie eccentrically. Chordomas tend to arise from the lower sacral segments or sacrococcygeal region; by contrast, chondrosarcomas generally arise from the mid to upper sacrum. When calcification is present in chordomas, it is amorphous and predominates in the periphery of the lesion, as opposed to the ring-and-arc calcification seen in chondrosarcomas from the chondroid matrix. When present, dense amorphous osteoid matrix is a characteristic finding in osteosarcomas.”
Imaging features of primary and secondary malignant tumours of the sacrum
E Thornton et al.
The British Journal of Radiology 2012 85:1011, 279-284 - “Osteosarcoma (OS) is a common primary malignant tumor of bone that produces osteoid matrix. According to the World Health Organization, OS of bone is classified into eight subtypes with distinct biologic behaviors and clinical outcomes: conventional, telangiectatic, small cell, low-grade central, secondary, parosteal, periosteal, and high-grade surface. Imaging plays a crucial role in the diagnosis of each subtype of OS and ultimately in patients’ survival because the diagnosis is based on a combination of histopathologic and imaging features. Conventional OS is the most common subtype of OS and is readily identified at radiography as an intramedullary mass with immature cloudlike bone formation in the metaphyses of long bones.”
Imaging Characteristics of Primary Osteosarcoma: Nonconventional Subtypes
Yarmish G et al. et al.
RadioGraphics 2010; 30:1653–1672 - “Osteosarcoma (OS) is a malignant tumor of connective tissue that produces osteoid matrix and variable amounts of cartilage matrix and fibrous tissue. Although it accounts for less than 1% of all cancers diagnosed in the United States, OS is the most common primary bone tumor in children and adolescents (4.4 cases per million persons per year). The current World Health Organization classification of OS of bone includes eight categories: conventional, telangiectatic, small cell, low-grade central, secondary, parosteal, periosteal, and high-grade surface . Although conventional OS and secondary OS are histologically indistinguishable, diagnoses of conventional OS and secondary OS are made on the basis of typical radiographic appearances (ie, a destructive mass with cloudlike radiopacity in long bones and a mass arising from a preexisting abnormality such as Paget disease, respectively).”
Imaging Characteristics of Primary Osteosarcoma: Nonconventional Subtypes
Yarmish G et al. et al.
RadioGraphics 2010; 30:1653–1672 - “The classification of nonconventional subtypes of primary OS is based not only on histologic features but also on gross morphologic features, which are reflected at imaging. Each subtype exhibits distinct radiologic features that may be mimicked by various benign and malignant entities. For accurate diagnosis, it is important to be aware of radiographic and cross-sectional imaging features that allow differentiation of each nonconventional subtype of OS from its mimics.”
Imaging Characteristics of Primary Osteosarcoma: Nonconventional Subtypes
Yarmish G et al. et al.
RadioGraphics 2010; 30:1653–1672 - “Juxtacortical or surface OS refers to OS originating from the surface of bone. It is primarily associated with the periosteum, with variable medullary canal involvement. The term juxtacortical osteosarcoma was initially used to describe parosteal OS. In 1992, after various types of surface OS that exhibited distinctive histopathologic features and biologic behaviors were recognized, the World Health Organization redefined the classification of “juxtacortical osteosarcoma” to include all surface types of OS. Juxtacortical OS is now classified into three main subtypes— parosteal, periosteal, and high-grade surface OS—and these are further categorized by their histologic features and histologic grade.”
Imaging Characteristics of Primary Osteosarcoma: Nonconventional Subtypes
Yarmish G et al. et al.
RadioGraphics 2010; 30:1653–1672 - “Osteosarcoma is the most common primary osseous malignancy excluding malignant neoplasms of marrow origin (myeloma, lymphoma and leukemia) and accounts for approximately 20% of bone cancers. It predominantly affects patients younger than 20 years and mainly occurs in the long bones of the extremities, the most common being the metaphyseal area around the knee. These are classified as primary (central or surface) and secondary osteosarcomas arising in preexisting conditions. The conventional plain radiograph is the best for probable diagnosis as it describes features like sun burst appearance, Codman's triangle, new bone formation in soft tissues along with permeative pattern of destruction of the bone and other characteristics for specific subtypes of osteosarcomas.”
Classification, imaging, biopsy and staging of osteosarcoma.
Kundu ZS.
Indian J Orthop. 2014;48(3):238-246.
- “For initial diagnostic workup of patients suspected of having MM, the NCCN Panel recommends either whole- body low-dose CT or FDG PET/CT. The panel has also noted that skeletal survey including long bones is ac- ceptable where advanced imaging is not available (eg in low resource settings). CT contrast agents are not necessary for detection of myeloma bone disease and should be generally avoided in patients with myeloma when- ever possible.”
Multiple Myeloma, Version 3.2021
Shaji K. Kumar et al.
J Natl Compr Canc Netw 2020;18(12):1685–1717 - "FDG PET/CT too has been shown to identify more lesions than plain X-rays and detect lesions in patients with negative skeletal surveys. It is important to note that if PET/CT is chosen instead of whole-body low-dose CT, the imaging quality of the CT part of the PET/CT should be equivalent to a whole-body low-dose CT. Usually the CT part is used only for attenuation correction, which may not be sufficient to assess bone disease due to MM and stability of the spine. Whole body PET/CT is useful in detecting extramedullary disease outside of the spine.”
Multiple Myeloma, Version 3.2021
Shaji K. Kumar et al.
J Natl Compr Canc Netw 2020;18(12):1685–1717 - “In a multicenter analysis by the IMWG, conventional skeletal survey was compared with whole-body CT scans from 212 patients with monoclonal plasma cell disorders. Whole-body CT was positive in 25.5% of patients with negative skeletal survey. The sensitivity of the skeletal survey and whole-body low-dose CT in the long bones is not significantly different, the difference is mainly in detection of abnormalities in spine and pelvis. In a study of 29 patients, 5 (17%) showed osteolytic lesions in CT while skeletal survey results were negative. Furthermore, studies have shown whole-body low-dose CT is superior to skeletal survey radiographs in areas that are difficult to visualize with skeletal surveys such as skull and ribs.”
Multiple Myeloma, Version 3.2021
Shaji K. Kumar et al.
J Natl Compr Canc Netw 2020;18(12):1685–1717
- Purpose: To determine the diagnostic performance of dual-energy computed tomography (CT) for detection of bone marrow (BM) infiltration in patients with multiple myeloma by using a virtual noncalcium (VNCa) technique.
Results: In the visual analysis, VNCa images had an overall sensitivity of 91.3% (21 of 23), specificity of 90.9% (10 of 11), accuracy of 91.2% (31 of 34), positive predictive value of 95.5% (21 of 22), and a negative predictive value of 83.3% (10 of 12). ROI-based analysis of VNCa CT numbers showed a significant difference between infiltrated and normal BM (P < .001). Receiver operating characteristic analysis revealed an area under the curve of 0.978.
Conclusion: Visual and ROI-based analyses of dual-energy VNCa images had excellent diagnostic performance for assessing BM infiltration in patients with multiple myeloma with precision comparable to that of MR imaging.
Multiple Myeloma and Dual-Energy CT: Diagnostic Accuracy of Virtual Noncalcium Technique for Detection of Bone Marrow Infiltration of the Spine and Pelvis
Aleksander Kosmala et al.
Radiology 2018; 286:205–213
- “Incidental bone lesions on computed tomography examinations are often encountered. Accurate characterization, narrowing the differential diagnosis, and providing appropriate management for bone lesions can be challenging for the abdominal radiologist. CT evaluation of a bony lesion is based on similar principles of lesion evaluation on radiographs. Bone lesions can be classified as non-aggressive or aggressive lesions with widely accepted radiographic patterns: well defined with sclerotic border, well defined with non-sclerotic border, poorly defined with non-sclerotic border, moth-eaten, and permeative.”
The incidental bone lesion on computed tomography: management tips for abdominal radiologists.
Nguyen, M., Beaulieu, C., Weinstein, S. et al
Abdom Radiol 42, 1586–1605 (2017) - "Benign osteoid lesions or bone-containing lesions in the abdomen and pelvis include bone islands (enostosis) and osteoid osteomas. The pelvis, sacrum, and proximal femurs are common sites for bone islands. Bone islands are not true neoplasms but are foci of cortical bone within cancellous bone. Lesions are sharply marginated with thorny, radiating bony spicules on radiographs and CT. A recent paper that analyzed the CT attenuation values of untreated osteoblastic metastases in comparison with bone islands found that mean and maximum cutoff values of 885 and 1060 H.U., respectively, were highly sensitive and specific in that bone islands had attenuation values above these cutoffs.”
The incidental bone lesion on computed tomography: management tips for abdominal radiologists.
Nguyen, M., Beaulieu, C., Weinstein, S. et al
Abdom Radiol 42, 1586–1605 (2017) - “Paget’s disease or osteitis deformans can be incidentally identified on a body CT in patients older than 40 years . Paget’s disease in the pelvis and spine typically involves the osteosclerotic phase leading to cortical thickening, enlargement of bone, and coarsened trabeculae. In the vertebral body, these changes produce the “picture frame” vertebral body. The bony changes frequently involve the hemipelvis with thickening of the iliopubic and ilioischial lines and coarsened trabeculae.”
The incidental bone lesion on computed tomography: management tips for abdominal radiologists.
Nguyen, M., Beaulieu, C., Weinstein, S. et al
Abdom Radiol 42, 1586–1605 (2017) - “For solitary lesions with non-sclerotic borders, poorly defined margins, or a permeative or moth-eaten appearance, further imaging work-up and final pathologic diagnosis is recommended. The differentiation between a benign versus malignant lesion may not be possible on CT and may require further imaging with MRI, bone scintigraphy or PET/CT. Any frank bony destructive change indicates a more aggressive process and warrants a final diagnosis. For patients older than 40 year of age, malignant neoplastic lesions such as metastatic disease, multiple myeloma, sarcoma, and lymphoma should be on the differential diagnosis for aggressive bony lesions.”
The incidental bone lesion on computed tomography: management tips for abdominal radiologists.
Nguyen, M., Beaulieu, C., Weinstein, S. et al
Abdom Radiol 42, 1586–1605 (2017) - "Evaluation for bony abnormalities tends to be under-emphasized in the interpretation of abdominal and pelvic CT studies: yet focal lesions are common and their classification has important implications for cancer staging and the need for subsequent imaging or biopsy. When an incidental bony lesion is encountered on CT, the same analysis principles as those used for plain radiographs should be employed. Incidental, well-defined sclerotic lesions are highly likely to be benign. Incidental osteochondromatous and chondroid lesions are usually benign unless there is significant endosteal scalloping/cortical erosion or thick cartilage cap. Destructive bony changes or multifocal lytic lesions typically warrant a final diagnosis.”
The incidental bone lesion on computed tomography: management tips for abdominal radiologists.
Nguyen, M., Beaulieu, C., Weinstein, S. et al
Abdom Radiol 42, 1586–1605 (2017)
- “Ependymoma is the most common primary glial neoplasm of spinal cord representing 50%–60% of all intramedullary cord neoplasms. They frequently present in middle-aged adults but can occur at any age group. Ependymomas are believed to be slow-growing tumors and exhibit benign pathology behavior. Due to the tendency to compress rather than infiltrate the adjacent parenchyma, patients with spinal or conus ependymomas mostly have insidious clinical symptomatology, and often the tumors are present long before diagnosis.”
Spinal Cord Ependymoma – Surgical Management and Outcome
Wail Mohammed, Michael Farrell, Ciaran Bolger
J Neurosci Rural Pract. 2019 Apr-Jun; 10(2): 316–320 - "Bagley et al. suggested that signs and symptoms usually correspond to tumor volume, invasion, and presentation site. Ependymoma is known for the insidious clinical course, predominantly attributed to the tumor slow growth. Those findings are similar in our patients. Gavin Quigley et al. linked the outcome to preoperative neurological status, while the prognostic effect of symptoms, signs, and cytological features on long-term survival has been studied by other authors. Analyzing the outcome regarding neurology function in our patients, we found that normal neurological preoperative status is associated with better outcome.”
Spinal Cord Ependymoma – Surgical Management and Outcome
Wail Mohammed, Michael Farrell, Ciaran Bolger
J Neurosci Rural Pract. 2019 Apr-Jun; 10(2): 316–320 - Ependymomas are grouped in three grades based on their characteristics. Within each grade, are different ependymoma subtypes. Molecular testing is used to help identify subtypes that are related to location and disease characteristics.
Grade I ependymomas are low grade tumors. This means the tumor cells grow slowly. The subtypes include subependymoma and myxopapillary ependymoma. Both are more common in adults than in children. Myxopapillary tumors usually occur in the spine.
Grade II ependymomas are low grade tumors and can occur in either the brain or the spine.
Grade III ependymomas are malignant (cancerous). This means they are fast-growing tumors. The subtypes include anaplastic ependymomas. These most often occur in the brain, but can also occur in the spine.
Ependymoma was originally published by the National Cancer Institute.
- Ameloblastoma arises from the enamel-forming cells of the odontogenic epithelium. The tumor most commonly occurs in the posterior mandible, typically in the third molar region. On radiography, the mixed cystic and solid type of ameloblastoma appears as an expansile, radiolucent, multilocular mass, with internal septations that form a honeycomb or soap bubble appearance on all modalities, which is a classic finding.
- "Osteosarcoma is a primary malignant bone tumour in which the neoplastic cells produce osteoid or bone. It is a rather uncommon tumour constituting approximately 0.2% of all malignancies.Lesions of the mandible and maxilla constitute 6% to 9% of all osteosarcomas. Although it is comparatively rare, osteosarcoma is still a common primary bone tumour of the jaws."
Osteosarcoma of the jaws: demographic and CT imaging features
S Wang, H Shi,* and Q Yu
Dentomaxillofac Radiol. 2012 Jan; 41(1): 37–42 - "The characteristic clinical presentation of osteosarcoma of the jaw is swelling, compared with pain in long bone lesions. In our study, the most common symptoms included swelling with or without numbness and limitation of mouth opening."
Osteosarcoma of the jaws: demographic and CT imaging features
S Wang, H Shi,* and Q Yu
Dentomaxillofac Radiol. 2012 Jan; 41(1): 37–42 - "Osteosarcomas appearing as an area of bone permeation without a tumour and new bone formation could not be differentiated from metastatic disease radiographically.Osteosarcoma resembling cementoblastomas might mimic "benign" bone growth, but the hard-tissue component is connected with the root of the involved tooth, which usually shows signs of external resorption, and the sharp border between the tubular dentin of the root and the hard-tissue component forms the hallmark of cementoblastomas."
Osteosarcoma of the jaws: demographic and CT imaging features
S Wang, H Shi,* and Q Yu
Dentomaxillofac Radiol. 2012 Jan; 41(1): 37–42
- Chordomas are most common in individuals aged 40–70 years, and occur twice as often in males as in females [1]. They are the most common primary tumour of the sacrum, arising from notochordal rests. 50–60% of chordomas occur in the sacrococcygeal region [1]. Chordoma is a low-grade tumour but can cause significant morbidity and mortality with local recurrence. Metastatic disease is uncommon but is seen more frequently in sacral chordomas than in skull base chordomas.
Imaging features of primary and secondary malignant tumours of the sacrum
E Thornton et al.The British Journal of Radiology 2012 85:1011, 279-284 - “Sacral chordoma usually arises from the third, fourth or fifth sacral vertebra in the midline or paramedian location, and is often seen as a large destructive osteolytic lesion with extraosseous extension When there is extraosseous extension, the tumour can be seen to extend exophytically into the pre-sacral region or sacral canal, resulting in a “mushroom” or “dumbbell” shape Internal calcifications are frequently seen on plain radiographs and CT .”
Imaging features of primary and secondary malignant tumours of the sacrum E Thornton et al.The British Journal of Radiology 2012 85:1011, 279-284 - “The tumour can spread over several segments, with or without involvement of the intervertebral discs. In >50% of cases, there are areas of decreased attenuation within the tumour on CT, which reflect myxoid-type tissue presented pathologically. A fibrous pseudocapsule is common, which is of increased attenuation relative to the rest of the tumour .”
Imaging features of primary and secondary malignant tumours of the sacrum E Thornton et al.The British Journal of Radiology 2012 85:1011, 279-284 - “Chordomas lie predominantly in the midline, unlike chondrosarcomas which lie eccentrically. Chordomas tend to arise from the lower sacral segments or sacrococcygeal region; by contrast, chondrosarcomas generally arise from the mid to upper sacrum. When calcification is present in chordomas, it is amorphous and predominates in the periphery of the lesion, as opposed to the ring-and-arc calcification seen in chondrosarcomas from the chondroid matrix. When present, dense amorphous osteoid matrix is a characteristic finding in osteosarcomas .”
Imaging features of primary and secondary malignant tumours of the sacrum E Thornton et al.The British Journal of Radiology 2012 85:1011, 279-284 - Ewing sarcoma (ES) is a rare, highly malignant tumor that is most common in childhood and has an incidence of 0.5 to 2 cases/million. Since its first description by James Ewing in 1921, it was suggested that Ewing sarcoma shared characteristics with primitive neuroectodermal tumors and Askin tumors . Nevertheless, the etiologies of these tumors were not regarded to be similar until the 1990 discovery of a common genetic translocation in all these tumors led to their classification in the same family of ESs. Arising from soft or hard tissues, primitive neuroectodermal tumors and ESs share t(11;22) translocation but differ by their degree of differentiation.
Ewing Sarcoma of the Chest Wall: Prognostic Factors of Multimodal
Therapy Including En Bloc Resection Provost B et The Annals of Thoracic Surgery Volume 106, Issue 1, July 2018, Pages 207-213 - Thoracic localization of these sarcomas most often involves the ribs, and it is characterized by indolent progression. As a consequence, these tumors are often diagnosed at a locally advanced stage, with massive pleural cavity involvement (ie, consistent with the description by Askin and colleagues, or even at a metastatic stage (in 25% of cases).
Ewing Sarcoma of the Chest Wall: Prognostic Factors of Multimodal Therapy Including En Bloc Resection Provost B et The Annals of Thoracic Surgery Volume 106, Issue 1, July 2018, Pages 207-213 - The Ewing’s sarcoma family of tumours (ESFT) is an aggressive form of childhood cancer, which include classic Ewing’s sarcoma, Askin tumour, and peripheral primitive neuroectodermal tumour. While significant progress has been made in the diagnosis and treatment of localised disease over the past 30 years, there is much room for improvement.Before chemotherapy was introduced,about 10% of patients with Ewing’s sarcoma survived.Progress since then has been dramatic, with 75% of patients with localised tumours now surviving.
Ewing’s sarcoma Naomi J Balamuth, Richard B Womer Lancet Oncol 2010; 11: 184–92
- “Hematologic malignancies comprise a set of prevalent yet clinically diverse diseases that can affect every organ system. Because blood components originate in bone marrow, it is no surprise that bone marrow is a common location for both primary and metastatic hematologic neoplasms. Findings of hematologic malignancy can be seen with most imaging modalities including radiography, computed tomography (CT), technetium 99m (99mTc) methylene diphosphonate (MDP) bone scanning, fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, and magnetic reson
ance (MR) imaging.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “Multiple myeloma is a malignant neoplastic clonal proliferation of plasma cells of B-cell origin. This leads to overproduction of immunoglobulins and multiple systemic effects, including hypercalcemia, renal failure, hemato- logic dyscrasias, pathologic fractures, and bone pain. Multiple myeloma is rare in patients under 30 years of age, but is the third most common blood cancer in adults, with a reported prevalence of 4.3 cases per 100 000 population.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - Multiple Myeloma: Risk Factors
• male sex,
• increasing age
• African American ethnicity
• radiation exposure
• monoclonal gammopathy of undetermined signi cance (MGUS). - Poems Syndrome: facts
The rare constellation of findings of has been referred to as POEMS syndrome, also known as Crow-Fukase syndrome or Takatsuki disease.
• polyneuropathy,
• organomegaly,
• endocrinopathy,
• elevated monoclonal immunoglobulin level,
• skin changes - Osteosclerotic myeloma is a rare variant of multiple myeloma that may be associated with POEMS syndrome. In osteosclerotic myeloma, radiography may show either sclerotic or mixed lytic and sclerotic osseous lesions, and patients typically present clinically with a different picture than in usual multiple myeloma cases, including younger age at presentation, peripheral neuropathy, and rarely renal failure, hypercalcemia, or anemia.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “The International Myeloma Working Group has recommended that FDG PET/CT, low-dose whole-body CT, or whole-body and/or spine MR imaging be performed in all patients with a clinical presentation of smoldering multiple myeloma and solitary plasmacytoma; MR imaging is not recommended for routine evaluation of MGUS.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “Radiographic findings of multiple myeloma include focal or diffuse osteolysis. Multiple myeloma can affect any bone, including the skull, spine, pelvis, ribs, and proximal long bones. Osteolytic lesions involving long bones tend to show signs of cortical erosion from the medullary side, known as endosteal cortical scalloping. Pathologic fractures, particularly compression fractures of the vertebral bodies, are common in multiple myeloma.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “Radiographic ndings of multiple myeloma include focal or diffuse osteolysis. Multiple myeloma can affect any bone, including the skull, spine, pelvis, ribs, and proximal long bones. Osteolytic lesions involving long bones tend to show signs of cortical erosion from the medullary side, known as endosteal cortical scalloping. Pathologic fractures, particularly compression fractures of the vertebral bodies, are common in multiple myeloma.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “CT shows well-circumscribed, sometimes ex- pansile, lytic “soap bubble” osseous lesions with a narrow zone of transition; such lesions demon- strate 40–80 HU of attenuation, similar to soft tissue. FDG PET/CT has high sensitiv- ity and speci city for multiple myeloma lesions and is especially good at demonstrating extra- medullary disease. FDG PET/CT can be used to monitor for treatment response because the 18F-FDG uptake of osseous lesions will decrease with successful treatment.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900. - “Since patients with hematologic malignancies frequently receive chemotherapy and/or radia- tion therapy, it is helpful to understand some of the characteristic treatment-related bone mar- row imaging changes. After radiation therapy,
there is typically an increase in the amount of fat within bone marrow, causing increased T1 signal intensity at MR imaging compared with that in pretreatment marrow. Radiation osteitis may occur after radiation therapy and is best detected with radiography or CT.”
Musculoskeletal Imaging Findings of Hematologic Malignancies. Navarro SM et al. Radiographics. 2017 May-Jun;37(3):881-900.
- Sclerotic Metastases to the Spine: Differential Diagnosis
• Prostate cancer
• Breast cancer
• Carcinoid tumor and other neuroendocrine tumors
• Mucinous adenocarcinoma of the GI tract
• Lymphoma
• Neuroblastoma
- “Fibrous dysplasia is a noninherited bone disease in which abnormal differentiation of osteoblasts leads to replacement of normal marrow and cancellous bone by immature bone and fibrous stroma. It is usually an incidental imaging finding, generally not requiring further investigation. However, fibrous dysplasia may be complicated by pathologic fracture, and rarely by malignant degeneration.”
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation Fitzpatrick KA et al. AJR 2004;182:1389–139 - “Fibrous dysplasia is categorized as either monostotic or polyostotic and may occur as a component of McCune-Albright syndrome or the rare Mazabraud syndrome.”
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation Fitzpatrick KA et al. AJR 2004;182:1389–139 - “The polyostotic form of fibrous dysplasia may involve many or few bones, most commonly the skull and facial bones, pelvis, spine ,and shoulder. Polyostotic fi- brous dysplasia is often unilateral, some- times showing a monomelic pattern. It tends to involve larger segments of bone and is frequently associated with fractures and severe deformities.”
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation Fitzpatrick KA et al. AJR 2004;182:1389–139 - “McCune-Albright syndrome is an endocrin- opathy occurring mainly in girls, consisting of the triad of precocious puberty, polyostotic fi- brous dysplasia, and characteristic cutaneous pigmentation. The cutaneous lesions are flat pigmented macules, often referred to as “café au lait” spots and likened to the coast of Maine because of their irregular contour. Fibrous dysplasia lesions associated with McCune-Albright syndrome tend to be more disabling than those of pure polyostotic disease.”
Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation Fitzpatrick KA et al. AJR 2004;182:1389–139
- OBJECTIVE. The purpose of this study was to determine whether CT attenuation thresholds can be used to distinguish untreated osteoblastic metastases from enostoses.
CONCLUSION. CT attenuation measurements can be used to distinguish untreated osteoblastic metastases from enostoses. A mean attenuation of 885 HU and a maximum attenuation of 1060 HU provide reliable thresholds below which a metastatic lesion is the favored diagnosis.
Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements Ulano A et al. AJR 2016; 207:362–368 - “The most common malignancy of bone is metastatic disease, affecting approximately 400,000 people in the United States each year. Prostate, breast, and lung cancer account for approximately 80% of skeletal metastases.”
Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements Ulano A et al. AJR 2016; 207:362–368 - “Our study shows that a mean CT attenuation threshold of 885 HU and a maximum attenuation threshold of 1060 HU can be helpful in differentiating untreated osteoblastic metastasis from enostosis with 95% sensitivity and 96% specificity.”
Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements Ulano A et al. AJR 2016; 207:362–368 - “An enostosis is a benign osseous lesion that consists of a focal area of mature compact (cortical) bone within the cancellous bone (spongiosa). The finding was initially described by Stieda and Fischer in the early 20th century as “compact bone nuclei” and “islands,” respectively.”
Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements Ulano A et al. AJR 2016; 207:362–368 - “In our study, the distribution of tumors may have affected the threshold. For example, if more cases of prostate cancer had been included, the threshold may have been higher. Further investigation should also be performed to confirm these thresholds. Because prostate metastases disproportionately measured out- side the thresholds, lesions in patients with a history of prostate cancer should be interpreted with added caution.”
Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements Ulano A et al. AJR 2016; 207:362–368
- “No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated.”
ACR appropriateness criteria on metastatic bone disease. Roberts CC et al. J Am Coll Radiol. 2010 Jun;7(6):400-9 - “Skeletal metastases are the most common malignant tumor in bone. Certain types of cancer (e.g., of the prostate or breast) are particularly likely to give rise to skeletal metastases, with prevalences of up to 70%. The diagnosis of skeletal metastases has a major impact on the overall treatment strategy and is an important determinant of the course of illness and the quality of life. The goal of diagnostic imaging is to detect skeletal metastases early, whenever they are suspected on the basis of clinical or laboratory findings or in patients who are at high risk. Other important issues include assessment of the risk of fracture and the response to treatment.”
The Diagnostic Imaging of Bone Metastases Heindel W et al. Dtsch Arztebl Int. 2014 Oct; 111(44): 741–747.
- “MM derived from the following malignancies: lung cancer (25.1%), gastrointestinal tumours (21.0%), and urological tumours (13.2%). Other neoplasias with MM were rare. MM were localised most frequently in the thigh muscles, the extraocular musculature, and the gluteal and paravertebral muscles. The localisation of MM was different in several primary malignancies.”
Muscle metastases: comparison of features in different primary tumours.
Surov A,
Cancer Imaging. 2014 May 6;14(1):21 - “On computed tomography (CT), five different patterns of MM occurred: masses with homogeneous contrast enhancement (type I, 46.5%), abscess-like lesions (type II, 27.7%), diffuse infiltration with muscle swelling (type III, 18.1%), intramuscular calcifications (type IV, 6.5%), or MM presented as intramuscular bleeding (type V, 1.2%). MM from several primary tumours manifested with different CT patterns.”
Muscle metastases: comparison of features in different primary tumours.
Surov A,
Cancer Imaging. 2014 May 6;14(1):21 - “According to Haygood et al., most common primary malignancies were lung cancer, sarcomas, melanoma, renal cell carcinoma and breast cancer in decreasing order of frequency. In a previously reported mono-center study, MM from urogenital tumours occurred most commonly, followed by gastrointestinal tumours and malignant melanoma. In the present analysis, lung cancer, gastrointestinal tumours, urogenital tumours, and breast cancer were the most frequent primary malignant diseases.”
Muscle metastases: comparison of features in different primary tumours.
Surov A,
Cancer Imaging. 2014 May 6;14(1):21 - Secondary Bone Involvement by Lymphoma
- Secondary involvement of the bone with lymphoma (secondary bone lymphoma) much more common than primary bone lymphoma, occurring in ~15% of disseminated lymphomas.
- Secondary bone lymphoma is defined as lymphoma involving the bone with nodal disease occurring within six months or secondary lymphoma involving the bone at least six months after diagnosis. - Secondary bone involvement can result from direct spread from nodal disease or haematogenous metastases. The axial skeleton is more often affected than the appendicular skeleton . Most frequent locations of involvement are :
- spine
- bony pelvis
- skull
- ribs
- facial bones - “Lymphoma can involve any part of the musculoskeletal system. Primary musculoskeletal lymphoma is rare but can occur in bone (reticulum cell sarcoma) or in the skin and subcutaneous tissues (mycosis fungoides). Secondary involvement in the musculoskeletal system is more common and can have a variety of radiologic findings. The definitive diagnosis of musculoskeletal lymphoma, however, is difficult to make by using imaging criteria alone.”
Lymphoma of bone, muscle, and skin: CT findings.
P C Malloy, E K Fishman and D Magid
AJR 1992;159: 805-809. - “Primary and secondary bone lymphoma can be indistinguishable radiologically and histologically, but modern imaging techniques allow more accurate differentiation of primary from secondary bone involvement. This pictorial essay illustrates the CT findings of primary and secondary lymphoma involving bone, muscle, and skin and subcutaneous tissues.”
Lymphoma of bone, muscle, and skin: CT findings.
P C Malloy, E K Fishman and D Magid
AJR 1992;159: 805-809.
- “ Lung cancer is the most common neoplasm diagnosed worldwide. Metastatic presentation of the disease is frequent. Apart from the usual sites of metastatic disease (bone, adrenals, liver, brain), a particular site for metastases is represented by skin. The case we report is about a 66 year-old man with cutaneous metastasis from lung cancer.”
Cutaneous metastasis from lung cancer. Case report.
Fratus G et al.
Ann Ital Chir. 2014 Jul 21;85(epub).
- “ FD represents approximately 7% of all benign tumour-like bone lesions. However, the spine is affected in only 2.5% of cases, and FD of the spine is very rarely observed without there being disease elsewhere in the body . Spinal involvement occurs mostly in the polyostotic form of FD; it is unusual for it to occur in the monostotic form. When present in the elderly with multiple vertebral lesions, a biopsy may be indicated because metastatic disease or multiple myeloma may simulate a benign non-aggressive process.”
CT and MRI of fibrous dysplasia of the spine
Park SD et al
Br J Radiol Jul 2012; 85(1015):996-1001 - “However, typical radiographic findings of FD were represented on spine CT scans, with GGO the most common CT finding. In addition, an expansile nature, lytic lesions, sclerotic rims and a decrease in body height were common CT features in our study.”
CT and MRI of fibrous dysplasia of the spine
Park SD et al
Br J Radiol Jul 2012; 85(1015):996-1001 - “In conclusion, FD should be included in the differential diagnoses of patients with expansile osteolytic lesions with GGO, sclerotic margins or lesions in the vertebral bodies and posterior elements, especially when seen on spine CT scans. Moreover, these characteristic CT imaging findings of spinal FD may be helpful for diagnosing FD on spine CTs and preventing unnecessary procedures, especially in adult patients.”
CT and MRI of fibrous dysplasia of the spine
Park SD et al
Br J Radiol Jul 2012; 85(1015):996-1001 - Fibrous Dysplasia: Facts
- Monostotic form usually presents in 2nd-3rd decade of life (ribs, proximal fenur, tibia, craniofascial)
- Polyostotic form usually presents under age 10 (femur,tibia, pelvis, foot, ribs, skull and fascial bones - Fibrous Dysplasia: CT Findings
- Ground glass lucencies in bone
- Shepherd’s crook deformity
- Tibial bowing
- Sclerotic margins and well defined borders in bone especially spine
- Expansile changes in bone - Fibrous Dysplasia: Differential DX
- Pagets disease
- Neurofibromatosis
- Hyperparathyroidism
- Giant cell tumor
- Osteoblastoma
- Hemangioma
- Osteoid Osteoma: CT Findings
-Nidus surrounded by variable amount of sclerosis
-Nidus may enhance on contrast enhanced CT
-Periosteal reaction common
-CT can be used as a guide for RF ablation of the lesion - Osteoid Osteoma: Facts
-Age 5-25 yrs is 90% of cases
-M:F is 2-1
-Local pain usually worse at night
-Common locations include proxiaml femur, hands and feet
-Classic finding is nidus which is 1.5 cm or less - Extraosseous Myeloma: Sites of Involvement
- Spleen
- Liver
- Kidneys
- Small bowel
- Lymph nodes
- Pulmonary nodules
- Pleural implants "Extraosseous myeloma can affect virtually any organ, and the imaging findings of extraosseous myeloma are nonspecific and can mimic other disorders."
Imaging of Extraosseous Myeloma: CT, PET/CT, and MRI Features
Hall MN et al.
AJR 2010; 195:1057-1065"The presence of radiologically detectable extraosseous myeloma is associated with a poor prognosis and thus is an important factor in the initial workup and follow-up evaluation"
Imaging of Extraosseous Myeloma: CT, PET/CT, and MRI Features
Hall MN et al.
AJR 2010; 195:1057-1065"Extraosseous myeloma may affect any organ and can mimic other malignancies. The objective of this article is to describe the clinical relevance of extraosseous myeloma and to present the diverse imaging findings of extraosseous myeloma."
Imaging of Extraosseous Myeloma: CT, PET/CT, and MRI Features
Hall MN et al.
AJR 2010; 195:1057-1065- Secondary Osteosarcoma: facts
- Tumor arises in preexisting condition in bone like;
- Pagets disease
- Prior radiated bone
- Dedifferentiated chondrosarcoma
- Bone infarct - Osteosarcoma: Differential Dx includes
- Ewing sarcoma
- Chondrosarcoma (clear cell)
- Fibrous dysplasia
- Metastases
- Aggressive osteomyelitis - Osteosarcoma: Facts
- Most common primary bone tumor in children and young adults
- Occurs in metaphysis of long bones in 80% of cases 55% of cases occur around the knee
- 20% of cases occur in flat bones and spine
- Aggressive periosteal reaction with sunburst appearance - Classic Osteosarcoma: facts
- Origin in metaphysis
- Most common in long bones (70-80%) and especially around the knee
- Usually has aggressive periosteal reaction with new bone formation
- CT shows osteoid component of the tumor very nicely - Osteosarcoma: Facts
- Most common primary bone tumor in childhood and young adulthood
- 2nd most common primary bone tumor
- High grade intramedullary osteosarcoma makes up 75% of cases - Clinical presentation
- Lower back pain
- Sensory loss
- Gait disturbances
- Bladder and bowel dysfunction - Extradural Sacral Myxopapillary Ependymoma: Factoids
- Patients in 3rd or 4th decade
- Slow, insidious onset - Differential Dx
- Chordoma-age 60-70
- Metastases-usually >40
- Myeloma or plasmacytoma-age >40
- Giant cell tumor
- Aneurysmal bone cyst-age 10-20
- Neurogenic tumor - Extradural Sacral Myxopapillary Ependymoma
- Myxopapillary Ependymoma almost always occurs in the region corresponding to the filum terminale or cauda equina
- May be extradural in the presacral space or within the sacrum
- Although primarily suggesting a bone tumor on imaging a presacral mass is not uncommon
- These are slow growing tumors with local recurrence common - Extradural Sacral Myxopapillary Ependymoma
- Ependymomas represent 4-6% of primary CNS lesions
- Ependymomas make up 63% of intraparenchymal lesions of the spinal cord
- Myxopapillary ependymoma account for 25% of all ependymomas (most common type) - “Whole body MDCT leads to a significantly lower detection rate and staging in patients with multiple myeloma.” Whole Body MRI Versus Whole Body MDCT for Staging of Multiple Myeloma
Baur-Melnyk A et al.
AJR 2008; 190:1097-1104