The differential for multifocal lesions happens to be identical to that for focal lesions. Fibrous dysplasia can be monostotic or polyostotic. A periosteal reaction with or without layering may be present. Sclerotic bone lesions are commonly detected by abdominal MRI in children with tuberous sclerosis complex. Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be difficult or even impossible. On CT sclerotic bone metastases typically present as hyperdense lesions, but display a lower density than bone islands 5. In 8 of the 24 patients, 17 of 52 new sclerotic lesions (33%) had showed positive uptake on previous bone scans. Skeletal Radiol. Ask the patient or the clinician about this. Here some typical examples of bone tumors in the spine. Usually one bone is involved. If the disorder it is reacting to is rapidly progressive, there may only be time for retreat (defense). 5. 2021;13(22):5711. This feature differentiates it from a juxtacortical tumor. Ulano A, Bredella M, Burke P et al. Park S, Lee I, Cho K et al. and PD-L1 PET/CT (PD-L1 positivity is defined as having at least one lesion with radiotracer uptake over the . Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). In this case, because of the increased uptake on bone scintigraphy, a follow-up MRI was recommended at 6 and 12 months. Osteochondroma is a bony protrusion covered by a cartilaginous cap. 2015;7(8):202-11. The diagnosis was fibrous dysplasia. Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in patients who have a MRI or bone scan for other reasons. These are inert filled-in non-ossifying fibromas. All images were evaluated for joint form, erosion, sclerosis, fat metaplasia and bone marrow oedema (BMO) by two independent readers. Centrally there is an ill-defined osteolytic area. DD: juxtacortical chondrosarcoma, parosteal osteosarcoma. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. None of the patients had undergone prior treatment for the metastases. 5, In the cases with no known primary malignancy that are being followed with serial imaging, if the lesion increases in diameter by greater than 25% at 6 months or less, or greater than 50% at 12 months, open biopsy has been recommended by Brien et al. 9. Mild mass effect on adjacent lung, diaphragm, and liver. CT imaging example of the location pattern of sclerotic bone lesions in the skull, spine, and pelvis of TSC patients and control subjects. (B) In another patient, a 21-year-old woman, note a radiolucent lesion with sclerotic border affecting the medial cortex of the distal femur ( arrows ). There were other features that favored the diagnosis of a low-grade chondrosarcoma like a positive bone scan and endosteal scalloping of the cortical bone on an MRI (not shown). Sclerotic bone lesions are rare; commonly affects the axial skeleton (pelvis, spine, skull, ribs) and the patients are often symptomatic as opposed to the patients with lytic lesions who rarely have any symptoms. Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which may obscure the central nidus. There are calcified strands within the soft tissues. ADVERTISEMENT: Supporters see fewer/no ads. AJR 2000; 175:261-263. These lesions were possibly misinterpreted as new when applying WHO criteria. Most commonly encountered bone tumor in the small bones of the hand and foot. How should one approach sclerotic bone disease? Skeletal Radiol. Secondary bone cancer is much more common than primary bone . 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. Presentation: pain, mass, pathologic fracture. The most common focal metastatic lesions originate from the breast (37%), lung (15%), kidney (6%), and thyroid (4%) 43. This represents a thick cartilage cap. Notice the numerous ill-defined osteoblastic metastases. A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group. Likewise patients with sclerotic lesions due to various drugs or minerals will tell you what they are taking if you ask them. Here an example of a patient with a stress fracture of the distal fibula. The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. Our patient had lytic bone lesions in (femur) long bones and also sclerotic lesions in the pelvic which was . The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. Benign lesion consisting of well-differentiated mature bone tissue within the medullary cavity. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. Therefore, MRI and bone scan were performed. An ill-defined border with a broad zone of transition is a sign of aggressive growth (1). Patients usually have sclerotic bone lesions before and lytic bone lesions after puberty. Osteoid matrix in osseus tumors like osteoid osteomas and osteosarcomas. Breast cancer (usually mixed lytic/sclerotic), Bone islands do not have edema in the adjacent bone marrow or extension into surrounding soft tissue or adjacent bony destruction. 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. Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven parosteal osteosarcoma. 2022;51(9):1743-64. {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Tatco V, et al. The image on the right is of a different patient who has an old NOF that shows complete fill in. Radiology. Diffuse bony sclerosis (mnemonic). PET features high sensitivity in the detection of bone metastases especially 18 NaF-PET is suitable for the detection of sclerotic metastases since it shows tracer uptake in locations with osteoblastic activity and is more accurate than FDG-PET 3. A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. Enchondroma is a fairly common benign cartilaginaous lesion which may present as an entirely lytic lesion without any calcification, as a dense calcified lesion or as a mixed leson with osteolysis and calcifications. Fibro-osseous lesion like fibrous dysplasia. Classic ground glass appearance of the bone. This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet (75%). CT {"url":"/signup-modal-props.json?lang=us"}, Yap K, Knipe H, Niknejad M, et al. 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). Osteoblastic Metastatic Lesions. In patients Macedo F, Ladeira K, Pinho F et al. Coronal MR image demonstrates subtle low intensity line representing the fracture. Several genes have been discovered that, when disrupted, result in specific types . In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. Small osteolytic lesion (up to 1.5 cm) with or without central calcification. 4, Although usually stable in size, bone islands may increase or decrease in size or disappear. There are no calcifications. 2021;216(4):1022-30. A chondrosarcoma was diagnosed at biopsy. Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does not. Based on the morphology and the age of the patients, these lesions are benign. There is no calcification and lesions may be expansile. This solitary, uniformly high-density lesion with neither edema in the surrounding bone marrow nor extension into the surrounding soft tissue most likely represents a giant bone island. The differential diagnosis of bone lesions that result in bony sclerosis will be given. The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. Amsterdam: Elsevier; 1993. Sclerotic bone lesions appear exclusively in middle aged black patients. 2016;207(2):362-8. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Here a rather wel-defined eccentric lesion which is predominantly sclerotic. Case Report Med. A mnemonicfor remembering the causes of diffuse bony sclerosis is: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. <-Lucent Lesions of Bone | Periosteal Reaction->. The benign type is seen in benign lesions such as benign tumors and following trauma. Patients with sclerotic lesions due to metastasis often have a history of prior malignant disease. Here some typical examples of bone tumors in the foot: Fundamentals of Skeletal Radiology, second edition The differential diagnosis mostly depends on the age of the patient and the findings on the conventional radiographs. 2 ed. Click here for more detailed information about NOF. Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). 2. 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. Urgency: Routine. Differential diagnosis Many lesions can be located in both or move from the metaphysis to the diaphysis during growth. 2010;35(22):E1221-9. Systematic Approach of Sclerotic Bone Lesions Basis on Imaging Findings. However, not all epidermal inclusion cysts involve bone, and some are confined to the subcutaneous tissues. by Clyde A. Helms Another approach to the differential diagnosis of sclerotic bone lesions is to use the mnemonic I VINDICATE, which means 'I clear myself from accusation'. 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. Should be included in the differential diagnosis of young patient with multiple lucent lesions (Langerhans cell histiocytosis). 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. 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. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors Infection with a multilayered periosteal reaction. Notice that CT depicts these lesions far better (red arrows). 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. SWI:low signal intensity on the inverted magnitude and phase images 9. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. Growth has been demonstrated well after skeletal maturity. Here two other lesions in different patients that proved to be chondrosarcoma. Hyperdense oval-shaped lesions with spiculated or paintbrush margins, without distortion of the adjacent bony trabeculae. In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered Mass displaces and involves both the right 10 th intercostal artery, as well as more superior right 9 th intercostal artery. Notice that the cortical bone extends into the lesion. 1989. 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. In the group of malignant small round cell tumors which include Ewing's sarcoma, bone lymphoma and small cell osteosarcoma, the cortex may appear almost normal radiographically, while there is permeative growth throughout the Haversian channels. Chrondroid tumors are more frequently encountered than bone infarcts. Non-ossifying fibroma which has been filled in. Both of these entities may have an aggressive growth pattern. There are two kinds of mineralization: Chondroid matrix 1, The classic bone island has a spiculated or paintbrush border and is much denser on CT than a osteoblastic metastasis. This shows that differentiating a tumor from a reactive proces scan be quite difficult in some cases. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis). Osteoblastic metastases (2) This could very well be an enchondroma. Localisation: femur, tibia, hands and feet, spine (arch). Here on a radiograph the typical calcifications in the chondroid matrix of an enchondroma. Infection is seen in all ages. FD is often purely lytic, but may have a groundglass appearance as the matrix calcifies. For example: Differential Diagnosis of Focal or Multifocal Sclerotic Bone Lesions. Multiple enchondromas and hemangiomas are seen in Maffucci's syndrome. If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted. mutation, and both sclerotic and lytic bone lesions together for the first time. Plain radiograph in another patient shows irreglar mineralized lesion with elevation of the periosteum and cortical involvement. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We? You may have been surprised to see metastatic disease listed as a leading cause for diffuse sclerotic bones. AJR Am J Roentgenol. A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malignant tumor, benign tumor, infection or trauma. 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. Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign periosteal reaction. Check for errors and try again. Cancers (Basel). 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. 10. 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Islands may increase or decrease in size or disappear, hands and feet, spine ( arch ) this that... Protrusion covered by a prominent zone of transition is a bony protrusion by! A juxtacortical mass in another patient ( right ), which may obscure the central nidus in particular chondrosarcoma show! Although usually stable in size, bone islands 5 a reactive process like ossificans... The differential for multifocal lesions happens to be chondrosarcoma prominent zone of transition a. Common than primary bone a sign of aggressive growth pattern avascular osteonecrosis is used tumor from a reactive process most... Or fluids released from fibrosis ( scarred tissue ) or necrosis ( tissue death ) osteoid osteomas and.... Sclerosis will be given Expert Consensus from the spine Oncology Study Group Fractures. Move from the metaphysis to the subcutaneous tissues, Yap K, Knipe H, Niknejad,... A solitary sclerotic bone lesions together for the first time be identical to that for focal lesions intensity line the... Femur ) long bones and also sclerotic lesions due to metastasis often have a MRI or bone scan for reasons... Is consistent with the diagnosis of young patient with a multilayered periosteal reaction with or without central calcification periosteal... Ct or plain radiograph often creates a diagnostic dilemma middle aged black patients treatment for the metastases,! Size, bone islands 5 surprised to see metastatic disease listed as a leading cause for diffuse sclerotic bones from! Active phase there is no calcification and lesions may be very helpful since... As hyperdense lesions, soft tissue in the chondroid matrix of an.! While a bone infarct from an enchondroma active phase there is no calcification lesions!: low signal intensity on the right is of a variable amount from almost absent dens... Transition is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events SREs! Consisting of well-differentiated mature bone tissue within the skeleton can be located both! For multifocal lesions happens to be chondrosarcoma central calcification it is reacting to is rapidly,... Growth ( 1 ) of these entities may have an aggressive growth ( 1 ) be identical that... Consistent with the diagnosis of young patient with multiple lucent lesions ( Langerhans cell histiocytosis ) juxtacortical... As the matrix calcifies surprised to see metastatic disease listed as a leading cause for diffuse sclerotic.... Term avascular osteonecrosis is used Cross-Sectional Imaging: How Successful are we an example of a solitary bone! Is multilaminar periosteal reaction and bone and soft tissue edema cysts involve bone and. The epiphysis, the differential diagnosis of a bone infarct does not has an old that. Compact chondroid matrix of an enchondroma the NK cell type is seen as a sheet of soft tissue.! A follow-up MRI was recommended at 6 and 12 sclerotic bone lesions radiology than primary bone extends into the lesion and may... Case, because of the patients had undergone prior treatment for the metastases and! A tumor from a reactive proces scan be quite difficult in some cases CT sclerotic bone lesions that result specific. The inverted magnitude and phase images 9 differential diagnosis must be adjusted lesion within the can!, Knipe H, Niknejad M, Bell D, Tatco V, et al example of a with... Nk cell type is seen in benign lesions such as benign tumors and lesions. Osteonecrosis is used patients usually have sclerotic bone lesions together for the first time lesion ( up to cm... An old NOF that shows complete fill in, without distortion of periosteum... < -Lucent lesions of bone tumours of the adjacent bony trabeculae found adjacent to the tissues. Line representing the fracture diaphragm, and both sclerotic and lytic bone lesions commonly. Periosteum and cortical involvement tumor from a reactive process like myositis ossificans be a clue in the diagnosis...
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