Click here for more examples of eosinophilic granuloma. Presentation: pain, mass, pathologic fracture. This could very well be an enchondroma. Click here for more detailed information about fibrous dysplasia. Uncommonly it can be difficult to differentiate a stress fracture from a bone tumor like an osteoid osteoma or from a pathologic fracture, that occurs at the site of a bone tumor. A juxtacortical chondrosarcoma has be considered in the differential diagnosis when a mineralized lesion adjacent to the cortical bone is seen. Notice the numerous predominantly osteoblastic metastases. <-Lucent Lesions of Bone | Periosteal Reaction->. Bone Metastases: An Overview. giant cell tumor, metastasis, and myeloma; (3) sclerotic . Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. One of the first things you should notice about sclerotic bone lesions is whether they are single and focal, multifocal, or diffuse. The lesson here is that when we are dealing with a very common disorder, even its less common presentations will be seen commonly. AJR Am J Roentgenol. Large lesions tend to expand into both areas. 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. 2022;51(9):1743-64. Sclerotic bone metastases typically present as radiodense bone lesions that are round/nodular with relatively well-defined margins 3. (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 ). The use of radiological imaging in medical care dates back to 1895 when As part of the test, a healthcare professional takes a sample of the CSF 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. D'Oronzo S, Coleman R, Brown J, Silvestris F. Metastatic Bone Disease: Pathogenesis and Therapeutic Options. Adam Greenspan, Gernot Jundt, Wolfgang Remagen. Clin Orthop Relat Res. NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic Ewing' s sarcoma. Fibrous dysplasia, enchondromas, EG, Mets and myeloma, Hyperparathyroidism, Infection. Imaging of skull vault tumors in adults: Author: Pons Escoda, Albert Naval Baudin, Pablo . In this chapter, we will discuss key imaging features that strongly indicate the lesion is benign and those that warn further evaluation is warranted. Oncol Rev. CT can detect osteoblastic metastases with a higher sensitivity than plain radiographs and shines in the assessment of bones which are characterized by a small bone marrow cavity and a high amount of cortical bone such as the ribs 2,3. Continue with the MR-images. Despite their remarkable clinical success, the low degradation rate of these materials hampers a broader clinical use. All images were evaluated for joint form, erosion, sclerosis, fat metaplasia and bone marrow oedema (BMO) by two independent readers. Sclerotic jaw lesions are not rare and are frequently encountered on radiographs and computed tomography (CT). Osteosarcoma, chondrosarcoma, and Ewing's sarcoma are the most common types of bone cancer. 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, Location: epiphysis - metaphysis - diaphysis, Location: centric - eccentric - juxtacortical, Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging, Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography, The 'Mini Brain' Plasmacytoma in a Vertebral Body on MR Imaging, HPT = Hyperparathyroidism with Brown tumor, The morphology of the bone lesion on a plain radiograph. It is most commonly located in the outer table of the neurocranium or in a paranasal sinus. ADVERTISEMENT: Supporters see fewer/no ads. Notice that many benign osteolytic lesions that are frequently seen in younger age groups may heal and appear as sclerotic lesions in the middle aged group. 105-118. At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found. Polyostotic lesions It is a feature of malignant bone tumors. and PD-L1 PET/CT (PD-L1 positivity is defined as having at least one lesion with radiotracer uptake over the . In order to classify osteolytic lesions as well-defined or ill-defined, we need to look at the zone of transition between the lesion and the adjacent normal bone. They usually affect posterior vertebral elements and their number and size increase with age. General Considerations Fisher C, DiPaola C, Ryken T et al. Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common. Recommendation: No specific imaging recommendation. The zone of transition only applies to osteolytic lesions since sclerotic lesions usually have a narrow transition zone. 2016;207(2):362-8. Semin. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. Complete destruction may be seen in high-grade malignant lesions, but also in locally aggressive benign lesions like EG and osteomyelitis. This occurs in early knee osteoarthritis and indicates the potential for cartilage loss and misalignment of a knee compartment. Here some typical examples of bone tumors in the foot: Fundamentals of Skeletal Radiology, second edition In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. When you are considering osteonecrosis in your differential diagnosis, look at the joints carefully. 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. Radiographically, GCTs are eccentrically located radiolucent lesions with well-defined lytic 1B margins and geographic bone destruction. However, not all epidermal inclusion cysts involve bone, and some are confined to the subcutaneous tissues. Bone cyst is one of the manifestations of CGL with AGPAT2 mutation. DD: old SBC. 6. These lesions usually regress spontaneously and may then become sclerotic. Differential diagnosis based on the periosteal reaction and the extensive edema: Here a patient with a juxtacortical sclerotic mass of the proximal humerus (left). 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. (2005) ISBN: 9780721602707 -. 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 Lesions of the Spine 1311. predominant hypointensity on all imaging sequences mimicking a sclerotic process due to a variety of fac- . Multiple enchondromas are seen in Morbus Ollier. Subchondral bone attrition is the flattening or depression of the bone surface that forms part of a joint. 7. Sclerosis can also be reactive, e.g. Impact of Sclerotic. These are infections and eosinophilic granuloma. 1. 2018;2018:1-5. It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur. Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). Imaging: 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. However, a specific density range has not been specified for those terms 1. Sclerotic bone metastases. In fact, in areas where sickle cell disease is common, this may be the leading cause of diffuse sclerotic bones. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-22391. AJR 2000; 175:261-263. The bone marrow compartment is not involved which is important for the surgical strategy. 1. A bone island larger than 1 cm is referred to as a giant bone island (12). by Mulder JD, et al. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow). Hyperdense oval-shaped lesions with spiculated or paintbrush margins, without distortion of the adjacent bony trabeculae. Localisation: femur, tibia, hands and feet, spine (arch). Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive lesions like GCT. Here images of a patient with prostate cancer. Notice the lytic peripheral part with subtle calcifications. 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. The images show on the left a typical osteolytic NOF with a sharp sclerotic border. Paget disease is a chronic disorder of unknown origin with increased breakdown of bone and formation of disorganized new bone. The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging findings. It is assumed that several tumor-derived growth factors increase osteoblast activity while osteoclast activity is restricted 3,4. Here a patient with a broad-based osteochondroma. Concerning the above factors the differential diagnosis includes the following lesions 1-3: sclerotic bone metastasis: might be solitary because no others are present or have been imaged, infection: e.g. (A) Small radiolucent lesion exhibiting a thin sclerotic border (arrow) is present in the lateral cortex of the distal tibia of a 13-year-old boy. WSI digital slide: https://kikoxp.com/posts/4606. Lumbar CT-HU has the highest pooled correlation (r 2 =0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r 2 =0.5) and lumbar MRI with hip (r 2 =0.44) and spine (r 2 =0.41) DEXA. Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any bone lesion in patients < 20 years. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Increased uptake on bone scan has been reported in bone islands, especially giant ones, but warrants imaging follow-up. (2007) ISBN:0781765188. Ossification in parosteal osteosaroma is usually more mature in the center than at the periphery. Most of the time, sclerotic lesions are benign. Lets apply the good old universal differential diagnosis to sclerotic bone lesions. Density measurements on CT scan revealed greater than 1,000 HU throughout the lesion. Eosinophilic granuloma like osteomyelitis, can be a serious mimicker of malignancy (particularly Ewing sarcoma). 2017;11(1):321. Rib lesions detected on bone scintigraphy often require further characterization with radiography or CT to improve specificity (Figs. MRI of the sacrum: axial T1-weighted (T1w; Fig. Cortical destruction (3) This is an example of progression of an osteochondroma to a peripheral chondrosarcoma. For example: Differential Diagnosis of Focal or Multifocal Sclerotic Bone Lesions. Radiographs are specific but suffer from low sensitivity 1. J Korean Soc Radiol. Arthritis Rheum., 42 (2012), pp. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. Distinct phenotypes are described: osteoblastic, the more common osteolytic and mixed. Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements. 10. Materials and Methods MR usually shows a large amount of reactive changes in bone and soft tissue. some benign entities in this region may mimic malignancy if analyzed using classical bone-tumor criteria, and proper patient management requires being familiar with these presentations. brae in keeping with diffuse bone infarcts. Osteoblastic Metastatic Lesions. Most cases of chronic osteomyelitis look pretty nonspecific. Halo of increased signal on T2 W images about the low signal central lesion is suggestive of metastatic disease. 33.1d). 33.1a) and sagittal short tau inversion recovery (STIR; Fig. Cancers (Basel). The image on the right is of a different patient who has an old NOF that shows complete fill in. A chondrosarcoma was diagnosed at biopsy. Here some typical examples of bone tumors in the spine. Here images of an osteosarcoma in the right femur. In an older patient one should first consider an osteoblastic metastasis. 4 , 5 , 6. Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. The homogeneous pattern is relatively uncommon compared to the heterogeneous pattern. The MR image shows that the lesion has lobulated contours and nodular enhancement. Therefore, knowing the homogeneously sclerotic bone lesions can be useful, such as enostosis (bone island) (), osteoma (), and callus or bone graft.The plain radiography and CT images of enostosis consist of a circular or oblong area of dense bone with an irregular and speculated margin, which have been . Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most commonly of the hallux. Benign lesion consisting of well-differentiated mature bone tissue within the medullary cavity. Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications. Biopsy revealed dedifferentiated chondrosarcoma. There are a number of other helpful findings you can look for that can help you to cone in on or away from specific entities in one of these differential lists. Bone metastases are the most common malignancy of bone of which sclerotic bone metastases are less common than lytic bone metastases. Growth of the osteochondroma takes place in the cap, corresponding with normal enchondral growth at the growth plates. sclerosing osteomyelitis of Garr, aggressive features might require an oncological referral and/or biopsy 1, history of malignancy will almost always require additional imaging, follow-up or oncologic referral, high CT attenuation values might help in the differentiation of bone island from osteoblastic metastases 5 but attenuation values should not be used exclusively for the assessment of sclerotic bone lesions 6, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-10490, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10490,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/sclerotic-bone-metastases/questions/1747?lang=us"}. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. Coronal MR image demonstrates subtle low intensity line representing the fracture. SusanaBoronat, IgnasiBarber, VivekPargaonkar, JoshuaChang, Elizabeth A.Thiele . This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet (75%). 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. Infections and eosinophilic granulomaInfections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a malignant bone tumor due to their aggressive biologic behavior. Logistic regression analyses were used to assess the association of joint form and lesions on imaging for axSpA patients and controls. Is suggestive of Metastatic disease in Long bones: a Proposed Scoring System Diagnosing! A Pathologic fracture, that occurs at the site of a joint to a peripheral chondrosarcoma infections be... Of bone of which sclerotic bone lesions greater than 1,000 HU throughout the lesion has lobulated contours and nodular.. 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( red arrow ) metastases are the most common malignancy of plasma cells that causes bone-destructive and... ( SREs ) 1 cm is referred to as a giant bone island ( 12 ) with scattered irregular! To osteolytic lesions since sclerotic lesions are not rare and are frequently encountered on and. Representing the fracture characterization with radiography or CT to improve specificity ( Figs HU throughout the lesion as... ( red arrow ) VivekPargaonkar, JoshuaChang, Elizabeth A.Thiele on 02 Mar 2023 ) https: //doi.org/10.53347/rID-22391 well-differentiated bone... Baudin, Pablo of hands or feet ( 75 % ) whether they are single focal! Mr image demonstrates subtle low intensity line representing the fracture formation of disorganized new bone may become... Mr image shows that the lesion Ewing sarcoma ) broader clinical use Fisher C DiPaola... 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