6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

Bone tumors - Differential diagnosis

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Alrijne hospital in Leiderdorp, the
Netherlands

Publicationdate 2010-04-10 / update 2022-03-17

In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-
like lesions.
The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the
patient.

Abbreviations used:
ABC = Aneurysmal bone cyst
CMF = Chondromyxoid fibroma
EG = Eosinophilic Granuloma
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
NOF = Non Ossifying Fibroma 001
SBC = Simple Bone Cyst

Systematic Approach
Age
Zone of transition
Periosteal reaction
Cortical destruction
Location: epiphysis - metaphysis - diaphysis
Location: centric - eccentric - juxtacortical
Matrix
Polyostotic or multiple lesions
Spine lesions
Foot lesions

Systematic Approach

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6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

Bone tumors - Differential diagnosis

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Alrijne hospital in Leiderdorp, the
Netherlands

Publicationdate 2010-04-10 / update 2022-03-17

In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-
like lesions.
The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the
patient.

Abbreviations used:
ABC = Aneurysmal bone cyst
CMF = Chondromyxoid fibroma
EG = Eosinophilic Granuloma
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
NOF = Non Ossifying Fibroma
SBC = Simple Bone Cyst

Systematic Approach
Age
Zone of transition
Periosteal reaction
Cortical destruction
Location: epiphysis - metaphysis - diaphysis
Location: centric - eccentric - juxtacortical
Matrix
Polyostotic or multiple lesions
Spine lesions
Foot lesions

Systematic Approach

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6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

003

The most important determinators in the analysis of a potential bone tumor are:
1. The morphology of the bone lesion on a plain radiograph
Well-defined osteolytic
ill-defined osteolytic
Sclerotic
2. The age of the patient

It is important to realize that the plain radiograph is the most useful examination for differentiating these le-
sions.
CT and MRI are only helpful in selected cases.

Here are links to other articles about bone tumors:

Bone tumors in Alphabethic Order
Well-defined osteolytic bone tumors
ill-defined osteolytic bone tumors
Sclerotic bone tumors
Bone tumors A-G
Bone tumors H-O
Bone tumors P-Z

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6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

The most important determinators in the analysis of a potential bone tumor are:
1. The morphology of the bone lesion on a plain radiograph
Well-defined osteolytic
ill-defined osteolytic
Sclerotic
2. The age of the patient

It is important to realize that the plain radiograph is the most useful examination for differentiating these le-
sions.
CT and MRI are only helpful in selected cases.

Here are links to other articles about bone tumors:

Bone tumors in Alphabethic Order
Well-defined osteolytic bone tumors
ill-defined osteolytic bone tumors
Sclerotic bone tumors
Bone tumors A-G
Bone tumors H-O
Bone tumors P-Z

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005

Approach

Most bone tumors are osteolytic.

The most reliable indicator in determining whether these lesions are benign or malignant is the zone of tran-
sition between the lesion and the adjacent normal bone (1).
Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has a well-defined or ill-
defined margins, the next question should be: how old is the patient?

Age is the most important clinical clue.

Finally other clues need to be considered, such as a lesion's localization within the skeleton and within the
bone, any periosteal reaction, cortical destruction, matrix calcifications, etc.

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Approach

Most bone tumors are osteolytic.

The most reliable indicator in determining whether these lesions are benign or malignant is the zone of tran-
sition between the lesion and the adjacent normal bone (1).
Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has a well-defined or ill-
defined margins, the next question should be: how old is the patient?

Age is the most important clinical clue.

Finally other clues need to be considered, such as a lesion's localization within the skeleton and within the
bone, any periosteal reaction, cortical destruction, matrix calcifications, etc.

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007

Age

Age is the most important clinical clue in differentiating possible bone tumors.
There are many ways of splitting age groups, as can be seen in the table, where the morphology of a bone
lesion is combined with the age of the patient.

Some prefer to divide patients into two age groups: 30 years.

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Age

Age is the most important clinical clue in differentiating possible bone tumors.
There are many ways of splitting age groups, as can be seen in the table, where the morphology of a bone
lesion is combined with the age of the patient.

Some prefer to divide patients into two age groups: 30 years. 008

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Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases
and myeloma in the differential diagnosis.

Notice the following:

Infections, a common tumor mimicker, are seen in any age group.
Infection may be well-defined or ill-defined osteolytic, and even sclerotic.
Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any
bone lesion in patients < 20 years.
Many sclerotic lesions in patients > 20 years are healed, previously osteolytic lesions which have
ossified, such as: NOF, EG, SBC, ABC and chondroblastoma.

Zone of transition

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.
The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or
malignant (1).
The zone of transition only applies to osteolytic lesions since sclerotic lesions usually have a narrow transition
zone.

009

Narrow zone of transition: NOF, SBC and ABC

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Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases
and myeloma in the differential diagnosis.

Notice the following:

Infections, a common tumor mimicker, are seen in any age group.
Infection may be well-defined or ill-defined osteolytic, and even sclerotic.
Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any
bone lesion in patients < 20 years.
Many sclerotic lesions in patients > 20 years are healed, previously osteolytic lesions which have
ossified, such as: NOF, EG, SBC, ABC and chondroblastoma.

Zone of transition

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.
The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or
malignant (1).
The zone of transition only applies to osteolytic lesions since sclerotic lesions usually have a narrow transition
zone.

Narrow zone of transition: NOF, SBC and ABC

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Small zone of transition

A small zone of transition results in a sharp, well-defined border and is a sign of slow growth.
A sclerotic border especially indicates poor biological activity.

In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metas-
tasis or plasmacytoma also have to be considered

On the left three bone lesions with a narrow zone of transition.

Based on the morphology and the age of the patients, these lesions are benign.
Notice that in all three patients, the growth plates have not yet closed.

Images
1. Non-ossifying fibroma
2. Solitary bone cyst
3. Aneurysmal bone cyst

Metastases and multiple myeloma

In patients > 40 years metastases and multiple myeloma are the most common bone tumors. 011
Metastases under the age of 40 are extremely rare, unless a patient is known to have a primary malignancy.
Metastases could be included in the differential diagnosis if a younger patient is known to have a malignancy,
such as neuroblastoma, rhabdomyosarcoma or retinoblastoma.

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Small zone of transition

A small zone of transition results in a sharp, well-defined border and is a sign of slow growth.
A sclerotic border especially indicates poor biological activity.

In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metas-
tasis or plasmacytoma also have to be considered

On the left three bone lesions with a narrow zone of transition.

Based on the morphology and the age of the patients, these lesions are benign.
Notice that in all three patients, the growth plates have not yet closed.

Images
1. Non-ossifying fibroma
2. Solitary bone cyst
3. Aneurysmal bone cyst

Metastases and multiple myeloma

In patients > 40 years metastases and multiple myeloma are the most common bone tumors.
Metastases under the age of 40 are extremely rare, unless a patient is known to have a primary malignancy.
Metastases could be included in the differential diagnosis if a younger patient is known to have a malignancy,
such as neuroblastoma, rhabdomyosarcoma or retinoblastoma.

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Wide zone of transition indicates malignancy or infection or eosinophilic granuloma

Wide zone of transition

013
An ill-defined border with a broad zone of transition is a sign of aggressive growth (1).
It is a feature of malignant bone tumors.
There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential
diagnosis.
These are infections and eosinophilic granuloma.
Both of these entities may have an aggressive growth pattern.

Images
1. Osteosarcoma
2. Osteomyelitis
3. Eosinophilic granuloma

Infections and eosinophilic granuloma

Infections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a
malignant bone tumor due to their aggressive biologic behavior.

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Wide zone of transition indicates malignancy or infection or eosinophilic granuloma

Wide zone of transition

An ill-defined border with a broad zone of transition is a sign of aggressive growth (1).
It is a feature of malignant bone tumors.
There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential
diagnosis.
These are infections and eosinophilic granuloma.
Both of these entities may have an aggressive growth pattern.

Images
1. Osteosarcoma
2. Osteomyelitis
3. Eosinophilic granuloma

Infections and eosinophilic granuloma

Infections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a
malignant bone tumor due to their aggressive biologic behavior. 014

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These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reac-
tion may also be seen.

Periosteal reaction

A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malig-
015
nant tumor, benign tumor, infection or trauma.

There are two patterns of periosteal reaction: a benign and an aggressive type.
The benign type is seen in benign lesions such as benign tumors and following trauma.
An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as
infections and eosinophilic granuloma.

Fibrous dysplasia, Enchondroma, NOF and SBC are common bone lesions.
They will not present with a periosteal reaction unless there is a fracture.
If no fracture is present, these bone tumors can be excluded.

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These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reac-
tion may also be seen.

Periosteal reaction

A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malig-
nant tumor, benign tumor, infection or trauma.

There are two patterns of periosteal reaction: a benign and an aggressive type.
The benign type is seen in benign lesions such as benign tumors and following trauma.
An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as
infections and eosinophilic granuloma.

Fibrous dysplasia, Enchondroma, NOF and SBC are common bone lesions.
They will not present with a periosteal reaction unless there is a fracture.
If no fracture is present, these bone tumors can be excluded.

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Benign periosteal reaction

017
Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign pe-
riosteal reaction.
A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irrita-
tion.
In the case of benign, slowly growing lesions, the periosteum has time to lay down thick new bone and re-
model it into a more normal-appearing cortex.

Image
Benign periosteal reaction in an osteoid osteoma.
Large arrow indicates solid periosteal reaction.
Small arrow indicates nidus.

Aggressive periosteal reaction

This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the corti-
cal bone.
It may be spiculated and interrupted - sometimes there is a Codman's triangle.
A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where

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Benign periosteal reaction

Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign pe-
riosteal reaction.
A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irrita-
tion.
In the case of benign, slowly growing lesions, the periosteum has time to lay down thick new bone and re-
model it into a more normal-appearing cortex.

Image
Benign periosteal reaction in an osteoid osteoma.
Large arrow indicates solid periosteal reaction.
Small arrow indicates nidus.

Aggressive periosteal reaction

This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the corti-
cal bone.
It may be spiculated and interrupted - sometimes there is a Codman's triangle.
A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where

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the elevated periosteum and bone come together.

In aggressive periostitis the periosteum does not have time to consolidate.

019
Aggressive periosteal reaction

Aggressive periosteal reaction (2)

1. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow).
There is periosteal bone formation perpendicular to the cortical bone and extensive bony matrix
formation by the tumor itself.
2. Ewing sarcoma with lamellated and focally interrupted periosteal reaction. (white arrows)
3. Infection with a multilayered periosteal reaction.
Notice that the periostitis is aggressive, but not as aggressive as in the other two cases.

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the elevated periosteum and bone come together.

In aggressive periostitis the periosteum does not have time to consolidate.

Aggressive periosteal reaction

Aggressive periosteal reaction (2)

1. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow).
There is periosteal bone formation perpendicular to the cortical bone and extensive bony matrix
formation by the tumor itself.
2. Ewing sarcoma with lamellated and focally interrupted periosteal reaction. (white arrows)
3. Infection with a multilayered periosteal reaction.
Notice that the periostitis is aggressive, but not as aggressive as in the other two cases.

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Osteosarcoma (left) and Ewings sarcoma (right)

Cortical destruction

Cortical destruction is a common finding, and not very useful in distinguishing between malignant and benign021
lesions.
Complete destruction may be seen in high-grade malignant lesions, but also in locally aggressive benign le-
sions like EG and osteomyelitis.
More uniform cortical bone destruction can be found in benign and low-grade malignant lesions.
Endosteal scalloping of the cortical bone can be seen in benign lesions like Fybrous dysplasia and low-grade
chondrosarcoma.

Images
1. Osteosarcoma
Irregular cortical destruction
2. Ewing's sarcoma
Cortical destruction (green arrow) and aggressive periosteal reaction (arrow heads).

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Osteosarcoma (left) and Ewings sarcoma (right)

Cortical destruction

Cortical destruction is a common finding, and not very useful in distinguishing between malignant and benign
lesions.
Complete destruction may be seen in high-grade malignant lesions, but also in locally aggressive benign le-
sions like EG and osteomyelitis.
More uniform cortical bone destruction can be found in benign and low-grade malignant lesions.
Endosteal scalloping of the cortical bone can be seen in benign lesions like Fybrous dysplasia and low-grade
chondrosarcoma.

Images
1. Osteosarcoma
Irregular cortical destruction
2. Ewing's sarcoma
Cortical destruction (green arrow) and aggressive periosteal reaction (arrow heads).

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Chondromyxoid fibroma (left), Giant cell tumor (right)

Ballooning
Ballooning is a special type of cortical destruction. 023
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.

This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive le-
sions like GCT.

Images
1. Chondromyxoid fibroma
A benign, well-defined, expansile lesion with regular destruction of cortical bone and a peripheral layer
of new bone.
2. Giant cell tumor
A locally aggressive lesion with cortical destruction, expansion and a thin, interrupted peripheral layer of
new bone.
Notice the wide zone of transition towards the marrow cavity, which is a sign of aggressive behavior (red
arrow).

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Chondromyxoid fibroma (left), Giant cell tumor (right)

Ballooning
Ballooning 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.

This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive le-
sions like GCT.

Images
1. Chondromyxoid fibroma
A benign, well-defined, expansile lesion with regular destruction of cortical bone and a peripheral layer
of new bone.
2. Giant cell tumor
A locally aggressive lesion with cortical destruction, expansion and a thin, interrupted peripheral layer of
new bone.
Notice the wide zone of transition towards the marrow cavity, which is a sign of aggressive behavior (red
arrow).

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Ewing's sarcoma with permeative growth through the haversian channels accompanied by a large soft tissue mass

Cortical destruction (3)

In the group of malignant small round cell tumors which include Ewing's sarcoma, bone lymphoma and small 025
cell osteosarcoma, the cortex may appear almost normal radiographically, while there is permeative growth
throughout the Haversian channels.
These tumors may be accompanied by a large soft tissue mass while there is almost no visible bone
destruction.

Images
1. Ewing's sarcoma
The radiograph does not shown any signs of cortical destruction.
2. MRI shows large tumor within the bone and permeative growth through the Haversian channels
accompanied by a large soft tissue mass, which is barely visible on the X-ray.

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Ewing's sarcoma with permeative growth through the haversian channels accompanied by a large soft tissue mass

Cortical destruction (3)

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.
These tumors may be accompanied by a large soft tissue mass while there is almost no visible bone
destruction.

Images
1. Ewing's sarcoma
The radiograph does not shown any signs of cortical destruction.
2. MRI shows large tumor within the bone and permeative growth through the Haversian channels
accompanied by a large soft tissue mass, which is barely visible on the X-ray.

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027

Location within the skeleton

The location of a bone lesion within the skeleton can be a clue in the differential diagnosis.
The illustration on the left shows the preferred locations of the most common bone tumors.
In some locations, such as in the humerus or around the knee, almost all bone tumors may be found.

Top five location of bone tumors in alphabethic order:

Aneurysmal Bone Cyst - tibia, femur, fibula, spine, humerus

Adamantinoma - tibia shaft, mandible
Chondroblastoma - femur, humerus, tibia, tarsal bone (calc), patella
Chondromyxoid fibroma - tibia, femur, tarsal bone, phalanx foot, fibula
Chondrosarcoma - femur, rib, iliac bone, humerus, tibia
Chordoma - sacrococcygeal, spheno-occipital, cervical, lumbar, thoracic
Eosinophilic Granuloma - femur, skull, iliac bone, rib, vertebra

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Location within the skeleton

The location of a bone lesion within the skeleton can be a clue in the differential diagnosis.
The illustration on the left shows the preferred locations of the most common bone tumors.
In some locations, such as in the humerus or around the knee, almost all bone tumors may be found.

Top five location of bone tumors in alphabethic order:

Aneurysmal Bone Cyst - tibia, femur, fibula, spine, humerus

Adamantinoma - tibia shaft, mandible
Chondroblastoma - femur, humerus, tibia, tarsal bone (calc), patella
Chondromyxoid fibroma - tibia, femur, tarsal bone, phalanx foot, fibula
Chondrosarcoma - femur, rib, iliac bone, humerus, tibia
Chordoma - sacrococcygeal, spheno-occipital, cervical, lumbar, thoracic
Eosinophilic Granuloma - femur, skull, iliac bone, rib, vertebra
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Enchondroma - phalanges of hands and feet, femur, humerus, metacarpals, rib

Ewing's sarcoma - femur, iliac bone, fibula, rib, tibia
Fibrous dysplasia - femur, tibia, rib, skull, humerus
Giant Cell Tumor - femur, tibia, fibula, humerus, distal radius
Hemangioma - spine, ribs, craniofacial bones, femur, tibia
Lymphoma - femur, tibia, humerus, iliac bone, vertebra
Metastases - vertebrae, ribs, pelvis, femur, humerus
Non Ossifying Fibroma - tibia, femur, fibula, humerus
Osteoid osteoma - femur, tibia, spine, tarsal bone, phalanx
Osteoblastoma - spine, tarsal bone (calc), femur, tibia, humerus
Osteochondroma - femur, humerus, tibia, fibula, pelvis
Osteomyelitis - femur, tibia, humerus, fibula, radius
Osteosarcoma - femur, tibia, humerus, fibula, iliac bone
Solitary Bone Cyst - proximal humerus, proximal femur, calcaneal bone, iliac bone

029

Location: epiphysis - metaphysis - diaphysis

Epiphysis
Only a few lesions are located in the epiphysis, so this could be an important finding.
In young patients it is likely to be either a chondroblastoma or an infection.
In patients over 20, a giant cell tumor has to be included in the differential diagnosis.

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Enchondroma - phalanges of hands and feet, femur, humerus, metacarpals, rib

Ewing's sarcoma - femur, iliac bone, fibula, rib, tibia
Fibrous dysplasia - femur, tibia, rib, skull, humerus
Giant Cell Tumor - femur, tibia, fibula, humerus, distal radius
Hemangioma - spine, ribs, craniofacial bones, femur, tibia
Lymphoma - femur, tibia, humerus, iliac bone, vertebra
Metastases - vertebrae, ribs, pelvis, femur, humerus
Non Ossifying Fibroma - tibia, femur, fibula, humerus
Osteoid osteoma - femur, tibia, spine, tarsal bone, phalanx
Osteoblastoma - spine, tarsal bone (calc), femur, tibia, humerus
Osteochondroma - femur, humerus, tibia, fibula, pelvis
Osteomyelitis - femur, tibia, humerus, fibula, radius
Osteosarcoma - femur, tibia, humerus, fibula, iliac bone
Solitary Bone Cyst - proximal humerus, proximal femur, calcaneal bone, iliac bone

Location: epiphysis - metaphysis - diaphysis

Epiphysis
Only a few lesions are located in the epiphysis, so this could be an important finding.
In young patients it is likely to be either a chondroblastoma or an infection.
In patients over 20, a giant cell tumor has to be included in the differential diagnosis.
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In older patients a geode, i.e. degenerative subchondral bone cyst must be added to the differential
diagnosis.
Look carefully for any signs of arthrosis.
Metaphysis
NOF, SBC, CMF, Osteosarcoma, Chondrosarcoma, Enchondroma and infections.
Diaphysis
Ewing's sarcoma, SBC, ABC, Enchondroma, Fibrous dysplasia and Osteoblastoma.

Differentiating between a diaphyseal and a metaphyseal location is not always possible.

Many lesions can be located in both or move from the metaphysis to the diaphysis during growth.
Large lesions tend to expand into both areas.

031

Location: centric - eccentric - juxtacortical

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In older patients a geode, i.e. degenerative subchondral bone cyst must be added to the differential
diagnosis.
Look carefully for any signs of arthrosis.
Metaphysis
NOF, SBC, CMF, Osteosarcoma, Chondrosarcoma, Enchondroma and infections.
Diaphysis
Ewing's sarcoma, SBC, ABC, Enchondroma, Fibrous dysplasia and Osteoblastoma.

Differentiating between a diaphyseal and a metaphyseal location is not always possible.

Many lesions can be located in both or move from the metaphysis to the diaphysis during growth.
Large lesions tend to expand into both areas.

Location: centric - eccentric - juxtacortical

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Centric in long bone

SBC, eosinophilic granuloma, fibrous dysplasia, ABC and enchondroma are lesions that are located
centrally within long bones.
Eccentric in long bone
Osteosarcoma, NOF, chondroblastoma, chondromyxoid fibroma, GCT and osteoblastoma are located
eccentrically in long bones.
Cortical
Osteoid osteoma is located within the cortex and needs to be differentiated from osteomyelitis.
Juxtacortical
Osteochondroma. The cortex must extend into the stalk of the lesion.
Parosteal osteosarcoma arises from the periosteum.

1. SBC: central diaphyseal

2. NOF: eccentric metaphyseal
3. SBC: central diaphyseal
4. Osteoid osteoma: cortical
5. Degenerative subchondral cyst: epiphyseal
6. ABC: centric diaphyseal

033

Chondroid matrix

Matrix

Calcifications or mineralization within a bone lesion may be an important clue in the differential diagnosis.
There are two kinds of mineralization:
Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa
Osteoid matrix in osseus tumors like osteoid osteomas and osteosarcomas.

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Centric in long bone

SBC, eosinophilic granuloma, fibrous dysplasia, ABC and enchondroma are lesions that are located
centrally within long bones.
Eccentric in long bone
Osteosarcoma, NOF, chondroblastoma, chondromyxoid fibroma, GCT and osteoblastoma are located
eccentrically in long bones.
Cortical
Osteoid osteoma is located within the cortex and needs to be differentiated from osteomyelitis.
Juxtacortical
Osteochondroma. The cortex must extend into the stalk of the lesion.
Parosteal osteosarcoma arises from the periosteum.

1. SBC: central diaphyseal

2. NOF: eccentric metaphyseal
3. SBC: central diaphyseal
4. Osteoid osteoma: cortical
5. Degenerative subchondral cyst: epiphyseal
6. ABC: centric diaphyseal

Chondroid matrix

Matrix

Calcifications or mineralization within a bone lesion may be an important clue in the differential diagnosis.
There are two kinds of mineralization:
Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa
Osteoid matrix in osseus tumors like osteoid osteomas and osteosarcomas.
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Chondroid matrix
Calcifications in chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or floccu-
lent.

Images
1. Enchondroma, the most commonly encountered lesion of the phalanges.
2. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis).
3. Chondrosarcoma of the rib.

035

Osteoid matrix in Osteosarcoma (left) and Osteoid osteoma (right).

Osteoid matrix
Mineralization in osteoid tumors can be described as a trabecular ossification pattern in benign bone-forming
lesions and as a cloud-like or ill-defined amorphous pattern in osteosarcomas.
Sclerosis can also be reactive, e.g. in Ewing's sarcoma or lymphoma.

left
Cloud-like bone formation in osteosarcoma.
Notice the aggressive, interrupted periosteal reaction (arrows).
right
Trabecular ossification pattern in osteoid osteoma.
Notice osteolytic nidus (arrow).

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Chondroid matrix
Calcifications in chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or floccu-
lent.

Images
1. Enchondroma, the most commonly encountered lesion of the phalanges.
2. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis).
3. Chondrosarcoma of the rib.

Osteoid matrix in Osteosarcoma (left) and Osteoid osteoma (right).

Osteoid matrix
Mineralization in osteoid tumors can be described as a trabecular ossification pattern in benign bone-forming
lesions and as a cloud-like or ill-defined amorphous pattern in osteosarcomas.
Sclerosis can also be reactive, e.g. in Ewing's sarcoma or lymphoma.

left
Cloud-like bone formation in osteosarcoma.
Notice the aggressive, interrupted periosteal reaction (arrows).
right
Trabecular ossification pattern in osteoid osteoma.
Notice osteolytic nidus (arrow).

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LEFT: Polyostotic Fibrous Dysplasia. RIGHT: Multiple osteolytic lesions in femurshaft

037
Polyostotic or multiple lesions

Most bone tumors are solitary lesions.

If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted.

Polyostotic lesions
NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic
Ewing' s sarcoma.
Multiple enchondromas are seen in Morbus Ollier.
Multiple enchondromas and hemangiomas are seen in Maffucci's syndrome.

Polyostotic lesions > 30 years

Common: Metastases, multiple myeloma, multiple enchondromas.
Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts.

Mnemonic for multiple oseolytic lesions: FEEMHI:

Fibrous dysplasia, enchondromas, EG, Mets and myeloma, Hyperparathyroidism, Infection.

Spine lesions

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LEFT: Polyostotic Fibrous Dysplasia. RIGHT: Multiple osteolytic lesions in femurshaft

Polyostotic or multiple lesions

Most bone tumors are solitary lesions.

If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted.

Polyostotic lesions
NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic
Ewing' s sarcoma.
Multiple enchondromas are seen in Morbus Ollier.
Multiple enchondromas and hemangiomas are seen in Maffucci's syndrome.

Polyostotic lesions > 30 years

Common: Metastases, multiple myeloma, multiple enchondromas.
Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts.

Mnemonic for multiple oseolytic lesions: FEEMHI:

Fibrous dysplasia, enchondromas, EG, Mets and myeloma, Hyperparathyroidism, Infection.

Spine lesions

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039

Here some typical examples of bone tumors in the spine.

1. Hemangioma.
2. Metastasis.
3. Multiple myeloma.
4. Plasmocytoma: vertebra plana.
This 'Mini Brain' appearance of plasmacytoma in the spine is sufficiently pathognomonic to obviate
biopsy (9).

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Here some typical examples of bone tumors in the spine.

1. Hemangioma.
2. Metastasis.
3. Multiple myeloma.
4. Plasmocytoma: vertebra plana.
This 'Mini Brain' appearance of plasmacytoma in the spine is sufficiently pathognomonic to obviate
biopsy (9).

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041

More examples

1. ABC
2. Chondrosarcoma
3. Metastasis of breast cancer
4. Osteoblastoma

Foot lesions

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More examples

1. ABC
2. Chondrosarcoma
3. Metastasis of breast cancer
4. Osteoblastoma

Foot lesions

042

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Here some typical examples of bone tumors in the foot:

1. Geode or subchondral cyst in the navicular bone

043
2. Geode or subchondral cyst in the tarsal bone
3. Chondroblastoma in the tarsal bone
4. X-ray and MRI of a chondroblasoma in the tarsal bone
5. Chondroblastoma in the tarsal bone

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Here some typical examples of bone tumors in the foot:

1. Geode or subchondral cyst in the navicular bone

2. Geode or subchondral cyst in the tarsal bone
3. Chondroblastoma in the tarsal bone
4. X-ray and MRI of a chondroblasoma in the tarsal bone
5. Chondroblastoma in the tarsal bone

044

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1. Aneurysmal bone cyst in the tarsal bone

2. Chondroblastoma in the tarsal bone
3. Chondromyxoid fibroma (CMF) in the calcaneus
4. Same patient MRI 045

5. CMF in the second metatarsal bone

1. Ewing sarcoma in the calcaneus

2. Glomus tumor
3. Same patient MRI

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms

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1. Aneurysmal bone cyst in the tarsal bone

2. Chondroblastoma in the tarsal bone
3. Chondromyxoid fibroma (CMF) in the calcaneus
4. Same patient MRI
5. CMF in the second metatarsal bone

1. Ewing sarcoma in the calcaneus

2. Glomus tumor
3. Same patient MRI

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms
046

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6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

W. B. Saunders company 1995

2. Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging
by Mark J. Kransdorf and Donald E. Sweet
AJR 1995;164:573-580
3. Lucent Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
4. Sclerotic Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
5. Periosteal Reaction
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
6. Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography
by Theodore Miller March 2008 Radiology, 246, 662-674
7. [Link]
by Henri de Groot
8. Parosteal sarcoma (pdf)
by Jack Edeiken
9. The 'Mini Brain' Plasmacytoma in a Vertebral Body on MR Imaging
by Nancy M. Major, Clyde A. Helms and William J. Richardson.
AJR 2000; 175:261-263
10. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors
by Mulder JD, et al.
Amsterdam: Elsevier, 1993.

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

047

[Link] 24/24
6/3/22, 3:08 PM The Radiology Assistant : Bone tumors - Differential diagnosis

W. B. Saunders company 1995

2. Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging
by Mark J. Kransdorf and Donald E. Sweet
AJR 1995;164:573-580
3. Lucent Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
4. Sclerotic Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
5. Periosteal Reaction
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
6. Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography
by Theodore Miller March 2008 Radiology, 246, 662-674
7. [Link]
by Henri de Groot
8. Parosteal sarcoma (pdf)
by Jack Edeiken
9. The 'Mini Brain' Plasmacytoma in a Vertebral Body on MR Imaging
by Nancy M. Major, Clyde A. Helms and William J. Richardson.
AJR 2000; 175:261-263
10. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors
by Mulder JD, et al.
Amsterdam: Elsevier, 1993.

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

048

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6/3/22, 3:09 PM The Radiology Assistant : Osteolytic - well defined

Osteolytic - well defined

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2011-01-01

In the article Bone Tumors - Differential diagnosis we discuss a systematic approach to the differential diag-
nosis of bone tumors and tumor-like lesions.
In this article we will discuss the differential diagnosis of well-defined osteolytic bone tumors and tumor-like
lesions.

Abbreviations used:
ABC = Aneurysmal bone cyst
CMF = Chondromyxoid fibroma
EG = Eosinophilic Granuloma
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
NOF = Non Ossifying Fibroma 049
SBC = Simple Bone Cyst

Introduction
Fegnomashic
Fibrous dysplasia
Enchondroma
Eosinophilic granuloma
Giant cell tumor
NOF
Osteoblastoma
Metastases
Multiple Myeloma
Aneurysmal Bone Cyst
Solitary Bone Cyst
Hyperparathyroidism
Infection
Chondroblastoma
Chondromyxoid Fibroma

Introduction

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6/3/22, 3:09 PM The Radiology Assistant : Osteolytic - well defined

Osteolytic - well defined

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2011-01-01

In the article Bone Tumors - Differential diagnosis we discuss a systematic approach to the differential diag-
nosis of bone tumors and tumor-like lesions.
In this article we will discuss the differential diagnosis of well-defined osteolytic bone tumors and tumor-like
lesions.

Abbreviations used:
ABC = Aneurysmal bone cyst
CMF = Chondromyxoid fibroma
EG = Eosinophilic Granuloma
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism with Brown tumor
NOF = Non Ossifying Fibroma
SBC = Simple Bone Cyst

Introduction
Fegnomashic
Fibrous dysplasia
Enchondroma
Eosinophilic granuloma
Giant cell tumor
NOF
Osteoblastoma
Metastases
Multiple Myeloma
Aneurysmal Bone Cyst
Solitary Bone Cyst
Hyperparathyroidism
Infection
Chondroblastoma
Chondromyxoid Fibroma

Introduction

050

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051

On the left the most common well-defined bone tumors and tumor-like lesions.
These lesions are sometimes referred to as benign cystic lesions, which is a misnomer since most of them are
not cystic, except for SBC and ABC.
It is true that in patients under 30 years a well-defined border means that we are dealing with a benign lesion,
but in patients over 40 years metastases and multiple myeloma have to be included in the differential
diagnosis.

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On the left the most common well-defined bone tumors and tumor-like lesions.
These lesions are sometimes referred to as benign cystic lesions, which is a misnomer since most of them are
not cystic, except for SBC and ABC.
It is true that in patients under 30 years a well-defined border means that we are dealing with a benign lesion,
but in patients over 40 years metastases and multiple myeloma have to be included in the differential
diagnosis.

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053

On the left a table with well-defined osteolytic bone tumors and tumor-like lesions in different age-groups.

Notice the following:

In patients In patients > 40 years metastases and multiple myeloma are by far the most common well-
defined osteolytic bone tumors.
Patients with Brown tumor in hyperparathyroidism should have other signs of HPT or be on dialysis.

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On the left a table with well-defined osteolytic bone tumors and tumor-like lesions in different age-groups.

Notice the following:

In patients In patients > 40 years metastases and multiple myeloma are by far the most common well-
defined osteolytic bone tumors.
Patients with Brown tumor in hyperparathyroidism should have other signs of HPT or be on dialysis. 054

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Differentiation between a benign enchondroma and a low grade chondrosarcoma can be impossible
based on imaging findings only.
Infection is seen in all ages.

Fegnomashic

055

Most bone tumors present as well-defined osteolytic lesions, sometimes referred to as 'bubbly lesions'.
It is important to have a good differential diagnostic approach to these lesions.
You can use the table above, but another way to look at the differential diagnosis of well defined osteolytic
bone lesions is to use the mnemonic Fegnomashic, which is popularized by Clyde Helms (1).
Some prefer to use the mnemonic Fogmachines, which is formed by the same letters, but is a real word.

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Differentiation between a benign enchondroma and a low grade chondrosarcoma can be impossible
based on imaging findings only.
Infection is seen in all ages.

Fegnomashic

Most bone tumors present as well-defined osteolytic lesions, sometimes referred to as 'bubbly lesions'.
It is important to have a good differential diagnostic approach to these lesions.
You can use the table above, but another way to look at the differential diagnosis of well defined osteolytic
bone lesions is to use the mnemonic Fegnomashic, which is popularized by Clyde Helms (1).
Some prefer to use the mnemonic Fogmachines, which is formed by the same letters, but is a real word.

056

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057

Fibrous dysplasia: various presentations with or without sclerotic margin, with groundglass appearance, with calcifications or
ossifications

Fibrous dysplasia

Fibrous dysplasia is a benign disorder characterized by tumor-like proliferation of fibro-osseus tissue and can
look like anything.
FD most commonly presents as a long lesion in a long bone.
FD is often purely lytic and takes on ground-glass look as the matrix calcifies.
In many cases there is bone expansion and bone deformity.
The ipsilateral proximal femur is invariably affected when the pelvis is involved.
When FD in the tibia is considered, adamantinoma should be in the differential diagnosis.

Discriminator:
If periosteal reaction or pain is present, exclude fibrous dysplasia, unless there is a fracture.
More on Fibrous dysplasia

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Fibrous dysplasia: various presentations with or without sclerotic margin, with groundglass appearance, with calcifications or
ossifications

Fibrous dysplasia

Fibrous dysplasia is a benign disorder characterized by tumor-like proliferation of fibro-osseus tissue and can
look like anything.
FD most commonly presents as a long lesion in a long bone.
FD is often purely lytic and takes on ground-glass look as the matrix calcifies.
In many cases there is bone expansion and bone deformity.
The ipsilateral proximal femur is invariably affected when the pelvis is involved.
When FD in the tibia is considered, adamantinoma should be in the differential diagnosis.

Discriminator:
If periosteal reaction or pain is present, exclude fibrous dysplasia, unless there is a fracture.
More on Fibrous dysplasia

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059

Enchondroma

Enchondroma is a benign cartilage tumor.

Frequently it is a coincidental finding.
In the phalanges of the hand it frequently presents with a fracture.
It is the most common lesion in the phalanges, i.e. a well-defined lytic lesion in the hand is almost always an
enchondroma.
In some locations it can be difficult to differentiate between enchondroma and bone infarct.
It is almost impossible to differentiate between enchondroma and low grade chondrosarcoma based on ra-
diographic features alone.
Ollier's disease is multiple enchondromas.
Maffucci's syndrome is multiple enchondromas with soft tissue hemangiomas.

Features that favor the diagnosis of a low-grade chondrosarcoma:

Higher age
Size > 5 cm
Activity on bone scan
Fast enhancement on dynamic contrast enhanced MR series
Endosteal scalloping of the cortical bone

Discriminators :
Must have calcification except in phalanges.
No periostitis.

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Enchondroma

Enchondroma is a benign cartilage tumor.

Frequently it is a coincidental finding.
In the phalanges of the hand it frequently presents with a fracture.
It is the most common lesion in the phalanges, i.e. a well-defined lytic lesion in the hand is almost always an
enchondroma.
In some locations it can be difficult to differentiate between enchondroma and bone infarct.
It is almost impossible to differentiate between enchondroma and low grade chondrosarcoma based on ra-
diographic features alone.
Ollier's disease is multiple enchondromas.
Maffucci's syndrome is multiple enchondromas with soft tissue hemangiomas.

Features that favor the diagnosis of a low-grade chondrosarcoma:

Higher age
Size > 5 cm
Activity on bone scan
Fast enhancement on dynamic contrast enhanced MR series
Endosteal scalloping of the cortical bone

Discriminators :
Must have calcification except in phalanges.
No periostitis.
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left
Fat suppressed coronal PD-image of the knee. Typical enchondromas in the femur and tibia as seen
frequently as coincidental finding in MR-examinations. 061
middle
Well-defined lytic lesion in the rib with cortical thinning.
right
Well-defined lytic lesion with a sclerotic margin and without calcifications in the end phalanx.

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left
Fat suppressed coronal PD-image of the knee. Typical enchondromas in the femur and tibia as seen
frequently as coincidental finding in MR-examinations.
middle
Well-defined lytic lesion in the rib with cortical thinning.
right
Well-defined lytic lesion with a sclerotic margin and without calcifications in the end phalanx.

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063

Eosinophilic granuloma

EG is a non-neoplastic proliferation of histiocytes and is also known as Langerhans cell histiocytosis.

It should be included in the differential diagnosis of any sclerotic or osteolytic lesion, either well-defined or ill-
defined, in patients under the age of 30.
The diagnosis EG can be excluded in age > 30.
EG is usually monostotic, but can be polyostotic.

left
Osteolytic lesion arising from the neurocranium with associated soft tissue swelling.
middle
Mixed lytic-sclerotic lesion, not well-defined with solid periosteal reaction.
right
Sharply defined osteolytic lesion of the skull. There is no 'button sequestrum', which is more or less
pathognomonic.

Discriminator:
Must be under age 30.

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Eosinophilic granuloma

EG is a non-neoplastic proliferation of histiocytes and is also known as Langerhans cell histiocytosis.

It should be included in the differential diagnosis of any sclerotic or osteolytic lesion, either well-defined or ill-
defined, in patients under the age of 30.
The diagnosis EG can be excluded in age > 30.
EG is usually monostotic, but can be polyostotic.

left
Osteolytic lesion arising from the neurocranium with associated soft tissue swelling.
middle
Mixed lytic-sclerotic lesion, not well-defined with solid periosteal reaction.
right
Sharply defined osteolytic lesion of the skull. There is no 'button sequestrum', which is more or less
pathognomonic.

Discriminator:
Must be under age 30.

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Giant cell tumor in the tibia abuts the articular surface

Giant cell tumor

Giant cell tumor is a lesion with multinucleated giant cells.

In most cases it is a benign lesion. 065
Malignant GCT is rare and differentiation between benign or malignant GCT is not possible based on the ra-
diographs.
GCT is also included in the differential diagnosis of an ill-defined osteolytic lesion, provided the age and the
site of the lesion are compatible.

Discriminators:
Epiphyses must be closed.
Must be an epiphyseal lesion and abut the articular surface.
Must be well-defined and non-sclerotic margin.
Must be eccentric.

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Giant cell tumor in the tibia abuts the articular surface

Giant cell tumor

Giant cell tumor is a lesion with multinucleated giant cells.

In most cases it is a benign lesion.
Malignant GCT is rare and differentiation between benign or malignant GCT is not possible based on the ra-
diographs.
GCT is also included in the differential diagnosis of an ill-defined osteolytic lesion, provided the age and the
site of the lesion are compatible.

Discriminators:
Epiphyses must be closed.
Must be an epiphyseal lesion and abut the articular surface.
Must be well-defined and non-sclerotic margin.
Must be eccentric.

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NOF: typical presentation as an eccentric, multi-loculated subcortical lesion with a central lucency and a scalloped sclerotic 067
margin.

NOF

NOF is a benign well-defined, solitary lesion due to proliferation of fibrous tissue.

It is the most common bone lesion.
NOF is frequently a coincidental finding with or without a fracture.
NOF usually has a sclerotic border and can be expansile.
They regress spontaneously with gradual fill in.
NOF may occur as a multifocal lesion.
The radiographic appearance is almost always typical, and as such additional imaging and biopsy is not
warranted.

Discriminators:
Must be under age 30.
No periostitis or pain.

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NOF: typical presentation as an eccentric, multi-loculated subcortical lesion with a central lucency and a scalloped sclerotic
margin.

NOF

NOF is a benign well-defined, solitary lesion due to proliferation of fibrous tissue.

It is the most common bone lesion.
NOF is frequently a coincidental finding with or without a fracture.
NOF usually has a sclerotic border and can be expansile.
They regress spontaneously with gradual fill in.
NOF may occur as a multifocal lesion.
The radiographic appearance is almost always typical, and as such additional imaging and biopsy is not
warranted.

Discriminators:
Must be under age 30.
No periostitis or pain.

068

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Osteoblastoma

Osteoblastoma is a rare solitary, benign tumor that produces osteoid and bone.
Consider osteoblastoma when ABC is in the differential diagnosis of a spine lesion (figure).
A typical osteoblastoma is larger than 2 cm, otherwise it completely resembles osteoid osteoma.
069

Discriminator:
Mention when ABC is mentioned.

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Osteoblastoma

Osteoblastoma is a rare solitary, benign tumor that produces osteoid and bone.
Consider osteoblastoma when ABC is in the differential diagnosis of a spine lesion (figure).
A typical osteoblastoma is larger than 2 cm, otherwise it completely resembles osteoid osteoma.

Discriminator:
Mention when ABC is mentioned.

070

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Metastases

Metastases are the most common malignant bone tumors.

Metastases must be included in the differential diagnosis of any bone lesion, whether well-defined or ill-de- 071
fined osteolytic or sclerotic in age > 40.
Bone metastases have a predilection for hematopoietic marrow sites: spine, pelvis, ribs, cranium and proxi-
mal long bones: femur, humerus.
Metastases can be included in the differential diagnosis if a younger patient is known to have a malignancy,
like neuroblastoma, rhabdomyosarcoma, retinoblastoma.
Most common osteolytic metastases: kidney, lung, colon and melanoma.
Most common osteosclerotic metastases: prostate and breast.

Discriminator:
Must be over age 40.

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Metastases

Metastases are the most common malignant bone tumors.

Metastases must be included in the differential diagnosis of any bone lesion, whether well-defined or ill-de-
fined osteolytic or sclerotic in age > 40.
Bone metastases have a predilection for hematopoietic marrow sites: spine, pelvis, ribs, cranium and proxi-
mal long bones: femur, humerus.
Metastases can be included in the differential diagnosis if a younger patient is known to have a malignancy,
like neuroblastoma, rhabdomyosarcoma, retinoblastoma.
Most common osteolytic metastases: kidney, lung, colon and melanoma.
Most common osteosclerotic metastases: prostate and breast.

Discriminator:
Must be over age 40.

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073

Multiple Myeloma: multiple lytic lesions in the humerus

Multiple Myeloma

Multiple myeloma must be included in the differential diagnosis of any lytic bone lesion, whether well-defined
or ill-defined in age > 40.
The most common location is in the axial skeleton (spine, skull, pelvis and ribs) and in the diaphysis of long
bones (femur and humerus).
Most common presentation: multiple lytic 'punched out' lesions.
Multiple myeloma does not show any uptake on bone scan.

Discriminator:
Must be over age 40.

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Multiple Myeloma: multiple lytic lesions in the humerus

Multiple Myeloma

Multiple myeloma must be included in the differential diagnosis of any lytic bone lesion, whether well-defined
or ill-defined in age > 40.
The most common location is in the axial skeleton (spine, skull, pelvis and ribs) and in the diaphysis of long
bones (femur and humerus).
Most common presentation: multiple lytic 'punched out' lesions.
Multiple myeloma does not show any uptake on bone scan.

Discriminator:
Must be over age 40.

074

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Multiple Myeloma (2)

Differential diagnosis:
multiple lesions: metastases.
solitary lesion: chondrotumor, GCT and lymphoma.
075

On the left a CT-image of a patient with multiple myeloma.

Notice the numerous osteolytic lesions and permeative cortical destruction pattern.
In the left sacral wing there is a larger lesion with a high density due to replacement of fatty bone marrow by
myeloma (red arrow).

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Multiple Myeloma (2)

Differential diagnosis:
multiple lesions: metastases.
solitary lesion: chondrotumor, GCT and lymphoma.

On the left a CT-image of a patient with multiple myeloma.

Notice the numerous osteolytic lesions and permeative cortical destruction pattern.
In the left sacral wing there is a larger lesion with a high density due to replacement of fatty bone marrow by
myeloma (red arrow).

076

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ABC of the proximal fibula: well-defined, expansile osteolytic lesion with thin peripheral bone shell

Aneurysmal Bone Cyst

ABC is a solitary expansile well-defined osteolytic bone lesion, that is filled with blood.
It is named aneurysmal because it is expansile.
ABC is thought to be the result of a reactive process secondary to trauma or increased venous pressure. 077
Sometimes an underlying lesion like GCT, osteoblastoma or chondroblastoma can be found.
ABC can occur almost anywhere in the skeleton.

Discriminators:
Must be under age 30.
Must be expansile
More on ABC

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ABC of the proximal fibula: well-defined, expansile osteolytic lesion with thin peripheral bone shell

Aneurysmal Bone Cyst

ABC is a solitary expansile well-defined osteolytic bone lesion, that is filled with blood.
It is named aneurysmal because it is expansile.
ABC is thought to be the result of a reactive process secondary to trauma or increased venous pressure.
Sometimes an underlying lesion like GCT, osteoblastoma or chondroblastoma can be found.
ABC can occur almost anywhere in the skeleton.

Discriminators:
Must be under age 30.
Must be expansile
More on ABC

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SBC: well-defined osteolytic lesion without expansion of the proximal meta-diaphysis of the humerus with pathologic fracture

079
Solitary Bone Cyst

Solitary bone cyst, also known as unicameral bone cyst, is a true cyst.
Many well-defined osteolytic lesions are often called cystic, but this is a misnomer.
SBC frequently presents with a fracture.
Sometimes a fallen fragment is appreciated.
Predilection sites: proximal humerus and femur.
Usually less expansion compared with ABC.
Differential diagnosis: ABC, FD when cystic.
SBC may migrate from metaphysis to diaphysis during growth of the bone.

Discriminators:
Must be under age 30.
Must be centric

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SBC: well-defined osteolytic lesion without expansion of the proximal meta-diaphysis of the humerus with pathologic fracture

Solitary Bone Cyst

Solitary bone cyst, also known as unicameral bone cyst, is a true cyst.
Many well-defined osteolytic lesions are often called cystic, but this is a misnomer.
SBC frequently presents with a fracture.
Sometimes a fallen fragment is appreciated.
Predilection sites: proximal humerus and femur.
Usually less expansion compared with ABC.
Differential diagnosis: ABC, FD when cystic.
SBC may migrate from metaphysis to diaphysis during growth of the bone.

Discriminators:
Must be under age 30.
Must be centric

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Hyperparathyroidism

Brown tumors can occur in any bone and present as osteolytic lesions with sharp margins.
Septa and ridges may be seen.
Differential diagnosis: ABC, metastases and GCT depending on location and age.

On the left a patient who had a nefrectomy for renal cell carcinoma and who was on dialysis.
Multiple well-defined osteolytic lesions were found on a follow up CT scan.
The differential diagnosis included metastases and Brown tumors in hyperparathyroidism.
Biopsy revealed Brown tumor. 081

Discriminators:
Must have other signs of HPT.

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Hyperparathyroidism

Brown tumors can occur in any bone and present as osteolytic lesions with sharp margins.
Septa and ridges may be seen.
Differential diagnosis: ABC, metastases and GCT depending on location and age.

On the left a patient who had a nefrectomy for renal cell carcinoma and who was on dialysis.
Multiple well-defined osteolytic lesions were found on a follow up CT scan.
The differential diagnosis included metastases and Brown tumors in hyperparathyroidism.
Biopsy revealed Brown tumor.

Discriminators:
Must have other signs of HPT.

082

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Osteomyelitis

Infection

Infection or osteomyelitis is the great mimicker of bone tumors. 083

It has a broad spectrum of radiographic features and occurs at any age and has no typical location.
In the chronic stage it can mimic a benign bone tumor (Brodies abscess).
In the acute stage it can mimic a malignant bone tumor with ill-defined margins, cortical destruction and an
aggressive type of periostitis.
Only when there is a thick solid periosteal reaction we can recognize the non-malignant underlying process.

Discriminators:
None.

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Osteomyelitis

Infection

Infection or osteomyelitis is the great mimicker of bone tumors.

It has a broad spectrum of radiographic features and occurs at any age and has no typical location.
In the chronic stage it can mimic a benign bone tumor (Brodies abscess).
In the acute stage it can mimic a malignant bone tumor with ill-defined margins, cortical destruction and an
aggressive type of periostitis.
Only when there is a thick solid periosteal reaction we can recognize the non-malignant underlying process.

Discriminators:
None.

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Chondroblastoma: notice extensive edema (middle) and fluid-fluid level due to secondary ABC.

Chondroblastoma

The patella, carpal and tarsal bones can be regarded as epiphysis concerning the differential diagnosis.
On the left a chondroblastoma located in the patella.

Discriminators :
must be under age 30.
must be in the epiphysis.

085

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Chondroblastoma: notice extensive edema (middle) and fluid-fluid level due to secondary ABC.

Chondroblastoma

The patella, carpal and tarsal bones can be regarded as epiphysis concerning the differential diagnosis.
On the left a chondroblastoma located in the patella.

Discriminators :
must be under age 30.
must be in the epiphysis.

086

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087
Chondromyxoid Fibroma

Chondromyxoid Fibroma

Chondromyxoid Fibroma is a rare lesion.

CMF resembles NOF.
Preferential sites: proximal tibia and foot.
Although the name suggests that CMF is a chondroid lesion, calcifications are usually not seen.

On the left images of a CMF.

There is an eccentric osteolytic lesion in the metaphysis of the proximal tibia.
On the inner side there is a sclerotic margin.
On the outer side there is a regular cortical destruction with peripheral bone layer.
The MR also shows a sclerotic margin with low signal intensity.

Discriminators :
Mention when an NOF is mentioned.

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Chondromyxoid Fibroma

Chondromyxoid Fibroma

Chondromyxoid Fibroma is a rare lesion.

CMF resembles NOF.
Preferential sites: proximal tibia and foot.
Although the name suggests that CMF is a chondroid lesion, calcifications are usually not seen.

On the left images of a CMF.

There is an eccentric osteolytic lesion in the metaphysis of the proximal tibia.
On the inner side there is a sclerotic margin.
On the outer side there is a regular cortical destruction with peripheral bone layer.
The MR also shows a sclerotic margin with low signal intensity.

Discriminators :
Mention when an NOF is mentioned.

088

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089
Discriminative features of well-defined osteolytic lesions

On the left a summary of things to look for in well-defined osteolytic lesions.

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms
W. B. Saunders company 1995

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

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Discriminative features of well-defined osteolytic lesions

On the left a summary of things to look for in well-defined osteolytic lesions.

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms
W. B. Saunders company 1995

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

090

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Osteolytic - ill defined

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2011-01-01

In the article Bone Tumors - Differential diagnosis

we discussed a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions.

In this article we will discuss the differential diagnosis of ill-defined osteolytic bone tumors in alphabetic or-
der.
You can click on an item on the left.

Introduction
Chondrosarcoma
Eosinophilic granuloma
Ewing's sarcoma
Giant cell tumor
091
Lymphoma
Metastases
Multiple Myeloma / Plasmacytoma
Osteomyelitis
Osteosarcoma

Introduction

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Osteolytic - ill defined

Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2011-01-01

In the article Bone Tumors - Differential diagnosis

we discussed a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions.

In this article we will discuss the differential diagnosis of ill-defined osteolytic bone tumors in alphabetic or-
der.
You can click on an item on the left.

Introduction
Chondrosarcoma
Eosinophilic granuloma
Ewing's sarcoma
Giant cell tumor
Lymphoma
Metastases
Multiple Myeloma / Plasmacytoma
Osteomyelitis
Osteosarcoma

Introduction

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093

On the left the most common ill-defined bone tumors and tumor-like lesions.

An ill-defined zone of transition is seen in:

Malignant bone tumors:
Ewing's sarcoma
Osteosarcoma (most common presentation: sclerotic)
Leukemia
Metastases and Myeloma.
Aggressive benign lesions:
Infection
Eosinophilic granuloma
locally aggressive Giant Cell Tumor

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On the left the most common ill-defined bone tumors and tumor-like lesions.

An ill-defined zone of transition is seen in:

Malignant bone tumors:
Ewing's sarcoma
Osteosarcoma (most common presentation: sclerotic)
Leukemia
Metastases and Myeloma.
Aggressive benign lesions:
Infection
Eosinophilic granuloma
locally aggressive Giant Cell Tumor

094

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095

On the left a table with the most common bone tumors and tumor-like lesions in different age-groups.
In the middle column common ill-defined osteolytic lesions.

Notice the following:

Infection is seen in all ages.
ill-defined borders in GCT is seen in a locally aggressive lesion.

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On the left a table with the most common bone tumors and tumor-like lesions in different age-groups.
In the middle column common ill-defined osteolytic lesions.

Notice the following:

Infection is seen in all ages.
ill-defined borders in GCT is seen in a locally aggressive lesion. 096

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Chondrosarcoma is usually well-defined, but high grade chondrosarcoma can be ill-defined.

Metastases and myeloma are also usually well-defined, but sometimes ill-defined.

Chondrosarcoma

097

Chondrosarcoma

Key facts
Most commonly presents as a well-defined lesion, but uncommonly it can be encountered as an ill-
defined lytic lesion.
Calcifications can be seen when there is a large myxoid component within the tumor, but they are not
essential for the diagnosis.

On the left a partially ill-defined osteolytic lesion with endosteal scalloping.

There are cloud-like calcifications indicating a chondroid matrix.
These imaging findings and the size of the lesion favor the diagnosis of a chondrosarcoma.

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Chondrosarcoma is usually well-defined, but high grade chondrosarcoma can be ill-defined.

Metastases and myeloma are also usually well-defined, but sometimes ill-defined.

Chondrosarcoma

Chondrosarcoma

Key facts
Most commonly presents as a well-defined lesion, but uncommonly it can be encountered as an ill-
defined lytic lesion.
Calcifications can be seen when there is a large myxoid component within the tumor, but they are not
essential for the diagnosis.

On the left a partially ill-defined osteolytic lesion with endosteal scalloping.

There are cloud-like calcifications indicating a chondroid matrix.
These imaging findings and the size of the lesion favor the diagnosis of a chondrosarcoma.
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On the left two other lesions that proved to be a chondrosarcoma.

Notice that calcifications are not essential in chondrosarcoma.
099

More on Chondrosarcoma

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On the left two other lesions that proved to be a chondrosarcoma.

Notice that calcifications are not essential in chondrosarcoma.

More on Chondrosarcoma

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101

On the left a lobulated partially ill-defined lytic lesion of the proximal humerus.
The presence of calcifications suggest that this is a chondroid tumor.
The lytic parts with cortical involvement and expansion should raise the suspicion of a high grade
chondrosarcoma.

Eosinophilic granuloma

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On the left a lobulated partially ill-defined lytic lesion of the proximal humerus.
The presence of calcifications suggest that this is a chondroid tumor.
The lytic parts with cortical involvement and expansion should raise the suspicion of a high grade
chondrosarcoma.

Eosinophilic granuloma

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Eosinophilic granuloma with ill-defined borders.

Key facts
EG is like osteomyelitis a great mimicker of benign and malignant bone tumors.
Must be included in the differential diagnosis of almost any ill-defined osteolytic bone lesion in patients
under the age of 30.
May also present as a well-defined lesion.
EG can be excluded in patients > 30 years. 103
Commonly found in the skull, mandible, spine and long bones, but can occur anywhere.

On the left some examples of EG with ill-defined borders.

There are single or multiple layered periosteal reactions.

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Eosinophilic granuloma with ill-defined borders.

Key facts
EG is like osteomyelitis a great mimicker of benign and malignant bone tumors.
Must be included in the differential diagnosis of almost any ill-defined osteolytic bone lesion in patients
under the age of 30.
May also present as a well-defined lesion.
EG can be excluded in patients > 30 years.
Commonly found in the skull, mandible, spine and long bones, but can occur anywhere.

On the left some examples of EG with ill-defined borders.

There are single or multiple layered periosteal reactions.

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105
On the left a typical presentation of EG in the skull as an ill-defined osteolytic lesion.

More on Eosinophilic granuloma

Ewing's sarcoma

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On the left a typical presentation of EG in the skull as an ill-defined osteolytic lesion.

More on Eosinophilic granuloma

Ewing's sarcoma

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Ewing's sarcoma in diaphysis of the femur. Notice ill-defined zone of transition (blue arrow) and aggressive type of periosteal
reaction (red arrows)
107

Key facts
Most common presentation: ill-defined osteolytic lesion with multiple small holes in the diaphysis of a
long bone in a child with a large soft tissue mass.
Presentation with pain, mass, fever, anemia and leukocytosis.
Most common location: femur, iliac bone, fibula, rib, tibia.
Differential diagnosis: Osteosarcoma, lymphoma, infection and EG.
Frequently aggressive type of periosteal reaction, but never a benign type.

On the left a patient with a Ewing's sarcoma in the femur.

Notice the ill-defined osteolysis.
There is an aggressive periosteal reaction.

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Ewing's sarcoma in diaphysis of the femur. Notice ill-defined zone of transition (blue arrow) and aggressive type of periosteal
reaction (red arrows)

Key facts
Most common presentation: ill-defined osteolytic lesion with multiple small holes in the diaphysis of a
long bone in a child with a large soft tissue mass.
Presentation with pain, mass, fever, anemia and leukocytosis.
Most common location: femur, iliac bone, fibula, rib, tibia.
Differential diagnosis: Osteosarcoma, lymphoma, infection and EG.
Frequently aggressive type of periosteal reaction, but never a benign type.

On the left a patient with a Ewing's sarcoma in the femur.

Notice the ill-defined osteolysis.
There is an aggressive periosteal reaction.

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109
On the left an ill-defined lytic lesion in the femur of a young patient.
There is a permeative destruction pattern with irregular cortical destruction.
There is an aggressive periosteal reaction (arrow).
This is also called sunburst appearance.

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On the left an ill-defined lytic lesion in the femur of a young patient.

There is a permeative destruction pattern with irregular cortical destruction.
There is an aggressive periosteal reaction (arrow).
This is also called sunburst appearance.

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On the left an ill-defined lytic lesion of the right iliac bone in a young patient which can easily be overlooked.
Final diagnosis: Ewing's sarcoma.

More on Ewing's sarcoma 111

Giant cell tumor

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On the left an ill-defined lytic lesion of the right iliac bone in a young patient which can easily be overlooked.
Final diagnosis: Ewing's sarcoma.

More on Ewing's sarcoma

Giant cell tumor

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GCT of the radius with ill-defined margins on the left and a GCT in the tibia with well-defined margins

Key facts
Giant cell tumor is a benign lesion, but can be locally aggressive.
A well-defined margin is associated with a locally less aggressive biologic behavior.
In many cases the margin is ill-defined (figure). 113

These tumors often thin the cortex and may expand into the soft tissues surrounding the bone.
Most commonly seen in age 20-40 years. In the age group > 40 years, metastasis and plasmacytoma
have to be included in the differential diagnosis.

On the left a giant cell tumor of the distal radius with ill-defined margins, destruction of the subchondral bone
plate and extension towards the soft tissues.
On the right a giant cell tumor in the proximal tibia with somewhat better defined margin and non-inter-
rupted cortical bone.

More on Giant cell tumor

Lymphoma

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GCT of the radius with ill-defined margins on the left and a GCT in the tibia with well-defined margins

Key facts
Giant cell tumor is a benign lesion, but can be locally aggressive.
A well-defined margin is associated with a locally less aggressive biologic behavior.
In many cases the margin is ill-defined (figure).
These tumors often thin the cortex and may expand into the soft tissues surrounding the bone.
Most commonly seen in age 20-40 years. In the age group > 40 years, metastasis and plasmacytoma
have to be included in the differential diagnosis.

On the left a giant cell tumor of the distal radius with ill-defined margins, destruction of the subchondral bone
plate and extension towards the soft tissues.
On the right a giant cell tumor in the proximal tibia with somewhat better defined margin and non-inter-
rupted cortical bone.

More on Giant cell tumor

Lymphoma

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115

Key facts
Primary non-Hodgkin's lymphoma of bone is rare.
Presentation: usually pain and palpable mass.
Preferential sites: femur and humerus.
Radiographic appearance may differ from virtually normal to severely permeative.
Differential diagnosis:
Ewing's sarcoma, however, lymphoma usually in higher age group
Metastasis and plasmacytoma in age > 40y.

The plain radiograph on the left shows an ill-defined lytic lesion of the humerus diaphysis.
Notice tunneling of the cortical bone (red arrows).
On the MR notice the linear abnormalities within the cortical bone and the circumferential soft tissue mass.
Differential diagnosis (depending on age): Ewing's sarcoma, osteomyelitis and bone lymphoma.
Biopsy revealed Non-Hodgkin lymphoma

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Key facts
Primary non-Hodgkin's lymphoma of bone is rare.
Presentation: usually pain and palpable mass.
Preferential sites: femur and humerus.
Radiographic appearance may differ from virtually normal to severely permeative.
Differential diagnosis:
Ewing's sarcoma, however, lymphoma usually in higher age group
Metastasis and plasmacytoma in age > 40y.

The plain radiograph on the left shows an ill-defined lytic lesion of the humerus diaphysis.
Notice tunneling of the cortical bone (red arrows).
On the MR notice the linear abnormalities within the cortical bone and the circumferential soft tissue mass.
Differential diagnosis (depending on age): Ewing's sarcoma, osteomyelitis and bone lymphoma.
Biopsy revealed Non-Hodgkin lymphoma

116

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Metastases

Metastasis in distal femur

117
Key facts
Most common malignancy in bone.
Must be considered in the differential diagnosis of any bone lesion in a patient > 40 years.
May present as well-defined osteolytic, ill-defined osteolytic and also as sclerotic bone lesion.
Majority of osteolytic metastases originate from breast, lung, kidney, colon, melanoma and thyroid.

On the left a 60 year old patient with a known malignancy.

There is a lesion in the distal femur, that you could easily overlook and think that it was focal osteopenia.
The lesion presents as a large ill-defined osteolytic mass extending into the epiphysis and almost abuttting
the articular surface.
In a patient 20-40 years of age GCT would be a possible diagnosis.
It proved to be a metastasis.

Multiple Myeloma / Plasmacytoma

Key facts
Multiple myeloma must be included in the differential diagnosis of any lytic bone lesion, either well-
defined or ill-defined in age > 40.
Most common presentation: multiple lytic 'punched out' lesions. A solitary presentation is referred to as
plasmacytoma.
Usually no increased uptake on bone scan.

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Metastases

Metastasis in distal femur

Key facts
Most common malignancy in bone.
Must be considered in the differential diagnosis of any bone lesion in a patient > 40 years.
May present as well-defined osteolytic, ill-defined osteolytic and also as sclerotic bone lesion.
Majority of osteolytic metastases originate from breast, lung, kidney, colon, melanoma and thyroid.

On the left a 60 year old patient with a known malignancy.

There is a lesion in the distal femur, that you could easily overlook and think that it was focal osteopenia.
The lesion presents as a large ill-defined osteolytic mass extending into the epiphysis and almost abuttting
the articular surface.
In a patient 20-40 years of age GCT would be a possible diagnosis.
It proved to be a metastasis.

Multiple Myeloma / Plasmacytoma

Key facts
Multiple myeloma must be included in the differential diagnosis of any lytic bone lesion, either well-
defined or ill-defined in age > 40.
Most common presentation: multiple lytic 'punched out' lesions. A solitary presentation is referred to as
plasmacytoma.
Usually no increased uptake on bone scan.
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The most common location is in the axial skeleton (spine, skull, pelvis and ribs) and in the diaphysis of
long bones (femur and humerus).

Osteomyelitis

Key facts
Broad spectrum of radiographic features.
May occur at any age, no typical location.
Radiographic appearance: predominant reactive changes, including periosteal reaction, sclerosis and
edema.
Periosteal reaction and permeative pattern may mimic malignant process: Ewing's sarcoma,
osteosarcoma, lymphoma, leukemia.
In the pediatric age group eosinophilic granuloma may also mimic osteomyelitis.
Pediatric osteomyelitis: most commonly in central metaphysis, may cross to epiphysis.
Adult osteomyelitis: most commonly in central metaphysis or diaphysis.
May be highly permeative with cortical breakthrough, abcesses and fluid along fascia on MR imaging.

119

On the left a subacute form of osteomyelitis.

There is an eccentric ill-defined lesion seen on both sides of the physeal plate in the proximal tibia.
This is highly suggestive for osteomyelitis.
Other lesions do not cross the growth plate in general.
On the right coronal T1-weighted MR image reveals a well-defined epi-metaphyseal lesion.
There is a dark peripheral zone of reactive sclerosis, and extensive edema with low signal Intensity in the
metaphysis.

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The most common location is in the axial skeleton (spine, skull, pelvis and ribs) and in the diaphysis of
long bones (femur and humerus).

Osteomyelitis

Key facts
Broad spectrum of radiographic features.
May occur at any age, no typical location.
Radiographic appearance: predominant reactive changes, including periosteal reaction, sclerosis and
edema.
Periosteal reaction and permeative pattern may mimic malignant process: Ewing's sarcoma,
osteosarcoma, lymphoma, leukemia.
In the pediatric age group eosinophilic granuloma may also mimic osteomyelitis.
Pediatric osteomyelitis: most commonly in central metaphysis, may cross to epiphysis.
Adult osteomyelitis: most commonly in central metaphysis or diaphysis.
May be highly permeative with cortical breakthrough, abcesses and fluid along fascia on MR imaging.

On the left a subacute form of osteomyelitis.

There is an eccentric ill-defined lesion seen on both sides of the physeal plate in the proximal tibia.
This is highly suggestive for osteomyelitis.
Other lesions do not cross the growth plate in general.
On the right coronal T1-weighted MR image reveals a well-defined epi-metaphyseal lesion.
There is a dark peripheral zone of reactive sclerosis, and extensive edema with low signal Intensity in the
metaphysis.
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121

On the left an ill-defined osteolytic lesion in the proximal metaphysis of the tibia with extensive reactive scle-
rosis and solid periosteal reaction.

Osteosarcoma

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On the left an ill-defined osteolytic lesion in the proximal metaphysis of the tibia with extensive reactive scle-
rosis and solid periosteal reaction.

Osteosarcoma

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123
Osteosarcoma

Key facts of Osteosarcoma

Hallmark of osteosarcoma is the production of bony matrix, which is reflected by the sclerosis seen on
the radiograph.
Usually typical malignant features including permeative-motheaten pattern of destruction, irregular
cortical destruction and aggressive (interrupted) periosteal reaction.
Occasionally an osteosarcoma may present as a lytic or mixed lytic-sclerotic lesion.
Completely lytic osteosarcoma may represent telangiectatic subtype, composed of multiple cavities
filled with blood (may resemble aneurysmal bone cyst!).

On the left a mixed osteolytic and sclerotic lesion in the proximal humerus with irregular cortical destruction.
There is an aggressive periosteal reaction and a soft tissue mass.

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Osteosarcoma

Key facts of Osteosarcoma

Hallmark of osteosarcoma is the production of bony matrix, which is reflected by the sclerosis seen on
the radiograph.
Usually typical malignant features including permeative-motheaten pattern of destruction, irregular
cortical destruction and aggressive (interrupted) periosteal reaction.
Occasionally an osteosarcoma may present as a lytic or mixed lytic-sclerotic lesion.
Completely lytic osteosarcoma may represent telangiectatic subtype, composed of multiple cavities
filled with blood (may resemble aneurysmal bone cyst!).

On the left a mixed osteolytic and sclerotic lesion in the proximal humerus with irregular cortical destruction.
There is an aggressive periosteal reaction and a soft tissue mass.

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Sclerotic tumors
Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2013-11-01

In the article Bone Tumors - Differential diagnosis we discussed a systematic approach to the differential di-
agnosis of bone tumors and tumor-like lesions.
The differential diagnosis mostly depends on the age of the patient and the findings on the conventional ra-
diographs.

In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more
detail.

Introduction
Bone infarction
Bone island
Chondroblastoma
125
Chondrosarcoma
Peripheral chondrosarcoma
Periosteal or juxtacortical chondrosarcoma
Enchondroma
Eosinophilic granuloma
Fibrous dysplasia
Melorrheostosis
Metastases
Non-ossifying fibroma
Osteochondroma
Osteoid osteoma
Osteoma
Osteomyelitis
Osteosarcoma
Parosteal osteosarcoma
Paget's disease of bone
Reactive processes
Myositis ossificans
Stress fractures
Posttraumatic calcifications
Subungual exostoses
Nora's lesion

Introduction
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Sclerotic tumors
Henk Jan van der Woude and Robin Smithuis
Radiology department of the Onze Lieve Vrouwe Gasthuis, Amsterdam and the Rijnland hospital, Leiderdorp, the
Netherlands

Publicationdate 2013-11-01

In the article Bone Tumors - Differential diagnosis we discussed a systematic approach to the differential di-
agnosis of bone tumors and tumor-like lesions.
The differential diagnosis mostly depends on the age of the patient and the findings on the conventional ra-
diographs.

In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more
detail.

Introduction
Bone infarction
Bone island
Chondroblastoma
Chondrosarcoma
Peripheral chondrosarcoma
Periosteal or juxtacortical chondrosarcoma
Enchondroma
Eosinophilic granuloma
Fibrous dysplasia
Melorrheostosis
Metastases
Non-ossifying fibroma
Osteochondroma
Osteoid osteoma
Osteoma
Osteomyelitis
Osteosarcoma
Parosteal osteosarcoma
Paget's disease of bone
Reactive processes
Myositis ossificans
Stress fractures
Posttraumatic calcifications
Subungual exostoses
Nora's lesion

Introduction 126

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Here an illustration of the most common sclerotic bone tumors. 127

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Here an illustration of the most common sclerotic bone tumors.

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129

In the table the most common sclerotic bone tumors and tumor-like lesions in different age-groups are
presented.

Fibrous dysplasia and eosinophilic granuloma more commonly present as osteolytic lesions, but they can be
sclerotic.
Notice that many benign osteolytic lesions that are frequently seen in younger age groups may heal and ap-
pear as sclerotic lesions in the middle aged group.

Infection is seen in all ages.

Particularly chronic osteomyelitis may have a sclerotic appearance.

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In the table the most common sclerotic bone tumors and tumor-like lesions in different age-groups are
presented.

Fibrous dysplasia and eosinophilic granuloma more commonly present as osteolytic lesions, but they can be
sclerotic.
Notice that many benign osteolytic lesions that are frequently seen in younger age groups may heal and ap-
pear as sclerotic lesions in the middle aged group.

Infection is seen in all ages.

Particularly chronic osteomyelitis may have a sclerotic appearance.

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131

Another approach to the differential diagnosis of sclerotic bone lesions is to use the mnemonic I VINDICATE,
which means 'I clear myself from accusation'.

The mnemonic I VINDICATE is a commonly used mnemonic for the differential diagnostis of any radiological
lesion.

Bone infarction

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Another approach to the differential diagnosis of sclerotic bone lesions is to use the mnemonic I VINDICATE,
which means 'I clear myself from accusation'.

The mnemonic I VINDICATE is a commonly used mnemonic for the differential diagnostis of any radiological
lesion.

Bone infarction

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133

Multiple bone infarcts

Key facts
Typical presentation: central lesion in metaphysis or diaphysis with a well defined serpentiginous
border.
May resemble cartilaginous tumors.
Causes: corticosteroid use, sickle cell disease, trauma, Gaucher's disease, renal transplantation.
The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis.
If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used.

The radiograph shows typical bone infarcts in diaphysis and metaphysis of femur and tibia..

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Multiple bone infarcts

Key facts
Typical presentation: central lesion in metaphysis or diaphysis with a well defined serpentiginous
border.
May resemble cartilaginous tumors.
Causes: corticosteroid use, sickle cell disease, trauma, Gaucher's disease, renal transplantation.
The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis.
If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used.

The radiograph shows typical bone infarcts in diaphysis and metaphysis of femur and tibia..

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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.

Enhancement after i.v. Gadolinium is usually minimal or absent (see right image).
At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found.

135

Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be diffi-
cult or even impossible.
Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does
not.
Chrondroid tumors are more frequently encountered than bone infarcts.

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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.

Enhancement after i.v. Gadolinium is usually minimal or absent (see right image).
At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found.

Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be diffi-
cult or even impossible.
Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does
not.
Chrondroid tumors are more frequently encountered than bone infarcts.

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Here a lesion in the epiphysis, which was the result of post-traumatic osteonecrosis.
In the epiphysis we use the term avascular necrosis and not bone infarction.

Bone island 137

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Here a lesion in the epiphysis, which was the result of post-traumatic osteonecrosis.
In the epiphysis we use the term avascular necrosis and not bone infarction.

Bone island

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Key facts
Benign lesion consisting of well-differentiated mature bone tissue within the medullary cavity.
Also known as enostosis
The shape is usually round or oval.
Frequently encountered as a coincidental finding and can be found in any bone.
Occasionally slowly enlargement can be seen.
Bone islands can be large at presentation.
Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma
Click here for more information about bone island.

Chondroblastoma

139

key facts:
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.
Abundant edema is almost always present.
DD: Ganglion cyst, osteomyelitis, GCT, ABC, enchondroma.
Here a lesion located in the epi- and metaphysis of the proximal humerus.
The lesion is predominantly calcified.
Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications.

Click here for more examples of chondroblastoma.

Chondrosarcoma
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Key facts
Benign lesion consisting of well-differentiated mature bone tissue within the medullary cavity.
Also known as enostosis
The shape is usually round or oval.
Frequently encountered as a coincidental finding and can be found in any bone.
Occasionally slowly enlargement can be seen.
Bone islands can be large at presentation.
Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma
Click here for more information about bone island.

Chondroblastoma

key facts:
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.
Abundant edema is almost always present.
DD: Ganglion cyst, osteomyelitis, GCT, ABC, enchondroma.
Here a lesion located in the epi- and metaphysis of the proximal humerus.
The lesion is predominantly calcified.
Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications.

Click here for more examples of chondroblastoma.

Chondrosarcoma
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141

Low-grade chondrosarcoma

Key facts
Most common malignant bone tumor, which is almost always low-grade
Primary sites of origin: proximal long bones, around knee, pelvis and shoulder girdle, usually central and
metaphyseal
Radiological hallmark: formation of a chondroid (cartilagenous) matrix, which presents as punctuated,
stippled or popcorn-like calcifications.
The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix.
Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant
transformation.

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Low-grade chondrosarcoma

Key facts
Most common malignant bone tumor, which is almost always low-grade
Primary sites of origin: proximal long bones, around knee, pelvis and shoulder girdle, usually central and
metaphyseal
Radiological hallmark: formation of a chondroid (cartilagenous) matrix, which presents as punctuated,
stippled or popcorn-like calcifications.
The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix.
Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant
transformation.
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143

The image shows a calcified lesion in the proximal tibia without suspicious features.
This could very well be an enchondroma.
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).
A chondrosarcoma was diagnosed at biopsy.

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The image shows a calcified lesion in the proximal tibia without suspicious features.
This could very well be an enchondroma.
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).
A chondrosarcoma was diagnosed at biopsy.

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Here a 44-year old male with a mixed lytic and sclerotic mass arising from the fifth metacarpal bone.
There are calcified strands within the soft tissues.

T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with ex-
145
tension of a lobulated soft tissue mass.

Diagnosis: chondrosarcoma grade 2

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Here a 44-year old male with a mixed lytic and sclerotic mass arising from the fifth metacarpal bone.
There are calcified strands within the soft tissues.

T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with ex-
tension of a lobulated soft tissue mass.

Diagnosis: chondrosarcoma grade 2

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Here a chondrosarcoma of the left iliac bone.

Because of the large dimensions with soft tissue extension on plain radiograph and axial T2-weighted MR im-
age, a high grade chondrosarcoma was suspected.

Biopsy showed grade 2 chondroarcoma.

Continue with the bone scan.

147

Intense uptake on bone scintigraphy as we would expect in high grade chondrosarcoma.

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Here a chondrosarcoma of the left iliac bone.

Because of the large dimensions with soft tissue extension on plain radiograph and axial T2-weighted MR im-
age, a high grade chondrosarcoma was suspected.

Biopsy showed grade 2 chondroarcoma.

Continue with the bone scan.

Intense uptake on bone scintigraphy as we would expect in high grade chondrosarcoma.

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149

Chondrosarcoma in humeral head and sternum

Here two other lesions in different patients that proved to be chondrosarcoma.

The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging find-
ings.
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.

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Chondrosarcoma in humeral head and sternum

Here two other lesions in different patients that proved to be chondrosarcoma.

The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging find-
ings.
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.

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Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and
sclerotic lesion of the distal femoral diaphysis.
Notice the homogeneous thickening of the cortical bone.
There are no calcifications.
The MR image shows that the lesion has lobulated contours and nodular enhancement. 151

The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a
low-grade chondrosarcoma.
A high grade chondrosarcoma must be considered in the differential diagnosis.

Biopsy revealed dedifferentiated chondrosarcoma.

Peripheral chondrosarcoma

Key facts
Accounts for 8% of all chondrosaromas.
Prevalence of 3-5% in patients with hereditary multiple osteohondromas.
Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common.
Consider peripheral chondrosaroma in growing osteochondromas with or without pain after closure of the
physeal plate.

Radiographic or CT features that suggest malignancy:

growth of osteohondroma in skeletally mature patients
irregular or indistinct surface of lesions
erosion or destruction of adjacent bone
soft tissue mass with scattered or irregular calcifications
Use MRI with water-sensitive sequence (T2 FS) to determine cartilage cap thickness.
Consider progression of osteohondroma to chondrosarcoma when cartilage cap measures > 10 mm.

Click here for more examples of chondrosarcoma.

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Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and
sclerotic lesion of the distal femoral diaphysis.
Notice the homogeneous thickening of the cortical bone.
There are no calcifications.
The MR image shows that the lesion has lobulated contours and nodular enhancement.
The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a
low-grade chondrosarcoma.
A high grade chondrosarcoma must be considered in the differential diagnosis.

Biopsy revealed dedifferentiated chondrosarcoma.

Peripheral chondrosarcoma

Key facts
Accounts for 8% of all chondrosaromas.
Prevalence of 3-5% in patients with hereditary multiple osteohondromas.
Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common.
Consider peripheral chondrosaroma in growing osteochondromas with or without pain after closure of the
physeal plate.

Radiographic or CT features that suggest malignancy:

growth of osteohondroma in skeletally mature patients
irregular or indistinct surface of lesions
erosion or destruction of adjacent bone
soft tissue mass with scattered or irregular calcifications
Use MRI with water-sensitive sequence (T2 FS) to determine cartilage cap thickness.
Consider progression of osteohondroma to chondrosarcoma when cartilage cap measures > 10 mm.

Click here for more examples of chondrosarcoma.

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Periosteal or juxtacortical chondrosarcoma

A juxtacortical chondrosarcoma has be considered in the differential diagnosis when a mineralized lesion ad-
jacent to the cortical bone is seen.

153
Here a partially calcified mass against the proximal humerus with involvement of the cortical bone on an axial
CT image.

T2-weighted MR image reveals a lobulated mass with high signal intensity.

The bone marrow compartment is not involved which is important for the surgical strategy.
A periosteal chondroma may have the same imaging characteristics, however, these are almost always much
smaller.

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Periosteal or juxtacortical chondrosarcoma

A juxtacortical chondrosarcoma has be considered in the differential diagnosis when a mineralized lesion ad-
jacent to the cortical bone is seen.

Here a partially calcified mass against the proximal humerus with involvement of the cortical bone on an axial
CT image.

T2-weighted MR image reveals a lobulated mass with high signal intensity.

The bone marrow compartment is not involved which is important for the surgical strategy.
A periosteal chondroma may have the same imaging characteristics, however, these are almost always much
smaller.

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Plain radiograph in another patient shows irreglar mineralized lesion with elevation of the periosteum and
cortical involvement. On the right T2-WI with FS of same patient.. The juxtacortical mass has a high SI and lob-
ulated contours. DD: juxtacortical chondrosarcoma, parosteal osteosarcoma.

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Enchondroma

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Plain radiograph in another patient shows irreglar mineralized lesion with elevation of the periosteum and
cortical involvement. On the right T2-WI with FS of same patient.. The juxtacortical mass has a high SI and lob-
ulated contours. DD: juxtacortical chondrosarcoma, parosteal osteosarcoma.

Enchondroma

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Most commonly encountered bone tumor in the small bones of the hand and foot.

Here on a radiograph the typical calcifications in the chondroid matrix of an enchondroma.

Notice how easily MRI depicts these lesions. 157
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.
Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in
patients who have a MRI or bone scan for other reasons.

Click here for more examples of enchondromas.

Eosinophilic granuloma

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Most commonly encountered bone tumor in the small bones of the hand and foot.

Here on a radiograph the typical calcifications in the chondroid matrix of an enchondroma.

Notice how easily MRI depicts these lesions.
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.
Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in
patients who have a MRI or bone scan for other reasons.

Click here for more examples of enchondromas.

Eosinophilic granuloma

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159

key facts:
Typically presents as a lytic lesion in a flat bone, vertebra or diaphysis of long bone.
May show extinction and become sclerotic and indolent,.
MR usually shows a large amount of reactive changes in bone and soft tissue.
In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema.
Eosinophilic granuloma like osteomyelitis, can be a serious mimicker of malignancy (particularly Ewing
sarcoma).

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key facts:
Typically presents as a lytic lesion in a flat bone, vertebra or diaphysis of long bone.
May show extinction and become sclerotic and indolent,.
MR usually shows a large amount of reactive changes in bone and soft tissue.
In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema.
Eosinophilic granuloma like osteomyelitis, can be a serious mimicker of malignancy (particularly Ewing
sarcoma). 160

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Should be included in the differential diagnosis of young patient with multiple lucent lesions
(Langerhans cell histiocytosis).

Eosinophilic granuloma as sclerotic lesion in the clavicle.

161
This image is of a 20 year old patient with a sclerotic expansile lesion in the clavicle.
Notice that there are small areas of ill-defined osteolysis.
In an older patient one should first consider an osteoblastic metastasis.
If the patient had fever and a proper clinical setting, osteomyelitis would be in the differential diagnosis.

Click here for more examples of eosinophilic granuloma.

Fibrous dysplasia

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Should be included in the differential diagnosis of young patient with multiple lucent lesions
(Langerhans cell histiocytosis).

Eosinophilic granuloma as sclerotic lesion in the clavicle.

This image is of a 20 year old patient with a sclerotic expansile lesion in the clavicle.
Notice that there are small areas of ill-defined osteolysis.
In an older patient one should first consider an osteoblastic metastasis.
If the patient had fever and a proper clinical setting, osteomyelitis would be in the differential diagnosis.

Click here for more examples of eosinophilic granuloma.

Fibrous dysplasia

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Fibrous dysplasia

FD is often purely lytic, but may have a groundglass appearance as the matrix calcifies.
Ossifications or calcifications can be present in variable amounts.
163
Here a rather wel-defined eccentric lesion which is predominantly sclerotic.

The differential diagnosis includes:

Fibro-osseous lesion like fibrous dysplasia.
Non-ossifying fibroma which has been filled in.
Adamantinoma in case of a sclerotic lesion with several lucencies of the tibia in a young patient.

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Fibrous dysplasia

FD is often purely lytic, but may have a groundglass appearance as the matrix calcifies.
Ossifications or calcifications can be present in variable amounts.

Here a rather wel-defined eccentric lesion which is predominantly sclerotic.

The differential diagnosis includes:

Fibro-osseous lesion like fibrous dysplasia.
Non-ossifying fibroma which has been filled in.
Adamantinoma in case of a sclerotic lesion with several lucencies of the tibia in a young patient.

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165

Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone.

The diagnosis was fibrous dysplasia.
DD: old SBC.

Bone scintigraphy can be either negative or show limited uptake.

The signal intensity on MR depends on the amount of calcifications and ossifications and fibrous tissue (low
SI) and cystic components (high SI on T2).

Fibrous dysplasia can be monostotic or polyostotic.

Usually it is a lesion of childhood or young adults. Not infrequently encountered as coincidental finding at
later age.

Central location most common with some expansion and cortical thinning

Click here for more detailed information about fibrous dysplasia.

Melorrheostosis

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Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone.

The diagnosis was fibrous dysplasia.
DD: old SBC.

Bone scintigraphy can be either negative or show limited uptake.

The signal intensity on MR depends on the amount of calcifications and ossifications and fibrous tissue (low
SI) and cystic components (high SI on T2).

Fibrous dysplasia can be monostotic or polyostotic.

Usually it is a lesion of childhood or young adults. Not infrequently encountered as coincidental finding at
later age.

Central location most common with some expansion and cortical thinning

Click here for more detailed information about fibrous dysplasia.

Melorrheostosis

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Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner
surface of cortical bone.

Usually one bone is involved.

The epiphysis, metaphysis and diaphysis may be involved. 167
Usually new bone is added to one side of the cortex only.
Complete envelopment may occur.

Here Melorrheostosis of the ulna with the appearance of candle wax.

A surface osteosarcoma could be considered in the differential diagnosis

Axial T1-weighted MR image shows homogeneous low signal intensity due to the compact bone apposition.

Click here for more examples.

Metastases

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Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner
surface of cortical bone.

Usually one bone is involved.

The epiphysis, metaphysis and diaphysis may be involved.
Usually new bone is added to one side of the cortex only.
Complete envelopment may occur.

Here Melorrheostosis of the ulna with the appearance of candle wax.

A surface osteosarcoma could be considered in the differential diagnosis

Axial T1-weighted MR image shows homogeneous low signal intensity due to the compact bone apposition.

Click here for more examples.

Metastases

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key facts
Sclerotic osteoblastic metastases must be included in the differential diagnosis of any sclerotic bone
lesion in a patient > 40 years.
Most commonly originate from prostate and breast cancer and less frequently from lung cancer,
lymphoma or carcinoid.
In breast cancer, metastases may present as lytic lesions that may become sclerotic expressing a
favourable response to chemotherapy.
Here images of a patient with prostate cancer.
Notice the numerous predominantly osteoblastic metastases. 169

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key facts
Sclerotic osteoblastic metastases must be included in the differential diagnosis of any sclerotic bone
lesion in a patient > 40 years.
Most commonly originate from prostate and breast cancer and less frequently from lung cancer,
lymphoma or carcinoid.
In breast cancer, metastases may present as lytic lesions that may become sclerotic expressing a
favourable response to chemotherapy.
Here images of a patient with prostate cancer.
Notice the numerous predominantly osteoblastic metastases.

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171

Here images of a patient with breast cancer.

There is a metastasis, which presents as a subtle sclerotic lesion in the humerus metaphysis.

This could be an osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy.

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Here images of a patient with breast cancer.

There is a metastasis, which presents as a subtle sclerotic lesion in the humerus metaphysis.

This could be an osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy.

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173

Osteoblastic metastases (2)

Here a radiograph of the pelvis with a barely visible osteoblastic metastasis in the left iliac bone (blue arrow).
Notice that CT depicts these lesions far better (red arrows).

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Osteoblastic metastases (2)

Here a radiograph of the pelvis with a barely visible osteoblastic metastasis in the left iliac bone (blue arrow).
Notice that CT depicts these lesions far better (red arrows).

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Here CT-images of a patient with prostate cancer. 175

Notice the numerous ill-defined osteoblastic metastases.

Non-ossifying fibroma

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Here CT-images of a patient with prostate cancer.

Notice the numerous ill-defined osteoblastic metastases.

Non-ossifying fibroma

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Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion.
Typically a NOF presents as an eccentric well-defined lytic lesion, usually found as a coincidental finding.
These lesions usually regress spontaneously and may then become sclerotic.

Other benign lesions, like solitary bone cyst, fibrous dysplasia, chondroblastoma and other benign bone tu-
mors may become inert and may also become sclerotic.

The images show on the left a typical osteolytic NOF with a sharp sclerotic border.
The image on the right is of a different patient who has an old NOF that shows complete fill in.

Click here for more detailed information about NOF.

177

Here an incidental finding of several eccentric sclerotic lesions of the distal femur.

These are inert filled-in non-ossifying fibromas.

No further examination is needed.

Osteochondroma

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Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion.
Typically a NOF presents as an eccentric well-defined lytic lesion, usually found as a coincidental finding.
These lesions usually regress spontaneously and may then become sclerotic.

Other benign lesions, like solitary bone cyst, fibrous dysplasia, chondroblastoma and other benign bone tu-
mors may become inert and may also become sclerotic.

The images show on the left a typical osteolytic NOF with a sharp sclerotic border.
The image on the right is of a different patient who has an old NOF that shows complete fill in.

Click here for more detailed information about NOF.

Here an incidental finding of several eccentric sclerotic lesions of the distal femur.

These are inert filled-in non-ossifying fibromas.

No further examination is needed.

Osteochondroma

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Osteochondroma is a bony protrusion covered by a cartilaginous cap.

Growth of the osteochondroma takes place in the cap, corresponding with normal enchondral growth at the
growth plates. 179

Accordingly, growth of osteochondromas is allowed until a patient reaches adulthood and the physeal plates
are closed.

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.

Here a patient with a broad-based osteochondroma.

Notice that the cortical bone extends into the lesion.

This feature differentiates it from a juxtacortical tumor.

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Osteochondroma is a bony protrusion covered by a cartilaginous cap.

Growth of the osteochondroma takes place in the cap, corresponding with normal enchondral growth at the
growth plates.
Accordingly, growth of osteochondromas is allowed until a patient reaches adulthood and the physeal plates
are closed.

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.

Here a patient with a broad-based osteochondroma.

Notice that the cortical bone extends into the lesion.

This feature differentiates it from a juxtacortical tumor.

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Here a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the
lesion.
Notice the lytic peripheral part with subtle calcifications.
This part corresponds to a zone of high SI on T2-WI with FS on the right.
This represents a thick cartilage cap. 181
This is an example of progression of an osteochondroma to a peripheral chondrosarcoma.

Malignant transformation

Radiographic features that should raise the suspicion of malignant transformation on plain radiographs or CT
include:
Growth of osteochondroma in skeletally mature patient
Irregular or indistinct surface of lesions
focal lucent regions in interior of lesions
erosion or destruction of adjacent bone
presence of soft tissue mass with scattered or irregular calcifications

Osteoid osteoma

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Here a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the
lesion.
Notice the lytic peripheral part with subtle calcifications.
This part corresponds to a zone of high SI on T2-WI with FS on the right.
This represents a thick cartilage cap.
This is an example of progression of an osteochondroma to a peripheral chondrosarcoma.

Malignant transformation

Radiographic features that should raise the suspicion of malignant transformation on plain radiographs or CT
include:
Growth of osteochondroma in skeletally mature patient
Irregular or indistinct surface of lesions
focal lucent regions in interior of lesions
erosion or destruction of adjacent bone
presence of soft tissue mass with scattered or irregular calcifications

Osteoid osteoma

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Osteoid osteoma

key facts:
Small osteolytic lesion (up to 1.5 cm) with or without central calcification.
Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which
may obscure the central nidus.
In juxta-articular localisation, the reactive sclerosis may be absent.
Localisation: femur, tibia, hands and feet, spine (arch).
Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture
183
Here the reactive sclerosis is the most obvious finding on the X-ray.
There is reactive sclerosis with a nidus that is barely visible on the radiograph (blue arrow), but clearly visible
on the CT (red arrows).

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.

MRI also may detect the nidus, combined with abundant bone marrow and soft tissue edema.

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Osteoid osteoma

key facts:
Small osteolytic lesion (up to 1.5 cm) with or without central calcification.
Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which
may obscure the central nidus.
In juxta-articular localisation, the reactive sclerosis may be absent.
Localisation: femur, tibia, hands and feet, spine (arch).
Axial imaging for differentiation from Brodie abscess, osteoblastoma, stress fracture
Here the reactive sclerosis is the most obvious finding on the X-ray.
There is reactive sclerosis with a nidus that is barely visible on the radiograph (blue arrow), but clearly visible
on the CT (red arrows).

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.

MRI also may detect the nidus, combined with abundant bone marrow and soft tissue edema.

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Osteoid osteoma (2)

In most cases of osteoid osteoma the radiographic appearance is determined by the reactive sclerosis.
In some cases however the osteolytic nidus can be visible on the radiograph (figure).

Osteoma 185

key facts

Osteoma consists of densely compact bone.

It is most commonly located in the outer table of the neurocranium or in a paranasal sinus.

Osteomyelitis

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Osteoid osteoma (2)

In most cases of osteoid osteoma the radiographic appearance is determined by the reactive sclerosis.
In some cases however the osteolytic nidus can be visible on the radiograph (figure).

Osteoma

key facts

Osteoma consists of densely compact bone.

It is most commonly located in the outer table of the neurocranium or in a paranasal sinus.

Osteomyelitis

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187

Osteomyelitis is a mimicker of various benign and malignant bone tumors and reactive processes that may
be accompanied by reactive sclerosis.
Acute osteomyelitis is characterised by osteolysis.

Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis.
A periosteal reaction with or without layering may be present.
Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of
the bone.

Here an image of a patient with chronic osteomyelitis.

Centrally there is an ill-defined osteolytic area.
The major part of the lesion consists of reactive sclerosis.

Osteosarcoma

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Osteomyelitis is a mimicker of various benign and malignant bone tumors and reactive processes that may
be accompanied by reactive sclerosis.
Acute osteomyelitis is characterised by osteolysis.

Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis.
A periosteal reaction with or without layering may be present.
Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of
the bone.

Here an image of a patient with chronic osteomyelitis.

Centrally there is an ill-defined osteolytic area.
The major part of the lesion consists of reactive sclerosis.

Osteosarcoma

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189

Key facts
2nd most common primary bone tumor and highly malignant.
50% around the knee.
Presentation: pain, mass, pathologic fracture.
Sclerosis is present from either tumor new bone formation or reactive sclerosis.
Age: most commonly seen in 10-25 years, but may occur in older patients.
Plain films typically reveal lesions with moth-eaten or permeative pattern of the transition zone with
irregular cortical destruction and an interrupted periosteal reaction with soft tissue extension.
A periosteal reaction known as Codman's triangle appears as tumor elevates periosteum from
underlying bone. Cortical soft tissue extension may produce radiating spicules of bone called sunray
appearance.

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Key facts
2nd most common primary bone tumor and highly malignant.
50% around the knee.
Presentation: pain, mass, pathologic fracture.
Sclerosis is present from either tumor new bone formation or reactive sclerosis.
Age: most commonly seen in 10-25 years, but may occur in older patients.
Plain films typically reveal lesions with moth-eaten or permeative pattern of the transition zone with
irregular cortical destruction and an interrupted periosteal reaction with soft tissue extension.
A periosteal reaction known as Codman's triangle appears as tumor elevates periosteum from
underlying bone. Cortical soft tissue extension may produce radiating spicules of bone called sunray
appearance.

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191
Osteosarcoma (2)
Here images of an osteosarcoma in the right femur.
It is barely visible within the bone, but an agressive periostitis is seen (arrow).
Continue with the MR-images.

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Osteosarcoma (2)
Here images of an osteosarcoma in the right femur.
It is barely visible within the bone, but an agressive periostitis is seen (arrow).
Continue with the MR-images.

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The sagittal T1WI and Gd-enhanced T1W-image with fatsat show a large tumor mass infiltrating a large por-
193
tion of the distal femur and extending through the cortex into the soft tissues.

Parosteal osteosarcoma

Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone.
It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow.
It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur.

Ossification in parosteal osteosaroma is usually more mature in the center than at the periphery. This is op-
posed to myositis ossificans which may present very close to the cortical bone, but maturation develops from
the center to the periphery.

Paget's disease of bone

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The sagittal T1WI and Gd-enhanced T1W-image with fatsat show a large tumor mass infiltrating a large por-
tion of the distal femur and extending through the cortex into the soft tissues.

Parosteal osteosarcoma

Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone.
It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow.
It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur.

Ossification in parosteal osteosaroma is usually more mature in the center than at the periphery. This is op-
posed to myositis ossificans which may present very close to the cortical bone, but maturation develops from
the center to the periphery.

Paget's disease of bone

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Paget disease is a chronic disorder of unknown origin with increased breakdown of bone and formation of
disorganized new bone.
The most common appearance is the mixed lytic-sclerotic.
195
In this case we see the pathognomonic triad of bone expansion, cortical thickening and trabecular bone thick-
ening in the mixed lytic and sclerotic phase of Paget's disease of right hemipelvis.

Reactive processes

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Paget disease is a chronic disorder of unknown origin with increased breakdown of bone and formation of
disorganized new bone.
The most common appearance is the mixed lytic-sclerotic.

In this case we see the pathognomonic triad of bone expansion, cortical thickening and trabecular bone thick-
ening in the mixed lytic and sclerotic phase of Paget's disease of right hemipelvis.

Reactive processes

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Myositis ossificans

Here a patient with a mineralized mass in the soft tissues.

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.
197

Contrast-enhanced T1-weighted MR image demonstrates heterogeneous enhancement of the mass with ex-
tensive surrounding edema.
This is consistent with the diagnosis of a reactive process like myositis ossificans.

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Myositis ossificans

Here a patient with a mineralized mass in the soft tissues.

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.

Contrast-enhanced T1-weighted MR image demonstrates heterogeneous enhancement of the mass with ex-
tensive surrounding edema.
This is consistent with the diagnosis of a reactive process like myositis ossificans.

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199
Stress fractures

Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones.
Usually stress fractures are easy to recognize.
Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the
site of a bone tumor.

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Stress fractures

Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones.
Usually stress fractures are easy to recognize.
Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the
site of a bone tumor.

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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.

201

Here an example of a patient with a stress fracture of the distal fibula.

Coronal MR image demonstrates subtle low intensity line representing the fracture.

Differential diagnosis based on the periosteal reaction and the extensive edema:
Osteomyelitis
Eosinophilic granuloma
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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.

Here an example of a patient with a stress fracture of the distal fibula.

Coronal MR image demonstrates subtle low intensity line representing the fracture.

Differential diagnosis based on the periosteal reaction and the extensive edema:
Osteomyelitis
Eosinophilic granuloma 202

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Posttraumatic calcifications

Here a patient with a juxtacortical sclerotic mass of the proximal humerus (left).
This proved to be a reactive calcification secondary to trauma. 203

Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven
parosteal osteosarcoma.

This shows that differentiating a tumor from a reactive proces scan be quite difficult in some cases.
When a reactive process is more likely based on history and imaging features, follow-up is sometimes still
needed.

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Posttraumatic calcifications

Here a patient with a juxtacortical sclerotic mass of the proximal humerus (left).
This proved to be a reactive calcification secondary to trauma.

Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven
parosteal osteosarcoma.

This shows that differentiating a tumor from a reactive proces scan be quite difficult in some cases.
When a reactive process is more likely based on history and imaging features, follow-up is sometimes still
needed.

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Subungual exostoses

Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most
commonly of the hallux.
These lesions are not osteochondromas, but consist of reactive cartilage metaplasia.

The radiographic appearance and location are typical. 205

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Subungual exostoses

Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most
commonly of the hallux.
These lesions are not osteochondromas, but consist of reactive cartilage metaplasia.

The radiographic appearance and location are typical.

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Nora's lesion

Here two patients with a bizar parosteal osteochondromatous proliferation (BPOP), also called Nora's lesion.
This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet
(75%).
The cortical bone and bone marrow compartment are not involved.
Rapid growth of the mineralized mass is not uncommon.

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms
W. B. Saunders company 1995
2. Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging
by Mark J. Kransdorf and Donald E. Sweet
AJR 1995;164:573-580
3. Sclerotic Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
4. Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography
by Theodore Miller March 2008 Radiology, 246, 662-674
5. [Link]
by Henri de Groot
6. Parosteal sarcoma (pdf)
by Jack Edeiken
7. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful
Are We?
by Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K.
Fishman.
AJR 2005; 185:915-924
8. Radiologic Atlas of Bone Tumors
by Mulder JD et al 207
2 ed. Amsterdam: Elsevier; 1993.

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

[Link] 42/42
6/3/22, 3:10 PM The Radiology Assistant : Sclerotic tumors

Nora's lesion

Here two patients with a bizar parosteal osteochondromatous proliferation (BPOP), also called Nora's lesion.
This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet
(75%).
The cortical bone and bone marrow compartment are not involved.
Rapid growth of the mineralized mass is not uncommon.

1. Fundamentals of Skeletal Radiology, second edition

by Clyde A. Helms
W. B. Saunders company 1995
2. Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging
by Mark J. Kransdorf and Donald E. Sweet
AJR 1995;164:573-580
3. Sclerotic Lesions of Bone
Online teaching by the Musculoskeletal Radiology academic section of the University of Washington
4. Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography
by Theodore Miller March 2008 Radiology, 246, 662-674
5. [Link]
by Henri de Groot
6. Parosteal sarcoma (pdf)
by Jack Edeiken
7. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful
Are We?
by Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K.
Fishman.
AJR 2005; 185:915-924
8. Radiologic Atlas of Bone Tumors
by Mulder JD et al
2 ed. Amsterdam: Elsevier; 1993.

Guidelines for authors About Us Disclaimer Charity Privacy and cookie statement Contact us Search

208

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