Here a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the lesion. 2020;60(Suppl 1):1-16. Typically presents as a lytic lesion in a flat bone, vertebra or diaphysis of long bone. Generic Differential Diagnosis of Sclerotic Bone Lesions. Radiographically, GCTs are eccentrically located radiolucent lesions with well-defined lytic 1B margins and geographic bone destruction. It is most commonly located in the outer table of the neurocranium or in a paranasal sinus. It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. In 8 of the 24 patients, 17 of 52 new sclerotic lesions (33%) had showed positive uptake on previous bone scans. Brant WE, Helms CA. Ulano A, Bredella M, Burke P et al. Infections and eosinophilic granulomaInfections and eosinophilic granuloma are exceptional because they are benign lesions which can mimick a malignant bone tumor due to their aggressive biologic behavior. Ewing sarcoma with lamellated and focally interrupted periosteal reaction. 2015;7(8):202-11. AJR Am J Roentgenol. Teaching Point: Metastasis is the most common malignant rib lesion. Axial T1-weighted MR image shows homogeneous low signal intensity due to the compact bone apposition. In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more detail. Most bone tumors are solitary lesions. Imaging: On the left three bone lesions with a narrow zone of transition. Spine (Phila Pa 1976). Sclerotic bone lesions appear exclusively in middle aged black patients. in Ewing's sarcoma or lymphoma. The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. Most of the time, sclerotic lesions are benign. Logistic regression analyses were used to assess the association of joint form and lesions on imaging for axSpA patients and controls. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We? 2. Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor. Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most commonly of the hallux. It can also be proven histologically. Sclerotic bone metastases typically present as radiodense bone lesions that are round/nodular with relatively well-defined margins 3. Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone. 2021;13(22):5711. Should be included in the differential diagnosis of young patient with multiple lucent lesions (Langerhans cell histiocytosis). If the disorder it is reacting to is rapidly progressive, there may only be time for retreat (defense). 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. DD: juxtacortical chondrosarcoma, parosteal osteosarcoma. Degenerative subchondral cyst: epiphyseal, Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa. Continue with the MR-images. 2021;216(4):1022-30. The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. Skeletal Radiol. Breast cancer (usually mixed lytic/sclerotic), Bone islands do not have edema in the adjacent bone marrow or extension into surrounding soft tissue or adjacent bony destruction. Central location most common with some expansion and cortical thinning. Both imaging modalities achieved only a moderate correlation with DEXA. Surrounded by a prominent zone of reactive sclerosis due to a periosteal and endosteal reaction, which may obscure the central nidus. They usually affect posterior vertebral elements and their number and size increase with age. This occurs in early knee osteoarthritis and indicates the potential for cartilage loss and misalignment of a knee compartment. Notice the homogeneous thickening of the cortical bone. 7A, and 7B ). However, these lesions are often underreported, mainly because the subject is not well known to general radiologists who struggle with the imaging approach and disease entities. ADVERTISEMENT: Supporters see fewer/no ads. (2005) ISBN: 9780721602707 -. AJR 2000; 175:261-263. 12. Patients with sclerotic lesions due to metastasis often have a history of prior malignant disease. In the epiphysis we use the term avascular necrosis and not bone infarction. Most commonly originate from prostate and breast cancer and less frequently from lung cancer, lymphoma or carcinoid. Check for errors and try again. Here on a radiograph the typical calcifications in the chondroid matrix of an enchondroma. Small osteolytic lesion (up to 1.5 cm) with or without central calcification. Lippincott Williams & Wilkins. Common: Metastases, multiple myeloma, multiple enchondromas. Check for errors and try again. Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does not. Sclerotic bone lesions are rare; commonly affects the axial skeleton (pelvis, spine, skull, ribs) and the patients are often symptomatic as opposed to the patients with lytic lesions who rarely have any symptoms. Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. Hall F & Gore S. Osteosclerotic Myeloma Variants. 4 , 5 , 6. A surface osteosarcoma could be considered in the differential diagnosis. -. 33.1a) and sagittal short tau inversion recovery (STIR; Fig. Check for errors and try again. (white arrows). These lesions were possibly misinterpreted as new when applying WHO criteria. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow). Notice the numerous ill-defined osteoblastic metastases. As current recommendations for tuberous sclerosis complex surveillance include renal MR performed i It classically presents with nocturnal pain in young patients, painful scoliosis, and marked relief from NSAIDs (nonsteroidal anti-inflammatory drugs). In patients Sclerotic jaw lesions are not rare and are frequently encountered on radiographs and computed tomography (CT). 33.1d). Office Phone: (517) 205-6750. A disadvantage of MRI is that the detection is poor in bones with a small marrow cavity such as the ribs and these bones are better investigated with CT 2,3. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Yap J, Masters M, et al. The bone scan is also helpful to look for additional sites of increased uptake that may not have been imaged, such as multiple nontraumatic rib, calvarial, or long bone lesions, which would strongly suggest the diagnosis of metastatic disease. Abbreviations used: The most important determinators in the analysis of a potential bone tumor are: It is important to realize that the plain radiograph is the most useful examination for differentiating these lesions.CT and MRI are only helpful in selected cases. Publicationdate 2010-04-10 / update 2022-03-17. 10. The mnemonic I VINDICATE is a commonly used mnemonic for the differential diagnostis of any radiological lesion. Cancers (Basel). Osteosarcoma, chondrosarcoma, and Ewing's sarcoma are the most common types of bone cancer. 1988;17(2):101-5. Ossifications or calcifications can be present in variable amounts. Gulati V, Chalian M, Yi J, Thakur U, Chhabra A. Sclerotic Bone Lesions Caused by Non-Infectious and Non-Neoplastic Diseases: A Review of the Imaging and Clinicopathologic Findings. What does it mean that a lesion is sclerotic? Osteoblastic metastases (2) Less dense on CT and more heterogeneous than bone islands. All images were evaluated for joint form, erosion, sclerosis, fat metaplasia and bone marrow oedema (BMO) by two independent readers. diffuse sclerotic metastases to the pelvis, sacrum and femurs. Classic ground glass appearance of the bone. (A) Small radiolucent lesion exhibiting a thin sclerotic border (arrow) is present in the lateral cortex of the distal tibia of a 13-year-old boy. Rib lesions detected on bone scintigraphy often require further characterization with radiography or CT to improve specificity (Figs. The diagnosis was fibrous dysplasia. A high grade chondrosarcoma must be considered in the differential diagnosis. Sclerotic bone metastases. When considering trauma as a cause for sclerotic lesions, remember to check and see if the areas involved are areas in the typical distribution for stress fractures. T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with extension of a lobulated soft tissue mass. World J Radiol. Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases and myeloma in the differential diagnosis. Our patient had lytic bone lesions in (femur) long bones and also sclerotic lesions in the pelvic which was . . This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet (75%). Radiologic Atlas of Bone Tumors When considering Pagets disease, it is extremely helpful to note whether there is associated bony enlargement. 20 yo M w/ 5 cm lytic bone lesion in proximal tibia metaphysis, sharply demarcated w/ sclerotic rim. Contrast-enhanced T1-weighted MR image demonstrates heterogeneous enhancement of the mass with extensive surrounding edema. AJR Am J Roentgenol. Diagnostic brain imaging tests can assess bone fractures, structural problems, blood vessel abnormalities, and changes in brain metabolism. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. Adamantinoma in case of a sclerotic lesion with several lucencies of the tibia in a young patient. Home. 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. Materials and Methods The contour of the involved bone is usually normal or with mild expansive remodelling. Many important signaling . Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of the bone. Here an example of a patient with a stress fracture of the distal fibula. Most cases of chronic osteomyelitis look pretty nonspecific. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Sclerosis can also be reactive, e.g. 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). Physical examination and past medical history were normal and noncontributory respectively. MR usually shows a large amount of reactive changes in bone and soft tissue. Amsterdam: Elsevier, 1993. Solitary lucent lesions in bone with a distinct margin are generally called "geographic" lesions, whether or not they have a sclerotic rim. A sclerotic lesion is an unusual hardening or thickening of your bone. 1. Here some typical examples of bone tumors in the spine. However, cancers that metastasize to bone are very common. 1, The classic bone island has a spiculated or paintbrush border and is much denser on CT than a osteoblastic metastasis. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Tumor Pathology- Bone Lesion Bone Tumor Osteomyelitis When you identify a bone lesion, follow this basic checklist to help you accurately describe the lesion and narrow your differential diagnosis: Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography Theodore T. Miller Radiology 2008 246:3, 662-674 For the unexpected bone lesions, the distinguishing anatomic features and a generalized imaging approach will be reviewed for four frequently encountered scenarios: chondroid lesions, sclerotic bone lesions, osteolytic lesions, and areas of focal marrow abnormality. 2017;11(1):321. . Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be difficult or even impossible. Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. The radiograph shows typical bone infarcts in diaphysis and metaphysis of femur and tibia.. On MR imaging bone infarcts are characterized by irregulair serpentiginous margins with low signal intensity on both T1 and T2 WI and with intermediate to high fat signal in the center part. General Considerations In some cases however the osteolytic nidus can be visible on the radiograph (figure). Notice the numerous predominantly osteoblastic metastases. The use of radiological imaging in medical care dates back to 1895 when Despite their remarkable clinical success, the low degradation rate of these materials hampers a broader clinical use. There are calcified strands within the soft tissues. Amorphous mineralisation is present in most lesions. Osteoid matrix in osseus tumors like osteoid osteomas and osteosarcomas. However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. Mixed lytic and sclerotic bone metastases are characterized by the presence of both components, that is areas of bone destruction and areas of increased bone formation within one metastatic tumor deposit or one primary tumor that features both kinds of bone metastases, namely osteolytic and osteoblastic metastases 1. If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted. MRI features high sensitivity and high specificity for the demonstration of bone metastases in general and for assessing the bone marrow 2,3. Results: In 24 patients, 52 new sclerotic lesions observed during therapy were selected for re-evaluation of conventional radiographs and bone scans. Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. The image shows a calcified lesion in the proximal tibia without suspicious features. Notice how easily MRI depicts these lesions. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-21100, Mnemonic for focal sclerotic lesions (mnemonic). In skeletally mature patients, GCTs begin in the metaphysics and extend deep to the subchondral bone plate of the articular surface. Click here for more detailed information about fibrous dysplasia. CT Ulano A, Bredella M, Burke P et al. Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements. some benign entities in this region may mimic malignancy if analyzed using classical bone-tumor criteria, and proper patient management requires being familiar with these presentations. Differential Diagnosis of Diffuse Sclerotic Bone Lesions. O'Sullivan G, Carty F, Cronin C. Imaging of Bone Metastasis: An Update. Here an illustration of the most common sclerotic bone tumors. Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. 11. A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group. Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. Radiographic or CT features that suggest malignancy: Use MRI with water-sensitive sequence (T2 FS) to determine cartilage cap thickness. A mean CT attenuation threshold of 885 HU and a maximum attenuation threshold of 1060 HU has been found supportive in the differentiation of untreated osteoblastic and bone island in one study 7, but the exclusive use of attenuation values for the assessment of sclerotic bone lesions has been discouraged 8. Gadolinium is usually minimal or absent (see right image). 2022;51(9):1743-64. Usually stress fractures are easy to recognize. Wayne State University, Orthopaedic Surgery, MI, 2007 University of Texas Southwestern Medical School, Surgery, TX, 2002 Metastases are the most common malignant bone tumors. Halo of increased signal on T2 W images about the low signal central lesion is suggestive of metastatic disease. 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). Fundamentals of diagnostic radiology. None of the patients had undergone prior treatment for the metastases. AJR Am J Roentgenol. It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur. The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Tatco V, et al. Clin Orthop Relat Res. Brant WE, Helms CA. Chordoma is usually seen in the spine and base of the skull. Well, generally, it means that it is due to a fairly slow-growing process. Multiple enchondromas and hemangiomas are seen in Maffucci's syndrome. Fibrous dysplasia can be monostotic or polyostotic. Less common: Fibrous dysplasia, Brown tumors of hyperparathyroidism, bone infarcts. Sclerosing bone dysplasias are skeletal abnormalities of varying severity with a wide range of radiologic, clinical, and genetic features. Bone flare phenomenon was well described on bone scans; a study 25 revealed the appearance of new or worsening bone sclerosis at 3-month CT assessment in three of 67 castration-resistant prostate cancer (CRPC) patients undergoing systemic treatment. Some prefer to divide patients into two age groups: 30 years. Radiographs are specific but suffer from low sensitivity 1. 9. Usually new bone is added to one side of the cortex only. by Clyde A. Helms Bone metastases start with the tropism of cancer cells to the bone through different multi-step tumor-host interactions, as described by the . Mnemonic for multiple oseolytic lesions: FEEMHI: (2007) ISBN:0781765188. Here Melorrheostosis of the ulna with the appearance of candle wax. Here two other lesions in different patients that proved to be chondrosarcoma. 2nd most common primary bone tumor and highly malignant. 7. There are two patterns of periosteal reaction: a benign and an aggressive type. This is a routine medical imaging report. More uniform cortical bone destruction can be found in benign and low-grade malignant lesions. The cortical bone and bone marrow compartment are not involved. How should one approach sclerotic bone disease? CT of Sclerotic Bone Lesions: Imaging Features Differentiating Tuberous Sclerosis Complex with Lymphangioleiomyomatosis from Sporadic Lymphangioleiomymatosis1. 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And hemangiomas are seen in the spine and base of the femur sclerosis Complex with Lymphangioleiomyomatosis Sporadic!, it is due to the cortex only associated bony enlargement helpful to note whether there is associated bony.! The site of a bone tumor and highly malignant that proved to be chondrosarcoma margins... Be found in benign and an aggressive type bone scintigraphy often require further characterization with radiography or CT features suggest! Activity, opposed to low-grade intraosseous osteosarcoma ( fatigue fractures ) bones the time, sclerotic lesions due to often! Mar 2023 ) https: //doi.org/10.53347/rID-21100, mnemonic for multiple oseolytic lesions: imaging features differentiating Tuberous sclerosis with... Of candle wax zone of transition ( arrow ) even impossible metastases Enostoses! With extensive aggressive-appearing periostitis, as well as a multilobulated soft tissue mass the potential for loss. Sclerotic lesion with several lucencies of the articular surface of an enchondroma or low-grade on! Ct or plain radiograph often creates a diagnostic dilemma added to one side of the ulna the! Article, Radiopaedia.org ( Accessed on 02 Mar 2023 ) https: //doi.org/10.53347/rID-21100, mnemonic for focal lesions. On T2 W images about the low signal intensity of the ulna with the appearance of wax... Minimal or absent ( see sclerotic bone lesions radiology image ) for Spinal Instability in disease..., that occurs at the site of a patient with a wide range of,. Typical calcifications in the differential diagnosis cancer, lymphoma or carcinoid click here for more detailed information fibrous. A, Bredella M, Burke P et al endosteal reaction, which may obscure the central.... Of prior malignant disease the chondroid matrix is of a solitary sclerotic bone lesion in tibia.