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The data on 98 new patients with O STEOBLASTOMA is a rare, benign er than 1 .5 cm, they were defined as oste-
osteoblastoma were studied. The primary bone tumor. It occurs oid osteoma. In 12 cases, the pathologists
clinical features of pain, scoliosis, most commonly in adolescents and were equivocal about the classification of
the tumor as osteoid osteoma on osteoblas-
and neurologic deficit were largely young adults in the 2nd and 3rd de-
toma. Consensus was reached between
consistent with those in previous cades of life (1,2). Approximately 60%
pathologists and radiologists by using cni-
reports. Osteoblastoma is usually a of the tumors occur in the spine and
teria such as initial size, size at follow-up
lytic lesion originating in the me- long tubular bones (1-3). The most examinations, and clinical history. In sev-
dulla of bones with matrix ossifica- frequent radiologic appearance is en of these 1 2 equivocal cases the size of
tion and mild surrounding sclerosis. that of a lytic lesion of bone, with or the lesion was less than 1 .5 cm on initial
Osteoblastoma of the spine demon- without matrix mineralization, sur- radiognaphs. They were nevertheless clas-
strated better tumor delineation in rounded by a narrow on broader zone sified as osteoblastoma because follow-up
the vertebrae, and a bony rim on the of sclerosis on, if expansive, a thin studies demonstrated growth to larger
soft-tissue side was seen less f me- bony shell (1-3). The strong nesem- than 1.5 cm. Furthermore, the nature of
the pain and the absence of reaction to sa-
quently than previously observed. blance between osteoblastoma and
licylates in these cases were more compat-
Osteoblastoma of the talus fre- osteoid osteoma can make it impossi-
ible with a diagnosis of osteoblastoma.
quently appears as a blister on the ble even for pathologists to distin-
With these criteria we studied 32 osteo-
surface of the bone and is accompa- guish these tumors based on histo- blastomas located in the vertebral col-
nied by osteoporosis. In the hands logic examination alone (1,4,5). The umn, 26 in the long tubular bones, 26 in
and feet, the radiographic appear- tumor easily recurs after incomplete the bones of hands and feet, and 14 in
ance is often very similar to that of surgical removal, but even incom- other locations. Also with these criteria,
aneurysmal bone cyst and giant cell plete curettage can effect a cure in a 1 87 cases of osteoid osteoma were exclud-
tumor. In the skull it strongly me- high percentage of cases (3). ed from this study. Another 21 cases of
We studied the case records of 98 cementoblastoma of the jaws were also
sembles a button sequestrum of
excluded from this review, although ac-
bone. The origin and extent of the new patients, a large collection of pa-
cording to the oral pathology literature
tumor, the presence of matrix mm- tients with this infrequent bone neo-
(6), they have considerable histologic
eralization, and tumor delineation plasm. The clinical and radiologic
similarities with osteoblastoma. Medical
depicted as a thin bony shell are of- findings, including 15 computed records were studied. In 94 of the 98 pa-
ten better appreciated on computed tomognaphic (CT) and three magnetic tients the clinical history and physical
tomographic (CT) scans. In addition, resonance (MR) imaging studies, are findings could be retrieved. Plain radio-
CT can demonstrate both edema and the subject of this report. graphs were available in all cases. In ad-
atrophy of the surrounding soft tis- dition, CT was performed on 15 patients,
sues. At magnetic resonance (MR) technetium-99m bone studies on 14 pa-
PATIENTS AND METHODS tients, angiography on six patients, and
imaging, osteoblastoma demon-
We studied the case records of 98 new MR imaging (0.5-T superconductive sys-
strates signal intensities similar to
patients with osteoblastoma. They were tem [Philips Medical Systems of North
those of other bone neoplasms. In America, Shelton, Conn]) on three pa-
addition to the advantages offered obtained from the files of the Nether-
lands Committee on Bone Tumors tients. Follow-up information was
by CT, MR imaging can help differ- present for 72 patients over a mean peri-
(NCBT), an advisory board of radiologists,
entiate tumor tissue from accompa- od of 43 months (range, 1-368 months).
pathologists, and clinicians concerned
flying edema. with the diagnosis and treatment of bone
tumors. Material for histologic examina-
RESULTS
Index terms: Bone neoplasms, diagnosis, tion was available in all cases. Lesions
30.3123, 40.3123 Neoplasms,
#{149} in infants and were classified as osteoblastoma based on
histologic evidence primarily. In addi-
Clinical and General Features
children Osteoblastoma,
#{149} 30.3123, 40.3123 #{149}
Spine, primary neoplasms, 30.3123 tion, size was the most important cniteri- The data on 64 male and 34 female
on. Lesions larger than 1 .5 cm in diameter patients were studied. Ages ranged
Radiology 1990; 175:783-790 were classified as osteoblastoma; if small- from 3 to 72 years (median, 16 years).
Ninety percent of the patients were be-
tween 6 and 30 years of age. The medi-
I From the Department of Diagnostic Radiology, University Hospital Leiden, Rijnsburgerweg 10,
2333 AA Leiden, The Netherlands. Received August 22, 1989; revision requested November 2; re-
vision received January 29, 1990; accepted February 21. Address reprint requests to H.M.K. Abbreviation: NCBT Netherlands Commit-
RSNA, 1990 tee on Bone Tumors.
783
an duration of complaints before the maining two tumors (6%) had their on-
diagnosis was made was 6 months gin in the vertebral body. Secondary
(range, 1 week to 72 months). The most extension into the vertebral body from
prominent complaint was a dull, local- lesions arising in the posterior ele-
ized, and gradually increasing pain ments occurred in nine cases (28%). On
that occurred in 93 (99%) of 94 patients. initial nadiographs the tumors were
Only seven patients (7.5%) indicated round or oval, ranging in size from 1 to
that this pain also interfered with 3 cm. In eight cases (25%) the lesion
sleep. None complained of pain occur- was entirely lucent. In 23 cases (72%)
ring predominantly at night. Relief of opacities were present in the tumor ma-
pain after administration of salicylates trix, and in one case (3%) bony ridges
was never mentioned. Swelling was were present. In 29 cases (91%) the le-
present in 27 of 94 patients (29%), spe- sion was well defined and surrounded
cifically when the lesion was near the by a sclerotic rim of variable thickness.
surface. In one case swelling (of the tib- In the remaining cases there was no
ia) was the most significant complaint. surrounding sclerosis or the contours
In six patients muscle wasting in a limb were moth eaten. In 30 cases (94%) the
was noticed. cortical bone was thinned or destroyed
Thirty-two cases (33%) of osteoblasto- due to an expansive growth of the tu-
ma occurred in the spine: 10 (31%) in mon. In 10 cases (31%) the tumor was
the cervical spine, 1 1 (34%) in the don- demarcated by a thin bone shell.
sal spine, 10 (31%) in the lumbar spine, In the long tubular bones, the tumor
and one (3%) in the sacrum. The medi- was located in the diaphysis in 15 of 26
an age in these patients was 16 years. cases (58%) and in the metaphysis in ii
a.
Scoliosis was seen in all 10 lumbar cases (42%). In 19 cases (73%) the lesion
(100%), three dorsal (27%), and two cem- was located in the proximal part of the
vical (20%) lesions (Fig 1). Scoliosis was bone and in the remaining seven (27%)
also present in two (of four) patients in the middle on distal end. In three in-
(50%) with an
osteoblastoma in the rib. stances (12%) the lesion originated in
In addition, neurologic deficits were the center of the bone, in 12 (46%) the
found in 12 patients with spinal lesions location was eccentric, and in 1 1 (42%)
(38%), ranging from mild muscle weak- the lesion was intracortical (Figs 2, 3).
ness to paraplegia. Restriction of mo- Twenty-four osteoblastomas (92%)
tion was found with seven (of 13) os- were seen as a round on oval lesion
teoblastomas in the femur (54%) but ranging in size from 1.5 to 2.5 cm. Only
was also present in six spinal (19%) and two (8%) were lobulated. In nine cases
two (of 16) talam (12%) locations. In one (35%) the lesion was entirely lucent,
patient with an osteoblastoma in the and in 17 (65%) matrix ossification was
fifth rib, remarkable findings included present. In 24 cases (92%) the lesion b.
profuse perspiration and hypenemia of was well defined with a usually thin Figure 1. Anteroposterior tomogram
the ipsilateral part of the chest, caused sclerotic rim. Two cases (8%) demon- (a) and CT scan (b) of the cervical spine with
by direct stimulation of the panaverte- stnated a moth-eaten contour. The con- osteoblastoma in the lateral part of C-4. Sco-
liosis with the convexity toward the affected
bral sympathetic chain. tex was partly or completely replaced
side and dense sclerosis with central lucency
Twenty-six of the 98 tumors (26%) oc- by tumor in 22 patients (85%). A solid
of the lateral mass are seen. Distinct muscle
curred in the long tubular bones; 13 of on lamellate periosteal reaction was
wasting and edema of the surrounding soft
the 26 (50%) occurred in the femur, five present in 20 lesions (77%). In addition, tissues are shown.
(19%) in the tibia, five (19%) in the hu- two of these demonstrated a thin shell
menus, two (7.7%) in the radius, and of reactive peniosteal bone. In another
one (3.8%) in the fibula. The median two patients a spiculated peniosteal me-
patient age in this group was 14 years. action could be appreciated. bones, or of the entire foot was seen at
In another 26 cases (26%) the tumor In the talus, all tumors originated in presentation or later in the course of
was located in the bones of the hands the dorsal part of the neck. On initial the disease in seven patients (44%) (Fig
and feet. Sixteen (62%) of these onigi- radiographs the lesion appeared as a 4). The single osteoblastoma of the cal-
nated in the talus; two each (7.7%) in round on oval lucency, 1-2 cm in diam- caneus was eccentric, lytic with small
the scaphoid, metacarpal bones, meta- eten, eccentric in the marrow (10 cases, calcifications in the center, and sun-
tarsal bones, and phalanges of the feet; 62%) or in the cortex (six cases, 38%) rounded by a thin sclerotic zone.
one (3.8%) in the calcaneus; and one in (Fig 4). Opacities in the tumor matrix In the small tubular bones, four os-
a phalanx of a hand. The median age of were present in eight cases (50%) and teoblastomas (57%) were located in the
these patients was 20 years. In the me- in two of these were extensive in the diaphysis, two (29%) in the metaphysis,
maining 14 cases (14%) the tumors onig- later stages of the disease. All were de- and one in the epiphysis (14%). Three
mated in the pelvis (n 5), nibs (n 4), mancated by a thin sclerotic line on the tumors (43%) originated in the proxi-
skull (n = 3), scapula (n 1), and clavi- talar side of the tumor and demonstnat- mal and four (57%) in the distal end of
cle (n = 1). Median patient age was 15 ed an expansive growth into the soft the bone. Three lesions (43%) were lo-
years. tissues, which could be as large as 7 cm cated in the center, three (43%) were
in diameter. Periosteal reaction was eccentric, and one (14%) was intracorti-
present in six cases (37.5%) and consist- cal. The size at presentation ranged
Plain Radiographic Studies
ed of a single bone layer that could be from 1 to 4 cm. The tumor was mainly
Thirty of 32 spinal osteoblastomas interrupted. In one patient reactive osteolytic with delicate trabeculation in
(94%) originated in the posterior verte- peniosteal new bone formation was also three cases (Figs 5, 6) and ossification
bral elements, predominantly in the found in the distal part of the tibia. Os- in one case. Surrounding sclerosis was
spinous processes and arches. The me- teoporosis of the talus, the adjacent present only in two metatarsal osteo-
784 Radiology
#{149} June 1990
b. C.
e. f.
Figure 2. Anteroposterior radiograph (a), CT scan (b), and MR images
of the right femur. (c-f) Osteoblastoma is seen as a lucent lesion with
a central density, surrounded by sclerosis and accompanied by a spiculated peniosteal reaction. Soft-tissue swelling is demonstrated (open ar-
rows). Ti- and T2-weighted images through the center (c, d) and slightly proximal to the center of the tumor (e, f) demonstrate low signal
intensities from the surrounding sclerosis, the periosteal reaction, and the pseudocapsule (arrowheads). The latter clearly defines the ex-
tnaosseous extent of the neoplasm. The Ti-weighted images (c, e) also demonstrate intermediate signal intensity coming from most of the
marrow of the femur. The T2-weighted images (d, f) show predominantly high signal intensities from the adjacent vastus muscle (solid ar-
rows) and bone marrow. In combination with the Ti-weighted images, this indicates edema. (MR study courtesy of Johan L. Bloem, MD,
University Hospital Leiden, The Netherlands.)
blastomas. In all cases the cortex was both tumors in the frontal bone dem- All four osteoblastomas located in
partially or completely replaced by the onstnated matrix mineralization. There the ribs had a central origin. Three
tumor. In four tumors in the small tu- was only a thin zone of sclerosis visible were predominantly lytic, with only
bular bones, slight on more prominent surrounding the frontal lesions (Fig 7). minor ossification within the tumor
expansion was present. Two metatarsal In the pelvis, all five tumors were os- matrix in two. One had quite distinct
tumors caused scalloping of the extem- teolytic. Matrix ossification was present mineralization (Fig 8). The fourth had
nal cortex of the adjacent metatansals. in three lesions. Four of them were ex- a mixed lucent/sclenotic appearance.
Similar trabeculation within the tumor pansive. Three had a lobulated contour. Three were sharply defined; one had
matrix, absence of surrounding scleno- Two had a dense sclerotic bonder. A fuzzy margins. One was distinctly ex-
sis, and slight expansive growth were peniosteal reaction was present in four pansive. The others caused a broaden-
visible in both lesions in the canpal cases, a thin bony shell was present in ing of the ribs through solid on layered
scaphoid (Fig 6). In the skull, all three one, and a lamellate reaction was peniosteal new bone formation. The
lesions were osteolytic. In addition, present in three. single osteoblastoma in the clavicle was
eccentric, osteolytic, and expansive, Figure 4. Lateral view of the right ankle
with an interrupted cortex. In the scap- with a blisterlike osteoblastoma on the dor-
ula the tumor was located in the gle- sal surface of the talus. Note the severe Os-
noid. It had a lobulated appearance teopenia of the bones in the ankle region
with a thick sclerotic margin and bony and the pronounced soft-tissue swelling
around the ankle caused by edema.
ridges within.
Radionuclide Bone Studies toma. In four cases the tumor was locat-
786 Radiology
#{149} June 1990
this finally resulted in an amputation.
Three years after initial presentation,
the patient with the sphenoid tumor
died of sudden intracranial hemon-
rhage resulting from the incompletely
removed tumor.
DISCUSSION
790 Radiology
#{149} June 1990