X-ray: Most useful of all imaging

techniques.
There might be obvious abnormality of the
bone:
1. Cortical thickening
2. Discrete lump
3. Cyst
4. defined destruction

Is it in the metaphysis or diaphysis?

Is it solitary or multiple lesions?
Margins are well or ill defined?
Note: cystic lesions are not necessarily hollow
cavities: any radiolucent material may look like
a cyst (e.g fibroma and chondroma)
If the boundaries of the cyst is well defined,
then it is mostly benign.
If it is hazy and diffuse it is mostly invasive
tumor.
Bone surfaces: periosteal new bone formation
and extension of the tumor to the soft tissues
are suggestive of a malignant tumor.

Soft tissues: are the muscle planes distorted

by the swelling? Is there any calcification?

X-ray is not a definitive diagnosis and

further investigation must be done to
confirm.

Other techniques of imaging used are: Radionuclide scanning-reveals site of small

tumour
CT-shows more accurately intraosseous and
extraosseous extension of tumour
MRI-useful for assessment of tumour spread
They all help in viewing the lesions better,
view soft tissue and detect skip lesions too.
Patient must not go for biopsy if MRI or CT is
planned for him as it will distort the image
and appearances.

A.
B.
C.
D.
E.
F.

Imaging analysis:
benign or malignant histology
Location of the lesion
Number of the lesion
Bony destruction
Hyperostosis
Periosteal reaction
Surrounding soft tissue
changes

chondroblastoma

Location and age of patient most important

parameters in classifying a primary bone
tumor.
Simple to determine from plain radiographs.

A.

Location of the
lesion
Giant cell tumor:
ending of long bone
Osteosarcoma:
metaphysis of long
bone
Ewing sarcoma:
diaphysis
Myeloma,
metastasis tumor:
flat bone, irregular
bone

Central: Enchondroma
Eccentric: GCT, CMF,
osteosarcoma
Cortical: osteoid osteoma,
NOF
Parosteal:
osteochondroma, parosteal
osteosarcoma

B Number of lesion
Primary tumor: single frequent
Metastasis: multiple
Myeloma: multiple

Giant cell tumor

Multiple
Myeloma

Osteogenic metastasis

Patterns of bone
destruction:
GEOGRAPHIC

Lytic

Well-defined smooth margin

Short zone of transition

PERMEATIVE

Poorly demarcated lesion imperceptibly

merging with uninvolved bone
Long zone of transition

MOTHEATEN

Areas of destruction with ragged borders.

Less well defined / demarcated lesional
margin Longer zone of transition

Sclerotic

Margin between tumor and native bone is

visible on the plain radiograph.
Slowly progressive process is walled-off
by native bone, producing distinct
margins.
Rapidly progressive process destroys
bone, producing indistinct margins.

Margin types 1A, 1B, 1C, 2, and 3

least aggressive 1A, to most aggressive 3

Aggressive lesions destroy bone.

Aggressiveness increases likelihood of
malignancy.

BUT, not all aggressive processes are malignant.

AND, not all malignant diseases are aggressive.

A well circumscribed lesion

with a narrow zone of
transition

increasing aggressiveness

simple cyst (UBC)

enchondroma
FD
chondroblastoma
GCT
chondrosarcoma
(rare)
MFH (rare)

GCT
enchondroma
chondroblastoma
myeloma,
metastatsis
CMF
FD
chondrosarcoma
MFH

chondrosarcoma
MFH
osteosarcoma
GCT
metastasis
infection
EG
lymphoma

myeloma,
metastases
infection
EG
osteosarcoma
chondrosarcoma
lymphoma

Multiple scattered holes that vary in

size & seem to arise separately

Ewing
EG
infection
myeloma,
metastasis
lymphoma
osteosarcoma

Poorly demarcated from normal, numerous

elongated holes/slots in cortex, run parallel to
long axis of bone

Limited responses of bone

Destruction:
Reaction:
Remodeling:

lysis (lucency)
sclerosis
periosteal reaction

Rate of growth determines bone

response
slow progression, sclerosis prevails
rapid progression, destruction prevails

Periosteal reaction must mineralize to be

seen on X ray
Configuration of periosteal reaction

Nature of inciting process

Intensity
Aggressiveness
Duration

Thick, uninterrupted
long standing process, often non-aggressive
stress fracture
chronic infection
osteoid osteoma

Spiculated, lamellated
aggressive process
tumor likely

periosteal reaction
Codman
Triangle
advancing tumor margin
destroys periosteal new
bone before it ossifies
tumor

Sunburst
Appearance

Matrix is the internal tissue of the tumor

Most tumor matrix is soft tissue in nature.

Radiolucent (lytic) on x-ray

Cartilage matrix
calcified rings, arcs, dots (stippled)
enchondroma, chondroblastoma, chondrosarcoma

Ossific matrix
osteosarcoma

Osteolytic bone metastases:

breast carcinoma shows multiple osteolytic bone lesions.

Osteoblastic bone metastases

Mixed pattern bone metastases:

LABORATORY INVESTIGATIONS
Blood Test : +ESR,+ ALP and Anemia are
non specific markers but may help in
differentiating between malignant and benign
bone lesion

Osteosarcoma: Alkali Phosphatase

(ALP)
Ewing's sarcoma: WBC
metastatic tumor & myeloma:
secondary anemia and blood
calcium
Myeloma: Bence-Jones protein in
urine

Principles of biopsy
From boundary or edge of tumor
Take several samples
Incision strategically placed
Ideally done by the treating surgeon
Wound closed without drain

There are three ways:

1.Needle biopsy: Must be performed by

experienced personal with help of US or CT scan
2. Open biopsy: most reliable way of obtaining a
representative sample.
3. Excisional biopsy: for benign tumors.