Amsterdam: Elsevier; 1993. Skeletal Radiol. This proved to be a reactive calcification secondary to trauma. Multiple enchondromas are seen in Morbus Ollier. Hereditary sclerosing bone dysplasias result from some disturbance in the pathways involved in osteoblast or osteoclast regulation, leading to abnormal accumulation of bone. Bone cyst is one of the manifestations of CGL with AGPAT2 mutation. A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group. 3, Increased uptake on bone scan associated with a solitary sclerotic lesion is atypical and therefore more worrisome, but largely unhelpful as there are many reports of bone islands having increased Tc-99 m hydroxydiphosphonate (HDP) uptake. The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. A cold bone scan is helpful in distinguishing the bone island from a sclerotic metastasis, whereas a warm bone scan is nondiagnostic. Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). Osteoid osteoma (2) 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. 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 Metastases are the most common malignant bone tumors. More heterogenous and irregular with bony trabecular destruction and possible extension beyond the confines of the cortex. BackgroundCongenital generalized lipodystrophy (CGL) is a rare disease. 105-118. Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. Centrally there is an ill-defined osteolytic area. Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone. Fundamentals of diagnostic radiology. 14. When considering Pagets disease, it is extremely helpful to note whether there is associated bony enlargement. Donald Resnick, Mark J. Kransdorf. Bone metastases are the most common malignancy of bone of which sclerotic bone metastases are less common than lytic bone metastases. Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any bone lesion in patients < 20 years. WSI digital slide: https://kikoxp.com/posts/4606. Here a lesion in the epiphysis, which was the result of post-traumatic osteonecrosis. 7, Behrang Amini, Susana Calle, Octavio Arevalo, Richard M. Westmark, and Kaye D. Westmark, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 33 Incidental Solitary Sclerotic Bone Lesion, 27 Approach to the Solitary Vertebral Lesion on Magnetic Resonance Imaging, 28 Diffusely Abnormal Marrow Signal within the Vertebrae on MRI, Incidental Findings in Neuroimaging and Their Management, Radiology (incl. Here a radiograph of the pelvis with a barely visible osteoblastic metastasis in the left iliac bone (blue arrow). 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). It is barely visible within the bone, but an agressive periostitis is seen (arrow). Subchondral bone attrition is the flattening or depression of the bone surface that forms part of a joint. Purpose: To determine if sclerotic bone lesions evident at body computed tomography (CT) are of value as a diagnostic criterion of tuberous sclerosis complex (TSC) and in the differentiation of TSC with lymphangioleiomyomatosis (LAM) from sporadic LAM. PET features high sensitivity in the detection of bone metastases especially 18 NaF-PET is suitable for the detection of sclerotic metastases since it shows tracer uptake in locations with osteoblastic activity and is more accurate than FDG-PET 3. It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. Sclerotic bone lesions appear exclusively in middle aged black patients. In Section 2, we give the general technical route for classification, detection and segmentation of multiple-lesion.After that, in Section 3, the paper will review the recognition of multiple-lesion in six organ and tissue areas, including brain, eye, skin, breast, lung, and abdomen. The mean and maximum attenuation were measured in Hounsfield units. Another approach to the differential diagnosis of sclerotic bone lesions is to use the mnemonic I VINDICATE, which means 'I clear myself from accusation'. This is an example of progression of an osteochondroma to a peripheral chondrosarcoma. Notice the lytic peripheral part with subtle calcifications. Amorphous mineralisation is present in most lesions. 5, In the cases with no known primary malignancy that are being followed with serial imaging, if the lesion increases in diameter by greater than 25% at 6 months or less, or greater than 50% at 12 months, open biopsy has been recommended by Brien et al. Logistic regression analyses were used to assess the association of joint form and lesions on imaging for axSpA patients and controls. Here a partially calcified mass against the proximal humerus with involvement of the cortical bone on an axial CT image. Resonance Imaging Saeed M. Bafaraj . 33.1d). 2nd most common primary bone tumor and highly malignant. SusanaBoronat, IgnasiBarber, VivekPargaonkar, JoshuaChang, Elizabeth A.Thiele . Most commonly encountered bone tumor in the small bones of the hand and foot. This shows that differentiating a tumor from a reactive proces scan be quite difficult in some cases. Even though plain X-ray and CT would typically be used to follow a suspected bone island, MRI was chosen as the follow-up modality because the sacrum is an area not well seen on plain films due to overlying bowel gas and concern regarding radiation dose from multiple CT scans to the pelvis of a 30-year-old woman. Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. Macedo F, Ladeira K, Pinho F et al. The differential diagnosis of bone lesions that result in bony sclerosis will be given. Plain radiograph and coronal T1-weighted contrast-enhanced fat-suppressed MR image of a mixed lytic and sclerotic lesion of the distal femoral diaphysis. As you can see, by just dropping the items that tend to cause generalized sclerosis, we have generated a fairly good differential for focal lesions. WSI digital slide: https://kikoxp.com/posts/4606. Scuba Certification; Private Scuba Lessons; Scuba Refresher for Certified Divers; Try Scuba Diving; Enriched Air Diver (Nitrox) On the left three bone lesions with a narrow zone of transition. Signed by [redacted] on 1/17/2020 11:42 AM Narrative I think that the best way is to start with a good differential diagnosis for sclerotic bones. Wide zone of transition mutation, and both sclerotic and lytic bone lesions together for the first time. Another finding classic for Pagets disease is that it almost always starts at one end of a bone and then spreads toward the other end of the bone. Home. Many important signaling . Osteomyelitis is a mimicker of various benign and malignant bone tumors and reactive processes that may be accompanied by reactive sclerosis. 2021;216(4):1022-30. When considering congenital causes of sclerotic lesions, benign causes such as bone islands or osteopoikilosis usually have a fairly typical appearance and are hard to mistake. 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. Metastases and multiple myelomaIn 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. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). MRI of the sacrum: axial T1-weighted (T1w; Fig. Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone. Radiologe. Sclerosing bone dysplasias are skeletal abnormalities of varying severity with a wide range of radiologic, clinical, and genetic features. Matching the degradation rate of the materials with neo bone formation remains a challenge for bone-repairing materials. Generally, this just follows common sense some lesions should logically be expected to be focal, others multifocal, and yet others diffuse or systemic. To determine if sclerotic bone lesions evident at body computed tomography (CT) are of value as a diagnostic criterion of tuberous sclerosis complex (TSC) and in the differentiation of TSC with lymphangioleiomyomatosis (LAM) from sporadic LAM. This is consistent with the diagnosis of a reactive process like myositis ossificans. Check for errors and try again. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. Notice that CT depicts these lesions far better (red arrows). Adamantinoma in case of a sclerotic lesion with several lucencies of the tibia in a young patient. 2, The primary utility of the bone scan is that if there is no increased uptake, sclerotic metastatic disease is highly unlikely; therefore, the lesion can be considered most likely a bone island and follow-up radiographic imaging obtained. by Clyde A. Helms 2019;290(1):146-54. Notice that in all three patients, the growth plates have not yet closed. 1988;17(2):101-5. 10. Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does not. Radiographic or CT features that suggest malignancy: Use MRI with water-sensitive sequence (T2 FS) to determine cartilage cap thickness. Osteochondroma is a bony protrusion covered by a cartilaginous cap. This solitary, uniformly high-density lesion with neither edema in the surrounding bone marrow nor extension into the surrounding soft tissue most likely represents a giant bone island. Mass displaces and involves both the right 10 th intercostal artery, as well as more superior right 9 th intercostal artery. Office Phone: (517) 205-6750. Osteoma consists of densely compact bone. Metastases must be included in the differential diagnosis of any bone lesion, whether well-defined or ill-defined osteolytic or sclerotic in age > 40. In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered Lippincott Williams & Wilkins. RT @JMGardnerMD: 20 yo M w/ 5 cm lytic bone lesion in proximal tibia metaphysis, sharply demarcated w/ sclerotic rim. The illustration on the left shows the preferred locations of the most common bone tumors. Finally, we conclude with a case of an incidentally presenting sclerotic vertebral body lesion. 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. Bone metastases have a predilection for hematopoietic marrow sites: spine, pelvis, ribs, cranium and proximal long bones: femur, humerus. Here an incidental finding of several eccentric sclerotic lesions of the distal femur. Lets apply the good old universal differential diagnosis to sclerotic bone lesions. Sclerosis can also be reactive, e.g. Rib metastases may be osteolytic, sclerotic, or mixed. Usually it is a lesion of childhood or young adults. (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. Adam Greenspan, Gernot Jundt, Wolfgang Remagen. 2021;13(22):5711. Most bone tumors are solitary lesions. 2015;7(8):202-11. Ahuja S & Ernst H. Osteoblastic Bone Metastases in Medullary Thyroid Carcinoma. The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant (1). Halo of increased signal on T2 W images about the low signal central lesion is suggestive of metastatic disease. Fisher C, DiPaola C, Ryken T et al. It may be spiculated and interrupted - sometimes there is a Codman's triangle. CT 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. The subchondral bone is key to cartilage and joint health. giant cell tumor, metastasis, and myeloma; (3) sclerotic . If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. Sclerosis is present from either tumor new bone formation or reactive sclerosis. 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. If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted. Infection is seen in all ages. Differential Diagnosis in Orthopaedic Oncology. Enhancement after i.v. This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet (75%). Skeletal Radiol. The bone marrow compartment is not involved which is important for the surgical strategy. Distinct phenotypes are described: osteoblastic, the more common osteolytic and mixed. Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of the bone. Here a patient with a mineralized mass in the soft tissues. This image is of a 20 year old patient with a sclerotic expansile lesion in the clavicle. An ill-defined border with a broad zone of transition is a sign of aggressive growth (1). Here a lesion located in the epi- and metaphysis of the proximal humerus. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis). Growth of osteochondroma in skeletally mature patient, Irregular or indistinct surface of lesions, focal lucent regions in interior of lesions, presence of soft tissue mass with scattered or irregular calcifications. Etiology Here some typical examples of bone tumors in the spine. 12. Usually stress fractures are easy to recognize. Differential diagnosis based on the periosteal reaction and the extensive edema: Here a patient with a juxtacortical sclerotic mass of the proximal humerus (left). Unable to process the form. Teaching Point: Metastasis is the most common malignant rib lesion. When you are considering osteonecrosis in your differential diagnosis, look at the joints carefully. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. 2022;51(9):1743-64. The contour of the involved bone is usually normal or with mild expansive remodelling. Diagnostic brain imaging tests can assess bone fractures, structural problems, blood vessel abnormalities, and changes in brain metabolism. Acute osteomyelitis is characterised by osteolysis. Click here for more examples of eosinophilic granuloma. Large lesions tend to expand into both areas. Sclerotic bone metastases typically present as radiodense bone lesions that are round/nodular with relatively well-defined margins 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. The major part of the lesion consists of reactive sclerosis. Growth of the osteochondroma takes place in the cap, corresponding with normal enchondral growth at the growth plates. Our patient had lytic bone lesions in (femur) long bones and also sclerotic lesions in the pelvic which was . A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malignant tumor, benign tumor, infection or trauma. However, a specific density range has not been specified for those terms 1. The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. 1. Differentiation of Predominantly Osteoblastic and Osteolytic Spine Metastases by Using Susceptibility-Weighted MRI. Brant WE, Helms CA. ( A1,A2) Transversal CT of the skull of a TSC patient and . Sclerotic jaw lesions are not rare and are frequently encountered on radiographs and computed tomography (CT). Causes include trauma, infection, autoimmune diseases, inflammatory diseases, spinal degeneration, congenital malformations, and benign or cancerous tumors. Prevalence of 3-5% in patients with hereditary multiple osteohondromas. You can then customize the above differential for whichever pattern of sclerosis that you see. 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. . Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. 7. In skeletally mature patients, GCTs begin in the metaphysics and extend deep to the subchondral bone plate of the articular surface. 2018;2018:1-5. A mnemonicfor remembering the causes of diffuse bony sclerosis is: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Mild mass effect on adjacent lung, diaphragm, and liver. The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. Chordoma is usually seen in the spine and base of the skull. Solitary lucent lesions in bone with a distinct margin are generally called "geographic" lesions, whether or not they have a sclerotic rim. There is a metastasis, which presents as a subtle sclerotic lesion in the humerus metaphysis. At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found. 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. 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. 1. Ulano A, Bredella M, Burke P et al. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-8429. Henry Ford Hospital, Neuro Surgery, MI, 1999 Universitat Dusseldorf, Neuro Surgery, 1990 Universitaire Instelling Antwerpen, Neuro Surgery, 1983 Journal of Bone Oncology. 8. In some locations, such as in the humerus or around the knee, almost all bone tumors may be found. The cause of sclerotic lesions was assessed histologically or by clinical and imaging follow-up. UW Radiology Sclerotic Lesions of Bone <-Lucent Lesions of Bone | Periosteal Reaction-> What does it mean that a lesion is sclerotic? You may have been surprised to see metastatic disease listed as a leading cause for diffuse sclerotic bones. Usually one bone is involved. Common: Metastases, multiple myeloma, multiple enchondromas. Sclerotic bone lesions at abdominal magnetic resonance imaging in children with tuberous sclerosis complex. However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. Here two other lesions in different patients that proved to be chondrosarcoma. Radiologic Atlas of Bone Tumors Patients usually have sclerotic bone lesions before and lytic bone lesions after puberty. Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be difficult or even impossible. Notice the numerous predominantly osteoblastic metastases. Here CT-images of a patient with prostate cancer. sclerosing osteomyelitis of Garr, aggressive features might require an oncological referral and/or biopsy 1, history of malignancy will almost always require additional imaging, follow-up or oncologic referral, high CT attenuation values might help in the differentiation of bone island from osteoblastic metastases 5 but attenuation values should not be used exclusively for the assessment of sclerotic bone lesions 6, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Therefore, MRI and bone scan were performed. Wayne State University, Orthopaedic Surgery, MI, 2007 University of Texas Southwestern Medical School, Surgery, TX, 2002 1. 7A, and 7B ). Rib lesions detected on bone scintigraphy often require further characterization with radiography or CT to improve specificity (Figs. Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven parosteal osteosarcoma. T2-weighted axial MR image demonstrates high signal intensity of the tumor in the metacarpal bone with extension of a lobulated soft tissue mass. This is extremely common in Pagets disease but extremely uncommon with a blastic metastasis. 2016;207(2):362-8. However, a specific density range has not been specified for those terms 1. 5 Biopsy should be considered in atypical cases or in high-risk patients with primary malignancies associated with osteoblastic metastatic disease. Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner surface of cortical bone.