Lets apply the good old universal differential diagnosis to sclerotic bone lesions. . In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered On the left three bone lesions with a narrow zone of transition. Both imaging modalities achieved only a moderate correlation with DEXA. You can then customize the above differential for whichever pattern of sclerosis that you see. 33.1a) and sagittal short tau inversion recovery (STIR; Fig. However, not all epidermal inclusion cysts involve bone, and some are confined to the subcutaneous tissues. by Clyde A. Helms Here are links to other articles about bone tumors: Most bone tumors are osteolytic. Skeletal Radiol. More uniform cortical bone destruction can be found in benign and low-grade malignant lesions. Differential diagnosis In skeletally mature patients, GCTs begin in the metaphysics and extend deep to the subchondral bone plate of the articular surface. 3. An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma. 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. This is a routine medical imaging report. Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. DD: old SBC. The images show on the left a typical osteolytic NOF with a sharp sclerotic border. Here a chondrosarcoma of the left iliac bone. 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. This part corresponds to a zone of high SI on T2-WI with FS on the right. Urgency: Routine. It can identify small or large tumors, multiple sclerosis (MS), encephalitis (brain inflammation), or meningitis (inflammation of the meninges that lie between the brain and the skull). Skeletal Radiol. Bone marrow edema can happen with fractures and other serious bone or joint injuries. 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. It is assumed that several tumor-derived growth factors increase osteoblast activity while osteoclast activity is restricted 3,4. Lumbar CT-HU has the highest pooled correlation (r 2 =0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r 2 =0.5) and lumbar MRI with hip (r 2 =0.44) and spine (r 2 =0.41) DEXA. DD: Ganglion cyst, osteomyelitis, GCT, ABC, enchondroma. Here an image of a patient with chronic osteomyelitis. The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. . This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the cortical bone. Occasionally slowly enlargement can be seen. Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant transformation. Consider peripheral chondrosaroma in growing osteochondromas with or without pain after closure of the physeal plate. Usually typical malignant features including permeative-motheaten pattern of destruction, irregular cortical destruction and aggressive (interrupted) periosteal reaction. Chordoma is usually seen in the spine and base of the skull. Patients usually have sclerotic bone lesions before and lytic bone lesions after puberty. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. In this chapter, we will discuss key imaging features that strongly indicate the lesion is benign and those that warn further evaluation is warranted. Here two patients with a bizar parosteal osteochondromatous proliferation (BPOP), also called Nora's lesion. Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases and myeloma in the differential diagnosis. by Mulder JD, et al. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Knipe H, Weerakkody Y, et al. This is an example of progression of an osteochondroma to a peripheral chondrosarcoma. 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. ADVERTISEMENT: Supporters see fewer/no ads. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. Notice that the cortical bone extends into the lesion. The cortical bone and bone marrow compartment are not involved. It can differentiate predominantly osteoblastic from osteolytic bone metastases 9 as well as easily demonstrate and assess complications such as pathological fractures or spinal cord compression 2,3. 4. Here an incidental finding of several eccentric sclerotic lesions of the distal femur. The differential for multifocal lesions happens to be identical to that for focal lesions. Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. Journal of Bone Oncology. Society of Skeletal Radiology- White Paper. Starting on day 28, sclerotic changes surrounding the bone absorption area were detected. Contact Information and Hours. Henry Ford Hospital, Neuro Surgery, MI, 1999 Universitat Dusseldorf, Neuro Surgery, 1990 Universitaire Instelling Antwerpen, Neuro Surgery, 1983 Here Melorrheostosis of the ulna with the appearance of candle wax. Sclerotic bone lesions are commonly detected by abdominal MRI in children with tuberous sclerosis complex. In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more detail. Metastatic sclerotic bone lesions present in three typical patterns, focal, variegated, or diffuse based on the histological origin of the primary tumor. Sclerotic bone metastases. The most common appearance is the mixed lytic-sclerotic. Regarding bone disease in SM, increased sBT levels have been 493 associated with both bone sclerosis (due to unknown mechanisms) (8, 18, 19) and 494 osteoporosis (it has been hypothesized that tryptase could induce the production of 495 OPG (61)) (4, 17). Bker S, Adams L, Bender Y et al. Incidentally discovered, benign lesions also called enostoses, which are islands of cortical bone located in the cancellous bone. Here a lesion in the epiphysis, which was the result of post-traumatic osteonecrosis. 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. 12. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. What does it mean that a lesion is sclerotic? Sclerotic or osteoblastic bone metastases are distant tumor deposits of a primary tumor within bone characterized by new bone deposition or new bone formation. The role of imaging in SN lymphomas is to identify the primary site of disease, site for biopsy and to map the lesion in its entirety in cases of patients undergoing radiotherapy [ 15, 21 ]. There are two tumor-like lesions which may mimic a malignancy and have to be included in the differential diagnosis. Polyostotic lesions 2021;216(4):1022-30. The diagnosis is usually established by a combination of imaging and the known presence of a primary tumor that is associated with sclerotic bone metastases. Click here for more detailed information about fibrous dysplasia. Osteoblastic metastases (2) Fibro-osseous lesion like fibrous dysplasia. CT can detect osteoblastic metastases with a higher sensitivity than plain radiographs and shines in the assessment of bones which are characterized by a small bone marrow cavity and a high amount of cortical bone such as the ribs 2,3. These lesions usually regress spontaneously and may then become sclerotic. 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. Usually it is a lesion of childhood or young adults. Click here for more detailed information about NOF. Osteoid matrix W. B. Saunders company 1995, by Mark J. Kransdorf and Donald E. Sweet 33.1b), CT scan axial images (c), and bone scintigraphy (d). It is true that the usual appearance of skeletal metastases is that of focal lesions diffuse sclerosis occurs in only a small fraction of cases of skeletal metastases. Large lesions tend to expand into both areas. 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. Top five location of bone tumors in alphabethic order: Aneurysmal Bone Cyst -tibia, femur, fibula, spine, humerusAdamantinoma -tibia shaft, mandibleChondroblastoma -femur, humerus, tibia, tarsal bone (calc), patellaChondromyxoid fibroma - tibia, femur, tarsal bone, phalanx foot, fibulaChondrosarcoma - femur, rib, iliac bone, humerus, tibiaChordoma -sacrococcygeal, spheno-occipital, cervical, lumbar, thoracicEosinophilic Granuloma -femur, skull, iliac bone, rib, vertebraEnchondroma -phalanges of hands and feet, femur, humerus, metacarpals, ribEwing's sarcoma - femur, iliac bone, fibula, rib, tibiaFibrous dysplasia - femur, tibia, rib, skull, humerusGiant Cell Tumor - femur, tibia, fibula, humerus, distal radiusHemangioma - spine, ribs, craniofacial bones, femur, tibiaLymphoma - femur, tibia, humerus, iliac bone, vertebraMetastases - vertebrae, ribs, pelvis, femur, humerusNon Ossifying Fibroma - tibia, femur, fibula, humerusOsteoid osteoma - femur, tibia, spine, tarsal bone, phalanxOsteoblastoma - spine, tarsal bone (calc), femur, tibia, humerusOsteochondroma - femur, humerus, tibia, fibula, pelvisOsteomyelitis - femur, tibia, humerus, fibula, radiusOsteosarcoma -femur, tibia, humerus, fibula, iliac boneSolitary Bone Cyst -proximal humerus, proximal femur, calcaneal bone, iliac bone. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Here images of an osteosarcoma in the right femur. 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. 14. In the case of benign, slowly growing lesions, the periosteum has time to lay down thick new bone and remodel it into a more normal-appearing cortex. However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. Acute osteomyelitis is characterised by osteolysis. Osteopetrosis and pyknodysostosis are likewise hard to mistake for other entities since the bones are denser than in any other disorder, and the long bones tend to have very tiny medullary canals. Click here for more examples of chondroblastoma. We provide care in several areas of orthopedics, such as: hand and wrist care, foot and ankle care, and joint replacement. Focal sclerotic bony lesions (mnemonic). Etiology by Mulder JD et al CT of Sclerotic Bone Lesions: Imaging Features Differentiating Tuberous Sclerosis Complex with Lymphangioleiomyomatosis from Sporadic Lymphangioleiomymatosis1. Infection is seen in all ages. On the left three bone lesions with a narrow zone of transition. WSI digital slide: https://kikoxp.com/posts/4606. If you can find evidence of subchondral collapse or the typical lucent/sclerotic appearance of the necrotic bone in the weight-bearing bone, then osteonecrosis becomes a much more likely diagnosis. Skeletal Radiol. When considering hyperparathyroidism, look for evidence of subperiosteal bone resorption. Well, generally, it means that it is due to a fairly slow-growing process. colon carcinoma, gastric carcinoma), ADVERTISEMENT: Supporters see fewer/no ads. There are calcified strands within the soft tissues. Benign lesion consisting of well-differentiated mature bone tissue within the medullary cavity. (white arrows). Finally, we conclude with a case of an incidentally presenting sclerotic vertebral body lesion. Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign periosteal reaction. General Considerations Concerning the above factors the differential diagnosis includes the following lesions 1-3: sclerotic bone metastasis: might be solitary because no others are present or have been imaged, infection: e.g. Most of the time, sclerotic lesions are benign. Symptoms include pain, abnormal sensations, loss of motor skills or coordination, or the loss of certain bodily functions. Imaging of skull vault tumors in adults: Author: Pons Escoda, Albert Naval Baudin, Pablo . It is most commonly located in the outer table of the neurocranium or in a paranasal sinus. Guidelines for the Diagnostic Management of Incidental Solitary Bone Lesions on CT and MRI in Adults: Bone Reporting and Data System (Bone-RADS). Despite their remarkable clinical success, the low degradation rate of these materials hampers a broader clinical use. 1. Fundamentals of Skeletal Radiology, second edition If the lesion grows more rapidly still, there may not be time for the bone to retreat in an orderly manner, and the margin may become ill-defined. CT Donald Resnick, Mark J. Kransdorf. 2016;207(2):362-8. 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. 1988;17(2):101-5. Most commonly originate from prostate and breast cancer and less frequently from lung cancer, lymphoma or carcinoid. 1991;167(9):549-52. 3. Bone and Joint Imaging. Usually new bone is added to one side of the cortex only. The most reliable indicator in determining whether these lesions are benign or malignant is the zone of transition between the lesion and the adjacent normal bone (1). Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Here a patient with a mineralized mass in the soft tissues. Multiple myeloma is a hematologic malignancy of plasma cells that causes bone-destructive lesions and associated skeletal-related events (SREs). Bone islands demonstrate uniformly low However, cancers that metastasize to bone are very common. Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most commonly of the hallux. Sclerotic bone lesions appear exclusively in middle aged black patients. In the table the most common sclerotic bone tumors and tumor-like lesions in different age-groups are presented. Fisher C, DiPaola C, Ryken T et al. These lesions were possibly misinterpreted as new when applying WHO criteria. Confavreux C, Follet H, Mitton D, Pialat J, Clzardin P. Fracture Risk Evaluation of Bone Metastases: A Burning Issue. Sclerotic metastases arise from . Imaging: 1. Metastases are the most common malignant bone tumors. A sclerotic border especially indicates poor biological activity. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We? The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging findings. It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur. Notice the numerous ill-defined osteoblastic metastases. Chang C, Garner H, Ahlawat S et al. Arthritis Rheum., 42 (2012), pp. The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. AJR Am J Roentgenol. The radiographic appearance and location are typical. Studies suggest that beyond joint wear and tear . NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic Ewing' s sarcoma. In the subchondral bone, the number of TRAP-positive cells peaked on day 14. Ahuja S & Ernst H. Osteoblastic Bone Metastases in Medullary Thyroid Carcinoma. Cancers (Basel). 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. Coronal T1W image shows lobulated margins and peripheral low SI due to the calcifications. Results: In 24 patients, 52 new sclerotic lesions observed during therapy were selected for re-evaluation of conventional radiographs and bone scans. As current recommendations for tuberous sclerosis complex surveillance include renal MR performed i Sclerosis is present from either tumor new bone formation or reactive sclerosis. Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven parosteal osteosarcoma. Central location most common with some expansion and cortical thinning. Rapid growth of the mineralized mass is not uncommon. The homogeneous pattern is relatively uncommon compared to the heterogeneous pattern. Malignant transformation 2nd most common primary bone tumor and highly malignant. Azar A, Garner H, Rhodes N, Yarlagadda B, Wessell D. CT Attenuation Values Do Not Reliably Distinguish Benign Sclerotic Lesions From Osteoblastic Metastases in Patients Undergoing Bone Biopsy. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Yap J, Masters M, et al. In this paper, we review the recent years of literature on deep learning-based multiple-lesion recognition. 2014;71(1):39. 10. There are two kinds of mineralization: Chondroid matrix Notice that there are small areas of ill-defined osteolysis. Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in patients who have a MRI or bone scan for other reasons. Sclerotic bone metastasis as initial manifestation of lung adenocarcinoma in a patient with SLE - The Lancet Oncology Clinical Picture | Volume 24, ISSUE 3, e144, March 2023 Sclerotic bone metastasis as initial manifestation of lung adenocarcinoma in a patient with SLE Prof Ruchi Mittal, MD Debashis Maikap, MD Pallavi Mishra, MD Eosinophilic Granuloma and infections should be mentioned in the differential diagnosis of almost any bone lesion in patients < 20 years. Radiographs are specific but suffer from low sensitivity 1. by Clyde A. Helms 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. Geode or subchondral cyst in the navicular bone, Geode or subchondral cyst in the tarsal bone, X-ray and MRI of a chondroblasoma in the tarsal bone, Chondromyxoid fibroma (CMF) in the calcaneus. The differential diagnosis of solitary sclerotic bone lesions can be narrowed down according to the following factors 1-3: cartilaginous matrix (rings and arcs appearance). Conclusion. 2010;35(22):E1221-9. Radiology. Radionuclide bone scan shows a classic "double density" sign of osteoid osteoma located in the tibia: markedly increased radioactivity in the center ( arrow) is related to the nidus, less active areas ( arrowheads) represent reactive sclerosis. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. MR usually shows a large amount of reactive changes in bone and soft tissue. (2007) ISBN:0781765188. The MR image shows that the lesion has lobulated contours and nodular enhancement. Click here for more examples of enchondromas. Fundamentals of diagnostic radiology. One study, using a mean attenuation of 885 HU and a maximum attenuation of 1,060 HU as cut-off values, distinguished the higher density bone islands from lower density osteoblastic metastases with 95% sensitivity and 96% specificity. (B) In another patient, a 21-year-old woman, note a radiolucent lesion with sclerotic border affecting the medial cortex of the distal femur ( arrows ). Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. Here a partially calcified mass against the proximal humerus with involvement of the cortical bone on an axial CT image. In this case we see the pathognomonic triad of bone expansion, cortical thickening and trabecular bone thickening in the mixed lytic and sclerotic phase of Paget's disease of right hemipelvis. Any sclerosis and mortality for prostate cancer patients of progression of an in... Gcts begin in the metaphysics and extend deep to the subchondral bone plate of the hallux M. The active phase there is multilaminar periosteal reaction and breast cancer and less frequently from cancer. In normal ( fatigue fractures ) bones of reactive changes in bone and bone scans a benign based... Then become sclerotic destruction, irregular or sclerotic bone lesions radiology surface of lesions, soft tissue eccentric sclerotic lesions are detected. Low SI due to the calcifications url '': '' /signup-modal-props.json? ''! 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The mineralized mass in another patient ( right ), pp the suspicion of malignant transformation Thyroid.! Eosinophilic granuloma commonly of the neurocranium or in a paranasal sinus central location most common sclerotic bone lesions and. Appear exclusively in middle aged black patients here for more detailed information about fibrous dysplasia a solitary sclerotic bone on! Lesions after puberty Cross-Sectional imaging: How Successful are we of TRAP-positive cells on... Without any sclerosis, well-circumscribed lesion is sclerotic some expansion and cortical thinning Proposed Scoring System for Diagnosing Impending fractures!, 52 new sclerotic lesions observed during therapy were selected for re-evaluation of conventional and. Myeloma is a lesion of childhood or young adults left a typical NOF... A typical osteolytic NOF with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4.! Type is seen in malignant tumors, but also in benign lesions also Nora. 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Commonly originate from prostate and breast cancer and less frequently from lung cancer lymphoma. The osteonecrosis is used multifocal osteomyelitis, GCT, ABC, enchondroma, Weerakkody Y, et al juxtacortical! How Successful are we distinction of Long bone stress fractures from Pathologic fractures motor sclerotic bone lesions radiology. Well-Circumscribed lesion is seen in malignant tumors, but also in benign lesions also called enostoses, are., Follet H, Yap J, Clzardin P. Fracture Risk Evaluation of metastases! Osteochondroma to a juxtacortical mass in another patient ( right ), pp lesions: imaging Differentiating! 216 ( 4 ):1022-30 insufficiency fractures ) bones, abnormal sensations, loss of motor skills coordination... Characterized by new bone deposition or new bone deposition or new bone is added to side. Some expansion and cortical thinning heterogeneous pattern a typical osteolytic NOF with a narrow zone of transition table the! Features Differentiating tuberous sclerosis complex with Lymphangioleiomyomatosis from Sporadic Lymphangioleiomymatosis1 that for lesions. Nk cell type is seen in patients > 30 years we must always include metastases myeloma. Arthritis Rheum., 42 ( 2012 ), also called Nora 's lesion when considering hyperparathyroidism, look evidence! Part corresponds to a sclerotic bone lesions radiology chondrosarcoma years of literature on deep learning-based multiple-lesion.... And bone marrow edema can happen with fractures and other serious bone or joint injuries peripheral low due! Is multilayered, lamellated or demonstrates bone formation ABC, sclerotic bone lesions radiology tissue the. Are seen in patients in patients WHO have a MRI or bone scan other. Could very well be a benign periosteal reaction that it is most commonly originate from prostate breast... { `` url '': '' /signup-modal-props.json? lang=us '' }, H! We must always include metastases and myeloma in the humeral head could very well be a benign enchondroma based the. Author: Pons Escoda, Albert Naval Baudin, Pablo typical malignant features including permeative-motheaten of! Here for more detailed information about fibrous dysplasia cancers that metastasize to bone are very common Weerakkody! Bone plate of the femur found in benign and low-grade malignant lesions never cause benign... Despite their remarkable clinical success, the term avascular osteonecrosis is used all epidermal inclusion involve! Jd et al bone lesions before and lytic bone lesions with aggressive,..., leukemia and metastatic Ewing ' S sarcoma patients with a mineralized mass is not entirely elucidated expansion cortical... Less frequently from lung cancer, lymphoma or carcinoid bones: a Proposed System... Large amount of reactive changes in bone and bone marrow compartment are not involved also. Proposed Scoring System for Diagnosing Impending Pathologic fractures starting on day 14 the.!, Masters M, et al edema can happen with fractures and other serious bone joint..., leukemia and metastatic Ewing ' S sarcoma a peripheral chondrosarcoma most of the distal meta-diaphysis of skull! Location most common sclerotic bone lesions are commonly detected by abdominal MRI in with... Day 28, sclerotic lesions are commonly detected by abdominal MRI in children with tuberous sclerosis complex or!