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1

how do you describe this?

what is it?

ground glass

fibrous dysplasia

2

what benign 1˚ bone neoplasm has a 1% chance of malignant transformation?

what benign 1˚ bone neoplasm has a 25% chance of malignant transformation?

 1% chance of malig = osteochondroma >30yo w/ Pain

25% chance of malig = Hereditary Multiple Exostosis (HME)

3

what is this?

aneurysmal bone cyst (ABC)

highly expansile
lytic, septated
eccentric
markedly thinned cortex
metaphyseal, can extend to epiphysis ITS THE ONLY BENIGN TUMOR TO CROSS GROWTH PLATE
periosteal response common

4

what is this?

malignant transformation rate? what does it turn into if it does transform?

ollier disease

  • multiple enchondromas: usually unilateral, monomelic

25-50%; chondrosarcoma

5

autosomal dominant diseases?

gardner syndrome
fibrous dysplasia
neurofibromatosis

6

what is this?

enlarged IVF

neurofibromatosis

7

how do you describe this?

what does it point to?

blade of grass

paget disease

8

what is this?

osteosarcoma

- MC location is distal femur/proximal tib
- cumulus cloud appearance
- cortical destruction, aggressive periosteal response

9

MC location for Ewing's sarcoma?

diaphysis of humerus and femur

10

what is this?

typical age?

osteoid osteoma

  • reactive sclerosis
  • nidus (black arrow on viewing right)
  • painful: not relieved by rest, worse at night, relieved by aspirin

10-25 yo

11

epiphysis / apophyseal region is key for...?

chondroblastoma

12

what is this?

acral mets

13

what is this?

what is the triad associated with it?

Gardner Syndrome

well efined
opaque
clean borders

  1. multiple osteomas
  2. colonic polyps (considered pre-malig)
  3. soft tissue fibromas

14

what is this?

multiple myeloma

- punched out lesions: multiple, well-defined, round, osteolytic defects

15

what is this?

how do you describe it?

paget disease

cotton wool appearance
basilar impression (tip of the odontoid process projects above the foramen magnum)

16

Local P and swelling.
Systemic signs: fever, anemia, increased ESR.

Ewing sarcoma

  • ​10-25 yo
  • laminated onion skin
  • periosteum getting eaten
  • endosteal scalloping
  • long zone of transition

17

what is the next step?

for multiple myeloma: get MRI

18

painless, lumpy joints?

what % chance of malignancy?

HME

malignant degeneration in 25% of cases

19

what is the ddx list for this?

  1. osteoblastic mets
    1. multiple ivory vertebra
  2. osteoid osteoma** most likely this
    1. pain
    2. has nidus
  3. osteoma
    1. located in sinuses
    2. smooth edges

20

what is this?

polyostotic fibrous dysplasia (FD)

21

what is this?
MC age group?

enchondroma
10-30 yo

22

what is this phenomenon called?

and what are the 3 most common causes of it?

ivory vertebra

osteoblastic mets (multiple ivory vertebrae), paget disease (cortical thickening, expansion), lymphoma (anterior body scalloping)

23

what is this?

ABC

24

describe this. what is this?

distal radius
extends into subchondral region
diminished bone density
appears aggressive

malignant GCT

25

what is this?

fibrosarcoma

  • 2% of primary bone malignancies
  • Major long bones: 50% at knee

26

cortical osteoid osteoma DDX list

  1. stress fx: radiolucent line perpendicular to cortex (see photo)
  2. cortical bone abscess
  3. intracortical osteosarcoma: cortex thickened or buldged

27

10% of benign bone tumors
70% in long bones, esp femur
PAINFUL rigid scoliosis
relieved by aspirin
what is it?

what is the DDX list for painful scoliosis?

osteiod osteoma
Photo: A - nidus

DDX list for Painful Scoliosis

  1. osteiod osteoma - sclerotic pedicle, rigid scoliosis
  2. aneurysmal bone cyst - lucent
  3. osteoblastoma - lucent
    1. painful scoliosis, not severe

28

what is this?

fibrous dysplasia

non-neoplastic, tumor-like bone lesion
defective osteoblasts, normal osteoclasts
"great imitator of bone disease"

asymptomatic, usually incidental finding

29

what is the description for this?

what is it?

what are the DDX?

Ivory vertebra

Paget disease (cortical thickening, expansion)

3 MC causes of ivory vertebra:

  • Ostoblastic mets (multiple ivory vertebra)
  • Paget disease (cortical thickening, expansion)
  • Lymphoma (anterior body scalloping)

30

MC tumor of phalanges?

enchondroma

50% in hands and feet
50% femur, tibia, humerus, ribs

31

what is it when you have multple enchondromas? (this photo)

multiple enchondromatosis? (next photo)

ollier disease (first photo)

Multiple lytic mildly expansile lesions in the proximal phalanx of the 1st, 2nd and 3rd toes showing thinned overlying intact cortex, narrow transition zones and normal surrounding bone matrix. No definite underlying fractures could be identified, consistent with multiple enchondromas.

maffucci syndrome (this photo)

Multiple expansile intramedullary lucent lesions involving multiple metacarpal and phalanges bones in keeping with multiple enchondromas. In addition, there are multiple rounded soft tissue densities seen around the 1st, 2nd, and 5th fingers associated with small rounded calcifications representing phleboliths related to soft tissue hemangiomas. Overall, findings are highly suggestive of Maffucci syndrome. 

32

what is this?

"twisted ribbon" ribs
kyphoscoliosis

neurofibromatosis

33

0.5% malignant transformation

FD

34

what is a common site to see here?

bone island (enostosis) with a "brush border"

ovoid, oblong, round
aligned on long axis of trabeculae
typically <1cm
sharp margins

35

what is the DDX for this?

  1. Parosteal osteosarcoma
    1. stalk attaches to cortex
    2. central portion more dense; periphery less dense
    3. grows over time
  2. DDX: myositis ossificans
    1. separated from bone
    2. less dense centrally; periphery of denser cortical bone
    3. smaller over time

36

what is this?

rib osteochondroma

37

what is this?

what is the DDX?

Ivory vertebra: Osteoblastic mets, hodgkin lymphoma - MC in vertebral body), paget disease

Why: because L1 isn't LARGER than other vertebra (so likely not pagets).

So blastic mets, lymph, then paget in this case.

38

what is this?

hereditary multiple exostosis (HME)

multiple osteochondromas, average 10

39

what is this?

chondroblastoma

radiographic:
lytic, geographic
eccentric (most)
sharp zone of transition
rim of sclerosis
calcification in 50%

50% at the knee

40

where are ABCs MC location

ABC is MC benign tumor of _____

long tubular bones 50-60%

metaphyseal, diaphyseal

MC benign tumor of the clavicle

41

what imaging is this?
and what is it called?
what is it?

top of DDX list?

MRI
Fluid/fluid level
its d/t settling of blood products (hematocrit)

Dx:

  • Aneurysmal Bone Cyst (ABC)
  • osteosarcoma
  • Giant Cell Tumor (GCT)
  • chondroblastoma

42

what is this?

metaphyseal region of distal tibia
growth plate, so young person
pathological fracture of the distal fibula

sessile osteochondroma

43

this is not a true neoplasm, it is fluid filled. what is it?

simple bone cyst

geographic, lytic
short zone transition
broad-base at physis, narrow toward diaphysis
mild bone expansion
"fallen fragment" sign with fx

44

what % malig degeneration does paget disease have?

1-3%

45

what is this?

lytic
expansion, mild, fusiform; deformity
thinned cortex, endosteal scalloping
distinct margins; thick rind of sclerosis
"ground glass" appearance

fibrous dysplasia

non-neoplastic, tumor-like bone lesion

46

what is this?

age group?

75% of these in the spine and skull

Spinal findings: 
vertebral body 10-15% go into arch
lytic lesion w/ coarse vertical striations
"corduroy cloth"

hemangioma

age group: >40 yo

47

prognosis? tx?

fibrosarcoma

  • Poor. frequent local recurrence
  • Amputation

48

cafe au lait spots
fibroma molluscum
elephantiasis neuromatosa

neurofibromatosis

cafe au lait spots show up in FD too: 30% of the polyostotic form and 100% in polyostotic + endocrine form

49

Tx for FD?

non required. avoid or treat deformity and pathological fracture in fibrous dyspasia (FD)

50

what are the two types of osteochondromas?

sessile and pedunculated

51

focal gigantism suggests?

neurofibromatosis

skeletal lesions:

  • multiple nonossifying fibromas
  • bare orbit: agenesis or hypoplasia of bones of posterior wall of orbit (pulsating exophthalmos)
  • lambdoid or asterion defect
  • macrocranium, macroencephaly

52

what is this?

what is the malignant transformation rate?

maffucci syndrome

  • multiple enchodromatosis
  • soft tissue hemangiomas (venous malformation) and PHLEBOLITHS!

25% malignant transformation

53

complications of paget disease

which one is MC complicatin?

OA

deformities

  • shepherd's crook
  • sabre shin
  • basilar invagination
  • protrusio acetabuli
  • leontiasis ossea
  • ​genu varum

MC - pathologic Fx

pseudofractures

stenosis

malig degeneration 1-3%

54

what lesion is in the lower extremity (90% in tibia or fibula) and humerus

fibrous cortical defect / Nonossifying fibroma (FCD/NOF)

most are asymptomatic unless they get huge. this kid twisted their ankle playing soccer.

radiographic appearance: lytic, ovoid, sclerotic border, things and may expand cortex. appears sclerotic when healing d/t osteoblastic activity.

55

poly- or monoostotic?

MC location of paget disease?

upper or lower ext MC?

right or left side MC?

usually polyostotic

pelvis, femur, skull, tibia, vertebrae, clavicle, humerus, ribs

Lower ext > Upper

Right side > Left

56

is fibrous dysplasia monostotic or polyostotic?

usually monostotic 70-80%
MC benign rib lesion

20-30% polyostotic

57

what is the MC soft tissue sarcoma in adults?

malignant fibrous histiocytoma (MFH)

  • histologically similar to fibrosarcoma
  • MC in LE
  • Painless, solid mass

58

what is the next step for imaging?

for osteosarcoma:
MRI for treatment planning,
Chest CT/bone scan to detect metastasis

59

what is this? what is it made up of?

what are the deets on the location?

GCT (giant cell tumor)

osteoclastic giant cells AKA osteoclastoma

Location:

  • metaphyseal extending to subarticular
  • knee, distal radius, proximal humerus

60

what is this?

is this self resolving or not?

FCD / NOF (fibrous cortical defect / Nonossifying fibroma)

yes - self resolving

61

what is this?

increased bone density
coarsened trabeculae
thickened cortex
bone expansion

paget disease

  • >40 yo
  • 75% asymptomatic

62

where are simple bone cysts MC located?

proximal humerus 50-60%
proximal femur

metaphyseal, adjacent to physis

central

63

what is this?

neurofibromatosis
neuroectodermal and mesodermal dysplasia

64

tx / prognosis?

for osteosarcoma: 

Resection, Radiation, Chemo

mets to lung is common "cannonball mets"

65

what is this?

tx?

GCT

  • lytic and soap bubbly appearance
  • cortical breakage - pathological fx
  • eccentrically located (classic)

TX: curettage and packing with bone chips

66

what is this?

what is the next step?

pathological fracture probably d/t mets

refer for MRI, bone pathologist

67

age group for this?

photo: parosteal osteosarcoma

age: 30-50 yo

68

what is this view?

what is it?

what is the next step?

what is treatment?

View: frog leg

It is likely osteoid osteoma

next: refer for CT

Tx: surgical excision to remove nidus or radiofrequency ablation

69

what is this?

  • well defined
  • Homogenously opaque
  • oval
  • unilateral (is typical)

osteoma

70

3% benign tumors
40% in neural arch of spine
70% under 20 yo (Young people!)
painful but not relieved with aspirin

osteoblastoma

Photo: scoliosis. so could be ABC, osteoblastoma, or osteoid osteoma. because the pedicle is lucent, this is either ABC or osteoblastoma.

71

DDX list for this lesion?

  1. chondroblastoma: young patients, open growth plates (previous photo was this)
  2. clear cell chondrosarcoma: older patients, larger mass
  3. GCT: larger, no sclerotic border, no calcification, skeletally mature-closed growth plates

72

what is the age range for this?

fibrous dysplasia

75% found under 30 yo

73

what is the 2nd MC benign tumor?

enchondroma

asymptomatic, most found incidently e.g. sx occur with pathological fx

74

MC reason for missing pedicle

osteolytic mets

AKA winking owl, one-eyed pedicle, blind vertebra sign

75

MC benign skeletal tumor?

osteochondroma

76

what is this?

  • pathological fracture
  • moth-eaten (larger areas)
  • long zone of transition
  • minimal periosteal response

lymphoma of bone

77

what is this?

what is the Tx? prognosis?

what is the chance of malig transformation?

enchondroma

surgical removal for deforming or painful lesions

<1% chance of malig

78

what is your concern when you see this?

what is the next step?

mets

refer for ancillary study: bone scan

79

how do you describe this deformity in the legs and what is the lesion called?

shepherd's crook (coxa vera) - polyostotic fibrous dyspasia

80

______________ (photo) is not common, but accounts for 5% of all _________

parosteal osteosarcoma accounts for 5% of all osteosarcoma

81

what is this?

what is the next step?

malignant GCT

refer to bone tumor specialist

82

benign or malignant?

symptomatic or asymptomatic?

1˚ benign osteoma

bony growth that forms in membranous bone.
skull: paranasal sinuses

typically asymptomatic

83

what is this?

how do you differentiate this from the DDX?

osteochondroma

DDX: myositis ossificans, parosteal osteosarcoma. With osteochondroma the cortex is continuous with the host bone and it has normal trabeculae.

84

what is this?

paget disease

85

notice the density. reactive because periosteum is involved, so likely painful.

what is this?

what is the next step?

osteoid osteoma

CT

86

what is the rarest primary benign tumor?

intraosseous lipoma

wide age range
asymptomatic
metaphysis, calcaneous
lytic, geographic, sclerotic border

"target" or "doughnut-shaped" sequestrum = central density

CT or MRI shows fat matrix

87

what is this?

osteosarcoma

- sunburst/spiculated periosteal response
- soft tissue involvement
- 75% metaphysis of long bone

88

what is the white arrow pointing to?

paget disease

protrusio acetabuli

89

tell me about osteoblastoma

  • radiographic findings
  • tx

expansile
lytic with a rim of sclerosis
large 4-6 cm in the spine or >2 cm in the extremities VS. histological relative, osteoid osteoma <1 cm

Image from radiopedia.org: "Left acetabular fossa pubic bone expansile predominantly lytic lesion with a rim of reactive sclerosis."

TX:

  • surgical resection/excision
  • Radiation/chemo
  • percutaneous ablation - emerging

90

what is this?

either chondrosarcoma or (this photo) enchondroma

  1. Chondrosarcoma
    1. 40-70 yo
    2. MC 1˚ malig of hand, sternum, scap (board Q)
    3. large, lytic, poorly defined
    4. popcorn, stippled, arcs and rings
    5. large soft tissue mass
    6. endosteal scalloping
  2. Enchondroma (PHOTO)
    1. 10-30 yo
    2. 50% hands and feet (MC tumor of phalanges)
    3. lytic, geographic, expansile
    4. thinned cortex
    5. endosteal scalloping
    6. NO soft tissue mass

 

*NOTE: clear cell chondrosarcoma is indistinguishable from chondrosarcoma

91

what is this?

what is the tx?

ABC

TX: surgical curettage & bone grafting

92

what is this?

osteoblastic mets

Why? because multiple ivory vertebra

3 MC causes of ivory vertebra:

  • Ostoblastic mets (multiple ivory vertebra)
  • Paget disease (cortical thickening, expansion)
  • Lymphoma (anterior body scalloping)

93

acute onset after trauma

osteochondroma

typically does not cause pain

94

prognosis for simple bone cyst?

surgical tx is recommended bc high pathological fx rate

30-40% recurrence rate w/ curettage

steroid injection into cyst reduces recurrence

95

what is this?

what is a ddx?

boney island (enostosis)

ddx: osteoma would have clear edges while bony island has brush border

96

what is this?

enchondroma

lytic, geographic
expansile
thinned cortex, endosteal scalloping
metaphyseal-diaphyseas

97

how do you describe this?

what does it point to?

candle flame appearance

paget disease

98

What is this?

where is this usually found?

where is it NOT common?

bone island (enostosis)

usually found: metaphysis or epiphysis

not common: spine

solitary, discrete area of sclerosis
homogenously dense
usually asymptomatic
found in any age

99

what is this?

what is typical Tx for all of these?

subungual exostosis = osteochondroma

osteochondroma: usually requires no tx

subungual exostosis: usually requires removal

100

This _____ is the MC benign tumor of the ____ and ____

GCT; sacrum and patella

101

medullary osteoid osteoma DDX list

  1. brodie abscess: lesion close to growth plate
  2. bone island: brush border, normal bone scan
  3. osteoblastoma: lesion >2cm, reactive sclerosis, periosteal reaction (see photo)

102

what is this?
describe the findings

enchondroma of the humerus

lytic, geographic.
expansile
thinned cortex, endosteal scalloping
metaphyseal-diaphyseal
NO periosteal rxn, NO soft tissue mass

103

what are the types of neurofibromatosis

neurofibromatosis
1 - von Recklinghausen disease
2 - bilateral

104

1% of primary bone malignancies

chordoma

  • 30-70 yo
  • plain film: midline lesion, lytic destruction, cortical expansion
  • DDX: lytic mets, chondrosarcoma, GCT, ABC, plasmacytoma

105

what age group gets this?

how common is this?

lymphoma of bone

20-50 yo

3-4% of primary bone malig

106

what is this?

FCD/NOF

fibrous cortical defect / Nonossifying fibroma

107

what is the age range for this?

GCT (giant cell tumor)

20-40 yo = CLOSED growth plates

108

ddx list for this?

  1. hemangioma
    1. single lesion
    2. normal cortex
    3. rare to have vertebral body expansion
  2. paget disease
    1. single OR multiple
    2. thickened cortex
    3. body expansion common
  3. osteoporosis
    1. multiple lesions
    2. thinned cortex
    3. NO body expansion

It's hemangioma because 1 body, no expansion, normal cortex.

109

what is this?

metaphyseal region of distal knee
growth plate, so young person

pedunculated osteochondroma with pathological fx

75% of cases are <20 yo

110

cortical lesion (80%)
reactive sclerosis

what is this?

osteoid osteoma

see the nidus?