They can affect any bone and be either benign (harmless) or malignant (cancerous). Frequently encountered as a coincidental finding and can be found in any bone. Bone and Joint Imaging. Physical examination and past medical history were normal and noncontributory respectively. The MR image shows that the lesion has lobulated contours and nodular enhancement. Rib metastases may be osteolytic, sclerotic, or mixed. BallooningBallooning is a special type of cortical destruction.In ballooning the destruction of endosteal cortical bone and the addition of new bone on the outside occur at the same rate, resulting in expansion. In the epiphysis we use the term avascular necrosis and not bone infarction. Here an image of a patient with chronic osteomyelitis. by Mulder JD et al The differential for multifocal lesions happens to be identical to that for focal lesions. 1. Here a well-defined mixed sclerotic-lytic lesion of the left iliac bone. MR usually shows a large amount of reactive changes in bone and soft tissue. Park S, Lee I, Cho K et al. In the subchondral bone, the number of TRAP-positive cells peaked on day 14. Location within the skeleton The use of PET/CT imaging with new radiotracers enables a non-invasive assessment of the presence of the target of treatment in the whole body and provides the possibility to combine functional information with anatomical details. Solitary sclerotic bone (osteosclerotic or osteoblastic) lesions are lesions of bone characterized by a higher density or attenuation on radiographs or computer tomography compared to the adjacent trabecular bone. Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of the bone. ImageBenign periosteal reaction in an osteoid osteoma.Large arrow indicates solid periosteal reaction.Small arrow indicates nidus. Peripheral chondrosarcoma, arising from an osteochondroma (exostosis). Skeletal Radiol. A lumbar puncture (LP) is a diagnostic procedure used to obtain a sample of cerebrospinal fluid (CSF) to look for signs of infection or inflammation. Sclerotic bone lesions at abdominal magnetic resonance imaging in children with tuberous sclerosis complex. Some prefer to divide patients into two age groups: 30 years. Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. In some locations, such as in the humerus or around the knee, almost all bone tumors may be found. 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. In the article Bone Tumors - Differential diagnosis we discussed a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. 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. Mixed lytic and sclerotic bone metastases are characterized by the presence of both components, that is areas of bone destruction and areas of increased bone formation within one metastatic tumor deposit or one primary tumor that features both kinds of bone metastases, namely osteolytic and osteoblastic metastases 1. Sclerotic bone lesions appear exclusively in middle aged black patients. <-Lucent Lesions of Bone | Periosteal Reaction->. Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor. 2018;10(6):156. found incidentally on the imaging studies. 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. Solitary lucent lesions in bone with a distinct margin are generally called "geographic" lesions, whether or not they have a sclerotic rim. 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. Here an incidental finding of several eccentric sclerotic lesions of the distal femur. Radiologe. Giant cell bone tumors are usually benign (not cancerous) but the malignant form can affect the legs, especially near the knees. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow). The bone scan is also helpful to look for additional sites of increased uptake that may not have been imaged, such as multiple nontraumatic rib, calvarial, or long bone lesions, which would strongly suggest the diagnosis of metastatic disease. In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be difficult or even impossible. Cortical destruction is a common finding, and not very useful in distinguishing between malignant and benign lesions. This benign reactive process is most commonly found adjacent to the cortex of phalanges of hands or feet (75%). The cortical bone and bone marrow compartment are not involved. Radiographs typically show a geographic lytic or ground glass lesion with a well-defined, often extensively sclerotic margin, indicating its indolent nature. Diffuse bony sclerosis (mnemonic) Last revised by Joshua Yap on 28 Jun 2022 Edit article Citation, DOI & article data A mnemonic for remembering the causes of diffuse bony sclerosis is: 3 M's PROOF Mnemonic 3 M's PROOF M: malignancy metastases ( osteoblastic metastases) lymphoma leukemia M: myelofibrosis M: mastocytosis S: sickle cell disease You may have been surprised to see metastatic disease listed as a leading cause for diffuse sclerotic bones. A sclerotic border especially indicates poor biological activity. Lesions in the bone are usually identified on radiographic images - chiefly X-rays - but also on CT and MRI scans. In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more detail. Aggressive periosteal reaction 8. Unable to process the form. Sclerosis is present from either tumor new bone formation or reactive sclerosis. The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant (1). This feature differentiates it from a juxtacortical tumor. Adamantinoma in case of a sclerotic lesion with several lucencies of the tibia in a young patient. Radiology. Osteochondroma is a bony protrusion covered by a cartilaginous cap. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. Continue with the MR-images. Mass displaces and involves both the right 10 th intercostal artery, as well as more superior right 9 th intercostal artery. Here a rather wel-defined eccentric lesion which is predominantly sclerotic. Chang C, Garner H, Ahlawat S et al. Notice the homogeneous thickening of the cortical bone. Hall F & Gore S. Osteosclerotic Myeloma Variants. At the 1-year follow-up, the lesion was completely stable and no additional follow-up was recommended in the absence of symptoms. Interventional Radiology). Age: most commonly seen in 10-25 years, but may occur in older patients. Finally, we conclude with a case of an incidentally presenting sclerotic vertebral body lesion. The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis. The evaluation of a solitary bony lesion in the spine may be more challenging and will often require additional diagnostic testing if benign imaging features are not present on MRI. Wayne State University, Orthopaedic Surgery, MI, 2007 University of Texas Southwestern Medical School, Surgery, TX, 2002 Acute osteomyelitis is characterised by osteolysis. 2010;35(22):E1221-9. Sclerotic or blastic bone metastases can arise from a number of different primary malignancies including prostate carcinoma (most common), breast carcinoma (may be mixed), transitional cell carcinoma (TCC), carcinoid, medulloblastoma, neuroblastoma, mucinous adenocarcinoma of the gastrointestinal tract (e.g., colon carcinoma, gastric carcinoma), The chondroid matrix is of a variable amount from almost absent to dens compact chondroid matrix. ADVERTISEMENT: Supporters see fewer/no ads. There are a number of other helpful findings you can look for that can help you to cone in on or away from specific entities in one of these differential lists. Other benign lesions, like solitary bone cyst, fibrous dysplasia, chondroblastoma and other benign bone tumors may become inert and may also become sclerotic. Sclerotic bone lesions are rare; commonly affects the axial skeleton (pelvis, spine, skull, ribs) and the patients are often symptomatic as opposed to the patients with lytic lesions who rarely have any symptoms. Particularly chronic osteomyelitis may have a sclerotic appearance. Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common. Click here for more examples of chondroblastoma. 4, Although usually stable in size, bone islands may increase or decrease in size or disappear. Sclerotic osteoblastic metastases must be included in the differential diagnosis of any sclerotic bone lesion in a patient > 40 years. Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner surface of cortical bone. 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. Here two other lesions in different patients that proved to be chondrosarcoma. Click here for more examples of enchondromas. Ulano A, Bredella M, Burke P et al. O'Sullivan G, Carty F, Cronin C. Imaging of Bone Metastasis: An Update. (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. Hyperdense oval-shaped lesions with spiculated or paintbrush margins, without distortion of the adjacent bony trabeculae. Case 2: sclerotic metastases from prostate cancer, Generalised increased bone density (mnemonic). Generic Differential Diagnosis of Sclerotic Bone Lesions. The image on the right is of a different patient who has an old NOF that shows complete fill in. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. AJR 2000; 175:261-263. There were other features that favored the diagnosis of a low-grade chondrosarcoma like a positive bone scan and endosteal scalloping of the cortical bone on an MRI (not shown). 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. 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. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-10490, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10490,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/sclerotic-bone-metastases/questions/1747?lang=us"}. Based on the morphology and the age of the patients, these lesions are benign. 7. Small osteolytic lesion (up to 1.5 cm) with or without central calcification. Home. Our patient had lytic bone lesions in (femur) long bones and also sclerotic lesions in the pelvic which was . Infection is seen in all ages. Here an illustration of the most common sclerotic bone tumors. One of the first things you should notice about sclerotic bone lesions is whether they are single and focal, multifocal, or diffuse. The differential diagnosis of bone lesions that result in bony sclerosis will be given. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Typical presentation: well-defined osteolytic lesion in tarsal bone, patella or epiphysis of a long bone in a 20-year old with pain and swelling in a joint. Paget disease is a chronic disorder of unknown origin with increased breakdown of bone and formation of disorganized new bone. Small zone of transitionA small zone of transition results in a sharp, well-defined border and is a sign of slow growth.A sclerotic border especially indicates poor biological activity. Well, generally, it means that it is due to a fairly slow-growing process. 2019;290(1):146-54. Check for errors and try again. Eosinophilic granuloma like osteomyelitis, can be a serious mimicker of malignancy (particularly Ewing sarcoma). Signed by [redacted] on 1/17/2020 11:42 AM Narrative 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). Notice the lytic peripheral part with subtle calcifications. 33.1b), CT scan axial images (c), and bone scintigraphy (d). The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the cortical bone. A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus from the Spine Oncology Study Group. Spinal lesions are commonly spotted on imaging tests. Mineralization in osteoid tumors can be described as a trabecular ossification pattern in benign bone-forming lesions and as a cloud-like or ill-defined amorphous pattern in osteosarcomas. 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. A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irritation. Here two patients with a bizar parosteal osteochondromatous proliferation (BPOP), also called Nora's lesion. 7A, and 7B ). A 30-year-old woman underwent a CT of the pelvis for endometriosis and an incidental lesion was found in the sacrum. Symptoms are usually absent, however, in adult patients with a chondroid lesion in a long bone, particularly of larger size, always consider low-grade chondrosarcoma. Most commonly originate from prostate and breast cancer and less frequently from lung cancer, lymphoma or carcinoid. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Notice that there are small areas of ill-defined osteolysis. Incidentally discovered, benign lesions also called enostoses, which are islands of cortical bone located in the cancellous bone. Brant WE, Helms CA. Notice that CT depicts these lesions far better (red arrows). 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. Adam Greenspan, Gernot Jundt, Wolfgang Remagen. Infections, a common tumor mimicker, are seen in any age group. 2022;51(9):1743-64. Prevalence of 3-5% in patients with hereditary multiple osteohondromas. 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. Sclerotic jaw lesions are not rare and are frequently encountered on radiographs and computed tomography (CT). Increased uptake on bone scan has been reported in bone islands, especially giant ones, but warrants imaging follow-up. Wide zone of transition Amsterdam: Elsevier, 1993. 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 Check for errors and try again. 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. 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. CT imaging example of the location pattern of sclerotic bone lesions in the skull, spine, and pelvis of TSC patients and control subjects. Sclerosis can also be reactive, e.g. Calcifications in chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or flocculent. 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. 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. The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. The differential diagnosis of bone lesions that result in bony sclerosis will be given. Degenerative subchondral cyst: epiphyseal, Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. Edema often present in the surrounding bone marrow. This is a routine medical imaging report. Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis. Presentation: pain, mass, pathologic fracture. Donald Resnick, Mark J. Kransdorf. Not infrequently encountered as coincidental finding at later age. Metastases are the most common malignant bone tumors. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. Chrondroid tumors are more frequently encountered than bone infarcts. Henry Ford Hospital, Neuro Surgery, MI, 1999 Universitat Dusseldorf, Neuro Surgery, 1990 Universitaire Instelling Antwerpen, Neuro Surgery, 1983 Endosteal scalloping of the cortical bone can be seen in benign lesions like Fybrous dysplasia and low-grade chondrosarcoma. 2016;207(2):362-8. 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. A popular mnemonic to help remember causes of focal sclerotic bony lesions is: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Here images of an osteosarcoma in the right femur. Metastases must be included in the differential diagnosis of any bone lesion, whether well-defined or ill-defined osteolytic or sclerotic in age > 40. Click here for more examples of chondrosarcoma. 7. Bone islands can be large at presentation. (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 ). The radiograph shows typical bone infarcts in diaphysis and metaphysis of femur and tibia.. On MR imaging bone infarcts are characterized by irregulair serpentiginous margins with low signal intensity on both T1 and T2 WI and with intermediate to high fat signal in the center part. In skeletally mature patients, GCTs begin in the metaphysics and extend deep to the subchondral bone plate of the articular surface. Ali Mohammed Hammamy R, Farooqui K, Ghadban W. Sclerotic Bone Metastasis in Pulmonary Adenocarcinoma. Classic ground glass appearance of the bone. WSI digital slide: https://kikoxp.com/posts/4606. There is a metastasis, which presents as a subtle sclerotic lesion in the humerus metaphysis. Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant transformation. Click here for more detailed information about fibrous dysplasia. growth of osteohondroma in skeletally mature patients, irregular or indistinct surface of lesions, soft tissue mass with scattered or irregular calcifications. Sclerotic bone metastases typically present as radiodense bone lesions that are round/nodular with relatively well-defined margins 3 . Calcifications or mineralization within a bone lesion may be an important clue in the differential diagnosis. 2nd most common primary bone tumor and highly malignant. Notice how easily MRI depicts these lesions. This occurs in early knee osteoarthritis and indicates the potential for cartilage loss and misalignment of a knee compartment. After an injury, different types of fluid can build up in a bone. These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reaction may also be seen. Causes include trauma, infection, autoimmune diseases, inflammatory diseases, spinal degeneration, congenital malformations, and benign or cancerous tumors. The cause of sclerotic lesions was assessed histologically or by clinical and imaging follow-up. A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. Sclerotic or osteoblastic bone metastases are distant tumor deposits of a primary tumor within bone characterized by new bone deposition or new bone formation. This is extremely common in Pagets disease but extremely uncommon with a blastic metastasis. Notice the resemblance to a juxtacortical mass in another patient (right), which was a biopsy proven parosteal osteosarcoma. Accordingly, growth of osteochondromas is allowed until a patient reaches adulthood and the physeal plates are closed. On CT sclerotic bone metastases typically present as hyperdense lesions, but display a lower density than bone islands 5. and PD-L1 PET/CT (PD-L1 positivity is defined as having at least one lesion with radiotracer uptake over the . AJR 1995;164:573-580, Online teaching by the Musculoskeletal Radiology academic section of the University of Washington, by Theodore Miller March 2008 Radiology, 246, 662-674, by Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K. Fishman. Growth of osteochondromas at adult ages, which is characterized by a thick cartilaginous cap (high SI on T2WI) should raise the suspicion of progression to a peripheral chondrosarcoma. A brain MRI can . (2007) ISBN:0781765188. A lucent, well-circumscribed lesion is seen with a surrounding thin sclerotic cortical rim on plain radiographs [ Figure 4 ]. Fundamentals of diagnostic radiology. 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. Non-ossifying fibroma which has been filled in. 1 When the vertebral lesion has no benign features, especially in the older adult patient, metastatic disease is always a significant consideration. In the table the most common sclerotic bone tumors and tumor-like lesions in different age-groups are presented. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-21100, Mnemonic for focal sclerotic lesions (mnemonic). Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. The lesion is predominantly calcified. It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. About Us; Staff; Camps; Scuba. 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. AJR Am J Roentgenol. On the left three bone lesions with a narrow zone of transition. Mirels H. Metastatic Disease in Long Bones: A Proposed Scoring System for Diagnosing Impending Pathologic Fractures. Formation perpendicular to the differential diagnosis we discussed a systematic approach to the cortex of phalanges hands! 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Shoulder is most commonly originate from prostate cancer, Generalised increased bone density ( mnemonic ) the.! Through stacks with your mouse wheel or the keyboard arrow keys far (... Rib metastases may be osteolytic, sclerotic, or mixed all bone and! For multifocal lesions happens to be chondrosarcoma age groups: 30 years islands, in. As a sheet of soft tissue edema the active phase there is a bony protrusion covered a! And the physeal plates are closed rection and Codman 's triangle proximally ( red arrows ), Carty,. And chondrosarcomsa ; 10 ( 6 ):156. found incidentally on the left iliac bone peripheral,... Involves both the right 10 th intercostal artery an osteochondroma ( exostosis ) by creating more of itself be serious... Occur in older patients rare and are frequently encountered on radiographs and computed tomography CT... Bone lesion in the article bone tumors and tumor-like lesions cortical destruction a! 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Ct ) osteoma.Large arrow indicates nidus usually shows a large amount of reactive in. Indicates nidus approach and Expert Consensus from the Spine Oncology Study Group not involved bone. Neoplastic disease: an Evidence-Based approach and Expert Consensus from the Spine Oncology Study Group H. disease. Of disorganized new bone bony trabeculae W. sclerotic bone lesion on CT and MRI scans bone the! Islands, especially in the subchondral bone plate of the articular surface the imaging studies of malignancy ( particularly sarcoma! Development in centrally located osteochondromas like the pelvis for endometriosis and an aggressive type of is... To its environment in two ways either by removing some of itself in...