Lecture 5 DDX of Neoplasms

Ivory vertebra

-Idiopathic

-Hodgkin’s Lymphoma

-Osteoblastic METS

-Paget’s

FEGNOMASHIC

-Fibrous Dysplasia

-Enchondroma

-Giant Cell tumor

-Non-Ossifying fibroma/Fibrous cortical defect

-Osteoblastoma

-Metastasis/Myeloma (blowout mets)

-Aneurysmal bone cyst (ABC)

-Simple bone cyst

-Intraosseous Lipoma

-Chondroblastoma

FEGNOMASHIC Under 25 Lesions

-Enchondroma

-NOF/FCD

-Osteoblastoma

-ABC

-Simple Bone Cyst

-Chondroblastoma

-Lipoma

FEGNOMASHIC 20 to 40 years old lesions

-Enchondroma

-Giant cell tumor

-Fibroxanthoma

-Lipoma

FEGNOMASHIC Over 40 Lesions

-Enchondroma

-Mets (blowout)

-Myeloma

-Lipoma

FEGNOMASHIC w/ Pain

-Giant cell tumor

-Osteoblastoma

-Mets

-Myeloma

-ABC

-Chondroblastoma

-Lipoma (dull)

FEGNOMASHIC w/ no pain

-Enchondroma

-NOF/FCD

-Mets

-Myeloma

-Simple Bone cyst

-Lipoma

Enchondroma (Summary)

-Geo lytic appearance is more common in hands/ feet than long bones

-10 to 30 years old but have it forever

-No pain

-MC tumor of hands/feet

-Benign cartilaginous tumor

-50% show stippled calcification

Giant Cell Tumor (Summary)

-20 to 40 years old

-Painful

-no sclerotic margin

-Subarticular extension (up to the joint)

NOF/FCD (Summary)

-4 to 20 years old (FCD 4-8; NOF 8-20)

-Painless

-Eccentric

-Hazy, ground glass matrix

-Most common in proximal/distal tibia and distal femur

NOF/FCD on X-ray

Osteoblastoma (Summary)

-10 to 25 years old

-Painful

-Like a giant osteoid osteoma without as much pain or sclerosis

-Most common in the spine and long bones

Metastasis (Blowout)

-Over 50 years old

-May or may not have pain

-From renal, adrenal, thyroid, skins (RATS)

-In axial skeleton and extremities proximal to elbow/knees

Blowout Mets on X-ray

Myeloma (Summary)

-Over 40 years old

-May or may not have pain

-Solitary version of multiple myeloma

-Most common in axial skeleton and extremities proximal to elbows/knees

-Much less common than mets

ABC (Summary)

-Less than 20 years old

-Painful

-Rapidly expansile

-Most common in long bones, spine, and pelvis

-Often seen in other lesions (GCT most common)

-Indicated by fluid fluid levels on advanced Imaging

ABC on X-ray

Simple Bone Cyst (summary)

-3 to 14 years old

-Painless until fracture (2/3 present with fracture)

-Most common in proximal humerus and femur as well as calcaneus

-Central within the long bone

-Often fracture (will have pain in this case) with possible fallen fragment

Intraosseous Lipoma (Summary)

-5 to 70 years old

-Dull pain or painless

-Most common in calcaneus and proximal long bones of lower extremity

-Possible central calcification (cockade sign)

Chondroblastoma (Summary)

-10 to 25 years old

-Painful

-In apophyses/epiphyses

-50% show punctate calcifications

Benign Lesions in posterior elements

-ABC

-GCT

-Osteoblastoma

-Osteochondroma

-Osteoid Osteoma

ABC age?

-Less than 20 years old

GCT age?

-20 to 40

Osteoblastoma age?

-10 to 25

Osteochondroma age?

-Less than 20

Osteoid Osteoma age?

-10 to 25

Most common primary malignancies to show geographic lytic pattern (Blowout mets)

-Renal

-Adrenal (Pheochromocytoma)

-Thyroid

-Skin (melanoma)

Most Common malignancies to metastasize to bone?

-Prostate

-Breast

-Kidney

-Thyroid

-Lung

(PB KTL)

Most Common Primary Osseous Malignancies in order

-Multiple Myeloma

-Osteosarcoma

-Chondrosarcoma

-Ewing Sarcoma

Multiple Myeloma Buzzwords

-Raindrop skull

-Bence Jones Proteinuria

-M spike on electrophoresis

-Vertebra plana

Osteosarcoma (Summary)

-Most common primary malignancy in kids

-Primary 10 to 25

-Secondary is over 50

-Blastic, mixed, or lytic lesion in around the knee

-Large osseous soft tissue mass

-Codman’s Triangle

-Sunburst periostitis

Chondrosarcoma (Summary)

-30 to 60 years old

-ICE lesion if intramedullary

-Most common in proximal long bones and pelvis

-Large soft tissue mass with arcs and rings calcification

-Most common malignancy to form from enchondroma and osteochondroma

Ewing Sarcoma

-10 to 25

-Diaphyseal

-Clinically and radiographically mimic infection

-Laminated periostitis

-Large soft tissue mass

ICE Lesion

-Punctate/Stippled/Flocculant calcification in the medullary canal of a Long bone

If Ice lesions is present lead with chondrosarcoma if:

-Over 40 years old

-over 5 cm in length

-Endosteal scalloping >2/3 width of cortex

-Pain not due to Fx

-Overt signs of aggression

Osteolytic (Geographic)

-Narrow zone of transition

-Possible sclerotic border

-Sharp margin/well-circumscribed

-Indicates slower growth (Likely benign)

Osteolytic (Motheaten)

-Wide zone of transition (Poorly defined margins)

-Multiple osteolytic punched out lesions

-Indicates more rapid growth/spread (Likely aggressive)

Osteolytic (Permeative)

-Wide zone of transition (poorly defined margins)

-Indicates more rapid growth/spread (likely aggressive)

Narrow Zone of Transiiton

-Well-defined border

-Seen with geographic lysis. Also common with blastic lesions

-Typically non-aggressive

Wide Zone of transition

-Indistinct margins

-Seen with moth eaten and permeative lysis

-Typically aggressive (Malignant or infection)

Periosteal Reaction

-Stimuli cause periosteum to react in various ways depending on degree of aggression

-10 to 21 day latency

Solid Periosteal Reaction

-Least aggressive pattern

-Caused by Osteoid osteoma, stress fracture, venous stasis, HOA, Intracortical abscess

Laminated Periosteal Reaction

-AKA lamellated, onion skin, layered

-Caused by cyclic exposure to stimuli

-may become solid

-Classically associated with Ewing sarcoma and infection

Sunburst Periosteal Reaction

-AKA hair on end, perpendicular brushed whiskers

-Seen in more aggressive process (Osteosarcoma)

Codman’s Triangle

-Most aggressive periosteal reaction

-Triangle of new bone with subperiosteal extension of aggressive process

-Seen in Osteosarcoma

Most common osseous site of infection and tumor?

-Metaphysis