January 1, 2011In the article Bone Tumors - Differential diagnosis we discussed a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions.
In this article, which is the first in a series of three, we will discuss the most common bone tumors and tumor-like lesions in alphabethic order.
Our goal is to show many cases in order to make you familiar with the images of these tumors. Aneurysmal bone cyst typically presents as a painful expansile or 'aneurysmal' well-defined osteolytic lesion in a patient younger than 30 years. On plain radiographs often ballooning with very thin peripheral bone shell and frequently internal thin bony ridges.
In the proximal humerus or femur of young children there is frequently a differential diagnosis of ABC, SBC and fibrous dysplasia.
Cavities filled with blood can also be found in giant cell tumor, osteoblastoma and chondroblastoma (i.e with secondary ABC). Notice the well-defined osteolytic presentation with multiple fluid-fluid levels on MR with the patient in supine position. On the left images of an aneurysmal or expansile well-defined osteolytic bone lesion in the fibula.
The T2-weighted MR-image shows the fluid content and on the T1-weighted image there is a subtle fluid-fluid level. On the left images of an aneurysmal or expansile well-defined osteolytic bone lesion in the proximal phalanx. On the left an expansile well-defined osteolytic lesion with a sclerotic margin in the talus.
Axial PD-weighted image shows lobulated contours and cystic appearance with fluid-fluid level (arrow). On the left two different patients with an intracortical or subperosteal osteolytic well-defined lesion in the tibia. The lesion on the far left was thought to be an adamantinoma because of the localisation in the anterior tibial cortex. The plain radiograph shows a layered periosteal reaction and Codman triangle in direct relationship to an expansile lytic lesion with a thin peripheral bone shell.
CT also reveals the subperiosteal origin of the lesion with secondary involvement of the cortical bone.
Axial T2-weighted image with fatsat and contrast enhanced T1-weighted image with fat sat show multiple fluid-fluid levels with rim enhancement of the cavities filled with blood. Rare low-grade malignant lesion, exclusively found in the diaphysis of the anterior cortex of the tibia.
On MRI, the lesion is lobulated with high signal intensity on T2-weighted images and strong enhancement after Gd-DTPA.
Young patient with a lobulated lytic lesion within the anterior cortical bone of the proximal tibia. Axail CT image prior to biopsy demonstrates the lytic appearance of the lesion within the thickened cortical bone. In the differential diagnosis could have been chondromyxoid fibroma or fibro-osseous lesion, however, the separate cortical lesion strongly suggests adamantinoma, which is almost exclusively found in the tibia and often multicentric. Here a mixed sclerotic-lytic lesion, cortically based in the tibia shaft in a 12-year old boy.
Differential diagnosis includes adamantinoma or osteofibrous dysplasia, based on the typical location, age (2nd-3rd decade) and radiographic appearance. Sagittal T2-weighted fat-suppressed images demonstrate multiple foci of high SI within the cortices of tibia and fibula. Typical presentation: central lesion in metaphysis or diaphysis with a well defined serpentiginous border.
Causes: corticosteroid use, sickle cell disease, trauma, Gaucher's disease, renal transplantation. If the osteonecrosis is located in the epiphysis, the term avascular osteonecrosis is used. 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.
At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found.
Typical MR pattern of bone infarctions with peripheral serpentiginous zones of low SI and central area of fat.

Differentiating a bone infarct from an enchondroma or low-grade chondrosarcoma on plain films can be difficult or even impossible.
Cartilaginous tumors in particular chondrosarcoma may show endosteal scalloping, while a bone infarct does not. A bone island consists of well-differentiated mature bone tissue within the marrow, also referred to as enostosis. In patients with breast- or prostate cancer a bone island can be mistaken for an osteoblastic metastasis. Bone changes in hyperparathyroidism are generally diffuse including subperiosteal resorption or generalized demineralization.
More extreme focal bone resorption may result in a lesion which resembles a primary bone tumor or metastatic lesion. On the left a patient who had a nefrectomy for renal cell carcinoma and who was on dialysis.
Here images of a 33-year old male with a diaphyseal eccentric sharply defined lytic lesion predominantly located in the cortical bone. CT shows the cortical origin with thin peripheral rim in this patients with hyperparathyroidism. 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.
The differential diagnosis of an epiphyseal lesion in young patients, besides chondroblastoma, includes osteomyelitis and ganglion cyst. There is a well-defined lytic lesion located posteriorly in the proximal epiphysis of the tibia. On the coronal T2-weighted image with fat suppression the lesion has a high SI and subtle internal ridges.
If there were signs of osteoarthrosis, the differential diagnosis would be a chondroblastoma and a degenerative cyst (or geode). Other diagnostic possibilities in the young population: SBC (no edema), ABC (fluid levels), or osteoblastoma. Notice the surrounding decreased signal intensity of the bone marrow, consistent with edema. Edema almost always accompanies chondroblastoma, but is unusual in other chondroid tumors, like enchondroma or low-grade chondrosarcoma. Coronal T2-WI with FS demonstrates high SI of the lesion with a low intensity sclerotic border with perilesional edema. Coronal T2-weighted image with fat saturation demonstratesa chondroblastoma in the femur epiphysis with perilesional edema (same case as above). Sagittal T1-weighted MR image of a lytic lesion with peripheral sclerotic rim in the posterior talar bone in a young patient. CMF is a rare benign osteolytic lobulated lesion preferentially found eccentric in the tibia metaphysis and less common in the femur and foot.
Eccentric well-defined lytic lesion in the metaphysis of the proximal tibia in a young child. Differential diagnosis, because of the eccentric manifestation: non-ossifying fibroma or chondromyxoid fibroma.
Axial T2-weighted image nicely shows the low SI sclerotic margin, high SI of the intrinsic part of the lesion, bone marrow edema and some soft tissue reaction. On the T1-weighted image before contrast there is a nonspecific intermediate signal intensity.
On the left a diaphyseal cortically based lytic lesion with expansion and a thin peripheral bone shell.
The lobulated morphology with high SI on the T2-weighted image with fat saturation suggests that this is a cartilaginous lesion.
Typical presentation: large osteolytic lesion with scalloping of the inner cortex and rings-and-arcs or popcorn calcifications in an elderly person with a painful swelling. Patients with multiple enchondromas like in Ollier's disease and Mafucci's syndrome are at risk.
Low grade tumor can usually not be differentiated from enchondroma based on imaging findings alone. High grade tumor may present as aggressive ill-defined lesion with extention into the soft tissues.
The differential diagnosis on the plain radiographs in all these three cases is enchondroma.

Additional MR imaging and bone scintigraphy may be helpful to make the diagnosis of chondrosarcoma more or less likely. On the left a massive chondrosarcoma of the skull base with extension to the nasal and paranasal cavities and orbita. Based on the imaging findings it is not possible to differentiate between an enchondroma or a low grade chonrosarcoma. This increased uptake in a chondroid tumor is in favor of the diagnosis of a low grade (grade I) chondrosarcoma. The fast dynamic contrast enhanced MR image with subtraction revealed early and progressive enhancement, which is also in favor of the diagnosis of a grade I chondrosarcoma.
On the MR, the lesion is far more extensive than suspected on the plain radiograph at first glance. On second inspection you will notice the subtle endoteal scalloping of the tumor on the radiogrph. On the coronal T2-weighted image the tumor is seen as a large lobulated mass with very high SI, which is typical for chondroid tumors. The size of the lesion and the high uptake on the bone scan suggest that this is a chondrosarcoma. Measuring the cartilage cap will help in distinguishing benign osteochondromas from chondrosarcomas. With 2 cm used as a cutoff for distinguishing benign osteochondromas from chondrosarcomas, the sensitivities and specificities were 100% and 98% for MR imaging and 100% and 95% for CT, respectively (3).
Notice that the tumor arises from an osteochondroma, which is shown in the center part of the image (arrow). On the left a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the lesion. The sagittal T2-WI FS much better demonstrates the presence and extension of a lesion with lobulated margins and a mixed pattern of high and low SI. The CT shows the calcifications with subtle endosteal thinning of the cortical bone (arrows).
The most likely diagnosis is enchondroma, however progression to a low-grade chondrosarcoma cannot be excluded based on the plain radiograph alone. There is increased activity on the nuclear bone scan, which is more in favor of the diagnosis of a chondrosarcoma.
On the sagittal T1-weighted CE image, the calcifications (low SI) are present in the proximal part. However, the lesion with septal-nodular enhancement pattern is far more extensive than suspected on the plain radiograph at first sight. This is, together with the diameter of the lesion in favor of the diagnosis chondrosarcoma. The T1WI+Gd with fatsat demonstrates the presence of a solid enhancing part and perilesional edema. Sagittal T1-weighted image (left) and sagittal T1-weighted image with fatsat after Gd-DTPA (right). Some reactive sclerosis and abundant perilesional edema on T2-weighted image with fat saturation. A combination of 67Ga citrate and 99mTc-MDP bone scanning is very sensitive and more specific than gallium alone. The midfoot area was visibly swollen and the patient experienced tenderness to the touch during the physical examination.
Bone marrow edema (bone bruise) of the cuneiforms, second, fourth and fifth metatarsals and cuboid. The referring physician suspected the patient may have suffered a sprain or tear of a ligament in the foot. A dedicated 8-channel ski-boot type foot and ankle coil was utilized on the 3T MRI scanner. Extremely high resolution images were obtained providing clear visualization of the pathology causing the patient’s symptoms. Images representative of the study are presented below with pathology clearly labeled and annotated.

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