Park S, Lee I, Cho K et al. Radiology. Bker S, Adams L, Bender Y et al. Sometimes a more solid periosteal reaction is present combined with cortical thickening and broadening of the bone. One of the first things you should notice about sclerotic bone lesions is whether they are single and focal, multifocal, or diffuse. Moreover, questions such as the . Interventional Radiology). Another approach to the differential diagnosis of sclerotic bone lesions is to use the mnemonic I VINDICATE, which means 'I clear myself from accusation'. 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. There is no calcification and lesions may be expansile. Here a chondrosarcoma of the left iliac bone. 6. 9. 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. Both imaging modalities achieved only a moderate correlation with DEXA. 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. 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. Hereditary sclerosing bone dysplasias result from some disturbance in the pathways involved in osteoblast or osteoclast regulation, leading to abnormal accumulation of bone. Melorrheostosis is a dysplasia of the bone, characterized by apposition of mature bone on the outer or inner surface of cortical bone. 2nd most common primary bone tumor and highly malignant. Skeletal Radiol. The cause of sclerotic lesions was assessed histologically or by clinical and imaging follow-up. A T1w/T2-weighted (T2w) hypointense nonexpansile lesion is seen involving the sacrum (asterisk). Should be included in the differential diagnosis of young patient with multiple lucent lesions (Langerhans cell histiocytosis). These lesions are not osteochondromas, but consist of reactive cartilage metaplasia. Typically a NOF presents as an eccentric well-defined lytic lesion, usually found as a coincidental finding. Differentiating between a diaphyseal and a metaphyseal location is not always possible. 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. A sclerotic lesion is an unusual hardening or thickening of your bone. Contact Information and Hours. NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic Ewing' s sarcoma. AJR Am J Roentgenol. 2016;207(2):362-8. Radiographically, GCTs are eccentrically located radiolucent lesions with well-defined lytic 1B margins and geographic bone destruction. Notice the lytic peripheral part with subtle calcifications. Most commonly originate from prostate and breast cancer and less frequently from lung cancer, lymphoma or carcinoid. Case 2: sclerotic metastases from prostate cancer, Generalised increased bone density (mnemonic). 2010;35(22):E1221-9. One can then apply various features of the lesions to this differential, and exclude some things, elevate some things, and downgrade others in the differential. (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 ). AJR 2000; 175:261-263. Sclerosis is usually the most prominent finding in subacute and chronic osteomyelitis. 2021;216(4):1022-30. mutation, and both sclerotic and lytic bone lesions together for the first time. Both of these entities may have an aggressive growth pattern. Mark Blumenkehl, MD is a specialist in Gastroenterology whose practice locations include: Detroit, Sterling Hgts However, a specific density range has not been specified for those terms 1. MRI of the sacrum: axial T1-weighted (T1w; Fig. Here are links to other articles about bone tumors: Most bone tumors are osteolytic. Sclerosis can also be reactive, e.g. Infections, a common tumor mimicker, are seen in any age group. 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. FIGURE 2.7 Computed tomography of osteoid osteoma. Radiological hallmark: formation of a chondroid (cartilagenous) matrix, which presents as punctuated, stippled or popcorn-like calcifications. 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. 5. We provide care in several areas of orthopedics, such as: hand and wrist care, foot and ankle care, and joint replacement. Fundamentals of diagnostic radiology. This image is of a 20 year old patient with a sclerotic expansile lesion in the clavicle. Giant cell bone tumors are usually benign (not cancerous) but the malignant form can affect the legs, especially near the knees. Several genes have been discovered that, when disrupted, result in specific types . It is a feature of malignant bone tumors. 5. You can then customize the above differential for whichever pattern of sclerosis that you see. At Henry Ford Orthopaedics in Chelsea our mission is to provide personalized treatment plans specific to each patient, to ensure the best possible outcome. Sclerotic bone lesions at abdominal magnetic resonance imaging in children with tuberous sclerosis complex. 11. Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant transformation. Yes, it is possible to have a clear lumbar puncture and still have Multiple Sclerosis (MS). Sclerotic bone lesions as a potential imaging biomarker for the diagnosis of tuberous sclerosis complex Authors Susanne Brakemeier 1 , Lars Vogt 2 , Lisa C Adams 2 , Bianca Zukunft 3 , Gerd Diederichs 2 , Bernd Hamm 2 , Klemens Budde 3 , Kai-Uwe Eckardt 3 , Marcus R Makowski 2 4 Affiliations 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. Guidelines for the Diagnostic Management of Incidental Solitary Bone Lesions on CT and MRI in Adults: Bone Reporting and Data System (Bone-RADS). 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 Nancy M. Major, Clyde A. Helms and William J. Richardson. Here Melorrheostosis of the ulna with the appearance of candle wax. Not infrequently encountered as coincidental finding at later age. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We? Osteoid matrix in osseus tumors like osteoid osteomas and osteosarcomas. The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. Radiographic features that should raise the suspicion of malignant transformation on plain radiographs or CT include: Here the reactive sclerosis is the most obvious finding on the X-ray. BackgroundCongenital generalized lipodystrophy (CGL) is a rare disease. Skeletal Radiol. Abbreviations used: The most important determinators in the analysis of a potential bone tumor are: It is important to realize that the plain radiograph is the most useful examination for differentiating these lesions.CT and MRI are only helpful in selected cases. 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. Coronal MR image demonstrates subtle low intensity line representing the fracture. There are two patterns of periosteal reaction: a benign and an aggressive type. Osteoid matrix 1 When the vertebral lesion has no benign features, especially in the older adult patient, metastatic disease is always a significant consideration. Conclusion. The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis. It is nost commonly located on the posterior side of the distal meta-diaphysis of the femur. Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has a well-defined or ill-defined margins, the next question should be: how old is the patient? Notice the homogeneous thickening of the cortical bone. Ahuja S & Ernst H. Osteoblastic Bone Metastases in Medullary Thyroid Carcinoma. by Mulder JD, et al. found incidentally on the imaging studies. Most common malignant bone tumor, which is almost always low-grade, Primary sites of origin: proximal long bones, around knee, pelvis and shoulder girdle, usually central and metaphyseal. Incidentally discovered, benign lesions also called enostoses, which are islands of cortical bone located in the cancellous bone. This represents a thick cartilage cap. Here a 44-year old male with a mixed lytic and sclerotic mass arising from the fifth metacarpal bone. Radiographs are specific but suffer from low sensitivity 1. This is an example of progression of an osteochondroma to a peripheral chondrosarcoma. Gadolinium is usually minimal or absent (see right image). Gulati V, Chalian M, Yi J, Thakur U, Chhabra A. Sclerotic Bone Lesions Caused by Non-Infectious and Non-Neoplastic Diseases: A Review of the Imaging and Clinicopathologic Findings. Here two other lesions in different patients that proved to be chondrosarcoma. 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). Sarcoidosis is a multi-system disease with a range of . 2. Click here for more information about bone island. A molecular classification has been also proposed. Increased uptake on bone scan has been reported in bone islands, especially giant ones, but warrants imaging follow-up. 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. The juxtacortical mass has a high SI and lobulated contours. 4. The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. This is especially true when the injury involves the spine, hip, knees, or ankle. Common: Metastases, multiple myeloma, multiple enchondromas. In the late stage of OA, the main feature is subchondral bone sclerosis, whose microarchitectural characteristics are elevated apparent density, increased bone volume, . Bone cyst is one of the manifestations of CGL with AGPAT2 mutation. 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. When considering Pagets disease, it is extremely helpful to note whether there is associated bony enlargement. Check for errors and try again. Notice the numerous predominantly osteoblastic metastases. This could be an osteoblastic metastasis or an osteolytic metastasis that responded to chemotherapy. Radiological atlas of bone tumours of the Netherlands Committee on Bone Tumors Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Focal sclerotic bony lesions (mnemonic). Bone reacts to its environment in two ways either by removing some of itself or by creating more of itself. Location within the skeleton Imaging is often helpful in determining a diagnosis, and it can sometimes make a particular diagnosis nearly certain. In patients Centrally there is an ill-defined osteolytic area. Degenerative subchondral cyst: epiphyseal, Chondroid matrix in cartilaginous tumors like enchondromas and chondrosarcomsa. More heterogenous and irregular with bony trabecular destruction and possible extension beyond the confines of the cortex. Here a radiograph of the pelvis with a barely visible osteoblastic metastasis in the left iliac bone (blue arrow). {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Tatco V, et al. Mass displaces and involves both the right 10 th intercostal artery, as well as more superior right 9 th intercostal artery. PET features high sensitivity in the detection of bone metastases especially 18 NaF-PET is suitable for the detection of sclerotic metastases since it shows tracer uptake in locations with osteoblastic activity and is more accurate than FDG-PET 3. A 30-year-old woman underwent a CT of the pelvis for endometriosis and an incidental lesion was found in the sacrum. Spinal lesions are commonly spotted on imaging tests. Typical bone metastases are osteolytic (87.5%), with medullary origin (91.6%), and they cannot be distinguished from other osteolytic metastases on the basis of imaging criteria alone. Most bone tumors are solitary lesions. On the left three bone lesions with a narrow zone of transition. In juxta-articular localisation, the reactive sclerosis may be absent. However, cancers that metastasize to bone are very common. This is a routine medical imaging report. Diffuse bony sclerosis (mnemonic). Localisation: femur, tibia, hands and feet, spine (arch). The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. Notice that there are small areas of ill-defined osteolysis. Central location most common with some expansion and cortical thinning. Subungual exostoses are bony projections which arise from the dorsal surface of the distal phalanx, most commonly of the hallux. 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. Non-ossifying fibroma which has been filled in. 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. How should one approach sclerotic bone disease? AJR 2005; 185:915-924. 3, Increased uptake on bone scan associated with a solitary sclerotic lesion is atypical and therefore more worrisome, but largely unhelpful as there are many reports of bone islands having increased Tc-99 m hydroxydiphosphonate (HDP) uptake. On CT sclerotic bone metastases typically present as hyperdense lesions, but display a lower density than bone islands 5. Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally (red arrow). Click here for more examples of chondroblastoma. Lippincott Williams & Wilkins. Tumor Pathology- Bone Lesion Bone Tumor Osteomyelitis When you identify a bone lesion, follow this basic checklist to help you accurately describe the lesion and narrow your differential diagnosis: Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography Theodore T. Miller Radiology 2008 246:3, 662-674 Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis. The illustration on the left shows the preferred locations of the most common bone tumors. At the periphery of the infarct a zone of relative high signal intensity on T2WI may be found. 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. 2018;10(6):156. Typical presentation: central lesion in metaphysis or diaphysis with a well defined serpentiginous border. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, How to Differentiate Carotid Obstructions, Periosteal or juxtacortical chondrosarcoma, Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging, Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography. Parkinson's disease, multiple sclerosis, brain tumors and brain trauma [2]. Here a lesion located in the epi- and metaphysis of the proximal humerus. Secondary bone cancer is much more common than primary bone . Most commonly encountered bone tumor in the small bones of the hand and foot. Detection of a solitary sclerotic bone lesion on CT or plain radiograph often creates a diagnostic dilemma. An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma. 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. Here a patient with a broad-based osteochondroma with extension of the cortical bone into the stalk of the lesion. Finally other clues need to be considered, such as a lesion's localization within the skeleton and within the bone, any periosteal reaction, cortical destruction, matrix calcifications, etc. 1. Notice that CT depicts these lesions far better (red arrows). 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. Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common. If the process is slower growing, then the bone may have time to mount an offense and try to form a sclerotic area around the offender. Radiologe. 2014;71(1):39. The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging findings. The epiphysis, metaphysis and diaphysis may be involved. 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. (see diagnostic imaging pearls). 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