Bone Tumors

Radiographic findings may include:

  • geographic, motheaten, or permeative destruction
  • trabeculations ("soap bubbles")
  • cortical "expansion"
  • periosteal reaction
  • ill-defined increased and/or decreased density
  • matrix calcification/ossification
  • exostosis
  • associated soft tissue mass

Here are presentations of bone tumors(with *interpretations):

  • Case 1
  • *Case 1
  • Case 2
  • *Case 2
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • Case 8
  • *Case 8
  • Case 9
  • *Case 9
  • Case 10
  • *Case 10
  • Case 11
  • *Case 11
  • Case 12
  • *Case 12
  • Case 13
  • *Case 13
bone cyst
bone cyst marked

Dorsoplantar foot view.
A geographic decreased density is bounded by a thin sclerotic margin (lines). No trabeculations (septations) are demonstrated. The lesion is centrally located within the proximal diametaphysis of the first metatarsal.
Diagnosis: solitary bone cyst.

GCT

Patient presents with arch pain.

GCT marked

Dorsoplantar foot view.
Findings include a geographic lesion of decreased density involving the entire first metatarsal proximal two-thirds diaphysis and base (black lines delineate its distal extent). There is "expansion" of the cortex (white arrow, aka a shell periosteal reaction). The black arrows also identify the thin, expanded cortex, a result of endosteal resorption and periosteal remodeling. Thin, delicate trabeculations (arrowheads) are seen throughout the lesion. Note that the cortex is still intact.
Diagnosis: Giant cell tumor.

UBC calcaneus
UBC calcaneus marked

Lateral foot view.
Findings include a geographic decreased density in the region of the calcaneal neutral triangle. It is bounded by a thin, sclerotic margin (black lines).
Diagnosis: Unicameral bone cyst. This was an incidental finding.

bone island
bone island marked

Lateral foot view.
Findings include a geographic increased density within the body of the calcaneus posterosuperiorly (black arrow). (FYI, the white arrowhead identifies the medial tubercle; the black arrowhead identifies the normal curvilinear increased density that is the lateral tubercle.)
Diagnosis: Enostosis (bone island). This was an incidental finding.

osteochondroma
osteochondroma marked

Dorsoplantar foot view.
An exostosis is identified along the lateral aspect of the 2nd metatarsal distal metadiaphysis (arrow). It continues as a curvilinear increased density within the distal metaphysis.
Diagnosis: Osteochondroma versus post-traumatic exostosis.

fibrosarcoma

This patient presented with heel pain.

fibrosarcoma marked

Lateral foot view.
An ill-defined lesion throughout the posterior half of the calcaneus demonstrates mixed increased (arrowheads) and decreased densities. This is not geographic destruction, but permeative.
Diagnosis: Fibrosarcoma (confirmed histologically).
FYI: Fibrosarcoma is one of the few malignant bone tumors that can demonstrate slow growth activity (i.e., no break through the cortex, no periosteal reaction, etc.).

fibrocortical defect tibia
fibrocortical defect tibia marked

Mortise view, distal leg/ankle.
A geographic, solitary lesion in the distal tibial diametaphysis demonstrates a sclerotic margin (black lines). Its position is eccentric. Though there is been "expansion" of the cortex (the so-called shell periosteal reaction, white arrows), the cortex is still intact. There is a "soap-bubbly" appearance (or, lobulated trabeculation, black arrowheads) within the lesion.
Diagnosis: fibrocortical defect.
FYI: This radiographic picture, in the child or adolescent, is virtually diagnostic of a fibrocortical defect (aka nonossifying fibroma when large in size). It is almost always an incidental finding (the patient is "x-rayed" for some other reason, such as for an ankle sprain). Complications would include pathologic fracture. Fibrocortical defects do heal in adulthood, becoming sclerotic throughout and, if small in size, may disappear.

non-ossifying fibroma

History of sprained ankle in young adult.

non-ossifying fibroma marked

Mortise view, distal leg/ankle.
A geographic lesion (black lines) is located eccentrically in the distal tibial diametaphysis. "Coarse" (thick) trabeculations are seen throughout the lesion, appearing lobulated or "soap-bubbly" (d). Some cortical expansion is noted along with cortical thickening (s), yet the cortex remains intact.
Diagnosis: Healing nonossifying fibroma. (This was an incidental finding.)
FYI: The appearance of fibrocortical defect/non-ossifying fibroma varies depending upon the patient/lesion age. Early on, it appears soap bubbly with fine delicate lines (see case 7); these lines become coarse and sclerotic with time and as it heals. Later, the lesion may appear wholly sclerotic. The lesion may eventually disappear if it originally was small in size. The thick/coarse trabeculations suggest chondromyxoid fibroma.

chondromyxoid fibroma calcaneus
chondromyxoid fibroma calcaneus marked

Lateral foot view.
A large, geographic lesion (it takes the shape of the calcaneal body) demonstrates coarse, thick trabeculations (arrowheads). Though there is some "expansion" of the calcaneus, the outer calcaneal margin is still intact. The bursal projection (bp) is enlarged and expanded, and the adjacent posterior talar process (ptt) has adapted to it.
Diagnosis: Chondromyxoid fibroma (confirmed histologically).
FYI: The lesion probably occurred during childhood, which may explain the compensatory growth/remodeling of the posterior talar process.

fibrous lesion

This patient presents with an ankle sprain.

fibrous lesion marked

Mortise view, distal fibula.
An ill-defined, geographic lesion (white lines) exhibits some "expansion" centrally. The cortex is intact, and the center of this lesion exhibits a hazy or "ground glass" (gg) appearance.
Diagnosis: a fibrous lesion, probably fibrous dysplasia (an incidental finding in this case; it was not symptomatic).
FYI: A "ground glass" appearance is highly suggestive of fibrous dysplasia. This patient was radiographed one and two years later, with no change noted.

a ABC dp b ABC lateral
a ABC dp marked b ABC lateral marked

Mortise and lateral views, distal leg and ankle.
A large, geographic lesion (black lines) can be identified centrally within the distal tibial metaphysis. It has not crossed the physis nor invaded the epiphysis (e). It is expansile (white arrows and arrowheads), but the cortex is not disrupted. Some trabeculations (black arrowheads) can be seen within the lesion.
Diagnosis: Aneurysmal bone cyst (histologically confirmed).
Images courtesy John Walter, D.P.M., Philadelphia, PA

enchondroma
enchondroma marked

Lateral oblique view, toes.
A geographic, expansile lesion (black arrow and arrowhead) involves the entire second toe proximal phalanx. It has a lobulated appearance, and punctate calcifications are identified in the matrix (white arrowheads).
Diagnosis: Enchondroma.

osteoid osteoma

Patient present with painful hallux.

osteoid osteoma marked

Dorsoplantar foot view.
A circular (geographic) radiolucent lesion is seen in the distal proximal phalangeal metaphysis laterally (arrowheads). Within it, a calcified nidus is visible (white arrow). Other findings include a circular increased density superimposed on the proximal phalangeal head (black arrow). and a geographic decreased density with sclerotic margin within the medial aspect of the first metatarsal head (c).
Diagnoses: Osteoid osteoma. Os interphalangeus. Subchondral bone cyst.

Should a radiographic study be ordered for suspicion of bone tumor?

Definitely yes.

What are the best views to order?

At a minimum order dorsoplantar (or AP, if ankle) and lateral views. For the toes, obtain dorsoplantar, medial oblique, and lateral oblique views.

Other information

MRI will be necessary for evaluation of suspicious soft tissue masses that are not "classic" benign presentations. MRI may be necessary for further evaluation of bone lesions with associated soft tissue pathology.

CT may be necessary to further assess bone lesions.

References:

  1. Christman, RA: Foot and Ankle Radiology, Churchill Livingstone, 2003.
  2. Madewell, JE, Ragsdale, BD, and Sweet, DE: Radiologic and pathologic analysis of solitary bone lesions. Parts I-III. The Radiologic Clinics of North America 19 (4): 715-814, 1981 (Dec).
  3. Resnick, D and Niwayama G: Diagnosis of Bone and Joint Disorders, 2nd Ed., WB Saunders Co., Philadelphia, 1989.