For students in orthopaedics

1. Radiological presentation and
staging of MSK tumours
Nor Azman MZ

2. Radiological presentation
• Plain radiograph very important for bone tumours
• For soft tissue tumour radiographs are useful to
identify osseous or mineralising lesions and what is
the tumour effect on bone
• MRI is superior in the assessment of a soft tissue
mass.

3. RADIOGRAPHIC EVALUATION
1. What is the age?
2. Where is the lesion? location
3. What is the lesion doing to the bone? Pattern of
destruction
4. How is the bone responding? Periosteal Reaction
5. What is in the lesion? Matrix
6. How many lesions?

4. What is the age?

6. Where is the lesion? location

7. Location
Location can provides clues
to its identity
– Medullary
– Medullary eccenteric
– Cortical
– Juxtacortical
LOCATION BENIGN BONE
TUMOR
JUXTACORTICAL TUMOR

8. Location
• Epiphyseal : PGCAT
– PVNS
– GCT
– Chondroblastoma
– ABC
– Tuberculous & other infections
• Metaphyseal
– NOF, UBC, OSC, CSC
• Diaphyseal
– ES, EG, Osteoid Osteoma
– metastasis

9. OSTEOID OSTEOMAOSTEOCHONDROMA
Location : Juxtacortical

10. RADIOGRAPHIC EVALUATION
1. What is the age?
2. Where is the lesion? location
3. What is the lesion doing to the bone? Pattern of
destruction
4. How is the bone responding? Periosteal Reaction
5. What is in the lesion? Matrix
6. How many lesions?

11. What is the lesion doing to the bone?
• Pattern of destruction
– Geographic
– Moth-eaten
– Permeative

12. Geographic Bone Destruction
• Destructive lesion with sharply defined border
• Implies a less-aggressive, more slow-growing, benign
process
• Narrow transition zone
e.g
– Non-ossifying fibroma
– Chondromyxoid fibroma
– Eosinophilic granuloma

13. Geographic

14. Moth-eaten Appearance
• Areas of destruction with ragged borders
• Implies more rapid growth
• Probably a malignancy
e.g
Myeloma
Metastasis
Lymphoma
Ewing sarcoma

15. Permeative Pattern
• Ill-defined lesion with multiple
“worm-holes”
• Spreads through marrow space
• Wide transition zone
• Implies an aggressive malignancy
– Round-cell lesions
Leukemia
Lymphoma, leukemia
Ewing’s Sarcoma
Myeloma
Osteomyelitis
Neuroblastoma

16. Less malignant More malignant

17. RADIOGRAPHIC EVALUATION
1. What is the age?
2. Where is the lesion? location
3. What is the lesion doing to the bone? Pattern of
destruction
4. How is the bone responding? Periosteal Reaction
5. What is in the lesion? Matrix
6. How many lesions?

18. How is the bone responding ?
Periosteal reaction
– Benign
• None
• Solid
– Malignant
• Lamellated
• Sunburst
• Codman’s triangle

19. SUNBURST
CODMANS
LAMELLATED
/ONION PEEL
Periosteal Reaction
SOLID
Less malignant More malignant

20. RADIOGRAPHIC EVALUATION
1. What is the age?
2. Where is the lesion? location
3. What is the lesion doing to the bone? Pattern of
destruction
4. How is the bone responding? Periosteal Reaction
5. What is in the lesion? Matrix
6. How many lesions?

21. WHAT IS THE LESION ?
MATRIX
• Osteoblastic
– Fluffy, cotton-like or cloud-
like densities
Osteosarcoma
• Cartilaginous
– Comma-shaped, punctate,
annular, popcorn-like
Enchondroma,
chondrosarcoma,
chondromyxoid fibroma
• Ground glass appearance
– Fibrous dysplasia

22. RADIOGRAPHIC EVALUATION
1. What is the age?
2. Where is the lesion? location
3. What is the lesion doing to the bone? Pattern of
destruction
4. How is the bone responding? Periosteal Reaction
5. What is in the lesion? Matrix
6. How many lesions?

23. How many lesions?
• Multiple bony lesion

24. DD for holes in the bone
• FOGMACHINE
– Fibrous dysplasia
– Osteoid osteoma, osteoblastoma, osteosarcoma
– Giant cell tumour
– Myeloma
– Aneurysmal Bone Cyst, adamantimoma
– Chondromyxoid fibroma, chondroblastoma,
chondrosarcoma
– Hystiocytosis
– Infection
– Nonossifying fibroma
– Enchondroma, Ewing sarcoma

25. Staging

28. Staging
Purpose
• Determine tumor type
• Determine prognosis
• Guide treatment
• Compare results between study groups
• Delineate extent of local and distant disease

29. Staging Studies
• Plain Radiograph
• MRI
• CT scan
• Chest CT
• Bone Scan

30. Plain Radiographs
Evaluate:
• Rate of tumor growth
• Tumor interaction with surrounding non-
neoplastic tissue
• Internal composition of tumor

31. MRI
Visualize entire bone and adjacent joint
Best test for intraosseous extent and soft tissue
extent
Identify skip metastases
Tumor proximity to neurovascular structures
Occasionally helpful in diagnosis of bone or soft
tissue tumors (experienced radiologist)

34. CT
• Good for evaluating cortical details and
destruction
• Subtle cortical erosions (endosteal;periosteal)
• not detectable on plain x-ray or MRI
• Subtle calcifications / ossification (Visible
tumor
matrix mineralization)

36. Chest CT
• Presence of metastatic disease

37. Bone Scan
• Whole body bone scan
• Sites of bony mets
• Active lesion??

40. Staging
• Benign Staging System
• Stage 1: Latent
– Grow slowly with growth of individual and
then stop; tendency to heal spontaneously
(ex. NOF; UBC)
• Stage 2: Active
Progressive growth
• Stage 3: Aggressive

41. Grading
G1 G2
LG Chondrosarcoma High Grade
Chondrosarcoma
Secondary Chondrosarc Conventional
Osteosarcoma
Parosteal Osteosarcoma Ewing’s
Sarcoma/PNET
Adamantinoma MFH
Angiosarcoma

42. Staging
Soft Tissue Sarcomas
• Important Prognostic Characteristics
–Tumor Size (>5cm, worse prognosis)
–Tumor Depth (Deep, worse prognosis)
–Grade (High grade, worse prognosis)
–Presence of Mets

43. Grading
Soft Tissue Sarcomas (Biological Behavior)
• Tumors that are definitionally high grade
– Ewing’s Sarcoma
– PNET
– Rhabdomyosarcoma
– Angiosarcoma
– Pleomorphic Liposarcoma
– Soft Tissue Osteosarcoma
– Mesenchymal Chondrosarcoma

44. Grading
Soft Tissue Sarcomas (Biological Behavior)
– Tumors that are definitionally low grade
• Well Differentiated Liposarcoma
• Dermatofibrosarcoma Protuberans
• Infantile Fibrosarcoma
• Angiomatoid MFH

45. Evaluating response to chemoRx