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MSK: Lucent Lesions Flashcards

1
Q

How can you tell the age of a pt on radiographs?

A
  • Open growth plates (pediatric pt)
  • Degenerative changes (pt likely over 40)
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2
Q

Differential for epiphyseal (or epiphyseal equivalent) lytic lesions

A
  • Giant cell tumor
  • Chondroblatoma
  • Infection
  • Clear cell chondrosarcoma

Note: Aneurysmal bone cysts can also involve the epiphysis (if the growth plates are closed), but they usually start in the metaphysis.

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3
Q

Malignant epiphyseal Lucent lesion…

A

Clear cell chondrosarcoma

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4
Q

What are the epiphyseal equivalents?

A
  • Carpal bones
  • Patella
  • Calcaneus
  • Apohyses (greater trochanter, lesser trochanter, tuberosities, etc.)

Note: Lesions here will also get the epiphyseal lesion differential.

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5
Q

What is the fastest growing area of bone?

A

The metaphysis

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6
Q

Which area of bone has the most blood supply?

A

The metaphysis

Note: This is why metastases and infection are common here.

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7
Q

Fibrous dysplasia

A

A skeletal developmental anomaly of osteoblasts (failure of normal maturation and differentiation) that results in replacement of the normal medullary space

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8
Q

What is the classic imaging feature of fibrous dysplasia?

A

Ground glass appearance of the bony matrix (without any periosteal reaction or pain)

Note: It can look like anything though with lytic, mixed, and plastic phases).

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9
Q

What are the most common locations for fibrous dysplasia?

A

Ribs and long bones

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10
Q

If there is fibrous dysplasia of the pelvis, what other area is usually involved?

A

The ipsilateral femur (often with the Shepherd Crook deformity)

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11
Q

When does fibrous dysplasia tend to develop?

A

Monostotic: 20s and 30s

Polyostotic: <10 y/o (usually associated with genetic syndromes)

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12
Q
A

Shephard Crook deformity (coxa vara angulation)

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13
Q

Differential for Shephard Crook deformity

A
  • Fibrous dysplasia (classically)
  • Paget
  • Osteogenesis imperfecta
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14
Q

Polyostotic fibrous dysplasia is associated with…

A
  • McCune Albright syndrome (young females with precocious puberty and cafe au lait spots)
  • Mazabraud syndrome (middle aged females with soft tissue myxomas and increased risk for malignant transformation)
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15
Q

Adamantinoma

A

A mixed lytic and sclerotic tibial lesion that resembles fibrous dysplasia, but is potentially malignant (very rare)

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16
Q
A

Think non ossifying fibroma/fibrous cortical defect

Note: Chondromyxoid fibroma can also look like this, but is much more rare.

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17
Q

Treatment for non ossifying fibroma

A

Nothing (they typically become more sclerotic and then regress)

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18
Q

What is the most common location for a non ossifying fibroma/fibrous cortical defect?

A

Around the knee

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19
Q

What is the most common location for a non ossifying fibroma/fibrous cortical defect?

A

Around the knee

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20
Q

Where are non ossifying fibromas/fibrous cortical defects usually located within a bone?

A

Metaphyses (eccentrically located)

Note: They usually appear in the metaphysis near the physis, but then get progressively farther from the physis as the pt grows.

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21
Q

How can you differentiate a nonossifyinng fibroma/fibrous cortical defect from a giant cell tumor?

A

NOF/FCD should have a sclerotic border

GCTs don’t have a sclerotic border

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22
Q

Nonossifying fibromas/fibrous cortical defects are associated with…

A

Neurofibromatosis 1

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23
Q

What is the difference between a nonossifying fibroma and a fibrous cortical defect?

A

Size:

If < 3 cm, it is a fibrous cortical defect

If > 3 cm, it is a nonossifying fibroma

Note: Fibroxanthoma is an umbrella term that includes both.

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24
Q

Jaffe-Campanacci syndrome

A
  • Multiple nonossifying fibromas
  • Cafe au lait spots
  • Mental retardation
  • Hypogonadism
  • Cardiac malformations

Note: These pts are at high risk for pathologic fractures.

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25
Q

Enchondroma

A

A hyaline cartilage tumor of the medullary cavity

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26
Q

What age group is enchondroma more common in?

A

10-30 y/o

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27
Q
A

Think enchondroma

Note: Chondroid matrix is usually visible when these are in the long bones (e.g. femur, humerus).

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28
Q
A

Think enchondroma

Note: These usually appear lytic in the fingers/toes.

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29
Q

What is the most common cystic lesion in the hands and feet?

A

Enchondroma

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30
Q

Do enchondromas typically have a periosteal reaction?

A

No, enchondromas are not associated with a periosteal reaction

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31
Q

Enchondroma with history of pain…

A

Think low grade chondrosarcoma

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32
Q

Enchondroma that is > 4-5 cm…

A

Think low grade chondrosarcoma

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33
Q

Enchondroma with a chondroid matrix that changes over time…

A

Think low grade chondrosarcoma

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34
Q

What syndromes are associated with multiple enchondromas?

A
  • Ollier disease
  • Maffucci syndrome (also will have hemangiomas)

Note: Both have an increased risk of chondrosarcoma, but Maffucci has a higher risk (“Maffucci has More”).

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35
Q

Multiple enchondromas and multiple hemangiomas…

A

Think Maffucci syndrome

Note: These pts are at increased risk for chondrosarcoma.

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36
Q

What is the usual age for eosinophilic granuloma?

A

< 30 y/o

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37
Q
A

Vertebra plana

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38
Q

Differential for vertebra plana

A

MELT:

  • Mets/Myeloma
  • Eosinophilic granuloma (Langerhans cell histiocytosis)
  • Lymphoma
  • Trauma/Tubercuosis
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39
Q

7 y/o

A

Think Langerhanscell histiocytosis (most common cause of vertebra plana in a children)

Note: When there is a single skeletal lesion, it is onften referred to as an eosinophilic granuloma.

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40
Q
A

Eosinophilic granuloma

Note: Beveled edge lytic skull lesion.

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41
Q

What is the classic appearance of eosinophilic granuloma?

A

Highly variable and can look like everything (lytic, blastic, +/- sclerotic border, +/- periosteal reaction, +/- osseous sequestrum)

Note: Its usually included in the differential for any bone bone lesion in pts under 30.

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42
Q

Differential diagnosis for an osseous sequestrum

A
  • Osteomyelitis
  • Lymphoma
  • Fibrosarcoma
  • Eosinophilic granuloma

Note: Osteoid osteoma can also mimic a sequestrum.

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43
Q

What features must be present for you to consider a giant cell tumor?

A
  • Physis must be closed
  • No sclerotic border
  • Lesion must abut the articular surface
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44
Q

Could this be a giant cell tumor metastasis?

A

Yes (5% of GCTs have pulmonary metastases)

Note: GCTs are considered quasi-malignant (they can be locally invasive and can have pulmonary metastases). The disease is still curable with resection of the pulmonary mets.

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45
Q

Treatment for giant cell tumor pulmonary mets

A

Wide margin resection (curable)

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46
Q

What is the most common location for a giant cell tumor?

A

The knee (abutting an articular surface)

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47
Q

What is the most common age for a giant cell tumor?

A

20-30

Note: The physes must be closed.

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48
Q

Giant cell tumors can turn into…

A

Aneurysmal bone cysts

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49
Q
A

Think giant cell tumor

Note: Well-defined lesion without a sclerotic border that abuts the articular surface in a pt with closed physes.

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50
Q

Bone pain at night that is relieved with aspirin…

A

Think osteoid osteoma

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51
Q

What is the typical pt age for an osteoid osteoma?

A

Adolescent (10-25 y/o)

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52
Q

Classic appearance of an osteoid osteoma

A

Lucent nidus surrounded by dense sclerotic cortical bone

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53
Q

What are the most common locations for an osteoid osteoma?

A
  • Metaphysis/diaphysis of long bones (especially the femoral neck)
  • Posterior elements of the spine
  • Fingers
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54
Q

Painful scoliosis…

A

Think osteoid osteoma

55
Q

What is the classic MRI appearance of an osteoid osteoma?

A

Severe edema out of proportion to the size of the lesion +/- adjacent soft tissue edema

56
Q
A

Think osteoid osteoma

Note: This is the “double density sign” (very intense central nidus with less intense surrounding reactive bone).

57
Q
A

Think osteoid osteoma

58
Q

Painful scoliosis is often due to an osteoid osteoma. Which direction does the scoliosis point?

A

The convexity of the scoliosis points away from the osteoid osteoma

59
Q

Treatment for osteoid osteoma

A

Percutaneous radio frequency ablation

60
Q

Contraindication for radio frequency ablation of an osteoid osteoma

A

Lesion is within 1 cm of a nerve or other vital structure (usually avoided in hands, spine, and pregnant pts)

61
Q

What growth deformities can occur if there is an osteoid osteoma?

A

Increased length and girth of bones

62
Q

What joint complications can occur in the setting of an osteoid osteoma?

A
  • Synovitis (if intraarticular)
  • Arthritis (due to primary synovitis or from altered joint mechanics)
63
Q

What is the difference between an osteoid osteoma and an a osteoblastoma?

A

Size:

If less than 2 cm -> osteoid osteoma

If greater than 2 cm -> osteoblastoma

64
Q

Osteoblastoma is most commonly seen in what pt age?

A

<30 y/o

Note: It’s basically an osteoid osteoma that is too large.

65
Q

What is the most common location for an osteoblastoma?

A
  • Posterior elements of the spine
  • Long bones (usually diaphysis)
66
Q

Differential for a lucent bone lesion in the posterior elements of the spine

A
  • Osteoblastoma
  • Aneurysmal bone cyst
  • Metastases
67
Q

What is the common pt age for aneurysmal bone cysts?

A

Less than 30 y/o

68
Q

What are the most common locations for an aneurysmal bone cyst?

A
  • Tibia (most common)
  • Vertebral body (2nd)
  • Femur (3rd)
  • Humerus (4th)
69
Q

Aneurysmal bone cyst

A

Aneurysmal bone lesions with thin-walled, blood-filled spaces that may develop after trauma

70
Q

What are the two major types of aneurysmal bone cysts?

A
  • Primary
  • Secondary (associated with another tumor, such as a giant cell tumor)
71
Q

40% of secondary aneurysmal bone cysts are associated with…

A

Giant cell tumors

72
Q

Most likely diagnosis

A

Aneurysmal bone cyst

73
Q

Solitary (unicameral) bone cysts are most often seen in what age group?

A

Pts under 30 y/o

74
Q

What is the most common location for a solitary (unicameral) bone cyst?

A

Tubular bones (90-95%), usually the humerus or femur

75
Q

What is the main unique feature always seen in a solitary (unicameral) bone cyst?

A

They are always located centrally within the bone

76
Q

Fallen fragment sign…

A

Solitary (unicameral) bone cyst

77
Q
A

Solitary (unicameral) bone cyst

Note: Fallen fragment sign (arrow) is a bone fragment in the dependent portion of a lucent bone lesion. This is pathognomonic.

78
Q
A

Think solitary (unicameral) bone cyst

Note: This could also be an intraosseous lipoma, but these tend to contain dystrophic calcifications.

79
Q

Pt with hyperthyroidism

A

Think brown tumor (focal accumulations of giant cells and fibrous tissue that can be seen in the setting of hyperparathyroidism)

80
Q

Hyperparathyroidism

A

Subperiosteal resorption, which can be seen in hyperparathyroidism

81
Q

Hyperparathyroidism

A

Clavicular subchondral bone resorption with irregular feathery articular surface, which can be seen in hyperparathyroidism

82
Q
A

Subperiosteal bone resorption, which can be seen in hyperparathyroidism

Note: Subperiosteal resorption of the radial aspect of the middle phalanges of the second and third fingers (white arrows); feathery appearance and early tufts resorption-acroosteolysis (red arrows).

83
Q

Black arrow

A

Brown tumor

Note: Subperiosteal bone resorption (red arrows), suggesting hyperparathyroidism. There is also intracortical and trabecular resorption.

84
Q
A

Brown tumor (black arrow) with pathologic fracture (yellow arrow)

Note: Subperiosteal bone resorption suggesting hyperparathyroidism.

85
Q

What are the classic locations for subperiosteal bone resorption in hyperparathyroidism?

A
  • Fingers
  • Edge of clavicle
  • Inferior surface of ribs
86
Q

What is the typical age group for chondroblastoma?

A

Ages 5-25 (90%)

87
Q
A

Think chondroblastoma

Note: Epiphyseal lucent lesion in a pt with open physes.

88
Q

What is the typical location of a chondroblastoma within a bone?

A

Chondroblastomas are located in the epiphysis (or an epiphyseal equivalent)

89
Q

Is recurrence common following resection of a chondroblastoma?

A

Yes (30% of cases recur)

90
Q

20 y/o

A

Think chondroblastoma

Note: Epiphyseal lesion in a young pt.

91
Q

What is the most common location of a proximal femoral chondroblastoma?

A

The greater trochanter (an epiphyseal equivalent rather than the actual proximal femoral epiphysis)

92
Q

Differential for an intertrochanteric lucent lesion in the femur

A
  • Lipoma
  • Solitary bone cyst
  • Monostotic fibrous dysplasia
  • Liposclerosing myxofibroma
93
Q

Where are the epiphyseal equivalents in the calcaneus?

A

Green areas are epiphyseal equivalents

94
Q

Differential for lucent lesion in the calcaneus

A
95
Q

Classic location for a chondroblastoma in the calcaneus

A

Superior calcaneal epiphysis (but can occur at any of the 3 calcaneal epiphyses)

96
Q

Classic location for a giant cell tumor in the calcaneus

A

Posterior metaphyses/epiphysis

97
Q

Classic location for an osteoid osteoma in the calcaneus

A

Superior calcaneal epiphysis

98
Q

Classic location for metastases to the calcaneus

A

Posterior metaphyseal region (most blood supply)

99
Q

Classic location for a solitary bone cyst in the calcaneus

A

Anterior 1/3 of calcaneus on the lateral side

100
Q

Classic location for a calcaneal intraosseous lipoma

A

Anterior 1/3 of calcaneus on the lateral side

101
Q
A

Intraosseous lipoma

Note: The central density is due to fat necrosis (occurs in ~50% of cases).

102
Q
A

Think calcaneal pseudocyst

Note: Triangular appearance and persistence of thin trabeculae can be helpful.

103
Q

Which bone metastases are classically blastic?

A
  • Prostate
  • Carcinoid
  • Medulloblastoma
104
Q

Which bone metastases are predominantly lytic?

A
  • Renal cell cancer
  • Thyroid
  • Melanoma
  • Multiple myeloma
  • Non-small cell lung cancer
  • Non-hodgkin lymphoma
105
Q

Next step: You aren’t sure if a sclerotic lesion is a bone island or a prostate met

A

Compare to priors if available, if not then get a bone scan (only the prostate met will have uptake)

106
Q

What is the typical age range for multiple myeloma?

A

40s-80s

107
Q

Lytic vertebral lesions that destroy the vertebral body, but spare the posterior elements…

A

Think multiple myeloma

108
Q

Next step: Pt with multiple myeloma

A

Get a skeletal survey or MRI (MRI is most sensitive)

Note: Bone scans are often negative for multiple myeloma (which produces lytic lesion).

109
Q

Is multiple myeloma in the differential?

A

Yes, 15-25% of pts with multiple myeloma present with diffuse osteopenia rather than focal lytic lesions

110
Q

What age is typical for a plasmacytoma?

A

Under age 40

111
Q

Plasmacytoma

A

A discrete solitary mass of neoplastic monoclonal plasma cells that can occur in a bone or in soft tissues (extramedullary subtype)

Note: It can be considered a focal form of multiple myeloma.

112
Q
A

Plasmacytoma

Note: This is the “mini brain” appearance that can occur in vertebral bodies.

113
Q

POEMS

A

A rare medical syndrome consisting of plasma cell proliferation (usually multiple myeloma), neuropathy, and organomegaly

Note: Radiographically it appears similar to multiple myeloma, but with sclerotic metastases.

114
Q

Long lesion in a long bone…

A

Think fibrous dysplasia

115
Q

Lytic lesion with a hazy matrix…

A

Think fibrous dysplasia

Note: This is another way to say ground glass.

116
Q

Chondroid matrix lesion in the proximal humerus or distal femur…

A

Think enchondroma

117
Q

Lucent lesion in the finger or toe…

A

Think enchondroma

118
Q

Epiphyseal tibial lesion in a teenager…

A

Think chondroblastoma

119
Q

Lucent lesion in the greater trochanter…

A

Think chondroblastoma

120
Q

Lucent lesion with dependent fragment in the humerus…

A

Solitary bone cyst

121
Q

Calcaneal lesion with central calcification…

A

Intraosseous lipoma

122
Q

Lucent lesion in the skull of a young pt…

A

Think eosinophilic granuloma (the mildest form of Langerhans cell histiocytosis)

123
Q

Vertebra plana in a kid…

A

Think eosinophilic granuloma

124
Q

Vertebra plana in an adult…

A

Think metastasis (also myeloma)

125
Q

Lucent nidus in the tibia/fibula…

A

Think osteoid osteoma

126
Q

Calcified lesion in a posterior element of the C spine…

A

Think osteoblastoma

127
Q

Multiple sclerotic lesions centered around a joint…

A

Think osteopoikolosis

128
Q

Multiple lucent bone lesions in a pt over 40…

A

Think metastases, multiple myeloma, or non-Hodgkin lymphoma

129
Q

Chondral lesion in a long bone measuring 1-2 cm…

A

Think enchondroma

130
Q

Chondral lesion in a long bone measuring >4-5 cm…

A

Think low-grade chondrosarcoma

131
Q

Well-defined lytic lesion measuring <3 cm in the cortex of a long bone with a sclerotic rim…

A

Think fibrous cortical defect

132
Q

Well-defined lytic lesion measuring >3 cm in the cortex of a long bone with a sclerotic rim…

A

Think nonossifying fibroma

133
Q

Sclerotic lesion with central lucent nidus measuring < 2 cm…

A

Think osteoid osteoma

134
Q

Sclerotic lesion with central lucent nidus measuring > 2 cm…

A

Think osteoblastoma

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