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Skeletal Radiology I > Unit 1 SG > Flashcards

Unit 1 SG Flashcards

1
Q

Aggressive = fast growing (not necessarily malignant). Key features:

A

Long zone of transition (ZOT)
Cortical disruption
Soft tissue involvement

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2
Q

Malignant (characteristics)

A

Laminated

Spiculated

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3
Q

Number of Lesions: Solitary (MC)

A

Ex: Simple Bone Cyst (SBC); Osteosarcoma

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4
Q

Number of Lesions: Multiple Lesions (Multiplicity)

A

Polyostotic presentation - multiple bones
Monostotic presentation - one bone
Multiplicity - multiple lesions

Ex: Metastatic Dz; multiple myeloma

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5
Q

Longitudinal Location: Diaphyseal Tumors (FEMALE)

A 
Fibrous Dysplasia
Eosinophilic Granuloma
Myeloma
Admentanoma
Lymphoma (Non-Hodgkin’s)
Ewings Sarcoma
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6
Q

Longitudinal Location: Diametaphyseal

A

Non-Ossifying Fibroma (NOF)

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7
Q

Longitudinal Location: Metaphyseal Tumors

A

SBC

Osteosarcoma

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8
Q

Longitudinal Location: Metaphyseal-Epiphyseal

A

Giant Cell Tumor (can grow into epiphysis but ALWAYS in metaphysis)
ABC (can grow into epiphysis)

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9
Q

Longitudinal Location: Epiphyseal

A

Chondroblastoma (only tumor that ORIGINATES in epiphysis)

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10
Q

Axial Location: Central

A

Dead center of AP and Lat

Ex: Enchondroma; SBC; Fibrous Dysplasia

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11
Q

Axial Location: Eccentric

A

MC seen overall. Central on AP and off-center on Lat; still primary in medullary cavity

Ex: Osteosarcoma; Giant Cell

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12
Q

Axial Location: Cortical

A

Overlies the cortex on AP or Lat; DDx from eccentric medullary; may overlie the medulla some, but primarily in cortex

Ex: Osteoid osteoma; Fibrous Cortical Defect (FCD)

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13
Q

Axial Location: Parosteal (AKA Juxtacortical)

A

Radiolucent cleft between tumor and cortex; mostly outside the bone but still attached to periosteum

Ex: Juxtacortical chondroma; parosteal osteosarcoma

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14
Q

Axial Location: Soft Tissue

A

Not connected to bone at all

Ex: Myositis ossificans

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15
Q

Skeletal Location: Skull

A

Osteoma

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16
Q

Skeletal Location: Hand

A

Enchondroma (MC benign tumor of hand)

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17
Q

Skeletal Location: Vertebra

A

Hemangioma (MC benign tumor of vertebra

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18
Q

Location: Malignant Tumors

A

Tend to like ANTERIOR vertebral bodies

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19
Q

Location: Benign Tumors

A

Tend to like POSTERIOR elements of vertebral bodies

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20
Q

Location: epidermoid Cysts (Terminal Tufts)

A

MC fingers and toes; result of trauma that drives epithelial tissue into bone where it continues to grow

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21
Q

Morphologic Features: Size

A

Most malignant or aggressive tumors >6cm

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22
Q

Morphologic Features: Margination

A

Can you clearly define the margins/ZOT? Is indicator of aggressiveness

Poor/wide ZOT = aggressive (aka imperceptible)
Clear/narrow ZOT - good (aka sharp); generally not malignant. Indicative of slow-growing process

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23
Q

Morphologic Features: Bone Destruction - Geographic

A

MC indicative of slow-growing lesion (least aggressive). Tends to be sharply marginated, circumscribed, uniformly lytic

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24
Q

Morphologic Features: Bone Destruction - Moth-Eaten

A

“Iffy” (usually malignancy or infection)
2-5mm in size
Outer margins poorly defined
Inner margins (moth holes) are well defined

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25
Q

Morphologic Features: Bone Destruction - Permeative

A

Most aggressive
Multiple holes <1mm
Poor ZOT

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26
Q

Morphologic Features: Matrix Characterization

A

Internal to bone, but extracellular to lesion

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27
Q

Morphologic Features: Matrix Characterization - Calcification

A

Most tumors have radiolucent matrix, SOME calcify/ossify

Dystrophic calcification: calcification due to devitalized tissue
Metastatic calcification: due to disturbance of Ca metabolism (hyperparathyroidism)

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28
Q

Morphologic Features: Matrix Characterization - Types (COFF)

A

Cartilage/Chondro
Osseous/Osteo
Fibrous/Fibro
Fat

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29
Q

Morphologic Features: Matrix Characterization - Types - Cartilage/Chondro

A

Calcified matrix; stippled, arc, ring-like, comma, popcorn

Ex: Chondrosarcoma, Enchondromas, Osteochondroma

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30
Q

Morphologic Features: Matrix Characterization - Types - Osseous/Osteo

A

Hazy, fluffy, cotton, cloud

Tumor new bone - can extend past cortex into soft tissue. Ex: Osteosarcoma

Reactive new bone - rarely extends beyond cortex. Ex: Prostatic metastasis (blastic)

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31
Q

Morphologic Features: Matrix Characterization - Types - Fibrous/Fibro

A

Ground-glass, frosted glass, smeared chalk appearance

Ex: Fibrous dysplasia

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32
Q

Morphologic Features: Trabeculation

A

Fine vs thick “soap bubbles”

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33
Q

Morphologic Features: Periosteal Response

A

Fundamental response to bone dz (bone forming irritants) that causes lifting of periosteum (blood, pus, edema, granulation tissue, neoplasm)

MC in children

2 basic patterns: Uninterrupted & Interrupted

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34
Q

Morphologic Features: Periosteal Response - Uninterrupted

A

Benign/slow-growing. Single layer of new bone

Ex: Osteoid osteoma; stress fx; hypertrophic pulmonary osteoarthopathy (HPO)

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35
Q

Morphologic Features: Periosteal Response - Interrupted

A

Laminated/Layered - “onion skin” multi-layered. Ex: Ewing’s Sarcoma

Spiculated - most aggressive. “Hair on end”/perpendicular or “sunburst”/radiating from central point. Ex: Osteosarcoma

Codman’s Triangle - aka periosteal cuff/buttress. May accompany malignant or benign tumors/infections

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36
Q

Morphologic Features: Soft Tissue Mass

A

Bone + soft tissue involvement (primary malignant tumor).
Benign tumors usually DON’T have soft tissue mass, except 4: Giant Cell; ABC; Osteoblastoma; Osteoid Osteoma
Infections MAY have soft tissue components (osteomyelitis). Generally obliterate myofacial planes and may cross joint spaces.
Tumors displace myofacial planes and DO NOT cross joint spaces

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37
Q

Metastatic Bone Tumors

A

MC osseous malignancy; usually from epithelial malignancy

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38
Q

Metastatic Bone Tumors: MC Primary Malignancy Sites - Male

A

Prostate - blastic metastasis

Lung - lytic metastasis

39
Q

Metastatic Bone Tumors: MC Primary Malignancy Sites - Female

A

Breast - lytic and blastic metastasis
Thyroid
Kidney
Cervix

40
Q

Metastatic Bone Tumors: MC Primary Malignancy Sites - Kids

A

<5yoa:
Neuroblastoma - lytic metastasis
Hodgkins Lymphoma - blastic metastasis

10-20yoa:
Ewing’s Sarcoma
Osteosarcoma

41
Q

Metastatic Bone Tumors: Clinical Manifestations

A

MC 4th decade

MC presentation insidious onset, progressive, bone pain

42
Q

Metastatic Bone Tumors: Laboratory

A

Basic bone profile to distinguish between metastasis and myeloma

ESR (erythrocyte sedimentation rate)
Ca - MC w/ osteoLYTIC tumors
Alk Phos - MC w/ osteoBLASTIC tumors
Proteins - MC w/ multiple myeloma
Uric Acid - MC w/ multiple myeloma
43
Q

Metastatic Bone Tumors: Dissemination

A

Hematologic (MC); via Batson’s plexus in spine

Direct extension; pan-coast tumor, surgery

44
Q

Metastatic Bone Tumors: Imaging Procedures

A

Bone Scintigraphy - procedure of choice for SCREENING b/c sensitive, cost-effective and see “whole body” simultaneously.

Works well for everything BUT Enostoma and Multiple Myeloma

45
Q

Metastatic Bone Tumors: Distribution of Metastasis

A

From MC to LC (tumors don’t corss joints, infections do!)

Vertebra: MC metastasis go to spine (specifically VB and pedicle of T&L Spine)
Ribs & Sternum: Extrapleural sign - pushes pleura towards lungs. MC from osteoLYTIC metastasis
Skull: osteoLYTIC metastasis. MC primary breast/thyroid (holes are larger and not as well defined)

46
Q

Metastatic Bone Tumors: Radiographic Features - OsteoLYTIC

A

MC osseous malignancy is osteolytic metastasis

Earliest radiographic manifestation, focal loss of bone density

MC cause of pedicle destruction; winking owl sign; one-eyed pedicle; blind vertebra (if both pedicles missing)

47
Q

Metastatic Bone Tumors: Radiographic Features - OsteoBLASTIC

A

Poorly defined margins = wide ZOT

Ivory Vertebra - MC caused by:
~Osteoblastic Metastasis - VB size NOT changed; older ppl
~Paget Dz - VB INCREASES in size; older ppl
~Hodgkins - Anterior VB scalloping from enlarged lymph nodes/aorta; young ppl

48
Q

Metastatic Bone Tumors: Characteristics of Metastasis vs Primary Tumor

A

Usually NO periosteal response
Rarely a soft tissue mass
Rarely expands bone

49
Q

Metastatic Bone Tumors: Blow-Out Metastasis

A

LARGE lytic lesion

MC primary sites - Thyroid; Kidney

Often expansile and bubbly

50
Q

Metastatic Bone Tumors: OsteoLYTIC Malignancies (FOGMACHINES)

A 
Fibrous Dysplasia
Osteoblastoma
Giant Cell
Metastasis/ Myeloma
ABC
Chondroblastoma/Chondromyxoidfibroma
Hemangioma/Hyperparathyroid
Infection
Non-Ossifying Fibroma
Enchondroma/Eosinophilic
SBC
51
Q

Round Cell Tumor Type (MEN)

A

If you see diaphysis involvement, need to think Round Cell Tumor

MEN:
~Myeloma
~Ewing’s Sarcoma
~Non-Hodgkin’s Lymphoma

52
Q

Multiple Myeloma

A

AKA: Myeloma, Kahler’s Dz

MC primary osseous malignancy

Generalized, many lesions = multiple myeloma
Single osseous lesion = solitary plasmacytoma (much less common); ~50yoa

53
Q

Multiple Myeloma: Signs/Symptoms

A

CARDINAL symptom is PROGRESSIVE LBP (bone pn), aggravated by exercise and weight bearing.

MC in older patients

54
Q

Multiple Myeloma: Laboratory Features

A 
Increased serum electrophoresis (most diagnostic)
Normocytic/normochormic anemia
Rouleaux Formation (clumping of RBC’s)
Increased ESR
Thrombocytopenia
Increased Ca
Increased Uric Acid
Proteinuria (BENCE JONES proteins)
55
Q

Multiple Myeloma: Locations

A

MC lower T&L Spine

56
Q

Multiple Myeloma: Advanced Imaging & Radiographic

A

Bone Scintigraphy unreliable

Well-defined “punched-out” lytic lesions is key radiographic difference between MM and Osteolytic Metastasis (OLM)

57
Q

Multiple Myeloma: Radiographic - Spine

A

Loss of bone density is EARLIEST manifestation; sharply defined end-plates that are “thin” is key indicator of VB bone loss. Males w/ osteopenic bone loss is RED FLAG!
Wrinkled vertebra = pathological collapse

Pedicle Sign: MM spares pedicles; OLM eats pedicles

58
Q

Multiple Myeloma: Prognosis

A

MC cause of death is pneumonia

2nd MC is renal failure

59
Q

Ewing’s Sarcoma

A

Connective tissue sarcoma in bone marrow.

4th MC primary osseous malignancy

MC <25yoa

***Mimics osteomyelitis radiographically and labs

60
Q

Ewing’s Sarcoma: Signs and Symptoms

A

Increasing local PAIN over months; if progressive pain over days/weeks = osteomyelitis

Fever, malaise & ESR

61
Q

Ewing’s Sarcoma: Location

A

MC primary osseous malignancy that metastasizes to bone. Metastasizes to lung also, frequent and early.

Young pt’s MC femur and tibia
>20yoa MC pelvis

62
Q

Ewing’s Sarcoma: Radiographic

A

Laminated periosteal response, “onion-skin”

Saucerization of cortex d/t pressure from soft tissue mass; ***Easy dx of Ewing’s Sarcoma

DDx - Osteomyelitis

63
Q

MC Primary Osseous Malignancies (MOCE)

A

Multiple Myeloma
Osteosarcoma
Chondrosarcoma
Ewing’s Sarcoma

64
Q

Non-Hodgkin’s Lymphoma

A

AKA: Primary bone lymphoma, histocytic lymphoma, lymphosarcoma, reticulum cell sarcoma

65
Q

Non-Hodgkin’s Lymphoma: Sign’s and Symptoms

A

25-50 yoa

MC primary osseous malignancy to initially present as pathologic fx

66
Q

Non-Hodgkin’s Lymphoma: Locations

A

MC Femur diaphysis

67
Q

Non-Hodgkin’s Lymphoma: Radiographic

A

NO periosteal response b/c usually older pt’s

DDx: Ewing’s Sarcoma, Paget Dz

68
Q

Hodgkin’s Lymphoma

A

Usually metastasis from primary Systemic Hodgkin’s in chest, liver, spleen; rarely a primary bone lesion

MC initial symptom is pain, that increases w/ alcohol consumption
MC site is VB in lower T-Spine & upper L-Spine

69
Q

Hodgkin’s Lymphoma: Radiographic

A

Ivory Vertebra; scalloping of anterior VB

MC form osteoLYTIC
MC presentation polyostotic

Exuberant periosteal response

DDx: presence of anterior VB scalloping on ivory vertebra ELIMINATES osteoBLASTIC metastasis and Paget Dz

70
Q

Osteosarcoma

A

Both primary and secondary can metastasize.

MC form is primary, <25yoa
Secondary malignancies arise from BENIGN primary disorder, whereas metastatic dz arises from a primary MALIGNANCY
MC cause of secondary osteosarcoma is malignant degeneration of Paget Dz, 60-80yoa

71
Q

Osteosarcoma: Signs and Symptoms

A

Bone Pain
Pyrexia (fever)
Cachexia (wasting)

72
Q

Osteosarcoma: Location

A

MC is eccentric presentation

MC metaphysis of distal FEMUR
Anytime there are sclerotic changes w/ bone pain around the knee = osteosarcoma

73
Q

Osteosarcoma: Radiographic - 3 Presentations

A

~MC sclerotic w/ soft tissue tumor new bone (B-day present)
~Lytic
~Mixed

74
Q

Osteosarcoma: Radiographic

A

MC in metaphysis BEFORE epiphyseal plate closure (may travel to epiphysis after)

MC tumor new bone - radiopaque within soft tissue lesion produces cumulus cloud appearance

75
Q

Osteosarcoma: Radiographic - Aggressive Periosteal Response

A

Sunburst is classic sign

Cannonball metastasis - looks like cannonball lesions in lungs. MC primary osseous malignancy to metastasize to LUNGS

Hair-On-End

Codman’s Triangle

76
Q

Osteosarcoma: Laboratory

A

Alkaline phosphatase - elevated d/t tumor new bone

77
Q

Parosteal Osteosarcoma

A

AKA: Periosteal or Juxtacortical Osteosarcoma

MC at posterior aspect of distal femur

25-40yoa

78
Q

Benign Bone Tumors

A

4 MC painful benign bone tumors (in order): Osteoid Osteoma; Osteoblastoma; ABC; Giant Cell
(First 3 like spine, Giant cell does not)

79
Q

Osteoma

A

Looks like enostoma; found in skull or sinuses. Enostoma’s DON’T occur in skull!

MC 15-35yoa

Gardner’s Syndrome - autosomal dominant, familial polyposis

80
Q

Osteoma: Signs and Symptoms

A

May block ostia (opening that connects sunuses to nasal cavity) of paranasal sinuses

81
Q

Osteoma: Complications

A

Proptosis - eyes popped out

82
Q

Osteoma: Locations

A

MC skull, paranasal sinuses, mandible

83
Q

Osteoma: Radiographic

A

Round or oval; well circumscribed

84
Q

Osteoma: Triad

A

Intestinal Polyposis - almost always undergo malignant degeneration

Multiple Osteomas

Soft Tissue Tumors

85
Q

Bone Islands

A

AKA Enostoma; small solitary foci of sense bone within spongiosa
Usually very stable
MC pelvis and proximal femur (if seen in skull = osteoma)
Metaphysis or epiphysis - NEVER diaphysis

DDx: Osteoblastic metastasis

86
Q

Bone Islands: Radiographic

A

MC <1cm
Thorn-like radiations or brush border

Scintigraphy = NO uptake (great way to differentiate from osteoblastic metastasis - esp in older pt’s)
~Always ask for old films; if no significant change in several years = bone island
~If pt has prostate cancer, always get scintigraphy

87
Q

Osteoid Osteoma

A

Nidus - radiolucent lesion <1cm CLASSICALLY surrounded by sclerosis (reactive new bone)

Highly vascular - usually demonstrates vascular blush on angiography

DDx: Brodies Abscess (appears identical; vascular blush in OO helps differentiate)

88
Q

Osteoid Osteoma: Signs and Symptoms

A

10-25yoa

HALLMARK: local pain, worse at night, relieved by activity and aspirin

Focal soft tissue swelling/tenderness

89
Q

Osteoid Osteoma: Locations

A

MC proximal femoral neck (metaphysis and diaphysis)

Vertebral arch

90
Q

Osteoid Osteoma: Types

A

MC Intracortical - in or attached to cortex, usually accompanied w/ plenty of cortical thickening and sclerosing

Intramedullary - little sclerosing

Subperiosteal

91
Q

Osteoblastoma

A

AKA giant osteoid osteoma
MC 10-20yoa

Osteoblastoma and osteoid osteoma are MC causes of scoliosis provoked by pn (neoplastic scoliosis)

DDx: If painful osteolytic lesion in neural arch of young pt, it’s either osteoblastoma or ABC

92
Q

Osteoblastoma: Location

A

MC VB’s posterior arch

93
Q

Osteoblastoma: Radiographic

A

Expansile w/ egg-shell thin cortical rim

Usually lytic

Skeletal Radiology I (4 decks)

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