7. Purpose: To determine if sclerotic bone lesions evident at body computed tomography (CT) are of value as a diagnostic criterion of tuberous sclerosis complex (TSC) and in the differentiation of TSC with lymphangioleiomyomatosis (LAM) from sporadic LAM. There is no calcification and lesions may be expansile. Secondary bone cancer is much more common than primary bone . Fibrous dysplasia, enchondromas, EG, Mets and myeloma, Hyperparathyroidism, Infection. Development in centrally located osteochondromas like the pelvis, hip and shoulder is most common. 33.1a) and sagittal short tau inversion recovery (STIR; Fig. Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. In the subchondral bone, the number of TRAP-positive cells peaked on day 14. Here a chondrosarcoma of the left iliac bone. Here a 44-year old male with a mixed lytic and sclerotic mass arising from the fifth metacarpal bone. The subchondral bone is key to cartilage and joint health. Metastases and multiple myelomaIn patients > 40 years metastases and multiple myeloma are the most common bone tumors.Metastases under the age of 40 are extremely rare, unless a patient is known to have a primary malignancy.Metastases could be included in the differential diagnosis if a younger patient is known to have a malignancy, such as neuroblastoma, rhabdomyosarcoma or retinoblastoma. The most common appearance is the mixed lytic-sclerotic. 33.1b), CT scan axial images (c), and bone scintigraphy (d). W. B. Saunders company 1995, by Mark J. Kransdorf and Donald E. Sweet Edema often present in the surrounding bone marrow. 6. This 'neocortex' can be smooth and uninterrupted, but may also be focally interrupted in more aggressive lesions like GCT. 9. Radiographs are specific but suffer from low sensitivity 1. A mean CT attenuation threshold of 885 HU and a maximum attenuation threshold of 1060 HU has been found supportive in the differentiation of untreated osteoblastic and bone island in one study 7, but the exclusive use of attenuation values for the assessment of sclerotic bone lesions has been discouraged 8. Systematic Approach of Sclerotic Bone Lesions Basis on Imaging Findings. Click here for more detailed information about fibrous dysplasia. Sarcoidosis is a multi-system disease with a range of . Bker S, Adams L, Bender Y et al. This is consistent with the diagnosis of a reactive process like myositis ossificans. Lumbar CT-HU has the highest pooled correlation (r 2 =0.6) with both spine DEXA and lowest skeletal t-score followed by lumbar CT-HU with hip DEXA (r 2 =0.5) and lumbar MRI with hip (r 2 =0.44) and spine (r 2 =0.41) DEXA. 1. Society of Skeletal Radiology- White Paper. 5. Sclerosis is present from either tumor new bone formation or reactive sclerosis. 2017;11(1):321. Rapid growth of the mineralized mass is not uncommon. A bone island larger than 1 cm is referred to as a giant bone island (12). Cortical destruction is a common finding, and not very useful in distinguishing between malignant and benign lesions. Most primary bone tumors are seen in patients In patients > 30 years we must always include metastases and myeloma in the differential diagnosis. NOF, fibrous dysplasia, multifocal osteomyelitis, enchondromas, osteochondoma, leukemia and metastatic Ewing' s sarcoma. Check for errors and try again. (see diagnostic imaging pearls). 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. A sclerotic lesion is an unusual hardening or thickening of your bone. 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. In fact, in areas where sickle cell disease is common, this may be the leading cause of diffuse sclerotic bones. Calcifications in chondroid tumors have many descriptions: rings-and-arcs, popcorn, focal stippled or flocculent. They usually affect posterior vertebral elements and their number and size increase with age. In the active phase there is multilaminar periosteal reaction and bone and soft tissue edema. In most cases of osteoid osteoma the radiographic appearance is determined by the reactive sclerosis. Well, generally, it means that it is due to a fairly slow-growing process. Parosteal osteosarcoma is a sarcoma that has it's origin on the surface of the bone. Bone scintigraphy can be either negative or show limited uptake. Disappearane of calcifications in a pre-existing enchondroma should raise the suspicion of malignant transformation. 4 , 5 , 6. FD is often purely lytic, but may have a groundglass appearance as the matrix calcifies. The lesson here is that when we are dealing with a very common disorder, even its less common presentations will be seen commonly. Metastases are the most common malignant bone tumors. 1988;17(2):101-5. Bone scan shows no high activity, opposed to low-grade intraosseous osteosarcoma. ADVERTISEMENT: Supporters see fewer/no ads. Brant WE, Helms CA. 1. The sclerotic lesion in the humeral head could very well be a benign enchondroma based on the imaging findings. In patients In patients > 30 years, and particularly > 40 years, despite benign radiographic features, a metastasis or plasmacytoma also have to be considered On the left three bone lesions with a narrow zone of transition. 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. Clin Orthop Relat Res. Likewise patients with sclerotic lesions due to various drugs or minerals will tell you what they are taking if you ask them. AJR Am J Roentgenol. The most reliable indicator in determining whether these lesions are benign or malignant is the zone of transition between the lesion and the adjacent normal bone (1). 2019;290(1):146-54. 2010;35(22):E1221-9. Starting on day 28, sclerotic changes surrounding the bone absorption area were detected. Notice that CT depicts these lesions far better (red arrows). Continue with the MR-images. Despite their remarkable clinical success, the low degradation rate of these materials hampers a broader clinical use. Solitary sclerotic bone lesion. Notice the numerous ill-defined osteoblastic metastases. Chang C, Garner H, Ahlawat S et al. It could be blood or fluids released from fibrosis (scarred tissue) or necrosis (tissue death). by Clyde A. Helms Age is the most important clinical clue in differentiating possible bone tumors.There are many ways of splitting age groups, as can be seen in the table, where the morphology of a bone lesion is combined with the age of the patient. 2018;2018:1-5. Results: In 24 patients, 52 new sclerotic lesions observed during therapy were selected for re-evaluation of conventional radiographs and bone scans. The major part of the lesion consists of reactive sclerosis. J Korean Soc Radiol. by Mulder JD, et al. Bone metastases have a predilection for hematopoietic marrow sites: spine, pelvis, ribs, cranium and proximal long bones: femur, humerus. (2007) ISBN:0781765188. The radiographic appearance and location are typical. 11. What does it mean that a lesion is sclerotic? There is reactive sclerosis with a nidus that is barely visible on the radiograph (blue arrow), but clearly visible on the CT (red arrows). It is a feature of malignant bone tumors. For the unexpected bone lesions, the distinguishing anatomic features and a generalized imaging approach will be reviewed for four frequently encountered scenarios: chondroid lesions, sclerotic bone lesions, osteolytic lesions, and areas of focal marrow abnormality. The bone marrow compartment is not involved which is important for the surgical strategy. 14. 2021;13(22):5711. 10. For those that are possibly cancerous, a biopsy is conducted to identify it. Macedo F, Ladeira K, Pinho F et al. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We? If the lesion grows more rapidly still, there may not be time for the bone to retreat in an orderly manner, and the margin may become ill-defined. Osteoid osteoma (2) Non-ossifying fibroma (NOF) can be encoutered occasionally as a partial or completely sclerotic lesion. It grows primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. General Considerations In an older patient one should first consider an osteoblastic metastasis. Differential Diagnosis of Diffuse Sclerotic Bone Lesions. However, the exact mechanism that leads to osteoblastic formation is not entirely elucidated. Fibrous dysplasia can be monostotic or polyostotic. It may be spiculated and interrupted - sometimes there is a Codman's triangle. You can then customize the above differential for whichever pattern of sclerosis that you see. Check for errors and try again. . More heterogenous and irregular with bony trabecular destruction and possible extension beyond the confines of the cortex. Sclerotic metastases arise from . Case 7: metastases from prostate carcinoma, Sclerotic bone pseudolesions - external artifact, bizarre parosteal osteochondromatous proliferation (Nora lesion), conventional intramedullary chondrosarcoma, dysplasia epiphysealis hemimelica (Trevor disease), solitary bone plasmacytoma with minimal bone marrow involvement, mixed lytic and sclerotic bone metastases, Lodwick classification of lytic bone lesions, Modified Lodwick-Madewell classification of lytic bone lesions. In this article we will discuss the differential diagnosis of sclerotic bone tumors and tumor-like lesions in more detail. Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. If there are multiple or polyostotic lesions, the differential diagnosis must be adjusted. Here a patient with a broad-based osteochondroma. Reference article, Radiopaedia.org (Accessed on 02 Mar 2023) https://doi.org/10.53347/rID-21100, Mnemonic for focal sclerotic lesions (mnemonic). The NK cell type is seen as a sheet of soft tissue in the nasal cavity with bone destruction and erosion without any sclerosis. AJR Am J Roentgenol. WSI digital slide: https://kikoxp.com/posts/4606. 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 Laura M. Fayad, Satomi Kawamoto, Ihab R. Kamel, David A. Bluemke, John Eng, Frank J. Frassica and Elliot K. Fishman. In breast cancer, metastases may present as lytic lesions that may become sclerotic expressing a favourable response to chemotherapy. These lesions usually regress spontaneously and may then become sclerotic. Osteoblastic metastatic disease (see Table 33.1): More often multiple with increased uptake on bone scan. Amorphous mineralisation is present in most lesions. These tumors may be accompanied by a large soft tissue mass while there is almost no visible bone destruction. The term bone infarction is used for osteonecrosis within the diaphysis or metaphysis. Here images of a patient with prostate cancer. 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. This represents a thick cartilage cap. and PD-L1 PET/CT (PD-L1 positivity is defined as having at least one lesion with radiotracer uptake over the . AJR 2000; 175:261-263. The image on the right is of a different patient who has an old NOF that shows complete fill in. Bone cyst is one of the manifestations of CGL with AGPAT2 mutation. Brant WE, Helms CA. Osteoblastic bone metastases are characterized by increased bone formation 2. giant cell tumor, metastasis, and myeloma; (3) sclerotic . (2005) ISBN: 9780721602707 -. Enchondromas aswell as low-grade chondrosarcomas are frequently encountered as coincidental findings in patients who have a MRI or bone scan for other reasons. The most common focal metastatic lesions originate from the breast (37%), lung (15%), kidney (6%), and thyroid (4%) 43. 2021;50(5):847-69. The use of radiological imaging in medical care dates back to 1895 when Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements. The mean and maximum attenuation were measured in Hounsfield units. Accordingly, growth of osteochondromas is allowed until a patient reaches adulthood and the physeal plates are closed. D'Oronzo S, Coleman R, Brown J, Silvestris F. Metastatic Bone Disease: Pathogenesis and Therapeutic Options. A surface osteosarcoma could be considered in the differential diagnosis. A T1w/T2-weighted (T2w) hypointense nonexpansile lesion is seen involving the sacrum (asterisk). There are two kinds of mineralization: Chondroid matrix Home. If the disorder it is reacting to is rapidly progressive, there may only be time for retreat (defense). The homogeneous enhancement in the upper part with edema and cortical thickening are not typical for a low-grade chondrosarcoma. Axial T1-weighted MR image shows homogeneous low signal intensity due to the compact bone apposition. In the late stage of OA, the main feature is subchondral bone sclerosis, whose microarchitectural characteristics are elevated apparent density, increased bone volume, . Interventional Radiology). Radiographs typically show a geographic lytic or ground glass lesion with a well-defined, often extensively sclerotic margin, indicating its indolent nature. Malignant transformation The X-ray features were divided into two groups according to typical and atypical skeletal lesions. 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