Herman M.

Kroon, MD #{149}Johan Schurmans, MD

Osteoblastoma: Clinical and Radiologic

Findings in 98 New Cases’

The data on 98 new patients with O STEOBLASTOMA is a rare, benign er than 1 .5 cm, they were defined as oste-
osteoblastoma were studied. The primary bone tumor. It occurs oid osteoma. In 12 cases, the pathologists
clinical features of pain, scoliosis, most commonly in adolescents and were equivocal about the classification of
the tumor as osteoid osteoma on osteoblas-
and neurologic deficit were largely young adults in the 2nd and 3rd de-
toma. Consensus was reached between
consistent with those in previous cades of life (1,2). Approximately 60%
pathologists and radiologists by using cni-
reports. Osteoblastoma is usually a of the tumors occur in the spine and
teria such as initial size, size at follow-up
lytic lesion originating in the me- long tubular bones (1-3). The most examinations, and clinical history. In sev-
dulla of bones with matrix ossifica- frequent radiologic appearance is en of these 1 2 equivocal cases the size of
tion and mild surrounding sclerosis. that of a lytic lesion of bone, with or the lesion was less than 1 .5 cm on initial
Osteoblastoma of the spine demon- without matrix mineralization, sur- radiognaphs. They were nevertheless clas-
strated better tumor delineation in rounded by a narrow on broader zone sified as osteoblastoma because follow-up
the vertebrae, and a bony rim on the of sclerosis on, if expansive, a thin studies demonstrated growth to larger
soft-tissue side was seen less f me- bony shell (1-3). The strong nesem- than 1.5 cm. Furthermore, the nature of
the pain and the absence of reaction to sa-
quently than previously observed. blance between osteoblastoma and
licylates in these cases were more compat-
Osteoblastoma of the talus fre- osteoid osteoma can make it impossi-
ible with a diagnosis of osteoblastoma.
quently appears as a blister on the ble even for pathologists to distin-
With these criteria we studied 32 osteo-
surface of the bone and is accompa- guish these tumors based on histo- blastomas located in the vertebral col-
nied by osteoporosis. In the hands logic examination alone (1,4,5). The umn, 26 in the long tubular bones, 26 in
and feet, the radiographic appear- tumor easily recurs after incomplete the bones of hands and feet, and 14 in
ance is often very similar to that of surgical removal, but even incom- other locations. Also with these criteria,
aneurysmal bone cyst and giant cell plete curettage can effect a cure in a 1 87 cases of osteoid osteoma were exclud-
tumor. In the skull it strongly me- high percentage of cases (3). ed from this study. Another 21 cases of
We studied the case records of 98 cementoblastoma of the jaws were also
sembles a button sequestrum of
excluded from this review, although ac-
bone. The origin and extent of the new patients, a large collection of pa-
cording to the oral pathology literature
tumor, the presence of matrix mm- tients with this infrequent bone neo-
(6), they have considerable histologic
eralization, and tumor delineation plasm. The clinical and radiologic
similarities with osteoblastoma. Medical
depicted as a thin bony shell are of- findings, including 15 computed records were studied. In 94 of the 98 pa-
ten better appreciated on computed tomognaphic (CT) and three magnetic tients the clinical history and physical
tomographic (CT) scans. In addition, resonance (MR) imaging studies, are findings could be retrieved. Plain radio-
CT can demonstrate both edema and the subject of this report. graphs were available in all cases. In ad-
atrophy of the surrounding soft tis- dition, CT was performed on 15 patients,
sues. At magnetic resonance (MR) technetium-99m bone studies on 14 pa-
PATIENTS AND METHODS tients, angiography on six patients, and
imaging, osteoblastoma demon-
We studied the case records of 98 new MR imaging (0.5-T superconductive sys-
strates signal intensities similar to
patients with osteoblastoma. They were tem [Philips Medical Systems of North
those of other bone neoplasms. In America, Shelton, Conn]) on three pa-
addition to the advantages offered obtained from the files of the Nether-
lands Committee on Bone Tumors tients. Follow-up information was
by CT, MR imaging can help differ- present for 72 patients over a mean peri-
(NCBT), an advisory board of radiologists,
entiate tumor tissue from accompa- od of 43 months (range, 1-368 months).
pathologists, and clinicians concerned
flying edema. with the diagnosis and treatment of bone
tumors. Material for histologic examina-
RESULTS
Index terms: Bone neoplasms, diagnosis, tion was available in all cases. Lesions
30.3123, 40.3123 Neoplasms,
#{149} in infants and were classified as osteoblastoma based on
histologic evidence primarily. In addi-
Clinical and General Features
children Osteoblastoma,
#{149} 30.3123, 40.3123 #{149}
Spine, primary neoplasms, 30.3123 tion, size was the most important cniteri- The data on 64 male and 34 female
on. Lesions larger than 1 .5 cm in diameter patients were studied. Ages ranged
Radiology 1990; 175:783-790 were classified as osteoblastoma; if small- from 3 to 72 years (median, 16 years).
Ninety percent of the patients were be-
tween 6 and 30 years of age. The medi-

I From the Department of Diagnostic Radiology, University Hospital Leiden, Rijnsburgerweg 10,
2333 AA Leiden, The Netherlands. Received August 22, 1989; revision requested November 2; re-
vision received January 29, 1990; accepted February 21. Address reprint requests to H.M.K. Abbreviation: NCBT Netherlands Commit-
RSNA, 1990 tee on Bone Tumors.

783
an duration of complaints before the maining two tumors (6%) had their on-
diagnosis was made was 6 months gin in the vertebral body. Secondary
(range, 1 week to 72 months). The most extension into the vertebral body from
prominent complaint was a dull, local- lesions arising in the posterior ele-
ized, and gradually increasing pain ments occurred in nine cases (28%). On
that occurred in 93 (99%) of 94 patients. initial nadiographs the tumors were
Only seven patients (7.5%) indicated round or oval, ranging in size from 1 to
that this pain also interfered with 3 cm. In eight cases (25%) the lesion
sleep. None complained of pain occur- was entirely lucent. In 23 cases (72%)
ring predominantly at night. Relief of opacities were present in the tumor ma-
pain after administration of salicylates trix, and in one case (3%) bony ridges
was never mentioned. Swelling was were present. In 29 cases (91%) the le-
present in 27 of 94 patients (29%), spe- sion was well defined and surrounded
cifically when the lesion was near the by a sclerotic rim of variable thickness.
surface. In one case swelling (of the tib- In the remaining cases there was no
ia) was the most significant complaint. surrounding sclerosis or the contours
In six patients muscle wasting in a limb were moth eaten. In 30 cases (94%) the
was noticed. cortical bone was thinned or destroyed
Thirty-two cases (33%) of osteoblasto- due to an expansive growth of the tu-
ma occurred in the spine: 10 (31%) in mon. In 10 cases (31%) the tumor was
the cervical spine, 1 1 (34%) in the don- demarcated by a thin bone shell.
sal spine, 10 (31%) in the lumbar spine, In the long tubular bones, the tumor
and one (3%) in the sacrum. The medi- was located in the diaphysis in 15 of 26
an age in these patients was 16 years. cases (58%) and in the metaphysis in ii
a.
Scoliosis was seen in all 10 lumbar cases (42%). In 19 cases (73%) the lesion
(100%), three dorsal (27%), and two cem- was located in the proximal part of the
vical (20%) lesions (Fig 1). Scoliosis was bone and in the remaining seven (27%)
also present in two (of four) patients in the middle on distal end. In three in-
(50%) with an
osteoblastoma in the rib. stances (12%) the lesion originated in
In addition, neurologic deficits were the center of the bone, in 12 (46%) the
found in 12 patients with spinal lesions location was eccentric, and in 1 1 (42%)
(38%), ranging from mild muscle weak- the lesion was intracortical (Figs 2, 3).
ness to paraplegia. Restriction of mo- Twenty-four osteoblastomas (92%)
tion was found with seven (of 13) os- were seen as a round on oval lesion
teoblastomas in the femur (54%) but ranging in size from 1.5 to 2.5 cm. Only
was also present in six spinal (19%) and two (8%) were lobulated. In nine cases
two (of 16) talam (12%) locations. In one (35%) the lesion was entirely lucent,
patient with an osteoblastoma in the and in 17 (65%) matrix ossification was
fifth rib, remarkable findings included present. In 24 cases (92%) the lesion b.
profuse perspiration and hypenemia of was well defined with a usually thin Figure 1. Anteroposterior tomogram

the ipsilateral part of the chest, caused sclerotic rim. Two cases (8%) demon- (a) and CT scan (b) of the cervical spine with
by direct stimulation of the panaverte- stnated a moth-eaten contour. The con- osteoblastoma in the lateral part of C-4. Sco-
liosis with the convexity toward the affected
bral sympathetic chain. tex was partly or completely replaced
side and dense sclerosis with central lucency
Twenty-six of the 98 tumors (26%) oc- by tumor in 22 patients (85%). A solid
of the lateral mass are seen. Distinct muscle
curred in the long tubular bones; 13 of on lamellate periosteal reaction was
wasting and edema of the surrounding soft
the 26 (50%) occurred in the femur, five present in 20 lesions (77%). In addition, tissues are shown.
(19%) in the tibia, five (19%) in the hu- two of these demonstrated a thin shell
menus, two (7.7%) in the radius, and of reactive peniosteal bone. In another
one (3.8%) in the fibula. The median two patients a spiculated peniosteal me-
patient age in this group was 14 years. action could be appreciated. bones, or of the entire foot was seen at
In another 26 cases (26%) the tumor In the talus, all tumors originated in presentation or later in the course of
was located in the bones of the hands the dorsal part of the neck. On initial the disease in seven patients (44%) (Fig
and feet. Sixteen (62%) of these onigi- radiographs the lesion appeared as a 4). The single osteoblastoma of the cal-
nated in the talus; two each (7.7%) in round on oval lucency, 1-2 cm in diam- caneus was eccentric, lytic with small
the scaphoid, metacarpal bones, meta- eten, eccentric in the marrow (10 cases, calcifications in the center, and sun-
tarsal bones, and phalanges of the feet; 62%) or in the cortex (six cases, 38%) rounded by a thin sclerotic zone.
one (3.8%) in the calcaneus; and one in (Fig 4). Opacities in the tumor matrix In the small tubular bones, four os-
a phalanx of a hand. The median age of were present in eight cases (50%) and teoblastomas (57%) were located in the
these patients was 20 years. In the me- in two of these were extensive in the diaphysis, two (29%) in the metaphysis,
maining 14 cases (14%) the tumors onig- later stages of the disease. All were de- and one in the epiphysis (14%). Three
mated in the pelvis (n 5), nibs (n 4), mancated by a thin sclerotic line on the tumors (43%) originated in the proxi-
skull (n = 3), scapula (n 1), and clavi- talar side of the tumor and demonstnat- mal and four (57%) in the distal end of
cle (n = 1). Median patient age was 15 ed an expansive growth into the soft the bone. Three lesions (43%) were lo-
years. tissues, which could be as large as 7 cm cated in the center, three (43%) were
in diameter. Periosteal reaction was eccentric, and one (14%) was intracorti-
present in six cases (37.5%) and consist- cal. The size at presentation ranged
Plain Radiographic Studies
ed of a single bone layer that could be from 1 to 4 cm. The tumor was mainly
Thirty of 32 spinal osteoblastomas interrupted. In one patient reactive osteolytic with delicate trabeculation in
(94%) originated in the posterior verte- peniosteal new bone formation was also three cases (Figs 5, 6) and ossification
bral elements, predominantly in the found in the distal part of the tibia. Os- in one case. Surrounding sclerosis was
spinous processes and arches. The me- teoporosis of the talus, the adjacent present only in two metatarsal osteo-

784 Radiology
#{149} June 1990
 b. C.

e. f.
Figure 2. Anteroposterior radiograph (a), CT scan (b), and MR images
of the right femur. (c-f) Osteoblastoma is seen as a lucent lesion with
a central density, surrounded by sclerosis and accompanied by a spiculated peniosteal reaction. Soft-tissue swelling is demonstrated (open ar-
rows). Ti- and T2-weighted images through the center (c, d) and slightly proximal to the center of the tumor (e, f) demonstrate low signal
intensities from the surrounding sclerosis, the periosteal reaction, and the pseudocapsule (arrowheads). The latter clearly defines the ex-
tnaosseous extent of the neoplasm. The Ti-weighted images (c, e) also demonstrate intermediate signal intensity coming from most of the
marrow of the femur. The T2-weighted images (d, f) show predominantly high signal intensities from the adjacent vastus muscle (solid ar-
rows) and bone marrow. In combination with the Ti-weighted images, this indicates edema. (MR study courtesy of Johan L. Bloem, MD,
University Hospital Leiden, The Netherlands.)

blastomas. In all cases the cortex was both tumors in the frontal bone dem- All four osteoblastomas located in
partially or completely replaced by the onstnated matrix mineralization. There the ribs had a central origin. Three
tumor. In four tumors in the small tu- was only a thin zone of sclerosis visible were predominantly lytic, with only
bular bones, slight on more prominent surrounding the frontal lesions (Fig 7). minor ossification within the tumor
expansion was present. Two metatarsal In the pelvis, all five tumors were os- matrix in two. One had quite distinct
tumors caused scalloping of the extem- teolytic. Matrix ossification was present mineralization (Fig 8). The fourth had
nal cortex of the adjacent metatansals. in three lesions. Four of them were ex- a mixed lucent/sclenotic appearance.
Similar trabeculation within the tumor pansive. Three had a lobulated contour. Three were sharply defined; one had
matrix, absence of surrounding scleno- Two had a dense sclerotic bonder. A fuzzy margins. One was distinctly ex-
sis, and slight expansive growth were peniosteal reaction was present in four pansive. The others caused a broaden-
visible in both lesions in the canpal cases, a thin bony shell was present in ing of the ribs through solid on layered
scaphoid (Fig 6). In the skull, all three one, and a lamellate reaction was peniosteal new bone formation. The
lesions were osteolytic. In addition, present in three. single osteoblastoma in the clavicle was

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#{149} 3 Radiology 785
#{149}
a. C. d.
Figure 3. Lateral radiograph (a), CT scan (b), and MR images (c, d) of an osteoblastoma of the right femur. The osteoblastoma is seen origi-
nating in the cortex on the dorsal side and appears as a lucent defect without mineralization surrounded by a thin bony shell. The tumor mi-
tiated cortical thickening (arrow in b) by a solid periosteal reaction. (c) The Ti-weighted transverse image demonstrates low signal intensity
from the thickened cortex (arrow) and an intermediate signal intensity from the neoplasm itself (arrowheads). (d) The coronal T2-weighted
image through the posterior aspect of the femur shows the low signal intensity from the thickened cortex and the predominantly high sig-
nal intensity of the surrounding muscles caused by edema.

eccentric, osteolytic, and expansive, Figure 4. Lateral view of the right ankle
with an interrupted cortex. In the scap- with a blisterlike osteoblastoma on the dor-
ula the tumor was located in the gle- sal surface of the talus. Note the severe Os-
noid. It had a lobulated appearance teopenia of the bones in the ankle region
with a thick sclerotic margin and bony and the pronounced soft-tissue swelling
around the ankle caused by edema.
ridges within.

Radionuclide Bone Studies toma. In four cases the tumor was locat-

All 14 radionuclide studies demon- ed in a long tubular bone, in two cases

strated an intense focal accumulation of in a nib, and in one case in the pelvis.
the bone-seeking agent. In the spine, CT gave better on addi-
tional information compared with
plain radiography regarding precise tu-
Angiographic Studies mon origin in six cases (75%), intnaos-
The six angiognaphic studies showed seous extent in seven (88%), and
displacement but no invasion of major growth into the soft tissues in five
vessels when the tumor was near such (83%) of six cases in which this oc-
a vessel. Within the tumor both regular curred. In none of these cases was CT
and irregular vasculanity could be inferior to plain radiography with me-
present. There was a pronounced tu- spect to these features. The relationship
mom blush in the capillary phase in of the tumor to the spinal cord was bet-
three patients (Fig 8). In only one pa- ten visualized in all cases at CT. Matrix ble on the ipsilateral side (Fig 1). In one
tient with a cervical osteoblastoma, no ossification was only visible or was bet- of these two patients the intenmuscular
certain abnormalities were visible. ten visible in seven patients (87.5%) at fat demonstrated changes compatible
CT. A bone shell surrounding the le- with edema (Fig 1). Of the seven CT
sion was either more apparent on visi- studies performed on patients with tu-
CT Studies
ble only at CT in five (83%) of six cases. moms in the nibs, long bones, and pel-
Of the 15 CT studies, eight were In two patients a pronounced wasting vis, CT was more valuable in determin-
done to evaluate a spinal osteoblas- of the panavertebnal muscles was visi- ing tumor origin in three patients

786 Radiology
#{149} June 1990
 this finally resulted in an amputation.
Three years after initial presentation,
the patient with the sphenoid tumor
died of sudden intracranial hemon-
rhage resulting from the incompletely
removed tumor.

DISCUSSION

General Considerations and

Clinical Findings
Osteoblastoma is a mane, benign pri-
Figure 7. Lateral view of the skull. A
well-defined lucent osteoblastoma of the
mary tumor of bone accounting for ap-
frontal bone with ringlike matrix mineral- proximately 1% of all primary bone tu-
ization and a thin sclerotic margin is seen. moms and 3% of all benign bone tumors
The neoplasm resembles lesions appearing (1). In the files of the NCBT, osteoblas-
as a button sequestrum of the skull. A an- toma accounts for 6% of all benign pni-
terior, P = posterior. many bone tumors and 2.4% of all pri-
many bone tumors. These differences
are probably caused by the means of Se-
lection of patients referred to the
a mixed intermediate and high signal NCBT.
intensity on spin-echo T2-weighted im-
Histologic differentiation between
Figure 5. Osteoblastoma of the third meta-
ages (2,000/50-100). In all three pa- osteoid osteoma and osteoblastoma can
carpal. Delicate bony septa instead of matrix
tients, MR imaging showed indistinct
ossification within the tumor and obvious be very difficult, and in a considerable
expansion are seen. areas of increased signal intensity in number of patients it can be impossible
the soft tissues on T2-weighted images
(1,2,4,5,7). Both are osteoid-pnoducing
(Figs 2, 3). These areas were outside the
tumors, but in the typical osteoblasto-
actual tumor extent into these struc-
ma the bone tnabeculae are broader and
tunes, indicating edema. These observa-
longer and seem less densely packed
tions were confirmed by the operative
and less coherent than those in osteoid
findings. In two patients an indistinct
osteoma. Furthermore, osteo-
area of decreased signal intensity on
blastomas generally lack the halo of
Ti-weighted images was present in the sclerotic bone, which is almost invani-
marrow of the involved bone beyond ably associated with osteoid osteoma.
the well-defined tumor margin, mdi- The most important criterion in equiv-
dating edema (Fig 2).
ocal cases is the size of the lesion. Os-
teoblastomas are usually larger than 2
Radiologic Diagnosis cm due to the absence of limited
growth potential, which is a feature of
In 47 cases (48%) osteoblastoma was osteoid osteoma. At presentation, how-
the single diagnosis based on nadiolog- even, osteoblastoma can be smaller than
ic findings. In 30 patients (31%) osteo- 2 cm, but growth is seen at subsequent
blastoma was mentioned in the differ- nadiologic examinations, a sometimes
ential diagnosis. In 2i patients (21%), confusing experience similar to that of
Figure 6. Osteoblastoma of the scaphoid of however, osteoblastoma was not con- other authors (2). A number of cases me-
the right hand. A lucent lesion with trabecu- sidened in the differential diagnosis. main in which the two tumors show
lation and slight expansion is seen.
significant overlap. McLeod et al (2)
partially solved this problem by anbi-
Treatment and Follow-up
tramily regarding a lesion as osteoblas-
(43%) and intraosseous extent in anoth- Information about treatment was toma when it had a diameter of 1.5 cm
em three patients (43%). Extraosseous available for 84 patients (86%). In 55 on larger. An additional feature that
growth was better visualized in four of cases the patient was treated by means can be helpful is the lack of chanactenis-
five patients (80%) in whom this oc- of excision, in 21 cases by resection, tic pain in osteoblastoma. Even then,
curred. In five patients (71%) matrix os- and in seven cases by curettage. In one however, problems in classification can
sification could be better appreciated. patient an amputation was carried out remain. Because the diagnostic divid-
In one femonal and one
rib osteoblasto- because of very rapid and destructive ing line between osteoid osteoma and
ma, soft-tissue swelling beyond the ad- growth. In 72 patients (73%) follow-up osteoblastoma is arbitrary, results deal-
tual margins of the tumor was found information was available. Recurrence ing with the size of the lesion, sun-
(Figs 2, 8). of the tumor was reported in 10 cases rounding bone sclerosis, and pain pat-
after a mean period of 12 months tern may therefore also be arbitrary.
(range, 5-24 months). Of these, three Another group of osteoblastomas can
MR Imaging Studies
were located in the talus; two in the fe- demonstrate histologic and radiograph-
In three patients, two with tumors in mum; two in the thonacic vertebrae; and ic features highly suggestive of malig-
the femur and one with an osteoblasto- one each in the tibia, the humerus, and nancy and can resemble low-grade Os-
ma of the pelvis, additional MR imag- the sphenoid. In five of these recur- teosancoma. Some authors (5,8,9) pro-
ing studies were performed (Figs 2, 3). nences the initial operation was exci- posed a separate classification for these
MR imaging demonstrated a low or in- sion; in three, resection; and in two, cu- so-called malignant, aggressive, or bon-
termediate signal intensity on spin- nettage. Four tumors, two located in the derline osteoblastomas. Our patholo-
echo Ti-weighted images (550/30 [rep- talus and two in dorsal vertebrae, ne- gists classify this type of tumor as low-
etition time msec/echo time msec]) and curred twice. In one of the talan tumors grade osteosancoma in accordance with

Volume 175 Number

#{149} 3 Radiology 787
#{149}
Bertoni and coworkers (iO). Features
that aid in distinguishing osteoblas-
toma from low-grade osteosarcoma are
absence of anaplasia, lack of pemme-
ation at the lesional edge, absence of
“trapping” of host lamellar bone by tu-
mom bone, focal osteoblastic “rim-
ming,” and absence of cartilage pro-
duction in osteoblastoma (1,7). Histo-
logic features resembling those of
aneurysmal bone cyst can occur
(1,3,11). We encountered these features
in three patients. In accordance with
the literature (1-5,12) the male to fe-
male ratio in our series was 2:1 both for
the total group of patients and for the
separate tumor locations. The median a. b.
age of the entire group of patients was
16 years, consistent with that in previ-
ous reports (1-5,13,14). The oldest pa-
tient recorded in the literature was 78
years old (i5). In our experience, pa-
tients with the tumors in the bones of
hands and feet appeared somewhat
olden (median, 20 years) than patients
with tumors in other locations. The du-
nation of complaints before a diagnosis
was made varied from 1 week to as
long as 6 years, with a median of 6
months. We did not find a notable dif-
femence in the duration of complaints
between different tumor locations.
None of our patients were asympto-
matic. Only one patient with an asymp-
tomatic osteoblastoma was described in
the literature (16). In agreement with
C. d.
previous publications, the most com-
mon complaint was pain. In only one Figure 8. Plain radiograph (a), subtraction angiogram (b), and CT scans (c, d) of an osteo-
blastoma arising in the left first rib. Expansive
lytic lesion with matrix mineralization sun-
of our patients was swelling a more
rounded by a thin rim of bone. The subtracted selective angiogram of the left thyrocervical
prominent complaint. Although fan
artery shows a distinct tumor blush in the capillary phase. The CT scan (d) slightly caudal to
more common in osteoid osteoma, pain the center of the lesion (c) clearly demonstrates soft-tissue swelling (arrowheads in d)
predominantly at night and responsive caused by edema outside the actual margins of the tumor indicated by the bone rim (arrow
to salicylates can occur in patients with md).
osteoblastoma (2,1 1). Other frequent
symptoms and findings, depending on teoblastoma in the vertebral column is tion arising proximally in the diaphysis
the tumor location, were swelling, neu- most commonly a lytic lesion of bone, (2,3,12). In the majority of our cases the
nologic symptoms, and limitation of arising in the posterior elements with tumor originated eccentrically in the
motion. Scoliosis can occur with spinal destruction of the cortex and expansion medulla, in contrast to the predilection
and rib osteoblastomas (i7-22). Scolio- into the surrounding soft tissues. Sec- for the cortex that has been reported
sis was invariably present with tumors ondary extension into the vertebral previously (2). A solid on laminated
in the lumbar spine. We could not find body is frequent. Rarely the tumor periosteal reaction, initiated by cortical
a frequency this high in previous stud- arises in the body of a vertebra involvement, is most common, but
ies. Contrary to the usual convexity of (2,3,i7,25). In our patients, most tumors even spiculation, suggestive of malig-
scoliosis toward the opposite side, we demonstrated matrix ossification and a nancy, was occasionally encountered
found that the convexity of mild scolio- sharp and sclerotic rim delineating the (Fig 2).
sis can be directed toward the ipsilater- vertebral side of the tumor, findings in The bones of the hands and feet were
al side. This occurred in fairly large, ex- contrast to earlier observations (2). A the third most common tumor location,
pansive lesions (Fig 1). To our knowl- thin rim of reactive bone surrounding with oven 26% of the osteoblastomas in
edge, this feature has not been reported the soft-tissue side of the tumor, me- our patients found there. We did not
before. garded by some authors (3,11) as almost find a frequency this high in the litena-
inherent to the tumor, was observed on tune. The talus was by fan the most fre-
plain radiognaphs in only a minority of quent site. Similar to the experience of
Plain Radiographic Findings
the cases in this study. Capanna and coworkers (26), all talar
Osteoblastoma can occur in nearly The second most common location of tumors arose from the dorsal part of the
every bone but is most commonly osteoblastoma is in the long tubular neck and were either eccentric in the
found in the spine. In accordance with bones, varying in frequency from 25% medulla on in the cortex. They were lyt-
other series (1-3,12,23,24), 33% of os- to 30% of patients. The femur and tibia ic, with on without mineralization; well
teoblastomas in our patients originated are most frequently involved (1- defined; and expanding into the soft
theme. Usually, the tumor is equally dis- 3,12,23). In the long bones, osteoblas- tissues. In one-third of the patients, the
tributed over the cervical, thoracic, toma usually is seen as a round or oval tumor was depicted as a blister on the
lumbar, and sacnal segments (2,12). Os- lucent tumor with matrix minenaliza- surface of the bone, which could be

788 . Radiology June 1990

surrounded by a thin bony shell (Fig They looked like nadiolucent coins the pelvis. They demonstrated low and
4). Images in previous studies (12,26) with amorphous matrix ossification in intermediate signal intensity on Ti-
seem to show a similar appearance but the center surrounded by a smooth weighted images and a predominantly
do not specifically mention this notable sclerotic zone (Fig 7). Although this high signal intensity on T2-weighted
presentation. We encountered a some- presentation has been mentioned images (Figs 2, 3). MR images in earlier
what similar appearance in only one (12,15,23), it has not been stressed studies (23,34,36,37) show similar sig-
case of osteoblastoma arising near the before. nal intensities. The signal intensities in
surface of long tubular bones (Fig 3). The tumors in the pelvis looked very the surrounding soft tissues indicated
Furthermore, the soft-tissue component much like those found in the spine. Os- edema of these structures well beyond
of the tumor could be very large com- teoblastoma in a rib appeared most the cleanly demarcated tumor margin
pared with the area of bone destruc- commonly as an osteolytic lesion, with (Figs 2, 3). In addition, one MR imag-
tion, especially in patients with recur- broadening of the nib caused by a lay- ing study of an osteoblastoma confined
nences. Along with ossification within ened peniosteal reaction. to the cortex of a femur and the MR im-
the tumor matrix, this could easily lead aging study of the pelvis demonstrated
to an erroneous diagnosis of malignan- edema of the marrow in absence of
Findings with Other Imaging
cy. In addition to tumor extension as a signs of direct tumor invasion (Fig 2).
Modalities
cause of soft-tissue swelling, swelling Although the signal intensities found
of the ankle region caused by edema Radionuclide bone scintigraphy in- in these three tumors do not differ
also occurred. Nearly half of the pa- variably demonstrates an intense focal from those found in other bone tumors
tients developed osteoporosis of the ta- increase of activity and can be of great (38), the MR studies added information
lus or the entire foot and ankle region, assistance in demonstrating and local- concerning not only the extent of the
probably due to a combination of dis- izing disease specifically in the spine lesions and the demonstration of a
use and hyperemia (Fig 4). This finding (17,18). pseudocapsule (Fig 2) but also the na-
has not come to our attention in other Angiognaphy was of no help in de- tune of the
changes in the surrounding
primary bone tumors in this part of the termining the nature of the lesion. We soft tissues and the adjacent bone man-
body. Although the observation of os- did not encounter specific features sug- row. This information was not avail-
teoporosis is similar to that of Capanna gestive of the diagnosis of osteoblas- able at CT. Important limitations of MR
et a! (26), this high frequency has not toma. A dense capillary blush, howev- imaging compared with CT can be the
been stressed. In our experience, osteo- en, was present on half of the angio- inability to demonstrate a thin sur-
ponosis is an important feature accom- grams (Fig 8). This observation was also rounding bony shell and subtle calcifi-
panying osteoblastoma of the talus. mentioned by Hudson (27) but does cation on ossification within the tumor
Peniosteal reaction is less common in not appear in other previous articles. matrix (36-38).
talan tumors than in those of long Angiognaphy can be of importance in
bones but occasionally can also be ob- the preoperative assessment of the pa-
Radiologic Diagnosis and
served in neighboring bones without tient.
Differential Diagnoses
direct tumor invasion. In agreement with the literature (18-
In the small tubular bones of the 20,23,28-35), CT generally offered in- Osteoblastoma was suggested as the
hands and feet, the diaphysis was most formation in addition to that available most likely diagnosis on as an impor-
commonly involved. A single osteo- with plain radiography. In our expeni- tant differential diagnostic possibility
blastoma with an epiphyseal origin was ence, the exact origin of the tumor of- in 80% of the patients in this study. In
located in the proximal phalanx of a ten was better demonstrated with CT. one-fifth of patients, however, osteo-
toe. This is consistent with previous ob- The intra- and extraosseous growth of blastoma was not considered in diagno-
servations (3,12). Compared with the the neoplasm was frequently better de- sis. These results parallel those of
long tubular bones, an origin in the lineated with on was only visible at CT. McLeod et al (2). Differential diagnos-
medulla was more frequently found. Furthermore, CT was superior in dem- tic considerations in patients with os-
The tumors, including the canpal tu- onstrating matrix ossification and a sun- teoblastoma of the spine are osteoid os-
moms, were lucent, sharply defined, rounding bony shell. These features teoma, aneurysmal bone cyst, giant cell
and expansive, which could result in frequently aided in making the diagno- tumor, and, occasionally, spinal osteo-
secondary erosion of the external con- sis. Noteworthy findings in two pa- myelitis. In the long tubular bones os-
tex of adjacent bones. In more than half tients were considerable muscle wast- teoblastoma can have an appearance
of the cases, mineralization within the ing and edema in the panavertebnal soft similar to that of large osteoid osteoma,
tumor matrix was demonstrated to be tissues (Fig 1). In two other patients, eosinophilic granuloma, and chronic
distinctly different from that within Os- soft-tissue swelling beyond the actual osteomyelitis. Osteoblastoma of the ta-
teoblastomas in other locations. Deli- margins of the well-defined tumor, lus may resemble osteoid osteoma, an-
date trabeculation was visible, instead most probably caused by edema, was eurysmal bone cyst, osteomyelitis, or
of the usual patchy on amorphous ossi- found (Figs 2, 8). To our knowledge, septic arthritis. In the later stages of
fication found in tumors elsewhere in these features have not been reported disease or after recurrence, the findings
the body. Together with the often before. The added value of CT com- can be extremely suggestive of osteo-
present expansive growth, this resulted pared with plain radiography was sarcoma. In the small bones of the
in a more cystic or soap-bubble appear- greater in the spine and pelvis than in hands and feet the differential diagnos-
ance of the tumor (Figs 5, 6). To our the long tubular bones. CT is also of tic options are aneurysmal bone cyst,
knowledge, this appearance has not value in planning the surgical proce- giant cell tumor, osteoid osteoma, on
been reported before in the literature. dune. This can result in resection of a chondroma. Because skull osteoblasto-
Only three of the osteoblastomas in smaller part of the vertebral body on mas demonstrated in the literature
this study were found in the skull. This arch, thus preventing unnecessary in- (12,15) appeared similar to those found
low frequency, compared with the stability of the spinal column after sun- in our patients (ie, strongly resembling
findings of others (1,2), is probably ne- gery (18). eosinophilic granuloma), we believe
lated to the exclusion of cementoblas- Our experience with the MR imaging osteoblastoma of the skull should be in-
toma of the jaw from this study. The findings in osteoblastoma is limited to cluded in the differential diagnosis of a
two osteoblastomas in the frontal bone three patients. Two tumors were locat- button sequestrum of the skull (39). It
had a remarkably similar appearance. ed in the femur, and one was located in must be mentioned, however, that in

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#{149} 3 Radiology #{149} 789
osteoblastoma the opacities in the tu- preciated in the capillary phase. CT and 18. Azouz EM, Kozlewski K, Marton D, Sprague
P. Zerhouni A, Asselah F. Osteoid osteoma
mom are caused by mineralization of the MR imaging are of great value for both and osteoblastoma of the spine in children:
matrix, while in the true button seques- diagnostic and therapeutic consider- report of 22 cases with brief literature review.
Pediatr Radiol 1986; 16:25-31.
trum of the skull these opacities are ations, especially in complex anatomic 19. Wimpee MW, Maale GE, Hudkins PG. Robert-
remnants of preexisting bone. In the locations such as the spine and pelvis. son WW. Scoliosis secondary to osteoblasto-
At CT and MR imaging, the tumor can ma of the rib. J Pediatr Orthop 1987; 7:589-
pelvis, other tumors to be considered
593.
are chondroma, chondrosancoma, aneu- be seen accompanied by considerable 20. Denis F, Armstrong GW. Scoliogenic osteo-
rysmal bone cyst, or giant cell tumor. muscle wasting. In addition, osteoblas- blastoma of the posterior end of the rib: a case
report. Spine 1984; 9:74-76.
The appearance of osteoblastoma in a toma can induce significant edema in 21. Fabris D, Traihiti C, Di Comun M, Agostini S.
rib can be similar to that of eosinophil- the surrounding soft tissues and even Scoliosis due to rib osteoblastoma: report of
in the marrow of the affected bone. MR two cases. J Pediatr Orthop 1983; 3:370-375.
ic granuloma or osteomyelitis. 22. Greenspan A. Scoliogenic osteoblastoma of
imaging is very valuable in diffenenti- the posterior rib (letter). Spine 1984; 9:841-
ating tumor tissue from this reactive 842.
Treatment and Follow-up 23. Resnick D, Kyriakos M, Greenway GD. Tu-
edema. Signal intensities on MR im- mors and tumor-like lesions of bone: imaging
ages of osteoblastoma, however, do not and pathology of specific lesions. In: Resnick
The treatment of choice is complete D, Niwayama C, eds. Diagnosis of bone and
excision on resection, but even incom- seem to differ from those in other pri- joint disorders. 2nd ed. Philadelphia:
plete curettage can effect a cure in a mary bone tumons. U Saunders, 1988; 3635-3645.
24. Lingg C, Roessner A, Telgmann CL, Kar-
high percentage of cases (2,3,16). In the bowski A, Peters PE. Zur rontgenmorpholo-
literature a recurrence rate of 10%-15% Acknowledgments: The authors are grateful gie und pathologischen anatomie des osteo-
to Gernit Kracht and Jan Beentjes for preparing blastoms. ROFO 1986; 145:49-56.
is mentioned (3,40). Our experience is 25. Capanna R, Ayala A, Bertoni F, et al. Sacral
the illustrations and to Johan L. Bloem, MD, for
comparable. osteoid osteoma and osteoblastoma: a report
support and constructive remarks aimed at im- of 13 cases. Arch Orthop Trauma Surg 1986;
proving the manuscript. 105:205-210.
26. Capanna R, Van Horn JR. Ayala A, Picci P.
CONCLUSIONS Bettelli C. Osteoid osteoma and osteoblasto-
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#{149} June 1990