Diagnosis of

Benign Bone Tumors

Brooke Crawford
OHSU
MS4

Understanding the physiology

Lesions often arise from specific parts of
the bone
location
cell type

Understanding bone development and

subsequent anatomy can help identify what
sort of lesion is present

Endochondral Ossification

Final Result

So, when theres a lesion

How did it present?

Incidental finding?
Pain?
Onset, quality, what makes it better/worse

Mass noticed by the patient/parent?

Swelling present?
Associated injury?

Is it malignant or benign?
Malignant
Rapid onset
Not activity related
Systemic symptoms?
Fevers/chills
Weight loss
Irritability

Benign
Mild
Dull ache
Slowly progressive
Worse with activity

Where is it?
In the body?
Arm or leg
Hand

Within the bone?

Epiphysis? Diaphysis? Metaphysis?
Periosteum? Cortex? Medullary?

Feature

- Modified from Sponseller

Lesion

Location
Metaphysis
Epiphysis

Most tumors
Chondroblastoma

Effect on Bone
Invasive
Displaces

Malignant
Benign

Reaction of Bone
Isolating
Reactive

Benign
Malignant

Interior of Lesion
Calcification
Ground glass
Cystic

Cartilage tumor
Fibrous dysplasia
Unicameral bone cyst

- Modified from Staheli

What does it look like on x-ray?

Enneking questions:
Where is the tumor?
What is the tumor doing to the bone?
Erosion? Pattern?

What is the bone doing to the tumor?

Periosteal/endosteal reaction?
Sharp borders?

What are the intrinsic characteristics of the tumor?

Calcification?
Radiolucent?

Case #1
A 17-year-old basketball player comes in
after jamming her right ring finger in her
last game. This is her x-ray:

Case #2
A 15-year-old boy comes in for an
assessment of a lump he has just above
his knee. Its painless, but it seems to be
getting bigger.

Case #3
An 8-year-old boy presents with intense
night pain in his left knee for the last month,
which his parents initially thought was due
to growing pains. The pain is completely
relieved with aspirin.

Case #4
A 4-year-old comes in because she jumped
off a step and smashed her lower shin on
the edge of a table. An x-ray of the leg is
taken.

Other lesions briefly

Some information to help you

with the cases
(Just look at the presentations
and radiograph columns for the
cases; the rest is FYI)

Tumor

Presentation

Pathology

Location

Radiograph

Osteoid Osteoma

Age: 5-25
Night pain,
dramatically relieved
by NSAIDs (thought
that tumor secretes
COX-2, PGE, and
prostacyclin)

Nidus of vascular
stroma, woven
trabecular bone,
numerous clasts/blasts.
Surrounded by
sclerotic, reactive bone

of cases in femur or
tibia

Radiolucent zone
(nidus), surrounded by
halo of increased
density

Osteoblastoma

Age: older compared

to O.O.
Usually no night pain,
no striking relief with
NSAIDs

Giant cells, greater

amount of stromal
tissue, broader osteoid
seams

Frequently involves
posterior elements of
vertebrae

Radiolucent zone and

thin margin of reactive
bone (very similar
appearance to O.O.)

Osteochondroma

Age: 10-20
Usually present as a
bony mass. May have
activity-related pain or
paresthesias. Can be
solitary & idiopathic
or multiple and
genetic.

Bony stalk covered by

cartilaginous cap
similar to but less
organized than physis.
Chondrocyte growth in
cap eventually
ossifies; cortical bone
merges to host bone.

Metaphyseal portion
of long bones
particularly distal
femur and proximal
tibia

Enchondroma

Age: any
Asymptomatic,
incidental. Or, may be
swelling of involved
bone or pathologic
fracture

Chondrocytes,
disorganized
chondroid matrix.
Difficult to
differentiate from
chondrosarcoma

>1/2 involve small

bones of hands/feet.
Also, distal femur,
proximal humerus

- Modified from Netter text

Central radiolucent
lesion and scant
stippled calcification;
surrounding cortex
thinned and expanded.

Tumor

Presentation

Pathology

Location

Radiograph

Chondroblastoma

Age: adolescents
Periarticular pain.

Cobblestone pattern,
with plump
chondroblasts
surrounded by thin
chondroid matrix
and giant cells

Epiphysis of long
bones
distal/proximal
femur, proximal
tibia, proximal
humerus

Lytic lesion in
epiphysis
surrounded by thin
margin of sclerotic
reactive bone.
Chicken-wire
calcification may be
present.

Non-ossifying
Fibroma

No symptoms,
incidental

Dense areas of
spindle-shaped cells
in whorled pattern;
multi-nucleated giant
cells with foci of
xanthomatous tissue

Metaphysis of femur
or tibia

Radiolucent lesion
abutting one cortex
and surrounded by
rim of sclerotic,
reactive bone.

Fibrous Dysplasia

Asymptomatic if
involving one bone,
possible pathologic
fracture. Polyostotic
patients develop
limp due to coxa
vara of hip.

Lesions of fibrous
tissue proliferation
among scattered
trabeculae of bone.
McCune Albright
association in
polyostotic patients

Monostotic location
rib is most
common.
Polyostotic
anywhere

Bone Cyst

Age:
Pain after pathologic
fracture occurs

Cavity lined with

fibrous tissue that
includes giant cells;
filled with clear
yellow fluid

Metaphysis of
proximal humerus,
proximal femur

- Modified from Netter text

Lytic lesion with

thinning of cortex;
active cysts abut
physis.

Images from the following websites:

1.
http://training.seer.cancer.gov/module_anatomy/unit3_3_bone_growth.html
2.
http://cal.vet.upenn.edu/saortho/chapter_01/01F6.jpg
3.
http://radiology.uthscsa.edu/CME/ELTXT/OOT/radiographicabnormalities.html
4.
http://www.emedicine.com/RADIO/topic247.htm
5.
http://gait.aidi.udel.edu/res695/homepage/pd_ortho/educate/clincase/clcsimge/mext2.jpg
6.
http://bonetumor.org/images/noftibia.jpg
7.
http://www.emedicine.com/RADIO/topic164.htm
8.
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=485&topcategory=Tumors
9.
http://www.emedicine.com/radio/topic642.htm
References:
Greene, Walter B, ed. Netters Orthopaedics. Saunders Elsevier. 2006: Philadelphia, PA.
Morrissy, Raymond T; Weinstein, Stuart L. Lovell and Winters Pediatric Orthopaedics.
Lippincott Williams & Wilkins. 2006: Philadelphia, PA.
Sponseller, Paul D; Stevens, Heidi M. Handbook of Pediatric Orthopedics. Little Brown and
Company. 1996: New York.
Staheli, Lynn T. Fundamentals of Pediatric Orthopedics. Lippincott Raven. 1998:
Philadelphia, PA.

Alright, I guess Ill give you the

answers, too.
CASES:
1. Enchondroma
2. Osteochondroma
3. Osteoid Osteoma
4. Non-ossifying
Fibroma

RADIOGRAPHS:
1. Simple Bone Cyst
2. Chondroblastoma
3. Fibrous Dysplasia