Bone Tumours and Benign Lytic Lesions. Bone Tumours and Benign Lytic Lesions. When interpreting whether an image is normal or abnormal, it is common to come across incidental lytic lesions, which, depending on their appearance, must be classified as either a normal variant, or something which warrants further investigation. It is difficult to determine radiologically with plain radiograph imaging if a lytic lesion is benign or malignant. It is more accurate to describe whether the process looks aggressive or non- aggressive.
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Some factors, as outlined below, help to determine whether a lesion looks aggressive or non- aggressive, and therefore the differential diagnosis. It is important to remember, however, that some benign processes such as osteomyelitis, can mimic malignant tumours, and some malignant lesions, such as metastases or myeloma, can look benign. Factors aiding in the diagnosis of bone tumours and benign lytic lesions: Age of patient.
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Specific lesions tend to occur in specific age ranges. Solitary bone cysts, non- ossifying fibromas, aneurysmal bone cysts and Ewings tumours occur in patients under the age of 3.
Metastases and myeloma will usually occur in patients over the age of 4. Location within the bone. Epiphyseal, metaphyseal or diaphyseal. Central within the bone, eccentric or cortical.
Lesions often arise within specific bones, and within specific areas of that bone. Giant cell tumours for example, usually arise within the distal femur or proximal tibia, and will always abut (push against) the articular surface. Size of lesion. Size of lesion is not necessarily an indication of how aggressive the process is, but recognition that specific lesions have a tendency to grow larger can help lead to the correct diagnosis. Solitary bone cysts within the proximal humerus, for example, often become large. A large lytic lesion is at risk of fracturing and it is therefore often prophylactically packed to prevent fracture and subsequent deformity. Monostotic (one lesion) or polyostotic (multiple lesions)Multiple lesions are also not necessarily indicative of an aggressive process.
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Although metastases and myeloma are usually multiple, most aggressive processes demonstrate a single lesion. Similarly, benign enchondromas often become multiple within the phalanges. Zone of transition from normal to abnormal bone. This is often the best indicator as to whether a lesion is aggressive or non- aggressive. A very definite, sharp, and therefore narrow area (zone) between the normal and abnormal bone indicates a non- aggressive lesion.
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A wide, hazy, and undefined zone of transition suggests a more aggressive process. However, be aware that some benign processes (osteomyelitis) have a wide zone of transition as they are fast acting. Reactive sclerosis. If there is a sclerotic margin to the lesion, it is most likely non- aggressive. Pattern of bone destruction. Geographic = Well defined margin; non- aggressive lesion. Moth- eaten = Less defined margin.
Permeative = Poorly demarcated with multiple small irregular holes. Suggests aggressive process. Presence of visible tumour matrix.
Cartilage = Chondroid calcifications. Osteoid = Sclerotic. Fibrous = "Ground glass", hazy opacification. Host (bone) response. Cortical thinning, expansion and penetration. Cortical destruction suggests an aggressive process.
Be aware, however, that what may appear to be cortical destruction may actually be cortical bone replacement by a fibrous or chondroid matrix, which is non- calcified and may be located within a benign lesion. This gives the false impression of cortical destruction when it is actually cortical replacement. Aneurysmal bone cysts, for example, often cause such thinning of the cortex as to make it undetectable radiographically. Periosteal reaction. Periosteal reaction will occur whenever the periosteum is irritated.
This may be due to a malignant process, a benign lytic lesion, osteomyelitis, or trauma. The appearance of the periostitis will give an indication as to cause. Benign periostitis looks thick, wavy, dense and uniform, as it is slow growing and therefore gives the periosteum time to lay down new bone. Aggressive periostitis is often described as lamellated (onion- skinned), amorphous and sunburst as the periosteum does not have time to consolidate. Soft tissue involvement.
Aggressive lesions often lead to cortical breakthrough to create a soft tissue mass. BENIGN LYTIC LESIONSNon- Ossifying Fibroma / Fibrous Cortical Defect. One of the most common benign lytic lesions seen. Asymptomatic and usually an incidental finding. Most often seen around the knee and distal tibia.
Non- Ossifying fibroma generally bigger than 2cm. Fibrous Cortical Defect generally smaller than 2cm. Arises in the under 3. Develops from cortex of metaphysis; is eccentric within the bone.
Usually has thin, sclerotic border that is often scalloped and slightly expansile. Become sclerotic as healing occurs and "disappears" as it ossifies. Therefore not seen in the over 3.
Simple / Solitary Bone Cyst.
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Cavernous angioma. Cavernoma or Cavernous angioma. How common are cavernomas? Approximately 1 in 2. How does a cavernoma develop?
Many are present at birth and in some of these cases there is a family link. The majority of patients diagnosed with cavernomas report no history of a family link. However, those with more than one cavernoma are suspected to be more likely to have an inherited factor. When the condition has been inherited approximately half of the family will have a cavernoma. Not all cavernomas are present at birth and in some cases they develop where the pressure where the brain has been subjected to high pressure within the veins (not your “blood pressure”) over prolonged periods of time. This can be due to blockage in veins of the brain (such as due to thrombosis of a brain vein) or an inefficient venous drainage system for a segment of brain that was present from birth – the so- called anomalous venous drainage (sometimes called a venous angioma). Who is at risk of having a cavernoma?
If there have been a number of family members diagnosed with a cavernoma then the risk for any one else in the family having a cavernoma is 5. Often there is no definite family history but there might be a suggestion of a family history if a number of family members have had small strokes and/or epilepsy.
In the absence of such a history (the majority of those with cavernomas), the condition is usually only diagnosed after a seizure (epileptic fit), a new loss of body function due to a bleed into the brain or an unsuspected finding when the MRI scan is performed for some other reason. Anyone may have a cavernoma and often there are no other health issues. It is common for cavernomas to be diagnosed in young adults. Little Mermaid Swimsuit For Adults on this page.
Both male and female are equally likely to have a cavernoma. How are cavernomas diagnosed? The managment options for cavernomas depends on whether they are located deeply within the brain (considered to be those occurring in the brainstem, cerebellar nuclei, thalamus and basal ganglia) or superficially.
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