Long Bone, Diaphyseal Lesion, Aggressive



Long Bone, Diaphyseal Lesion, Aggressive


B. J. Manaster, MD, PhD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Osteomyelitis, Pediatric


  • Ewing Sarcoma


  • Langerhans Cell Histiocytosis (LCH)


  • Leukemia


  • Osteosarcoma


  • Metastases, Bone Marrow


  • Lymphoma


Less Common



  • Sickle Cell Anemia


  • Malignant Fibrous Histiocytoma, Bone


  • Chondrosarcoma, Conventional


  • Adamantinoma


  • Radiation-Induced Sarcoma


Rare but Important



  • Hemophilia


  • Congenital Syphilis


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Hint: Most common of these lesions fall into small, round, blue cell category



    • All have appearance that may be indistinguishable from one another


    • Must consider each of these diagnoses with this aggressive appearance



      • Osteomyelitis


      • Ewing sarcoma


      • Langerhans cell histiocytosis


      • Leukemia


      • Metastases


      • Lymphoma


    • Hint: Note that in each of these cases, lesion may be polyostotic


  • Hint: Ewing sarcoma and osteosarcoma usually have distinct appearance from one another



    • Occasionally they can be indistinguishable, if



      • Osteosarcoma is diaphyseal and lytic


      • Ewing sarcoma is metadiaphyseal and has sclerotic reactive bone formation


      • Hint: In these cases, watch for tumor osteoid formation in soft tissue mass; this can only occur in osteosarcoma


  • Hint: Rarely, 4 of these lesions may be aggressive, yet induce endosteal and cortical thickening



    • Osteomyelitis


    • Ewing sarcoma


    • Lymphoma


    • Chondrosarcoma


Helpful Clues for Common Diagnoses



  • Osteomyelitis, Pediatric



    • Usually metaphyseal in children but diaphyseal with direct trauma


    • Highly aggressive and permeative, often with reactive sclerosis and periosteal reaction


  • Ewing Sarcoma



    • Common in long bones in children


    • Highly aggressive permeative lesion, cortical breakthrough, and soft tissue mass


    • Elicits reactive bone formation



      • May have appearance of tumor osteoid & mimic osteosarcoma


      • Reactive bone NOT in soft tissue mass in Ewing but present in osteosarcoma


    • May appear polyostotic since it may present with osseous metastases


  • Langerhans Cell Histiocytosis (LCH)



    • Ranges in appearance between geographic nonaggressive and highly aggressive



      • When aggressive, is permeative and may have soft tissue mass


      • May be indistinguishable from malignant lesions in differential


    • Often polyostotic


    • Beveled edge of skull lesion may help distinguish


  • Leukemia



    • Usually polyostotic


    • May be so highly infiltrative that it is not visible on radiograph; MR makes diagnosis


  • Osteosarcoma



    • Common lesion but usually is metaphyseal


    • Less frequently is diaphyseal; if it is lytic in this location, may not be distinguished from other lesions in differential


    • Usually some tumor osteoid is visible


  • Metastases, Bone Marrow



    • Usually polyostotic in children


    • Metaphyseal is more frequent but may be diaphyseal


    • Neuroblastoma is most frequent in children


  • Lymphoma



    • 50% of childhood lymphomas are polyostotic at presentation



    • Highly aggressive; metaphyseal more frequent than diaphyseal


Helpful Clues for Less Common Diagnoses



  • Sickle Cell Anemia



    • Early bone infarcts (particularly dactylitis) present with periosteal reaction


    • With evolution of infarct, will see mixed lytic and sclerotic pattern



      • Often longitudinal, involving entire diaphysis


      • Remember that bone infarct need not be serpiginous and subchondral, especially in sickle cell patients


  • Malignant Fibrous Histiocytoma, Bone



    • Unusual lesion in children; may be seen in teenagers


    • Aggressive; may be metaphyseal or diaphyseal


    • No other distinguishing characteristics


  • Chondrosarcoma, Conventional



    • Uncommon in children


    • Should be considered if subtle matrix is seen in diaphyseal lesion of teenager


    • May induce endosteal thickening rather than showing cortical breakthrough


  • Adamantinoma



    • Almost invariably tibial metadiaphysis; cortically based


    • Generally only moderately aggressive initially



      • May become aggressive and malignant


  • Radiation-Induced Sarcoma

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Long Bone, Diaphyseal Lesion, Aggressive

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