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Hello and welcome to Noon Conference,

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You can also sign up for a free trial of our premium membership to get access to

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hundreds of case-based micro learning courses across all key radiology

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subspecialties. Today we are honored to welcome Dr.

0:42

Jonathan Samit for an interactive lecture on the approach to pediatric bone

0:47

lesions. Dr.

0:48

Samit is an associate professor of radiology at Northwestern University Feinberg

0:53

School of Medicine,

0:54

primarily based at Ann and Robert Lurie Children's Hospital of Chicago.

0:59

He serves as a division head of body imaging and section head of MSK Imaging.

1:03

He also works in the adult MSK radiology section at Northwestern Memorial

1:08

Hospital. Dr. Samit trained in diagnostic radiology at Northwestern University,

1:13

followed by a subspecialization in MSK radiology at Johns Hopkins Hospital.

1:17

He studies nerve imaging with R I R I,

1:20

neurography and ultrasound rapid imaging and M r i techniques for

1:25

bone marrow evaluation. At the end of the lecture, please join Dr.

1:29

Sim in a q and a session where he'll address questions you may have on today's

1:33

topic.

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Please remember to use the q and a feature to submit your questions so we can

1:37

get to as many as we can before our time is up. With that,

1:40

we're ready to begin today's lecture. Dr. Samit, please take it from here.

1:45

So thank you everyone. My name is Jonathan Samit.

1:48

I'm in Chicago at Laurie Children's Hospital, and today, uh,

1:51

I have a two-part talk for you. I'll go over, um,

1:54

an approach to facing pediatric bone lesions and then, uh,

1:58

we'll go through a number of example cases and try to take those cases together.

2:04

So,

2:07

bone lesions are very hard. This is something that we all look at.

2:10

We see them in our day-to-day practice. No one wants to miss, uh, a bone cancer,

2:15

especially in a child. Um,

2:17

yet there are many bone lesions that we see that are benign and we want to

2:21

become familiar with them.

2:22

We also wanna develop a differential diagnosis and really feel comfortable with,

2:26

um, diagnosing these lesions. When you're trying to make a correct diagnosis,

2:31

you want to, um, think of the age of the patient.

2:34

These are all gonna be pediatric, but always age is important. Location.

2:39

Uh, in pediatrics, uh, if you think of a long bone,

2:43

remember that you have the different parts of the bone and that can really help

2:46

you narrow your differential diagnosis. So, for example, the epiphysis,

2:49

the metaphysis, and the middle of the bone, the diaphysis. And of course,

2:54

if there's a history of malignancy or infection or something that can help you,

2:58

um, you always wanna look at that past medical history.

3:00

When you're faced with an unknown lesion,

3:03

I think it's really important to look at three characteristics of that lesion

3:07

and describe them in your reports. You wanna look at the density,

3:11

so is it loosened or is it sclerotic? Then you wanna look at the margin.

3:16

Is it well-defined or is it ill-defined?

3:19

Is it really hard to tell where it starts and stops?

3:21

Or can you clearly see a sclerotic rim, for example?

3:25

If there is periosteal reaction,

3:27

we can use that to help us decide if it has a malignant or benign appearance.

3:32

So you may have that to, uh, help you decide.

3:38

I think what's really important is when you face a bone lesion to develop a

3:41

sixth sense of if it's benign or malignant. Traditionally,

3:46

we were all taught to look at a lesion and say,

3:48

is it aggressive or non-aggressive? Um,

3:51

and if you notice that sort of those terms,

3:53

benign and malignant were intentionally left out. Um,

3:57

and that is because there's obviously overlap between benign and malignant

4:00

lesions, but I think it does,

4:03

it does hurt a little bit when we're learning bone lesions because we really

4:07

wanna develop a sense of benign and malignant.

4:08

That's what the clinicians are asking us.

4:10

They're not asking us if it's aggressive or not aggressive. So try to, uh,

4:14

think about that. And then narrow versus wide zone.

4:17

I always found this confusing. Um,

4:19

so I have a little salmon method that I try to think about when I face a meeb

4:24

lesion. And so really wanna say to myself, does this look benign or malignant?

4:28

That's what they're gonna ask me. Instead of narrow versus wide zone,

4:32

basically just think to yourself, is well-defined or is it ill defined?

4:37

Ill defined will be more concerning, well defined, less concerning.

4:44

There's just bone lesions that you need to know. And I think, um,

4:48

when I first started setting bone lesions, um, I had the, you know,

4:52

the laundry list, uh,

4:54

diagnosis wasn't in any particular category and it was really hard for me to

4:58

kind of remember those lesions.

5:00

But I think if you actually look at lesions and you think of the tissue types,

5:05

there aren't that many in each category.

5:06

And I think if you develop kind of these differentials, these cases,

5:11

then um, you,

5:12

you can really in your mind wrap your head around all these lesions.

5:16

So we're gonna go over all of these types, but in general,

5:18

you're gonna have a benign lesion. Um,

5:21

malignant lesions and what I kind of term pseudo lesion,

5:24

these are basically lesions that aren't true growth.

5:26

They're sort of a spot on the bone that can look like a lesion.

5:30

So as we go over the, uh, the tissue types, there aren't that many, as I said.

5:35

So you have osteo lesions, which are basically bone producing lesions.

5:39

You have cartilage lesions, which are conoid lesions.

5:42

Then you have this category fibro osseous. We'll show examples of that.

5:46

And you have a couple of cysts that we're going to show.

5:50

So for the next few slides, you're gonna see, um,

5:53

a picture of a diagnosis and that will be shown in blue.

5:57

The benign entities are gonna be on the top part of the slide,

6:00

malignant on the bottom. So first,

6:03

when we look at osteo lesions or bone producing lesions,

6:06

they're gonna be sclerotic, right? So we have a few benign versions.

6:10

We have osteo, um, I'm sure you guys have all seen those. Um,

6:13

in the calvarium we see like a little small area of compact bone,

6:18

sclerotic bone, um, osteo. Osteo is that benign,

6:22

very painful lesion, uh, that, um,

6:26

will be relieved by NSAIDs at night. And, um,

6:29

it'll have that little dot of sclerosis.

6:32

You have enosis or what we commonly refer to as bone islands. Um,

6:36

there's just a small area of compact bone, totally benign.

6:40

I think of it as sort of similar to a mole on the face.

6:43

You get a mole on the bone. And then of course, in pediatrics,

6:46

one of our big two is osteosarcoma.

6:49

That is a sarcoma that is osteo producing. So in this example,

6:53

we see an ill-defined sclerotic lesion with this cloud-like

6:58

ossification in the soft tissues. This is a malignant osteo producing lesion,

7:03

osteosarcoma cartilage lesions.

7:07

So for cartilage lesions are over cartilage and chondro is the same thing.

7:11

We're gonna have a lot of very similar sounding lesions. Um, in this example,

7:15

this is an endon drma.

7:17

So endon drma very common in small tubular bones of the hands,

7:22

and it's gonna typically look like a lucent lesion.

7:25

I showed this case because it's a very large one, kind of scary looking one,

7:29

but still most commonly in the small of the bones of the hands and chondro is

7:34

going to be the answer. The prefix,

7:35

e n kind of implies that it's in the medullary space.

7:41

Next we have osteo choma. Uh,

7:44

this is another cartilage type lesion.

7:46

It's one of the only lesions I feel like that has an exophytic appearance.

7:50

Remember you have cortico medullary continuity. This is a very large one,

7:55

but showing you it has this cauliflower shape.

7:58

And what we don't see on x-ray is the cartilage cap,

8:02

and that is the cartilage part of the lesion.

8:03

And we want that to be thin less than two to two and a half centimeters.

8:07

And that is going to be an osteo chondral line.

8:11

Chondro is just another cartilage lesion,

8:14

but instead of it being in the medullary space like an endon drumma,

8:18

it is a lesion that can be juxta, cortical or periosteal. And as you see here,

8:24

the lesion is as lobular t2 hyperintense lesion sitting on the cortex.

8:29

But when you look at the x-ray and you don't have the mri,

8:32

you might kind of be confused at first. Where's the lesion?

8:35

The lesion itself is thought to be actually, um,

8:38

originating from between the periosteum and the cortex.

8:42

So if you think about that,

8:43

the periosteum is typically really flush against the cortex.

8:47

But as lesions that are growing between those two layers,

8:51

what's going to cause kind of a pressure scalloping on the underlying cortex.

8:55

That's why you have this kind of scallop look when then you see the m r i,

8:58

you have the lesion that is clearly there on the surface.

9:01

So this is a juxta cortical or periosteal chondro, again,

9:05

benign lesion on the surface.

9:08

Chondroblast is specific to pediatrics. That is a lesion that is benign,

9:12

but it can be locally aggressive, needs to be treated. Um,

9:15

and so the lesion loves the epiphysis.

9:18

We're gonna talk about that a lot in this talk.

9:20

The lesion loves the epiphysis and it has ton of marrow edema around it.

9:26

It is a lucent lesion and may or may not have cal calcifications,

9:30

but remember epiphysis epiphysis epiphysis or chondroblast contra

9:35

sarcoma, unfortunately is very rare in pediatrics.

9:40

How about this category? Fibro osseous,

9:43

fibro osseous lesions. And there's probably more than this,

9:47

but the one we see very commonly is non ossifying fibroma, n o f.

9:52

And what we typically are going to see is a lesion that is touching a

9:56

cortex. It is in the meta diaphysis region of a long bone,

10:01

very common around the knees and ankles.

10:04

And so you're gonna have a so-called bubbly lunt lesion with a

10:09

sclerotic rim.

10:11

And you can see the lesion is touching one of the cortices on m r I

10:16

can kind of look scary, but if you see on T1 and t2,

10:19

it has these low signal areas on T1 and t2,

10:24

no soft tissue and mass. And this was just a non fibroma.

10:28

As we age, these lesions will, um,

10:31

basically fade away and there's kind of a, a mouthful, uh,

10:35

a strange term called ossifying, non ossifying fibroma.

10:39

And these are basically what happens when these lesions heal and go away.

10:43

They'll become sclerotic and then they will kind of fade away,

10:46

will occasionally see sort of ghosts of these lesions when we read adult

10:50

imaging and fibroplasia.

10:55

We'll get to see more examples later in the talk.

11:00

When you look at bone lesions, uh, and you talk about, um, cysts rather,

11:05

there's really two cysts that I, i, I think people need to know about.

11:08

So there's the emeral or simple bone cysts. Those lesions are,

11:13

um, very,

11:15

very commonly in the proximal humerus and also the proximal femur.

11:20

And what you're gonna see is a lesion that is lucent, it is cystic on m r i,

11:24

but it doesn't really expand the bone too much.

11:27

The patient may or may not have antiseptic pain, they may not know they have it,

11:31

but then they fracture and all of a sudden do an x-ray.

11:34

And you see a cyst lesion.

11:37

Aneurysmal bone cyst is totally different. Beast. Uh,

11:40

so kind of put those in separate categories in your mind.

11:43

Aneurysmal bone cyst is, um, as an name of implies,

11:46

a lesion that will basically expand the bone, thin the bone.

11:50

So you have multiple LOEs,

11:53

multiple cystic spaces in this lesion. The lesion will bleed, bleed, bleed.

11:58

And you, you can basically see here on the t2 there's multiple fluid,

12:03

fluid levels.

12:04

And these are levels because of the differences in the blood product viscosity.

12:09

And what you can see in these examples is that the lesion is expanding the, the,

12:14

um, superior ramus so much that you can't even see the shell of the, um, the,

12:18

the, uh, outer cortex anymore. On this x-ray,

12:21

you have an aneurysmal bone cyst of the proximal fibula expanding the bone,

12:27

so aneurysmal, and you go to the m r and you see again, multiple compartments,

12:32

multiple fluid, fluid levels. This is different than mosis,

12:35

which is typically more ocular,

12:37

won't have the fluid fluid levels unless it's traumatized and won't be as

12:42

expansive. Then I like to talk about pseudo lesions. Um,

12:47

these are lesions that aren't true neoplastic gross,

12:49

but they're spots in the bone. They make us nervous, we see them,

12:52

we don't know what they are. So when you're looking at a case, for example,

12:55

in pediatrics, you're gonna see this entity called uls of cortical irregularity.

13:00

There is a term also that has been used called cortical desmoid.

13:04

I prefer the term uls of cortical irregularity because it's not really,

13:07

it doesn't sound like a tumor. This other one kind of sounds like a tumor.

13:10

I don't wanna get confused with other desmoid tumors.

13:13

So I use the top turn and what you're going to see is a lesion look, uh,

13:18

something that is always in the same location.

13:20

It's in the distal medial femoral metaphysis.

13:24

When you look on the apv, and that may be all you have,

13:27

and that's why you really wanna know what this uh, lesion is,

13:30

you're gonna see what looks like a lucent lesion With a sclerotic rim.

13:33

You might think, is this a broadus abscess? Is this a lesion? Is this a tumor?

13:36

What is this?

13:37

When you go to the lateral film note that you can't see it truly in the

13:41

medullary space, it's kind of hiding in the cortex. In fact,

13:43

it is sort of an intracortical lesion.

13:46

And what it is thought to be is kind of an evasive tug lesion at the origin of

13:51

the gastroc anus will originate right here.

13:54

And when you do CT and Mr you'll see that sort of just irregularity of the

13:58

cortex there. So this is again, just a leave a alone lesion.

14:02

You're gonna see it impedes. And usually smaller children,

14:05

and this is benign stress fracture or injury,

14:10

um, will show that as well. In this example,

14:13

we have an ischiopubic synosis. This is a,

14:16

this is a really good one to know of in pediatrics.

14:20

Remember that in kids we have all of our growth plates and they're gonna fuse at

14:23

different times as the isum is um, forming,

14:28

and the and the ray mi are forming,

14:29

there's a growth plate between the pubic bone and the isum.

14:34

And so, um, as that closes,

14:36

you might actually have this funny kind of bony hypertrophy or even

14:41

edema, um, at that interface. And what you see here,

14:45

and it can be especially troubling when it's asymmetrical,

14:48

you have this focal enlargement, a rounded area.

14:52

But remember this is where that growth plate is.

14:54

So this is termed the issu pubic synosis,

14:57

and you can have a pseudo lesion at the location.

15:00

There are syndromes that can cause pain as it's closing. We almost,

15:05

uh, we, we we often see it. Um, and it is just asymptomatic.

15:09

So it's important to realize this particular area is just a pseudo lesion.

15:16

This is a fun one, um, where you have a stress fracture, uh,

15:20

or stress injury that can actually simulate a malignancy. Uh,

15:24

this was a patient who was presented from the outside for a possible Ewing

15:28

sarcoma. So Ewing sarcoma is the other big, um, um,

15:32

malignant pediatric bone tumor that we have.

15:36

And we all remember that Ewing sarcoma goes in the diaphysis.

15:40

So when anytime someone sees something in the diaphysis with a lot of signal,

15:44

they get concerned. Could this be Ewing sarcoma? However,

15:49

in this particular case, notice how it sort of, uh, doesn't have a soft tissue,

15:53

a mass. Um, it really is just um, centered in the bone,

15:57

which is atypical for young sarcoma. We see the CT actually has nice smooth,

16:02

benign periosteal reaction. This was actually just a stress fracture.

16:06

It did go to biopsy. Um,

16:08

but this is an entity called Sive abductor syndrome,

16:11

sort of in the same family as shin splints. We term, uh,

16:15

eye splints and remember that the sive uh, um,

16:19

nature comes from the very broad adductor muscle, uh,

16:23

that is um, going to a broad attachment to the medial femur.

16:28

So um, that can pull on the medial femur and can cause a stress response.

16:32

So if you ever see something in the middle of the diop and you're kind of

16:35

thinking, I can't really explain that, remember SPLs

16:40

and just some lesions in the other category that don't quite fit.

16:44

This is a lesion in pediatrics. Langer hand cell histiocytosis,

16:49

previously known as eosinophilic granuloma has some other names,

16:52

but we use the term langer hand cell histic cytosis, L C h.

16:56

Now it is a lesion that um,

16:59

traditionally is known as the great mimicker,

17:01

but in fact it does have a predictable appearance on M R I.

17:06

It is a lesion that um, will have massive bone marrow edema around it.

17:11

It's a very, very inflammatory lesion. It has periosteal reaction,

17:17

but on x-ray it's sort of a punched out lytic lesion with smooth

17:22

benign appearing periosteal reaction and we'll show giant cell tumor in other

17:27

slides.

17:29

So those are sort of just lesions that you need to know and I encourage you to

17:33

re-listen to this talk and kind of put those in your bank of lesions that I,

17:37

you have to know the bone lesions when you're faced with an unknown lesion.

17:42

Um, what I'd like you to do,

17:44

and we'll do this as an example when we go over the cases,

17:47

is to say to yourself, what is the density of the lesion?

17:51

So in this particular case here we have an expansile lucent lesion.

17:56

Now why do I say lucent and not cystic right off the bat?

18:00

Because remember that there are lunt lesions that could be solid or

18:05

cystic lucent just tells you that the x-ray is going through the process and

18:09

it's not being blocked by something, for example, bone. Um,

18:13

and so there's a tendency to kind of jump to cystic when you see something that

18:18

is loosened. But let's, for the sake of this talk and for learning,

18:20

let's back up and just say that we see a lunt lesion and then realizing

18:25

that within Lucent you have cysts. So we talked about UBC and a bbc.

18:30

You have solid lucid lesions, you have fibroplasia flma,

18:35

you have lytic destructive lesions such as with have benign and

18:40

malignant. Um, this is an example of a GC t a giant cell tumor of bone.

18:44

It's a lesion seen in young adults that loves the end of the bone.

18:49

And though this is lucent on mri,

18:51

this is actually a solid hypervascular lesion.

18:56

Here's an example of another lunt lesion.

18:59

This is thickening of the rib has a ground glass density.

19:02

This was fibrous dysplasia of the rib.

19:06

Here's another lucent lesion. So you see a case, you see it's a lucent lesion,

19:10

it has a well-defined rib.

19:13

We know that the proximal humerus loves um, the uh,

19:17

location for unic emeral boney.

19:19

And this is just a simple boney in the proximal humerus.

19:24

Here's another lucent lesion,

19:26

but this time a little bit more ill defined and it's destroying the bones.

19:29

So you may say lytic or destructive, but it actually is osteomyelitis,

19:34

which in pediatrics is um,

19:37

very commonly in this location because it is a blunt board and infection goes to

19:42

areas of high blood flow near the growth plate. And this is just infection.

19:48

When you look at a lesion, you say this is sclerotic. Think to yourself,

19:51

is it well-defined or ill-defined?

19:53

If you have a sclerotic lesion that is ill-defined,

19:57

think osteosarcoma in this case a very prominent example,

20:02

very, very dense cloud-like osteo lesion,

20:06

osteosarcoma. Some of these other entities can be sporadic sometimes,

20:09

but are remember osteosarcoma.

20:13

Next I want you to look at the margin of the bone lesion.

20:15

So when you look at this lesion here it is lucent but the margin is well

20:20

defined, right?

20:21

And this is what you would previously call narrow zone or transition.

20:25

You can very easily see where the lesion starts and stops.

20:28

This lesion is another non ossifying fibroma. It is touching a cortex.

20:33

It is loosened and it is well defined. So well defined.

20:35

I want you to think benign in general, an ill defined worry about malignancy.

20:41

This is an ill defined lesion.

20:43

We see an ill-defined lesion that are mixed sclerotic and kind of

20:48

fades away. So when this case came through, I called the ED and I said,

20:52

does this patient have signs of infection?

20:54

Cuz we know that infection can also be ill-defined.

20:57

That's why in the past people would want to say aggressive versus non-aggressive

21:02

because we know that some aggressive things such like infection can

21:07

look like malignancies. However,

21:10

they told me that the patient had no signs of infection.

21:13

And so then when you see you have an ill-defined lesion, no signs of infection.

21:18

Now we're concerned for a malignant lesion.

21:19

This ended up being a lymphoma of bone.

21:25

If you have perio reaction and you may not, so don't let that dissuade you.

21:29

You want to try to assess if it's benign or malignant appearing every day.

21:34

I'm sure you all see fractures healing. You're gonna have a single line,

21:38

a periosteal new bone and that is a benign appearance.

21:41

We do have some malignant versions. They look very different.

21:45

So I remember the body is desperately trying to contain this process for a

21:48

fracture.

21:49

It has four to eight weeks to slowly kind of develop periosteum new bone.

21:53

It can contain that process no problem, it's just a fracture.

21:57

But if you have a tumor that is aggressively and fast growing high biologic

22:01

activity, you're going to see some of these other patterns.

22:04

This is termed onion skinning. So onion skinning looks like an onion.

22:08

There's multiple layers and it persists a laminated appearance because

22:13

remember the body is desperately trying to keep up with this process.

22:19

This is an interrupted codman's triangle where you see a

22:24

periosteal reaction but then it sort of just stops.

22:27

And this is because the soft tissue mass is actually going through this area.

22:31

And so again, the body cannot contain this process. This is a um,

22:36

a um, pattern that we don't see as commonly.

22:38

It is hair on end clearly does not look like a normal smooth line of periosteal

22:43

reaction. And finally, in pediatrics way more than adults,

22:48

you can use a location to help you If you have an epiphyseal lesion,

22:52

remember the end of bone or an epiphyseal equivalent, we'll talk about that.

22:57

Chondroblast one, two and three chondroblast.

23:00

What are epiphyseal equivalents? They are the hypotheses. So for example,

23:05

the crater trocanter, um, they are tarsal bones.

23:09

They are the patella.

23:11

You can use the same differential diagnosis for these cases. And again,

23:16

chondroblast,

23:18

if you see a lesion in the metaphysis sort of flared part of the bone,

23:22

you're gonna think osteomyelitis or is it a Brody Z as developing?

23:27

But if there's no history infection and you see an i'll defined sclerotic

23:30

lesion,

23:30

you're gonna think osteosarcoma if you see a mass in the

23:35

Diaphysis, Ewing sarcoma. Ewing sarcoma. Okay,

23:41

now we get to the second part of the talk and I'm going to

23:46

show these cases and then if you are brave enough,

23:49

go in the chat and comment and try to answer some of my questions.

23:53

Before we start, we have a couple of comments quick. We have a comment, uh,

23:58

from Sonya Aste, what the,

24:00

what we see one lemon or solid periosteal reaction in an older child.

24:06

So again, if we see just a single line of solid periosteal reaction,

24:11

that would typically be a benign periosteal reaction and you might think,

24:15

is this a haing fracture? Is this an infection?

24:19

But if we see those malignant patterns then we want to get an mri.

24:24

We also have a comment.

24:25

Can combining ultrasound with x-ray imaging add onto the information in such

24:29

cases?

24:31

So ultrasound is good for soft tissue but not so good for the bones.

24:35

And so for bone lesions we really wanna focus on x-ray, MRI and cat scan.

24:40

Alright, so people are already giving the answers. Thank you so much.

24:44

Let me try to ask my questions first.

24:47

And so what we see here is a loosen lesion

24:52

in the femoral neck. Is this lesion well-defined or ill-defined?

24:56

If you could please just put that in the chat.

24:58

So we're gonna try to use the salmon method, we're gonna talk about the density,

25:02

then we're gonna talk about the margin. So yes, this lesion is well defined,

25:07

so we're thinking this is probably benign.

25:09

This patient was a runner and they were just having new pain.

25:13

This is a stress fracture that you see here. So when we see lunt well-defined,

25:18

we're thinking benign.

25:20

So that's what I want you to kind of say to yourself before you even know the

25:23

lesion is I want you to think to yourself, this is probably benign.

25:26

We go to mri, it's very, very T2 bright, it's ocular and as people said,

25:31

this is a simple bone cyst and a simple bone cyst complicated

25:36

by a fracture. So I'm put pit lesion.

25:38

Pits pit is basically a fibrocystic formation related to

25:43

um, femoral acetabular impingement. It's typically um,

25:47

just a smaller area only in the inter lateral aspect kind of off to the side.

25:51

This would be way too big for a pits pit.

25:53

And in this case here we don't see a fallen fragment,

25:56

but that is correct to look for fallen fragment sign.

25:59

It helps you decide if something is cystic.

26:04

So for this lesion we see a lunt lesion.

26:08

Can someone say where this is in the long bone before you say the answer?

26:12

So where is this in the long bone? It is centered in what?

26:15

It's centered in the epiphysis. Is it well-defined or ill-defined?

26:20

It is well-defined and so you see a well-defined lucent

26:25

lesion. Thinking benign.

26:26

We know that in a pediatric patient we're thinking of

26:31

chondroblast. Someone put giant cell tumor of bone,

26:34

that's a good thought as well.

26:36

But typically we see those in patients with clothes growth placed.

26:39

They're a little bit older.

26:45

This is a patient with this ground glass density. Okay,

26:50

so the lesion is ground glass density,

26:54

fibrous dysplasia. Excellent.

26:56

This is the one that if you can detect fibrous dysplasia, that's really,

26:59

really helps you. Uh, ground glass density that helps you with fd.

27:04

This is kind of a thinking case.

27:05

So we don't see a lesion in the medullary space,

27:07

but we see this focal cortical thicken and the smooth cortical thickening.

27:11

So is this a benign or a malignant periosteal reaction or

27:15

periosteal kind of response?

27:21

Before we give the answer just try to say is this a benign or is this a

27:24

malignant um, response? Okay,

27:28

so it's benign because we don't have lam related, we don't have um,

27:33

onion skinning and you guys are too smart. When we do a ct,

27:37

we see the cortical thickening and buried within that cortex.

27:40

It's this focal with a little dot of sclerosis.

27:44

And so this was an osteo osteo excellent.

27:47

This was a patient who was playing basketball, had no antecedent pain,

27:52

fell and had a pathologic fracture.

27:54

They come to the ED and we're seeing a lunt lesion that is well defined.

27:59

So are we thinking benign or malignant?

28:04

So we are thinking benign because it is well defined and lunt we also

28:09

see a little fallen fragment. Now it becomes tricky because um,

28:13

we see some people saying a bbc,

28:15

some people saying UBC and you may not be able to tell always,

28:18

but I would argue this is not really super expansile.

28:21

There is a fracture here but it still has sort of the normal shape of the bone.

28:25

It's not really super widened. So this,

28:28

this is actually turned out to be a unicameral bone cyst.

28:35

This is a sclerotic lesion that is extending into

28:40

the epiphysis. So this is sort of ill-defined.

28:43

So are we concerned for a malignant lesion or a benign lesion?

28:47

You said ill-defined the sclerosis.

28:48

If you ever hear yourself saying Ill defined, uh, or uh,

28:53

on an sclerosis, you wanna be worried about a malignant lesion. That is correct.

29:00

This is osteo sarco and note that we didn't have perio reaction yet.

29:04

So don't let that dissuade you.

29:06

If you see someone that has an ill-defined sclerotic lesion,

29:10

worry about osteosarcoma,

29:14

this lesion is loosened and it has

29:18

an ill-defined margin. So is this benign or malignant?

29:26

Malignant, exactly. And then we use our location,

29:28

we say diap and we're thinking Ewing sarcoma.

29:32

So even if you don't know EW sarcoma, look at this lesion.

29:35

Say that it is ill-defined. We're concerned for a malignant lesion. Get an mr.

29:40

This was Ewing sarcoma. Ignore this little round circle here.

29:43

That was an incidental part of this case.

29:46

This patient has an ill-defined sclerotic lesion.

29:49

Are we worried or are we not worried?

29:54

We are worried we don't have periosteal reaction. But again,

29:57

don't wait for that. This patient had no history of osteomyelitis.

30:01

So what is this osteosarcoma?

30:06

Excellent. This is an exophytic lesion.

30:10

Remember we talked about lesions that are unique that have exophytic appearance

30:15

and it's the back of the knee. No perioa reaction and it's well defined.

30:20

Just patient just had a bump. Excellent.

30:24

This is osteo con joma. Exostosis is a general term.

30:28

Osteo chondro is the benign neoplastic uh, lesion with a cartilage cap.

30:34

Um, cortical desmoid, someone said desmoid. Um,

30:37

again that would usually be just smaller and buried in the cortex.

30:41

It doesn't have an exophytic appearance but it is the same location.

30:46

This is a fun case, you have to kind of really think about it,

30:49

but you can actually come to a histologic diagnosis.

30:52

So we have stir T1 and we have a CT here.

30:56

So we have a lesion that is centered within the greater cho canter.

31:01

If you look when you use the um, other side for comparison,

31:06

it has massive edema around it.

31:09

We have to know that the greater roc canter is an apophysis hypothesis,

31:13

which is an epiphyseal equivalent.

31:15

So that's really how you can come to this diagnosis. So it's in the apophysis,

31:19

which is an epiphyseal equivalent. When we look at the ct,

31:24

we see punctate calcifications which are characteristic of a chondro

31:28

lesion.

31:31

So this is another example of chondroblast.

31:35

So see how you can use the location as well to help you.

31:38

This is a patient who came into the ED with fever, white count and swelling.

31:43

We see some benign periosteal reaction.

31:46

Just one line of periosteal in your bone.

31:48

We see what someone thought was a bone tumor but remember that it is right up

31:52

against the growth plate. You guys are all over it.

31:56

This is infection and this is a Brody abscess or intraosseous

32:01

abscess. Excellent.

32:03

Another one we have an ill-defined lesion with sclerosis

32:08

and ency.

32:10

We don't have periosteal reaction but when you hear ill-defined and sclerotic,

32:14

what are we worried about in this case?

32:21

Osteosarcoma.

32:22

I show a lot of the same cases in the beginning cuz I want you guys to see all

32:26

the things that you might be afraid of missing. These are hard cases.

32:29

These are a collection of a lot of our cases and I think it's just important to

32:34

see if you see a lesion that is ill-defined and sclerotic worry about

32:37

malignancy, get an mr.

32:43

Here is a lucent lesion with a well-defined rim.

32:47

So we're thinking benign as we said well-defined. We use our location,

32:52

we say it's in the epiphysis,

32:56

but what is this lesion here? Chondroblast. Excellent.

33:03

Now we're gonna get into some cases that have multiple lesions.

33:07

We have two lesions. See if you can find them.

33:11

This is the same entity. One lesion looks more malignant than the other.

33:16

We have a punched out lytic lesion with the sclerotic rim has more of a benign

33:21

appearance. We also have a lesion that is destroying the pubic bone.

33:28

And I will tell you this was the same diagnosis. This is a child.

33:33

So sarcoma is rare.

33:37

The pubic body lesion alone could be a un sarcoma and you definitely want to

33:41

think about that. And that's what they were worried about clinically,

33:43

that it was ung sarcoma with a metastasis into the pelvis.

33:47

If I told you it was not Ewing sarcoma, what might you think?

33:51

I see some people that have put it in there.

33:53

The diagnosis that you want to always include differentials. L c h,

33:58

Langerhans Cytosis previously, uh, called u uh,

34:02

eosinophilic granuloma. Now we use L c H.

34:06

This patient had multiple lesions. They're all very similar in appearance.

34:11

They're in the metaphysis, they are exophytic, they're all over the body.

34:16

And this is an entity where you have multiple excess doses or osteochondral.

34:21

This is multiple hereditary excess doses and we do want to

34:26

follow them because there is a risk of malignant transformation.

34:31

This patient had a leg length discrepancy, has multiple lesions,

34:34

but they're kind of weird looking.

34:35

They're streak like they have some little punctate calcifications within them.

34:40

This

34:43

patient had multiple of these and these are multiple NDRs.

34:48

Excellent. And there are two entities that have multiple NDRs,

34:53

uh, that we want to know about. One of them has soft tissue hemangiomas,

34:57

this one does not.

34:59

And so this one starts with an O and it is S excellent.

35:03

So this is Ali air disease and again,

35:05

we want to worry about the possibility of malignant transformation.

35:09

Mucci syndrome is the other one with soft tissue hemangiomas.

35:14

And the little punctate calcifications is sort hint that this is probably a

35:17

chondro lesion.

35:19

And so that's why you want to think about end chondro osteo cants,

35:24

again, remember is the one with the exophytic lesions. This case,

35:28

these are not exophytic, they are in the bone.

35:32

This is a fun case where you have multiple osteo choros like

35:37

lesions, but instead of them just being in the metaphysis,

35:40

they actually extend intraarticular, they go into the joint.

35:44

So it's sort of another entity that is not m h e

35:49

Trevor Disease. Excellent. You guys are too smart. Uh,

35:52

this is Trevor disease dysplasia epiphysis Hemi Malica.

35:57

And these are these osteochondritis type lesions,

36:00

but I remember that they're intraarticular. You can see the cartilage cap here.

36:05

This was a patient who was eight years old and presented with a year of limited

36:09

range of motion of the elbow. When we did the m r i,

36:12

there was really severe synovitis and they thought that this was

36:17

a juvenile idiopathic arthritis, a rheumatoid arthritis kind of case.

36:21

When we looked at the ct though,

36:23

we found something in the bone that might be able to be blaming the

36:28

synovitis. It is a loosened lesion with a central sclerotic neuritis.

36:33

And um, this was in fact osteo osteo large.

36:38

So the teaching point about this case is that osteo osteo

36:43

will cause massive reaction wherever it is.

36:46

Most of the cases we see are along the shaft of the bone.

36:48

And so you're gonna see perioa reaction.

36:51

But remember that when you have an intraarticular osteo ooma,

36:55

they're even trickier and there can be delays in diagnosis.

36:58

When it's in the joint, the joint just responds.

37:00

However it knows how to respond and that is joint effusion and synovitis.

37:04

But this was the osteos foma causing all of these problems.

37:11

Love this case. This is a variant of a fibro dysplasia type lesion.

37:16

It loves the mid tibial diaphysis.

37:19

It is a lesion that is centered in the cortex.

37:21

So when you look at the actual ct,

37:24

this little thing back here is the medullary space. This is a cortex.

37:28

So this is actually a lesion that is centered in the cortex and it has a

37:33

ground glass density.

37:34

So there's two lesions that you kind of wanna say to yourself.

37:37

If it's a younger patient,

37:39

it's probably this one name or if it's an older patient,

37:42

you'd be concerned for adamant anoma. As you guys said, if this is benign,

37:46

I want you guys to also know the benign version of this.

37:50

This is called um, osteo fibrous dysplasia.

37:53

Osteo fibrous dysplasia,

37:55

which is basically fibrous dysplasia centered in the cortex. Yes,

37:59

you do want to give adamant as a differential, it's a spectrum.

38:03

And so this is osteo fibrous dysplasia.

38:07

Here's a normal variant.

38:08

I feel like the superolateral patella loves normal variants.

38:12

So if you see something in aup,

38:13

lateral patella always think could this be a normal variant?

38:16

This is not bi parte patella,

38:17

it's this invagination with a little loosened area.

38:21

This is dorsal defect of patella.

38:23

You guys are too smart and this is just a normal variant could cause pain,

38:28

but it is a normal variant.

38:31

Lastly here we see an expansile lesion. We do an mr and we see multiple fluid,

38:36

fluid levels.

38:39

And so this is a kind of cyst, but it's expansile.

38:43

This is aneurysmal bone cys. Someone said LAN oscopy are,

38:47

that is always something we want to think about.

38:49

I will tell you that on other images there was no solid components and this was

38:52

just an aneurysmal bone cyst for bonus points.

38:55

There's one other lesion on this case in the tibia and it is right here.

38:59

It is a lesion that is touching the cortex. In this case it is sclerotic.

39:03

This is just an N O F and an aneurysmal bonis.

39:08

You guys are awesome. And what we can do now is open it up for questions.

39:13

And let's see here, we have a question,

39:18

um, here. Thank you for the compliment.

39:20

My question is about lipos sclerosis,

39:24

mixup fibrous tumors and overlap of annihilation. So, um, L S M F T,

39:28

lipos sclerosis, mixup fibrous tumor, we didn't show in this case,

39:31

but it basically loves the, um, proximal femur on the femoral neck.

39:36

And typically you'll see a lesion that may or may not have fat,

39:39

it might have microscopic fat, um, might have some CYS in it,

39:42

it might be sclerotic. And um,

39:46

that can look like other lesions. And it it is thought to be,

39:49

I think a borderline. It can be a benign, but it might be malignant.

39:52

I think it's controversial. Um, it's not certainly a malignant lesion, but um,

39:58

if you just had fibro dysplasia or lipoma with cystic degeneration,

40:04

um, that could also have a similar appearance there as well. And

40:11

let's see here what other questions you guys have. Hopefully you guys, uh,

40:16

feel like now, um, if, if you didn't, that you also,

40:19

that you have kind of a better way to kind of just face an unknown lesion.

40:22

So remember that you want to, um, look if it's loosen or sclerotic,

40:26

is it well-defined or ill-defined And then just kind of put in your differential

40:30

diagnosis, some of those, um, lesions that we talked about.

40:32

We have a question here. Uh,

40:34

how to differentiate between chondro and periosteal osteosarcoma.

40:40

Um, so

40:43

you have these entities known as surface osteosarcoma, um,

40:47

which are par osteo, p a r, which is usually a very,

40:51

very dense neurotic lesion and peri osteosarcoma.

40:56

Um, and so that is, um, it is hard.

41:01

Um, those are, they have a, a different appearance. Uh,

41:04

osteosarcoma will typically have more of an aggressive appearance. Um,

41:07

more of a more malignant, more of a soft tissue mass choros, um,

41:11

you'll have that lobular micro lobulated, um, appearance.

41:15

And when you give contrast, it might have, uh,

41:18

kind of a rim enhancement sort of punctate,

41:20

areas of enhancement different than you might see with more of a solid enhancing

41:24

tumor in an osteosarcoma.

41:28

Are there specific radiographic features of B core sarcomas? Wow,

41:33

you guys are super advanced. Um, there probably are.

41:38

Um, I'm not totally sure, uh, if, if, if,

41:41

if there are specific that I know of,

41:43

but I I have heard of that and I know that's like a pathologic, uh,

41:47

distinction on some of the large lesions like A, B, C.

41:51

How are diagnosis being made? Are they resected for diagnosis?

41:54

What happens to the remaining mode? Is it blood? Ok, so ABC's,

41:59

um, aural, boney,

42:00

they are going to get worse and worse and get bigger over time and you need to

42:04

treat them. The typical treatment, uh,

42:07

was surgical curettage and bone graft.

42:11

Now there's some newer exciting treatments. Um,

42:13

our IR guys here are doing really, really exciting things. My, uh, partner, uh,

42:18

Shankar Rajas Warren is doing really exciting things with, um, these cysts.

42:22

He is going in there and he is doing, um, basically, um, sclerosis,

42:28

grafting and even cryoablation of these lesions or minimally invasive

42:32

techniques. And so there's some newer things coming out.

42:35

What about myeloproliferative disease and bone marrow changes? What to look up?

42:41

So, um, for example, if you are talking about, um,

42:45

malignant, uh, diffuse malignant processes such as, uh, leukemia,

42:50

uh, for example is one that I,

42:52

I think is important to know what that looks like,

42:54

you're gonna see a diffuse error replacement. So, uh,

42:58

the whole marrow will be very,

42:59

very T2 hyperintense and dark on t1, uh, uh,

43:04

for those cases. Does that answer the question there?

43:09

In the intraarticular osteos case,

43:11

can we differentiate Ooma as with sequestration? Very good question.

43:15

So sequestration, which is a small bit of sclerotic bone, dead bone,

43:19

which can serve as a NIS for infection, um, you're absolutely right.

43:23

That could look similarly to an osteo osteo.

43:26

You probably would have a history of osteomyelitis that was refractory to

43:31

treatment and then do a follow-up mr. And you find that, but you're right,

43:35

that could look similar. Usually it's more of just a dense,

43:38

sclerotic white piece, not like a beautiful round of uh, uh,

43:42

area of, of anni, but you're right, that could look similar. And, uh,

43:47

in this case, um, they did a cryoablation,

43:50

they biopsied it and they also then cryo it and there were no other, um,

43:55

some patient approved right away.

43:59

Can you explain case number 15 again? Yes, let's go back to that.

44:05

So for case 15, this is a hard case. We see two lesions.

44:10

One lesion is here and if I just saw this,

44:12

I would say that there is an ill-defined lucent lesion and I'd be concerned

44:17

hearing myself say Ill-defined lucent lesion and the pelvis.

44:20

I'd be concerned this was a malignant lesion such as you in sarcoma,

44:23

which can occur in the pelvis. Yet when I look at this other lesion,

44:28

this is a lucent lesion,

44:29

which has a well-defined margin and it has a sclerotic rim that actually looks

44:34

more benign. So, um,

44:39

you do have to give a differential diagnosis for this case.

44:41

So this could be you sarcoma with a metas to the pelvis. However,

44:45

I think it's important for us to give a differential diagnosis as a, uh,

44:50

young child, Pam family was very worried and they just asked,

44:54

is there anything that this could else be? Could this be something benign?

44:58

And that's when I said, well, it actually could be L C H.

45:01

And so that's what it was. So it's good to have a differential diagnosis. Um,

45:05

then there's a question here. Sorry, there's a question. Uh,

45:07

prognosis of osteo fibrous dysplasia. So, um,

45:12

osteo fibrous dysplasia, basically it's uh, it's fibrous dysplasia.

45:16

And if it's truly not a, um, adamant tooma,

45:19

it's a benign lesion and it may just kind of get better. They may have to,

45:23

if it has a pathologic fracture, they may have to treat that, uh,

45:26

they may have to stabilize the bone, but it is a benni.

45:29

And then what about the right si joint, especially the ileum,

45:33

I assume talking about the other case. Um, yes,

45:37

it does look a little sclerotic here. Um, is that,

45:39

that may be what you were worried about, um, in this case. Uh,

45:43

i I think it might just be some overlapping stool. Uh,

45:46

I don't remember the case exactly, but, um, don't worry about that.

45:49

There stress fractures in plain x-ray. Um,

45:54

so stress fractures, if you have, uh,

45:58

just a early stress fracture, you may not see anything on x-ray.

46:03

Uh, as we know, the MRI will show the edema where s x-ray could look normal.

46:07

However, uh, as we have a healing stress fracture, you're going to see the, um,

46:12

periosteal new bone and you're going to sometimes see a little loosened fracture

46:17

cleft buried in the cortex. So if you see periosteal reaction and thickening,

46:20

that's what a stress fracture will look like. When, uh, let's see here.

46:24

Best book for bone tumors. Um,

46:29

good question. Uh, I, I don't know the answer to that. Uh, and I don't wanna,

46:34

I I I I don't, I don't know. There's many good, there's many good things, uh,

46:38

many good things out there. Uh, let's see here.

46:40

When should we consider mets in pediatric x-rays and which all primary trigger

46:44

will first? So if you see mets,

46:46

so the thing in pediatrics is that it's not as common as an adult and adults

46:49

when you see bone lesions, you always throw in mets for, uh,

46:52

a diagnosis in pediatrics, um, neuroblastoma, um, which is very, very young,

46:57

children will go to bones. That's what we want to think about.

46:59

Neuroblastoma is a big one. Um,

47:04

so that would be a primary to rule out is neuroblastoma.

47:06

Please explain uls of cortico irregularity. So uls of cortico irregularities,

47:09

think of it as just the origin of the gastroc tendon is basically pulling on the

47:14

back of the femoral cortex.

47:15

So it just causes kind of a little bit of irregularity and a little bit of like

47:19

bone breakdown. So it can produces lucid lesion.

47:22

That's why it's just called sive portico regularity,

47:25

just the name is saying what it's doing. Um, sight of chemical bonus.

47:30

Can it be in the epiphysis? What is it ever between case five and case 14?

47:35

It can be in the epiphysis. Um, that is possible. It's not as common.

47:41

Um, so in case 14, you're right,

47:43

you could include this in the differential diagnosis.

47:45

When you do M r I though a cyst will have central non enhancement just rim

47:50

enhancement, whereas a chondroblast would actually be solid enhancement.

47:55

Um,

47:55

case five is basically a lunt lesion with a sclerotic

48:00

rim. And this is basically, um,

48:04

a more common location for chemical exists in the metaphysis.

48:09

Uh, is there a lesion in case two proximal fibula? Yes,

48:13

there is a lesion in case two. Very good. This is another non ossifying fibroma.

48:18

Very, very good.

48:24

Guys are excellent. You guys are awesome. You don't need my help,

48:27

but hopefully you guys feel more comfortable about approaching bone lesions,

48:32

which bone lesions need to know.

48:34

Are you related to possibly to send of my high school classmate Carol Simmons,

48:39

a cellist, I think class of 1967, St. Louis, Missouri. Sorry,

48:44

I am not, I'm from Baltimore, Maryland. Um, not that I know of.

48:49

N N O F versus, uh, F C D,

48:54

um, is that focal cartilaginous dysplasia, I assume?

49:00

Um,

49:01

focal cartilaginous dysplasia is a rare

49:06

entity that, um,

49:08

we typically see in the proximal tibia or distal radius and it looks like a,

49:12

a weird like notch or concavity in the bone,

49:15

whereas N O F is a lesion that is kind of filling the bone,

49:19

if that is the question you're asking how to differentiate conjure mix offi and

49:23

end chondro lesion in the distal tibial metaphysis? Forgot the case number.

49:29

So, um,

49:31

chondro mix of fibroma is a lesion that can also look locally aggressive.

49:34

It can be a lunt lesion.

49:37

It is not as common as end chondro and CHONDRO is much more common. Um,

49:43

NDRs love the fingers. So, um, that will be more common.

49:47

You may not be able to differentiate those as well. Um,

49:51

I actually had a case once that I presented at a meeting of chondro mix of

49:54

fibroma of the toe. And you're right, it could look similar,

49:57

but common things being common chondro,

49:59

more common appearance of chondro on M r I please.

50:03

So we showed a case of, uh,

50:05

a chondro and basically it is a lobular T2 hyperintense lesion,

50:10

which is, um, typical for a chondro lesion.

50:13

And what you can see here is that it has these like kind of micro lobulated

50:17

margins, um, that is very characteristic.

50:21

And if it is sitting on a cortex than you think of periosteal petrol,

50:26

what is the indication for mri? Can we diagnose most of em by plain x-ray?

50:30

Good question. We love to have x-ray first. Um,

50:34

x-ray can diagnose many of these lesions. I think M R I, um,

50:38

it traditionally people used to say M r MRI is only for staging of disease,

50:42

not for diagnosis of lesion. I don't totally agree with that.

50:45

I actually think m r I is really helpful to distinguish solid versus cystic.

50:49

As you saw in a lot of the cases and prior questions, some of these NT lesions,

50:54

you're not sure if it's cystic or solid,

50:56

so is it a chondroblast or is it a al bone cyst?

50:59

But when you do an MRI with contrast,

51:01

you can see that a cyst will have rim enhancement and the chondroblast will have

51:06

solid enhancement. So, um, that's when I would do m mri.

51:10

And also if you have a lesion on x-ray and you don't,

51:13

it doesn't fit into a benign category and you don't know what it is,

51:17

that is an indication for R mri. I think as radiologist, if you see a lesion,

51:21

it's not something that you can neatly put into a benign category.

51:24

I think you should do an MRI and I don't think you should let it go.

51:32

82 questions answered. I'm firing off the answers. Keep 'em coming.

51:36

You got any more questions?

51:43

Hey, so oh, there it is. One more question.

51:46

Typical location for Choma. Uh,

51:49

I assume you're referring to periosteal or juxta? Cortical choma.

51:55

Um, I've seen them in the humerus. Um,

51:58

I've seen them in the proximal tibia under the tibial tubercle, but uh,

52:02

I'd have to look up, uh, to see, uh, uh, distribution, uh,

52:06

if I was going to give you an exact answer.

52:13

All right, I think you answered everybody's questions. Oh,

52:16

one more just came in. Dr. Sam bone

52:20

Rads in children. Um,

52:24

I'm not sure what the question is. Is that referring to,

52:27

is there like an rads like a system to kind of, um, help define,

52:32

uh, help you put things good to grade lesions? Not that I know of.

52:36

I know that RADS is kind of coming up for adult lesions, but, um,

52:40

not that I know of. For pediatrics specifically,

52:43

how to TelePro between chondroblast and giant ssam bone? Good question.

52:46

So remember that kind of think of 20 years old as a cutoff. Uh,

52:51

we don't really see giant cell tumor of bone below 20. So if the,

52:54

the growth plates are open, you pretty much never see giant cell tumor of bone.

52:58

And so you can use kind of that to help you.

53:00

Chondroblast bone usually is in the epiphysis giant cell tumor of bone is in the

53:05

epiphysis, but it actually is in the metaphysis and the epiphysis. And so,

53:10

um, when we very, very rarely stem pediatrics,

53:14

it actually is in the metaphysis and that's why people think they originate from

53:18

there. So I would think 20 years old is kind of a good number to remember to

53:20

differentiate those.

53:23

All right, Dr. Samit, thank you so much for sharing your lecture and yes,

53:27

this interactive session and for everybody who attended today,

53:30

thank you so much for putting your answers in the chat and helping out with

53:33

such, such great, uh, questions and uh, suggestions.

53:37

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53:46

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53:49

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