J Korean Soc Radiol.  2015 Oct;73(4):240-248. 10.3348/jksr.2015.73.4.240.

Bone Tumors with an Associated Pathologic Fracture: Differentiation between Benign and Malignant Status Using Radiologic Findings

• Bae JH
• Lee IS
• Song YS
• Kim JI
• Cho KH
• Lee SM
• Lee YH
• Song JW

• KMID: 2068714
• DOI: http://doi.org/10.3348/jksr.2015.73.4.240

Abstract

PURPOSE
To determine whether benign and malignant bone tumors with associated pathologic fractures can be differentiated using radiologic findings.
MATERIALS AND METHODS
Seventy-eight patients (47 men and 31 women, age range: 1-93 years) with a bone tumor and an associated pathologic fracture from 2004 to 2013 constituted the retrospective study cohort. The tumor size, margin, and enhancement patterns; the presence of sclerotic margin, the peritumoral bone marrow, soft tissue edema, extra-osseous soft tissue mass, intratumoral cystic/hemorrhagic/necrotic regions, mineralization/sclerotic regions, periosteal reaction and its appearance; and cortical change and its appearance were evaluated on all images. Differences between the imaging characteristics of malignant and benign pathologic fractures were compared using Pearson's chi-square test and the 2-sample t-test.
RESULTS
There were 22 benign and 56 malignant bone tumors. Some factors were found to significantly differentiate between benign and malignant tumors; specifically, ill-defined tumor margin, the presence of sclerotic tumor margin and an extra-osseous soft tissue mass, the absence of cystic/necrotic/hemorrhagic portions in a mass, the homogeneous enhancement pattern, and the presence of a displaced fracture and of underlying cortical change were suggestive of malignant pathologic fractures.
CONCLUSION
Some imaging findings were helpful for differentiating between benign and malignant pathologic fractures.

MeSH Terms

Bone Marrow
Bone Neoplasms
Cohort Studies
Edema
Female
Fractures, Spontaneous*
Humans
Magnetic Resonance Imaging
Male
Retrospective Studies

Figure

• 

  Fig. 1 A 35-year-old female patient with an aneurysmal bone cyst of the distal radius. Anteroposterior radiograph (A) showing a well-defined, radiolucent mass lesion with a thin sclerotic rim and endosteal scalloping in the distal radius. Non-displaced, cortical disruption of clear-cut type (arrows) was noted on both sides of the distal radius. No evidence of intra-tumoral mineralization or periosteal reaction was shown. Fat-suppressed, sagittal contrast enhanced image (B) showing thin peripheral rim enhancement with a cystic or hemorrhagic portion within the lesion (arrows).

• 

  Fig. 2 An 83-year-old male patient with bone metastasis from prostatic cancer of the left femur. Plain radiograph (A) showing an ill-defined osteolytic mass lesion in the diaphysis of the femur. A permeative pattern (arrows) of cortical change was noted. There was no evidence of mineralization. Fat-suppressed, coronal T2-weighted MR image (B) showing extensive soft-tissue edema around the fracture site and an ill-defined bony and soft tissue mass (arrows) in the femoral diaphysis. Fat-suppressed, axial contrast enhanced image (C) showing ill-defined extra-osseous soft tissue formation with relatively homogeneous enhancement (arrows). The bony lesion was also homogeneously enhanced.

• 

  Fig. 3 A 56-year-old female patient with bone metastasis from lung cancer of the right tibia. Reformatted coronal CT scan (A) showing periosteal reaction with a sunburst pattern (arrows) adjacent to the mass lesion. Fat-suppressed, contrast-enhanced coronal T1-weighted MR image (B) showing a heterogeneously enhanced extra-osseous lesion (arrows) as compared with the homogeneous enhancement shown by the intra-osseous portion.

Reference

1. Miller SL, Hoffer FA. Malignant and benign bone tumors. Radiol Clin North Am. 2001; 39:673–699.

2. Ortiz EJ, Isler MH, Navia JE, Canosa R. Pathologic fractures in children. Clin Orthop Relat Res. 2005; (432):116–126.

3. Shin DS, Shon OJ, Byun SJ, Choi JH, Chun KA, Cho IH. Differentiation between malignant and benign pathologic fractures with F-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography. Skeletal Radiol. 2008; 37:415–421.

4. Springfield DS, Brower TD. Pathologic fractures. Philadelphia: J.B. Lippincott;1984.

5. Bridge JA, Orndal CC. Cytogenetic analysis of bone and joint neoplasms. In : Helliwell T, editor. Pathology of bone and joint neoplasms. Philadelphia: W.B. Saunders;1999. p. 59–78.

6. Springfield DS. Radiolucent Lesions of the Extremities. J Am Acad Orthop Surg. 1994; 2:306–316.

7. Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Benetos IS, Galanis EC, Soucacos PN. Pathological fractures in primary bone sarcomas. Injury. 2008; 39:395–403.

8. Jackson WF, Theologis TN, Gibbons CL, Mathews S, Kambouroglou G. Early management of pathological fractures in children. Injury. 2007; 38:194–200.

9. Sarahrudi K, Hora K, Heinz T, Millington S, Vécsei V. Treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients. Int Orthop. 2006; 30:519–524.

10. Coleman RE. Skeletal complications of malignancy. Cancer. 1997; 80:8 Suppl. 1588–1594.

11. Wedin R, Bauer HC, Wersäll P. Failures after operation for skeletal metastatic lesions of long bones. Clin Orthop Relat Res. 1999; (358):128–139.

12. Myers SP. MRI of bone and soft tissue tumors and tumorlike lesions. New York: Thieme;2008.

13. Bui KL, Ilaslan H, Bauer TW, Lietman SA, Joyce MJ, Sundaram M. Cortical scalloping and cortical penetration by small eccentric chondroid lesions in the long tubular bones: not a sign of malignancy? Skeletal Radiol. 2009; 38:791–796.

14. Priolo F, Cerase A. The current role of radiography in the assessment of skeletal tumors and tumor-like lesions. Eur J Radiol. 1998; 27:Suppl 1. S77–S85.

15. Helliwell TR. Pathology of bone and joint neoplasms. Philadelphia: Saunders;1999.

16. Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ. From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. Radiographics. 2001; 21:1283–1309.

17. James SL, Davies AM. Giant-cell tumours of bone of the hand and wrist: a review of imaging findings and differential diagnoses. Eur Radiol. 2005; 15:1855–1866.