Bone Tumours and Benign Lytic Lesions

Factors aiding diagnosis| Benign lesions | Malignant tumours | Osteomyelitis

Non-ossifying fibroma
| Solitary bone cyst | Aneurysmal bone cyst   
| Osteochondroma | Osteoid osteoma | Eosinophilic granuloma
Haemangioma | Fibrous dysplasia | Giant cell tumour

Osteosarcoma | Ewing's sarcoma | Chondrosarcoma | Metastases | Multiple myeloma

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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. 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
Location within the bone
Size of lesion
Monostotic (one lesion) or polyostotic (multiple lesions)
Zone of transition from normal to abnormal bone
Reactive sclerosis
Pattern of bone destruction
Presence of visible tumour matrix
Host (bone) response
Periosteal reaction
  • 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
Non-Ossifying Fibroma / Fibrous Cortical Defect
Non-ossifying fibroma - distal femur   Non-ossifying fibroma - distal femur
Simple / Solitary Bone Cyst
Solitary bone cyst - proximal humerus with fracture   Solitary bone cyst - calcaneum
Aneurysmal Bone Cyst
Aneurysmal bone cyst - proximal humerus   Aneurysmal bone cyst - proximal humerus
Enchondroma - proximal phalanx with pathological fracture   Ollier's disease with pathological fracture
Bone infarct - distal femur   Bone infarct - distal femur
Diaphyseal aclasia   Diaphyseal aclasia
Osteoid osteoma
Osteoid osteoma - 15 year old   Osteoid osteoma - 15 year old
Eosinophilic granuloma / Langerhan's cell histiocytosis
Eosinophilic granuloma   Eosinophilic granuloma
Haemangioma - T8   Haemangioma - T8
Fibrous Dysplasia
Fibrous dysplasia - femur   Fibrous dysplasia - tibia, with pathological fracture
Giant Cell Tumour
Giant cell tumour - proximal tibia   Giant cell tumour - proximal tibia

Giant cell tumour - distal femur   Giant cell tumour - distal femur
Osteosarcoma - 9 year old with sunburst periosteal reaction   Osteosarcoma - 9 year old with sunburst periosteal reaction   Osteosarcoma - 9 year old with sunburst periosteal reaction   Osteosarcoma - 9 year old with sunburst periosteal reaction
Osteosarcoma - 16 year old   Osteosarcoma - 16 year old
Ewing's sarcoma
Ewing's sarcoma
Chondrosarcoma - transverse processes L4
Metastatic Disease

Metastasis - C5/C6   Metastasis - left ileum   Metastasis - phalanx
Multiple Myeloma
Multiple myeloma - skull   Multiple myeloma - humerus   Multiple myeloma - femur   Multiple myeloma - thoracolumbar spine
Osteomyelitis - proximal tibia
Osteomyelitis - humerus

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