Version June 2024
| Entity | Radiographic features |
| Primary malignant tumors | |
| Conventional osteosarcomas | Destruction of the normal trabecular bone pattern, indistinct margins, and lack of endosteal bone response. There is usually a mixture of both radiodense and radiolucent areas, with periosteal new bone formation, and sometimes formation of a Codman's triangle. |
| Chondrosarcoma | Cartilage can be recognized on imaging because it tends to grow in nodules, has a very high water content (making it bright on T2-weighted MRI and dark on CT scan), and deposits mineral in dense "rings and arcs" whose density can focally exceed cortical bone. |
| Fibrosarcoma | Can present as a solitary lytic lesion and tends to resemble osteosarcoma, but without ossification. |
| Ewing sarcoma of bone | Has a characteristic "permeative" or "moth-eaten" pattern on imaging, with very poorly defined margins. The tumors can be large and frequently involve the diaphysis. The characteristic periosteal reaction produces layers of reactive bone, deposited in an "onion peel" appearance. The cortex is often permeated by tumor, which extends into the soft tissues. |
| Solitary plasmacytoma of bone/POEMS syndrome | The presence of a lytic bone lesion with or without a sclerotic rim or a single osteosclerotic bone lesion in a patient with a monoclonal gammopathy suggests the possibility of solitary plasmacytoma of bone; a small subset for these patients have POEMS syndrome (osteosclerotic myeloma: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes). However, a subset of patients may have bone metastases from kidney, breast, non-small cell lung cancer, and other primary lesions with an associated, unrelated monoclonal gammopathy (eg, MGUS). Typically, patients with metastatic carcinoma have multiple lytic bone lesions rather than a single lesion such as that seen with solitary plasmacytoma of bone. |
| Primary lymphoma of bone | Generally associated with less bone destruction than Ewing sarcoma. The earliest radiographic sign is diffuse medullary mottling. Plain films may demonstrate lytic or radiolucent lesions associated with a noncalcified soft tissue mass. |
| Benign bone tumors | |
| Hemangioma of bone (unicameral) | Coarse vertical striations within bone give a typical "polka dot" or honeycomb appearance on CT. |
| Bone cysts | |
| Typically appear as well-marginated cystic lesions of the metaphysis or metadiaphysis without reactive sclerosis. Usually involves the full diameter of bone with expansion of the cortex. |
| Sharply circumscribed, aggressive, expansile, lytic metaphysical lesions with an "eggshell" sclerotic rim. Maybe have a "soap bubble" appearance secondary to trabecular reinforcement. Cortex usually intact. |
| Osseous lipoma | Well-circumscribed radiolucency with a central calcification and sclerotic rim; occasional cortical expansion. |
| Eosinophilic granuloma | Typically a medullary-based lytic lesion with geographic destruction, lobular contour, and well-defined edges. Destructive eosinophilic granulomas are usually not associated with a sizable soft tissue mass. |
| Enchondroma | Usually a central metaphyseal oval well-circumscribed central lucent lesion with or without matrix calcification. |
| Osteoid osteoma | Small, round lucency with a sclerotic margin with or without central ossification. |
| Non-ossifying fibroma | Small, well-defined eccentric expansile lytic lesion located in the metaphysis with scalloped sclerotic borders (may be multiple). |
| Giant cell tumor of bone | Expansile, eccentrically placed lytic area on plain radiographs (the result of intratumoral hemorrhage), typically involving the epiphysis and adjacent diaphysis. Absent matrix calcification and reactive periosteal new bone formation. |
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