Radiography
Lateral radiograph of the cervical spine in a 10-year-old boy. The spinous process of the C3 vertebra is expanded by a mass with ossific matrix.
Knee radiograph from a 16-year-old boy with lower leg pain. This image reveals a somewhat poorly defined and nonspecific lucent lesion in the proximal tibial metaphysis.
Radiograph of the left hip in a 14-year-old boy. This image demonstrates a lytic lesion in the intertrochanteric region of the left femur with a faint, diffuse, surrounding sclerosis. The long bones are the second most common location for osteoblastomas.
Radiograph of the right shoulder in a 39-year-old woman. This image reveals a large lytic lesion arising in the proximal part of the humerus.
Oblique view of the ankle. This radiograph reveals a lucent lesion within the talus, an uncommon location for osteoblastomas. Although this appearance is consistent for an osteoblastoma, it is nonspecific.
Anteroposterior radiographic view of the pelvis in a 14-year-old girl who presented with right hip pain. This image reveals a lucent, slightly expansile lesion in the acetabulum.
Findings
Techniques and findings
The radiographic appearances of osteoblastomas vary. Occasionally, the osteoblastoma appears as a sclerotic lesion, and in other instances, it appears as a lucent expansile lesion. Findings in as many as 25% of patients may demonstrate features that are suggestive of a malignant process, such as cortical thinning, expansion of the bone, and the presence of a soft-tissue mass.32
Osteoblastomas in the spine usually occur in the posterior elements (see Image 1). When a well-defined expansile lesion is identified in this location, a diagnosis of osteoblastoma should always be considered. Approximately 50% of osteoblastomas in the spine contain matrix mineralization.
An osteoblastoma in the skull produces a sharply marginated radiolucent defect that contains central calcification or ossification; this finding is highly suggestive of the diagnosis. Lesions in the mandible are often located near the tooth root.
The varied radiologic appearance of the neoplasm in sites other than the posterior elements of the spine and the skull does not allow a precise diagnosis (see Image 6). The appearance of the lesion may resemble a large osteoid osteoma, with the typical radiographic features of a nidus and a surrounding area of reactive bone (see Image 10). The nidus of an osteoblastoma is larger than that of an osteoid osteoma, with some investigators using 2 cm as a size distinction. If the nidus is eccentrically located in the bone, thick periosteal reaction may be prominent.
The lesions may have radiographic features that are similar to those of an aneurysmal bone cyst, eosinophilic granuloma, enchondroma, fibrous dysplasia, chondromyxoid fibroma, or solitary bone cyst. The presence of an osseous matrix within the lesion may suggest an osteoblastoma. In patients in whom osteoblastoma simulates an aggressive tumor, neoplasms such as osteosarcoma and Ewing sarcoma are included in the differential diagnosis.
Osteoblastomas in the long tubular bones may arise from the medullary or cortical bone (see Image 15). These lesions usually appear as geographic lucencies with internal calcification and/or ossification, and they often expand the cortex. The surrounding sclerosis and periostitis, seen in as many as 50% of patients, can simulate an aggressive process and may be misinterpreted as evidence of a malignant neoplasm. Osteoblastomas may be encountered in the small bones of the hands, wrists, feet, and ankles (see Images 20 and 21), as well as in the flat bones (see Images 25 and 26).
Degree of Confidence
Radiographic findings are not diagnostic of osteoblastoma in most patients; therefore, further imaging studies are warranted.
Computed Tomography
Computed tomography scan of the cervical spine in a 10-year-old boy (same patient as in Images 1-4 in Multimedia). This image reveals a lytic lesion that involves the posterior elements of the C3 vertebra. Cortical expansion of the spinous process and an ossified matrix are noted; these findings are typical and classic findings in cases of osteoblastomas.
Computed tomography scan of the left proximal femur in a 14-year-old boy (same patient as in Images 10 and 12-14 in Multimedia). This image reveals a cortically based nidus with surrounding thickened bone.
Computed tomography scan in a 39-year-old woman (same patient as in Images 15-16 and 18-19 in Multimedia). This image demonstrates faint matrix mineralization.
Axial computed tomography scan that was obtained through the tibial diaphysis. This image demonstrates how an osteoblastoma can resemble a large osteoid osteoma, with the typical radiographic features of a central nidus and surrounding reactive bone.
Findings
Techniques and findings
CT scans aid in defining the extent of the osteoblastoma (see Image 22) and in detecting the presence of matrix mineralization (see Image 5).
CT scans, similar to conventional radiographs, may demonstrate a predominantly osteolytic and expansile lesion (see Image 17), with or without central mineralization (see Image 28). The images may also show a predominantly sclerotic lesion or a mixed lesion.
The medullary or cortical location of the tumor can be well defined (see Image 11). Adjacent bony sclerosis (see Image 31), periosteal reaction, or cortical erosion may be demonstrated.
Degree of Confidence
CT scan findings may support the diagnosis of osteoblastoma that has been made with the use of plain films, increasing the interpreter's degree of confidence.
Magnetic Resonance Imaging
T1-weighted sagittal magnetic resonance image of the spine in a 10-year-old boy (same patient as in Images 1 and 3-5 in Multimedia). This image suggests the presence of a mass that involves the posterior elements of the C3 vertebra.
T1-weighted sagittal magnetic resonance image in a 16-year-old boy with lower leg pain (same patient as in Images 6-7 and 9 in Multimedia). This image demonstrates a focal lesion of low signal intensity in the right proximal tibia, with surrounding low-signal-intensity edema.
T1-weighted magnetic resonance image in a 14-year-old boy (same patient as in Images 10-11 and 13-14 in Multimedia). The lesion demonstrates low signal intensity in this image.
T1-weighted magnetic resonance image of the shoulder in a 39-year-old woman (same patient as in Images 15-17 and 19). This image reveals a lesion of low signal intensity in the right proximal humerus. Note the extension of the predominantly metaphyseal tumor into the epiphysis. The pathologic specimen demonstrated findings that were consistent with aggressive osteoblastoma.
T1-weighted sagittal magnetic resonance image of the left foot (same patient as in Images 20-22 and 24). This image reveals a lesion with low signal intensity in the talus.
T1-weighted coronal gadolinium-enhanced magnetic resonance image. This image demonstrates a lesion that enhances slightly, as can be seen in cases with osteoblastomas.
Findings
Techniques and findings
Similar to CT scans, MRIs can aid in defining the extent of the osteoblastoma (see Image 23). MRI is often superior to CT scanning with regard to the detection of a soft-tissue mass, although this is a relatively uncommon feature of osteoblastomas. A typical osteoblastoma has decreased signal intensity on T1-weighted images (see Images 2, 8, 18, and 29).33
In the authors' experience, the signal intensity of osteoblastomas on T2-weighted images is variable. Although, in general, the tumors are hyperintense relative to marrow on T2-weighted images (see Image 24), many osteoblastomas encountered by the authors have been heterogeneously hypointense relative to marrow on non-fat-suppressed T2-weighted images (see Image 19), presumably reflecting the ossific matrix of the lesion. On MRIs that are obtained with all sequences, the foci of signal void in the tumor likely represent internal matrix mineralization (eg, calcification or ossification).
Adjacent cortical thickening may be demonstrated (see Image 12). MRI often reveals inflammatory edema-type changes in the adjacent marrow (see Images 9 and 14) and soft tissues (see Image 4), which are particularly evident on fat-suppressed T2-weighted sequences.
Both the mass and the inflammatory reaction may enhance after the intravenous administration of gadolinium-based contrast material (see Images 3, 13, and 30).
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
Although MRI is useful for delineating the extent of osteoblastomas, the appearance of the tumors is usually nonspecific.
False Positives/Negatives
MRI findings may lead to an osteoblastoma's appearance mimicking that of a malignancy.
Ultrasonography
Findings
Currently, ultrasonography has no role in the diagnosis of osteoblastomas.
Nuclear Imaging
Bone scan in a 16-year-old boy complaining of pain (same patient as in Images 6 and 8-9 in Multimedia). This image demonstrates increased radiotracer activity in the right proximal tibia that corresponds to the site of the lesion. The increased uptake in the right distal femur is likely due to tumor-associated relative hyperperfusion of the right knee.
Bone scan in a 39-year-old woman (same patient as in Images 15 and 17-19 in Multimedia). This image demonstrates abnormal radiotracer accumulation at the anatomic site corresponding to that which is shown in the radiograph in Image 15.
Bone scan in a 14-year-old girl (same area and same patient as in Images 25-26 and 28-29 in Multimedia). This image reveals radiotracer accumulation in the patient's right hip.
Findings
Although osteoblastomas accumulate radionuclide on bone scintigraphy studies (see Images 7, 16, and 27), the scintigraphic appearance of the tumors is nonspecific.
Degree of Confidence
Osteoblastomas have a nonspecific increased uptake of bone-seeking agents. This finding adds little to increase the degree of confidence in bone scanning for the diagnosis.
False Positives/Negatives
Various lesions, such as fractures, osteomyelitis, and other bone tumors, similarly accumulate radionuclide at the site of the lesion as osteoblastomas.
Angiography
Findings
Currently, angiography has a limited role, if any, in the diagnosis of osteoblastomas.
More on Osteoblastoma |
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Further Reading
Keywords
osteoblastoma, giant osteoid osteoma, bone neoplasm, osteoid osteoma, bone tumor, primary bone tumor, benign bone tumor, benign lesion of the bone, scoliosis, matrix mineralization
