Fibrous lesions of bones

A nonossifying fibroma of the femoral neck treated with curettage and dynamic hip screw with free fibular bone graft: a case report

Introduction and importance

Nonossifying fibroma (NOF) is a benign fibrogenic lesion that is related to dysfunctional ossification and one of the most common benign bone tumors in childhood with incidence rate of 30-40% of skeletally immature children.

Presentation of case

A 25-year-old female with left hip pain for the past 2 months, which was treated conservatively, presented with severe pain in the hip. X-ray showed a pathologic fracture in the neck of the femur with underlying lesion. MRI showed an osteolytic lesion in neck of the femur. Curettage of the lesion was done with free fibular bone graft and stabilized by Dynamic Hip Screw and specimen sent to pathology. The pathology report consisted with NOF. No-weight bearing for 8 weeks with physical rehabilitation were ordered and six months later the patient had a full range of motion and healed fracture.

Clinical discussion\Conclusion

This study revealed that the surgical treatment with bone graft for pathologic femoral neck fracture and underlying NOF allowed a quick return to mobility and can be fixed sufficiently to achieve excellent postoperative recovery.

The 'Eye Mask Sign' in Fibrous Dysplasia on 99mTc-MDP Skeletal Scintigraphy and SPECT/CT

Fibrous dysplasia (FD) is a fibro-osseous disorder that manifests with distinct or overlapping clinical patterns. FD may be monostotic or polyostotic and commonly associated with syndromes such as McCune-Albright syndrome and Mazabraud syndrome. We report a case of polyostotic FD with bilateral involvement of craniofacial bones in a distinct pattern and propose this characteristic appearance as the 'eye mask sign' on 99mTc-Methylene Diphosphonate (MDP) skeletal scintigraphy and SPECT/CT. Other unusual skeletal scintigraphic features noted in this case are also described (Figs. 1, 2, and 3).

Bone Tumor Risk Stratification and Management System: A Consensus Guideline from the ACR Bone Reporting and Data System Committee

The assessment and subsequent management of a potentially neoplastic bone lesion seen at diagnostic radiography is often complicated by diagnostic uncertainty and inconsistent management recommendations. Appropriate clinical management should be directed by risk of malignancy. Herein, the ACR-sponsored Bone Reporting and Data System (Bone-RADS) Committee, consisting of academic leaders in the fields of musculoskeletal oncology imaging and orthopedic oncology, presents the novel Bone-RADS scoring system to aid in risk assignment and provide risk-aligned management suggestions. When viewed in the proper clinical context, a newly identified bone lesion can be risk stratified as having very low, low, intermediate, or high risk of malignancy. Radiographic features predictive of risk are reviewed include margination, pattern of periosteal reaction, depth of endosteal erosion, pathological fracture, and extra-osseous soft tissue mass. Other radiographic features predictive of histopathology are also briefly discussed. To apply the Bone-RADS scoring system to a potentially neoplastic bone lesion, radiographic features predictive of risk are each given a point value. Point values are summed to yield a point total, which can be translated to a Bone-RADS score (1-4) with corresponding risk assignment (very low, low, intermediate, high). For each score, evidence-based and best practice consensus management suggestions are outlined. Examples of each Bone-RADS scores are presented, and a standardized diagnostic radiography report template is provided.

Edema-like marrow signal intensity (ELMSI) associated with nonossifying fibroma (NOF) on MRI: an uncommon finding in a common bone lesion

OBJECTIVE

To investigate the association between nonossifying fibroma (NOF) and perilesional edema-like marrow signal intensity (ELMSI) on MRI and discuss the clinical and diagnostic implications of this finding.

MATERIALS AND METHODS

A retrospective search for "nonossifying fibroma" and "NOF" on knee MRI reports of patients up to 20 years of age over a 5-year period was performed. A total of 77 patients (34 males, 43 females, ages 11-20) were identified, and each MRI was reviewed to evaluate for ELMSI associated with the NOF. Statistical analysis was performed to determine if there was a correlation with the presence of perilesional ELMSI and age, gender, lesion size, or signal characteristics.

RESULTS

Twelve patients out of 77 (16%) had ELMSI associated with a NOF. Excluding patients who had additional findings of pathologic fracture (n = 2), a known potential complication of NOFs, and edema related to an adjacent osteoid osteoma (n = 1), a total of 9 patients (12%) had otherwise unexplained perilesional ELMSI. There was no statistically significant difference between patients with vs. without perilesional ELMSI with respect to age (p = 0.08), gender (p = 0.28), lesion size (p = 0.52), or appearance on fluid-sensitive sequences (p = 0.81).

CONCLUSION

ELMSI can be seen about NOFs encountered around the knee joint on MRI, which may represent active healing and/or involutional change of this "do not touch" lesion in cases where no other explanation is identified.

Hydatid disease (Echinococcosis granulosis) diagnosis from skeletal osteolytic lesions in an early seventh-millennium BP forager community from preagricultural northern Vietnam

OBJECTIVES

Con Co Ngua is a complex, sedentary forager site from northern Vietnam dating to the early seventh millennium BP. Prior research identified a calcified Echinococcus granulosis cyst, which causes hydatid disease. Osteolytic lesions consistent with hydatid disease were also present in this individual and others. Hydatid disease is observed in high frequencies in pastoralists, and its presence in a hunter-gatherer community raises questions regarding human-animal interaction prior to farming. The objective of this article is to identify and describe the epidemiology of hydatid disease in the human skeletal assemblage at Con Co Ngua.

MATERIALS AND METHODS

One hundred and fifty-five individuals were macroscopically assessed for lesions. Of these, eight individuals were radiographed. Hydatid disease was diagnosed using a new threshold criteria protocol derived from clinical literature, which prioritizes lesions specific to the parasite.

RESULTS

Twenty-two individuals (14.2%) presented with osteolytic lesions consistent with hydatid disease, affecting the distal humerus, proximal femur and forearm, and pelvis. Seven individuals radiographed (4.5%) had multilocular cystic lesions strongly diagnostic for hydatid disease. All probable cases had lesions of the distal humerus. The remaining lesions were macroscopically identical to those radiographed and were considered possible cases.

DISCUSSION

While hydatid disease has previously been found in pre-agricultural communities, the high prevalence at Con Co Ngua is non-incidental. We propose that the presence of wild canids and management of wild buffalo and deer increased the risk of disease transmission. These findings further reveal subsistence complexity among hunter-gatherers living millennia prior to the adoption of farming in Southeast Asia.

Non-ossifying Fibroma Pathological Fracture in a Patient With Lactose Intolerance

Non-ossifying fibroma (NOF) is a frequently occurring benign tumor of children and adolescents. In the long bones, it appears as an eccentric, expanded lesion in the metaphyseal diaphyseal area. Most cases are asymptomatic and resolve at a later age while others might become symptomatic and have a high risk of fracture. We present a case of a 15-year-old boy who is known to have lactose intolerance, suffered a pathological fracture following trauma, and was diagnosed with non-ossifying fibroma of the proximal tibia. The etiology of these lesions is not well-known. However, there might be a relation between tendons and NOF. This reported case of NOF is in the proximal tibia, which is a common site of the lesion beside the distal femur. Our reported case was treated by open curettage and grafting, which is the recommended classical treatment. On follow-up, full union was achieved without complications.

Osteosarcomatous Transformation in Mazabraud Syndrome: A Case Report

Mazabraud 증후군은 다골성 섬유성 이형성과 근육 내 점액종이 동반되는 매우 드문 양성 질환이다. 섬유성 이형성에서 악성 변환이 일어나는 경우는 약 1%로 알려져 있고, Mazabraud 증후군의 섬유성 이형성에서 발생한 골육종으로 악성 변환에 대한 보고는 아직까지 전 세계에 8예에 불과하다. 저자들은 Mazabraud 증후군 환자에서 섬유성 이형성이 있었던 경골에 골육종이 발생한 증례를 경험하였기에 영상 소견을 중심으로 대한민국에서 처음으로 보고한다.

Possible Novel Treatment Modality for Non Ossifying Fibroma Neck of Femur

Nonossifying fibromas (NOFs) are benign bone tumors occurring in the second decade of life. Most of the NOFs are diagnosed incidentally on the basis of its presentation on plain radiographs where they typically appear as small, cortical osteolytic lesions with sclerotic margin. They are mostly asymptomatic but can result in pathologic fractures if the lesion involves more than 50% of bone diameter. They are mostly treated with curettage and bone grafting. But in challenging situations where the classical surgery has failed or there is impending fracture of the neck of femur, bone structural support is needed. We are discussing two cases diagnosed as NOFs of intracapsular femoral neck. Both cases underwent curettage of tumor followed by free vascularized fibular graft. Results in both the cases were very gratifying, with complete resolution of symptoms during 1 year of follow-up.

Nonossifying Fibromas: A Computed Tomography-based Criteria to Predict Fracture Risk

BACKGROUND

Nonossifying fibroma (NOF) is the most common benign osseous lesion in children; however, our understanding of which lesions progress to a fracture remains unclear. In this study, we seek to formulate a classification system for NOFs to assess for fracture risk and determine what this classification system tells us regarding fracture risk of the distal tibia and distal femur NOFs.

METHODS

Charts were retrospectively reviewed for patients with NOFs. A 4-point criteria was created and used to calculate fracture risk for distal tibia and distal femur NOFs. The analysis included incidence, specificity, and sensitivity.

RESULTS

One point was given for each of the following findings on computed tomography (CT) scan: (1) >50% width on coronal view; (2) >50% width on sagittal view; (3) any cortical breach; (4) lack of a neocortex. In total, 34 patients with NOFs of the distal tibia had CT scans, of which 14 fractured. Zero with a 0- or 1-point score fractured, 2 with a 2-point score fractured (20%), 4 with a 3-point score fractured (44%), and 8 with a 4-point score fractured (100%). Sensitivities of 1-, 2-, 3-, and 4-point scores were 100%, 100%, 85.7%, and 57.1%, respectively, and specificities were 71.4%, 71.4%, 80%, and 100%, respectively. A total of 41 patients with NOFs of the distal femur had CT scans, of which 5 fractured. Zero with a 0-point score fractured, 1 with a 1-point score fractured (4%), 0 with a 2-point score fractured, 1 with a 3-point score fractured (20%), and 3 with a 4-point score fractured (100%). Sensitivities of 1-, 2-, 3-, and 4-point scores were 100%, 80%, 80%, and 60%, respectively; and specificities were 60%, 87.8%, 90%, and 100%, respectively.

CONCLUSIONS

Our 4-point CT criteria is easy to apply and identifies patients at high risk of fracture, helping surgeons make decisions regarding treatment.

LEVEL OF EVIDENCE

Level IV-prognostic study.

Bone tumours around the elbow: a rare entity

Bone tumours around the elbow are rare. Even nowadays diagnostic dilemmas and delays are common. During recent decades the management and prognosis of patients with elbow bone tumours has improved significantly.Benign tumours can be treated using minimally invasive procedures, whereas malignant ones require a multidisciplinary team approach based on an adjuvant therapeutic regimen of chemotherapy, radiotherapy and limb salvage procedures.This article reviews the most commonly encountered elbow bone tumours and their management. Cite this article: EFORT Open Rev 2019;4:133-142. DOI: 10.1302/2058-5241.4.180086.

The aetiology of the non-ossifying fibroma of the distal femur and its relationship to the surrounding soft tissues

PURPOSE

We aim to retrospectively evaluate patients with non-ossifying fibroma (NOF) of the distal femur by radiographs, CT and MRI, and to provide a theory describing the reasoning for the distal femur NOF's location and aetiology.

METHODS

Charts of patients with NOFs between 2003 and 2014 were retrospectively reviewed. Inclusion criteria encompassed a diagnosis of NOF of the distal femur by imaging, and histologically, if available. Radiographs, CT and MRI were used to characterise the relationship of the NOF lesions with the surrounding soft tissues.

RESULTS

The 68 NOFs from 60 patients were included. By radiograph, 41 (60.3%) of the 68 lesions appeared at the medial and 25 (36.7%) at the lateral aspect of the distal femur. In total, 41 lesions had CT scans, showing 22 NOFs (53.7%) attached to the origin of the medial gastrocnemius, 12 (29.3%) to the origin of the lateral gastrocnemius and four (9.8%) at the attachment of the adductor magnus. Of the CT scans, 93% identified the NOF's relationship with an adjoining tendon of the distal femur. Six had MRIs, all of which showed attachment at the medial gastrocnemius.

CONCLUSION

The study reveals a relationship between tendinous structures and NOFs. NOFs of the distal femur occur most commonly at the origin of the medial and lateral gastrocnemius. They may originate from the physis/metaphysis but they do not always attach to the physis, as we observe them 'migrating' as patients grow. More research is required to understand the exact aetiology of NOFs.

Non-ossifying fibroma: natural history with an emphasis on a stage-related growth, fracture risk and the need for follow-up

Background

The aim of this study was to assess and present the radiological morphology of the non-ossifying fibroma (NOF), to describe the life span according to the Ritschl-stages in an effort to determine critical stages with regard to pathological fractures and discuss the need for a follow-up.

Methods

Reports of a consecutive series of 87 patients with 103 NOFs and a mean follow-up of 27 months were analysed according to the Ritschl-stages with regard to age at time of diagnosis, localisation, duration of stage and symptoms.

Results

Mean patient age in our series was 20 years and lesions most frequently affected the long bones of the lower extremity. Nineteen lesions were categorized in stage A, 53 in stage B, 17 in stage C and 14 in stage D. Most lesions were detected incidentally. In six of ten clinically symptomatic patients with an average age of ten years a pathological fracture occurred, and four of them were located in the tibia. All of these were in stage B with a mean length of 44 mm, an average expansion in relation to the bone-diameter of 75 % in transversal and 87 % in sagittal plane. Duration of the stages was variable. In the critical stage B the mean was 21 months.

Conclusion

The non-ossifying fibroma follows a characteristic radiomorphological course with variable duration of each stage. Stage B lesions were found to be at an increased risk of fracture, and the age range over which fractures occur was wide. No fractures were detected in the other three stages. Follow-up, including clinical survey and imaging, at six to twelve month intervals may therefore be considered in the case of larger stage B lesions until stage C is reached.

The myriad of diseases that present with polyostotic bone lesions

Many diseases result in polyostotic bone lesions including benign entities, benign entities with malignant potential, intermediate entities, and malignant entities. Imaging plays a key role in identifying complications of these disorders, most importantly malignant transformation of a benign lesion. The most common polyostotic bone lesions are reviewed and examples of malignant transformation are highlighted.

Tibial cortical lesions: a multimodality pictorial review

Shin pain is a common complaint, particularly in young and active patients, with a wide range of potential diagnoses and resulting implications. We review the natural history and multimodality imaging findings of the more common causes of cortically-based tibial lesions, as well as the rarer pathologies less frequently encountered in a general radiology department.

Non-ossifying fibroma mimicking distant metastasis of osteosarcoma on (99m)Tc-methylene diphosphonate bone scintigraphy: Diagnosis with single photon emission tomography/computed tomography

Non-ossifying fibromas (NOFs) are benign bone lesions with variable appearance on bone scintigraphy. Single photon emission tomography/computed tomography (SPECT/CT) can help in accurate characterization of these lesions. We present a case of 14-year-old boy with recurrent osteosarcoma where NOF was mimicking distant metastasis on ^99mTc-methylene diphosphonate bone scintigraphy. SPECT/CT was able to correctly characterize the lesion as NOF, thereby altering the management.

Incidental findings on knee radiographs in children and adolescents

Background

Despite the wide use of knee radiography in children and adolescent patients visiting the outpatient clinic, there has been no analysis about the prevalence and type of incidental findings yet. This study was performed to investigate the incidental findings on knee radiographs in children and adolescents according to age.

Methods

A total of 1,562 consecutive patients younger than 18 years of age were included. They who visited Seoul National University Bundang Hospital's outpatient clinic with a chief complaint of knee pain or malalignment between 2010 and 2011. We reviewed the knee radiographs and analyzed the prevalence and type of incidental findings, such as metaphyseal lucent area, epiphyseal cortical irregularity, osteochondroma and Harris growth arrest line.

Results

The mean age of the patients was 10.2 years (range, 1 month to 18 years). We identified 355 incidental findings in 335 patients (21.4%) and 98 abnormal findings (6.3%). The most common incidental finding was metaphyseal lucent area (131, 8.4%), followed by epiphyseal cortical irregularity (105, 6.7%), Harris growth arrest line (75, 4.8%), and osteochondroma (44, 2.8%). An epiphyseal cortical irregularity tended to have a higher prevalence at younger age (p < 0.001) and the prevalences of metaphyseal lucent area and Harris growth arrest line were also higher at a younger age (p = 0.001 and p < 0.001, respectively). However, the osteochondroma tended to have a higher prevalence at an older age (p = 0.004).

Conclusions

This study describes the incidental findings on knee radiographs in children and adolescents and provides effective information from a viewpoint of an orthopedic doctor. The authors recommend considering those incidental findings if unfamiliar findings appear on a knee radiograph in the pediatric outpatient clinic.

Fibrous dysplasia of the maxilla: diagnostic reliability of the study image. Literature review

Objective Fibrous dysplasia (FD) is a benign bone disorder in facial bones. This study evaluates the possibility of diagnosing fibrous dysplasia on imaging alone, without biopsy of the lesion, which is often burdensome for the patient. Materials and Methods The authors bring their experience of four cases of bone lesions of the maxillofacial region and present a review of published studies. The imaging techniques evaluated are computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast. Results The literature review demonstrates that it is impossible to make diagnosis of fibrous dysplasia exclusively by imaging. Radiographic images often show a ground-glass appearance, which is characteristic but not pathognomonic of fibrous dysplasia. Conclusion Although CT and MRI images may in many cases suggest a diagnosis of fibrous dysplasia, histological examination or follow-up imaging should follow.

Imaging characteristics of benign, malignant, and infectious jaw lesions: a pictorial review

OBJECTIVE

The purpose of this article is to describe the indications and appropriate imaging studies for various jaw tumors and tumorlike lesions, the imaging findings, the differential diagnosis, and appropriate treatment options.

CONCLUSION

It is important for radiologists to recognize the indications and appropriate imaging studies for various jaw lesions. Radiography is typically used for first-line imaging. If necessary, it is followed by CT for evaluation of osseous lesions and MRI for characterization of soft-tissue lesions.

A case of craniofacial polyostotic fibrous dysplasia

We present the case of a patient with craniofacial polyostotic fibrous dysplasia. Polyostotic fibrous dysplasia is relatively rare and usually presents in late childhood/early adulthood. It is occasionally associated with endocrine disorders such as McCune-Albright syndrome. The benign pathology of this bone tumor belies its implications in the region of the skull base. Craniofacial polyostotic fibrous dysplasia can have devastating complications depending on which ostia are involved, including vision loss. Our patient was already beginning to experience visual field deficits from ischemic neuropathy. He was treated surgically with optic nerve decompression; however, the efficacy of this approach is currently being debated.

Magnetic resonance imaging appearances of fibrous dysplasia

Fibrous dysplasia is a developmental disorder in which normal bone marrow is replaced by fibro-osseous tissue. The radiographic, CT and scintigraphic appearances of this condition are well known. The MRI appearances of fibrous dysplasia have not been widely published. The lesions are largely isointense with areas of hypointensity on T(1) weighted images and appear heterogeneously hyperintense on T(2) weighted images. The enhancement pattern is patchy central, rim, homogeneous, or a combination. The MRI features reflect the variable tissue components of this entity. This pictorial review aims at highlighting the MRI appearances, with pathological correlation.

Fibrous dysplasia

Fibrous dysplasia is a developmental disorder of bone that can present in a monostotic or polyostotic form. Primarily affecting adolescents and young adults, it accounts for 7% of benign bone tumors. Many of the asymptomatic lesions are found incidentally; the remainder present with symptoms of swelling, deformity, or pain. Fibrous dysplasia has been associated with multiple endocrine and nonendocrine disorders and with McCune-Albright and Mazabraud's syndromes. The etiology remains unclear, but molecular biology suggests a mutation in the G(s)alpha subunit and activation of c-fos and other proto-oncogenes. Fibrous dysplasia has a characteristic radiographic appearance. Most cases do not require intervention, but those that do usually are managed surgically with curettage, bone grafting, and, in some cases, internal fixation. When some intervention is necessary but surgery is not practical, treatment is with bisphosphonates. The prognosis generally is good, although poor outcomes are more frequent in younger patients and in those with polyostotic forms of the disease. The risk of malignant transformation is low.

Non-ossifying fibroma of the spine

Non-ossifying fibroma of the spine is a rare disease: three cases have been reported in adults. We report a 17-year-old boy who had an asymptomatic osteolytic lesion of the body of the 1st lumbar vertebra. There were several radiolucent areas with sclerotic margins. The radiologic diagnosis of a non-ossifying fibroma was made. The histologic findings confirmed the diagnosis. Four years after the initial examination, the 1st lumbar vertebra appeared almost normal.

MR appearance of distal femoral cortical irregularity (cortical desmoid)

PURPOSE

Our goal was to describe the MR appearance of distal femoral cortical irregularity (DFCI).

METHOD

With plain radiographs and MR images of 100 knees, the presence of DFCIs was determined, and the shapes of DFCIs were classified into three subgroups: concave, convex, and divergent cortical shapes. Radiographic and MR shapes of DFCIs were compared.

RESULTS

DFCIs were shown in various shapes on both the radiographs and the MR images. Forty-four DFCIs were found both on radiograph and by MR image. An additional 14 DFCIs were identifiable only on MR images. However, the majority of DFCIs showed an association between radiographic and MR shapes. MRI revealed that all 58 DFCIs were located at the attachment site of the medial gastrocnemius muscle. DFCIs were enhanced in three of the four patients who underwent postcontrast MR study.

CONCLUSION

A good understanding of radiographic and MR findings of the DFCI may be of great help in the differential diagnosis of distal femoral lesions.