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Staging of Bone Tumors: A Review with Illustrative Examples

Gregory S. Stacy1, Ravinder S. Mahal1,2 and Terrance D. Peabody3

1 Department of Radiology, University of Chicago, 5841 S Maryland Ave., MC2026, Chicago, IL 60637.
2 Present address: Department of Radiology, Mayo Clinic, Scottsdale, AZ.
3 Department of Orthodaedic Surgery, University of Chicago, Chicago, IL 60637.


Figure 1
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  		Fig. 1 —11-year-old girl with fibroxanthoma (i.e., nonossifying fibroma). Note benign characteristics of lesion: narrow zone of transition, intact cortex, lack of periostitis, and lack of soft-tissue mass.

 

Figure 2
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  		Fig. 2 —12-year-old girl with osteosarcoma. Note malignant characteristics of lesion: wide zone of transition, aggressive periostitis, and soft-tissue extension.

 

Figure 3
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  		Fig. 3A —58-year-old man with osteosarcoma. Radiograph shows poorly defined radiolucency in proximal femoral diaphysis. Accurate measurement of lesion length is not possible.

 

Figure 4
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  		Fig. 3B —58-year-old man with osteosarcoma. Fat-suppressed T2-weighted coronal MR image of proximal femur better reveals extent of lesion (arrowheads), which is well over 8 cm in length. This finding would be classified as T2 using revised American Joint Committee on Cancer staging system [17].

 

Figure 5
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  		Fig. 4A —24-year-old woman with telangiectatic osteosarcoma. Radiograph shows poorly defined radiolucency in proximal tibia.

 

Figure 6
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  		Fig. 4B —24-year-old woman with telangiectatic osteosarcoma. T1-weighted coronal MR image shows hemorrhagic tumor (arrowheads) in proximal tibia without soft-tissue extension, making it intracompartmental; it would be classified as T1 using Enneking staging system [14]. Tumor is greater than 8 cm in length and would be classified as T2 using revised American Joint Committee on Cancer staging system [17].

 

Figure 7
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  		Fig. 5A —20-year-old woman with parosteal osteosarcoma. Radiograph shows ossified mass along posterior aspect of distal femoral metadiaphysis.

 

Figure 8
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  		Fig. 5B —20-year-old woman with parosteal osteosarcoma. T2-weighted sagittal MR image shows low-signal-intensity mass (arrow) abutting posterior surface of distal femur. No intramedullary invasion is evident. This finding would be considered intracompartmental and classified as T1 using Enneking staging system [14].

 

Figure 9
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  		Fig. 6A —6-year-old girl with Ewing's sarcoma. Radiograph shows aggressive lesion of distal femur.

 

Figure 10
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  		Fig. 6B —6-year-old girl with Ewing's sarcoma. T2-weighted MR image with fat suppression shows abnormal hyperintense signal in marrow of femur with associated soft-tissue mass (arrowhead); such extension constitutes extracompartmental spread and would be classified as T2 using Enneking staging system [14].

 

Figure 11
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  		Fig. 7A —16-year-old boy with parosteal osteosarcoma. Radiograph shows ossified mass along distal femoral diaphysis.

 

Figure 12
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  		Fig. 7B —16-year-old boy with parosteal osteosarcoma. T1-weighted sagittal MR image shows tumor abutting posterior surface of distal femur (white arrow) with extension into medullary cavity (black arrow); such extension constitutes extracompartmental spread and would be classified as T2 using Enneking staging system [14].

 

Figure 13
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  		Fig. 8 —16-year-old boy with osteosarcoma. Fat-suppressed T2-weighted coronal image with wide field of view shows primary tumor in proximal tibia (arrow). Note skip metastasis (arrowhead) in tibial diaphysis distally. This finding would be classified as T3 using revised American Joint Committee on Cancer staging system [17].

 

Figure 14
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  		Fig. 9A —17-year-old boy with metastatic osteosarcoma. Arm radiograph shows osteosarcoma of proximal humerus with large soft-tissue mass.

 

Figure 15
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  		Fig. 9B —17-year-old boy with metastatic osteosarcoma. Axial CT image through thorax shows multiple pulmonary metastases, some with mineralization (arrow).

 

Figure 16
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  		Fig. 10A —11-year-old girl with metastatic osteosarcoma. Forearm radiograph shows osteosarcoma of ulnar diaphysis (arrowhead).

 

Figure 17
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  		Fig. 10B —11-year-old girl with metastatic osteosarcoma. Skeletal scintigram shows increased radiotracer activity in ulnar diaphysis (white arrowhead), corresponding to primary tumor, and increased activity in contralateral distal femur (black arrowhead) adjacent to physis.

 

Figure 18
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  		Fig. 10C —11-year-old girl with metastatic osteosarcoma. Knee radiograph shows histologically confirmed osteosarcoma metastasis (arrowhead) in distal femoral metaphysis.

 

Figure 19
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  		Fig. 11A —12-year-old boy with chondroblastoma. Knee radiograph shows radiolucent lesion with sclerotic margins (white arrowheads) in epiphysis of distal femur and with probable extension into metaphysis (black arrowhead).

 

Figure 20
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  		Fig. 11B —12-year-old boy with chondroblastoma. T1-weighted coronal MR image of knee better depicts transphyseal extension of chondroblastoma (arrow).

 

Figure 21
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  		Fig. 12A —50-year-old man with giant cell tumor of bone. Wrist radiograph shows slightly expansile radiolucent lesion of distal radius extending to articular surface.

 

Figure 22
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  		Fig. 12B —50-year-old man with giant cell tumor of bone. Fat-suppressed T1-weighted coronal MR image of wrist after IV administration of gadolinium chelate shows giant cell tumor with soft-tissue extension (arrow).

 

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