AJR 2000; 174:1729-1735
© American Roentgen Ray Society
Neoplasms of the Scapula
Marcia F. Blacksin1 and
Joseph Benevenia2
1
Department of Radiology, University of Medicine and Dentistry of New Jersey,
University Hospital, C-320, 150 Bergen St., Newark, NJ 07103-2426.
2
Department of Orthopedic Surgery, University of Medicine and Dentistry of New
Jersey, University Hospital, Newark, NJ 07103-2426.
Received August 30, 1999;
accepted after revision November 16, 1999.
Address correspondence to M. F. Blacksin.
Introduction
The scapula is a small bone in which many neoplasms can develop. Few
radiology articles report the types and appearances of these tumors. The
Musculoskeletal Tumor Society has developed a classification system for
shoulder girdle tumors that divides the scapula into two zones
[1]: the acromial—glenoid
complex comprises the S2 region and the blade—spine portion comprises
the S1 region (Fig. 1). The
system helps provide a functional classification for resections and
reconstructions and a logical division of the abnormalties that develop in the
scapula. Neoplasms of the S1 region include those that commonly develop in the
flat bones (i.e., Ewing's sarcoma, multiple myeloma, and lymphoma). Neoplasms
of the S2 region include those that commonly develop at the ends of the bone
(i.e., giant cell tumors and aneurysmal bone cysts)
[2]. We describe bone neoplasms
that develop in the scapula and present examples of these tumors on
radiographs, CT scans, and MR images.
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Fig. 1. —Drawing shows system for classification of skeletal resection,
developed by Committee of Musculoskeletal Tumor Society
[1]. S1 corresponds to scapular
blade and S2 to glenoid-acromial complex.
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Osteochondroma
Osteochondroma (Fig.
2A,2B)
is the most common primary benign neoplasm of the scapula with an incidence of
4.6% [3]. Usually, it is a
single lesion located on the anterior surface of the scapular body. Patients
with osteochondroma complain of a snapping sensation when internally rotating
and abducting their arm. Surgical resection is the treatment of choice for
osteochondroma.
Osteoid Osteoma
Osteoid osteoma is a rare tumor of the scapula with only 15 cases reported
in the literature [4]. The
location of this neoplasm remains unclear, though it has developed in the
coracoid process and the subglenoid region
[2,
4]. Most patients with osteoid
osteoma complain of night pain that can be relieved with salicylates.
Radiographic findings include sclerosis, but a nidus may be difficult to see
on radiography. CT may facilitate finding the nidus (Fig.
3A,3B,3C,3D).
Treatment includes surgical excision of the nidus
[2].
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Fig. 3A. —63-year-old man with asymptomatic osteoid osteoma.
99Tc-methyldiphosphonate bone scan obtained for prostatic cancer
metastasis screening shows focus of increased tracer uptake
(arrowhead) in lateral scapular body.
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Aneurysmal Bone Cyst
Aneurysmal bone cysts are lytic expansile lesions. They have been reported
in the coracoid (Fig.
4A,4B,4C),
a region that embryologically corresponds with the end of a long bone
[2,
5]. Fluid—fluid levels
can be seen on CT scans and MR images
[6]. These lesions usually
develop in patients that are between 11 and 30 years old. Surgical therapy
includes excision with cementation, bone grafting, or both
[2].
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Fig. 4B. —16-year-old girl with aneurysmal bone cyst after pathologic
fracture. Sagittal oblique fat-suppressed T2-weighted MR image shows
well-defined lesion (arrowhead) with large cystic component.
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Fig. 4C. —16-year-old girl with aneurysmal bone cyst after pathologic
fracture. Axial spin-echo T1-weighted MR image shows homogeneous high signal
intensity in cystic portion of lesion (arrowheads), consistent with
degraded blood products.
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Chondrosarcoma
Chondrosarcoma is the most common malignant neoplasm of the scapula, found
in both the S1 and S2 regions. These tumors have been seen in preexisting
osteochondromas [2,
7] (Fig.
5A,5B,5C,5D,5E).
Radiographs may show cortical destruction by a lesion containing a calcified
cartilaginous matrix, but the lesion can also appear lytic and expansile (Fig.
6A,6B).
This neoplasm can cause diagnostic difficulty on radiographs because the
lesion can resemble an aneurysmal bone cyst or a giant cell tumor.
Chondrosarcoma is usually seen in older patients and has not been reported to
contain fluid—fluid levels. CT may be helpful in revealing matrix
calcification and the absence of fluid levels. MR imaging can depict the
typical appearance of cartilage with a lobulated high-signal-intensity mass on
T2-weighted images. Therapy includes limb salvage procedures
[7].
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Fig. 6B. —34-year-old man with chondrosarcoma. Sagittal oblique fat-saturated
T2-weighted MR image shows large high-signal-intensity cartilage component and
infiltration of bone marrow (arrows).
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Osteosarcoma
Osteosarcoma is a frequent malignant neoplasm of the scapula
[2]. Both chondroblastic and
osteoblastic types have been reported
(Fig. 7A); however, we discuss
the telangiectatic type. Similar to the chondrosarcoma, the telangiectatic
type of osteosarcoma may be lytic and expansile (Figs.
7B,7C,7D)
and can mimic benign scapular neoplasms. We have seen the telangiectatic type
in the coracoid, but osteoblastic or central osteosarcomas are also seen in
the S1 region. Bone formation in scapular osteosarcomas is frequent, and many
tumors are associated with bulky soft-tissue masses
[8]. Patients with osteosarcoma
are usually between 11 and 30 years old
[5,
7,
8]. Neoadjuvant chemotherapy
followed by wide excision and limb salvage is commonly performed
[7].?
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Fig. 7C. —Osteosarcoma of scapula. Axial fat-saturated T2-weighted MR image of
patient in B shows heterogeneous expansile lesion (solid
arrows) with rim of high-signal-intensity edema (open arrows)
surrounding scapula.
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Ewing's Sarcoma
Ewing's sarcoma frequently develops in the pelvis and lower extremities but
it is also seen in the scapular body. This disease can have a permeative or
lytic pattern (Fig. 8A).
Similar to the appearance of this tumor in other bones, a soft-tissue mass and
periosteal reaction are frequent findings
[9] (Figs.
8B and
8C). Treatment is similar to
that of osteosarcoma with neoadjuvant chemotherapy and limb salvage
[7] (Fig. 8D).
Malignant Fibrous Histiocytoma
Malignant fibrous histiocytoma was recognized as a distinct abnormality in
the 1960s. As a primary bone tumor of the appendicular skeleton, this neoplasm
can occur at any age [10].
Fibrosarcoma has been reported in the scapula in older literature, but more
recently, only one case of primary scapular malignant fibrous histiocytoma has
been reported [8]. Our case is
also primary to the scapula with a lytic lesion
(Fig. 9A). Though regions
containing fibrous tissue can be seen on MR imaging of malignant fibrous
histiocytoma, images often show only heterogeneously increased signal
intensity on T2-weighted sequences
[11] (Figs.
9B and
9C). Treatment options are
similar to those used for osteosarcoma
[7].
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Fig. 9B. —33-year-old man with primary malignant fibrous histiocytoma of
scapula. Sagittal oblique spin-echo T1-weighted MR image shows lesion
(arrowheads) that is isointense to muscle with cortical
destruction.
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Fig. 9C. —33-year-old man with primary malignant fibrous histiocytoma of
scapula. Sagittal oblique fat-saturated T2-weighted MR image shows
heterogeneous high signal intensity with soft-tissue extension
(arrows).
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Multiple Myeloma
Multiple myeloma can appear with a honeycomb pattern or manifest as a lytic
expansile plasmacytoma [12]
(Fig.
10A,10B).
Multiple myeloma and lymphoma are tumors of adulthood that originate in the
marrow and occur in the scapula
[5]. In our patient, the
plasmacytoma occurred in the scapular body or the flat bone equivalent of the
scapula. The appearance of multiple myeloma can resemble that of a giant cell
tumor or an aneurysmal bone cyst. Treatment includes radiation therapy and
chemotherapy [7].
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Fig. 10B. —Multiple myeloma. Frontal radiograph of 80-year-old man with
honeycomb appearance of multiple myeloma in humerus, acromion, and ribs shows
discrete punched-out lesion in lateral cortex (arrowhead).
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In summary, the scapula may contain a wide range of benign and malignant
tumors, many of which have similar lytic expansile radiographic appearances.
Benign lesions such as aneurysmal bone cysts or giant cell tumors occur in the
S2 region. Common malignancies such as chondrosarcomas and osteosarcomas occur
throughout the scapula. Ewing's sarcoma, lymphoma, and multiple myeloma
frequently occur in the S1 region. With the advancement of limb salvage
procedures, it becomes incumbent on the radiologist to accurately identify
tumor extent because it dictates the type of surgery required
[1].
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Introduction
Osteochondroma
