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Differential Diagnosis of Bone Lesions by Age
Differential Diagnosis of Bone Lesions by Age
While malignant bone tumors (bone cancers) are very rare, benign bone tumors (tumours) are actually quite common. In one estimate nearly 40% of people walk around with some kind of bone tumor (tumour) - and they are very common in children. Obviously the vast majority of these must be benign with no treatment being necessary.
Birth to 5 Years
Benign Tumors: Eosinophilic granuloma
Malignant Tumors: Leukaemia, Metastatic neuroblastoma
Tumor-like Conditions: Osteomyelitis, Non-accidental injury
5 to 15 Years
Benign Tumors: Unicameral bone cyst, Osteochondroma, Aneurysmal bone cyst, Osteoid osteoma, Enchondroma, Non-ossifying fibroma, Chondromyxoid fibroma, Chondroblastoma
Malignant Tumors: Ewing's sarcoma, Osteosarcoma
Tumor-like Conditions: Fibrous dysplasia, Osteomyelitis, Osteofibrous dysplasia, Stress fracture
15 to 20 Years
Benign Tumors: Unicameral bone cyst, Osteochondroma, Osteoid osteoma, Aneurysmal bone cyst, Nonossifying fibroma, Giant cell tumor, Enchondroma, Chondroblastoma, Chondromyxoid fibroma
Malignant Tumors: Osteosarcoma, Ewing's sarcoma
Tumor-like Conditions: Fibrous dysplasia, Stress fracture
20 to 50 Years
Benign Tumors: Giant cell tumor, Enchondroma
Malignant Tumors: Chondrosarcoma
Tumor-like Conditions: Fibrous dysplasia
Above 50 Years
Benign Tumors: Brown tumors
Malignant Tumors: Metastasis, Chondrosarcoma, Malignant fibrous histiocytoma, Parosteal osteosarcoma
Tumor-like Conditions: Degenerate cysts, Metabolic disease
Challenges of Benign Bone Tumors
Challenges of Benign Bone Tumors
The clinical management of benign bone tumors involves addressing several distinct structural and physiological challenges:
Interference of bone growth: Disruption of the growth of the bone of origin (e.g., unicameral bone cysts, osteochondroma).
Interference of neighboring bones: Physical displacement or impingement on adjacent structures (e.g., osteochondroma).
Pathological Fracture: A significant tendency for the weakened bone to fracture under normal physiological load (e.g., unicameral bone cysts).
Pain: Specifically inflammatory pain that is unrelated to fracture risk (e.g., osteoid osteoma or osteoblastoma).
Diagnostic Ambiguity: A tendency to be misidentified as malignant tumors (e.g., osteoid osteoma appearing as Ewing's sarcoma).
Aggressive Bone Destruction: Localized destruction of the bone matrix in aggressive lesions (e.g., Giant cell tumors).
Malignant Transformation: The potential for benign lesions to evolve into malignancy (e.g., osteochondroma, enchondroma, and giant cell tumor).
Figure. Depending on where the tumor appears on the long bone we can make the diagnosis in up to 90% of cases with a plain x-ray
It is often more difficult to offer a cogent argument for or against a treatment modality then the case with malignant disease - because it is benign there is a tendency to feel that intervention is unnecessary. While often true, some of the risks, especially of fractures and a tendency for intractable pain make observation sometimes difficult.
Finally, while these benign bone tumours are very common they usually happen in children. Some of them do not have tumours ultra-structural features and may be better referred to as 'tumor-like' lesions as they are probably developmental in origin. These tumor-like lesions include the entities fibrous dysplasia and unicameral bone-cysts and often present with the problem of fracture risk.
Enclosed here are a number of benign conditions we have managed over the years that give but a sampling of the typical approaches that become necessary in their management.
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