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Computed tomography (CT) -guided bone biopsy is a diagnostic procedure performed on the musculoskeletal system with a high diagnostic yield and low complications. However, CT-guided bone biopsy has the disadvantage that it is difficult to confirm the presence of tumor cells during the biopsy procedure. Recently, the clinical benefits of dual-energy CT (DECT) over single-energy CT have been revealed. DECT can provide material decomposition images including calcium suppression images, and effective atomic number (Zeff) and electron density (ED) maps. ED maps have been reported to indicate cellularity. A 61-year-old woman with a history of breast cancer surgery was admitted to our hospital and underwent a CT-guided bone biopsy of the right ilium using ED maps. As a result, she was diagnosed with breast cancer metastases of intertrabecular bone. A comparison of ED maps with a pathological specimen revealed that high ED values occurred exclusively in the tumor area with high cellularity. This study indicates that ED maps produced using DECT may have potential utility in the accurate identification of metastases with high cellularity in bone lesions.

Aneurysmal bone cyst is a benign highly vascular lesion that occurs in children. Traditionally ABCs were treated by surgical resection. However, lesions at difficult to access anatomical locations such as the pelvis have higher morbidity when treated surgically. Recently with the advances in endovascular treatment selective arterial embolization became a promising option for primary treatment of ABC. The authors present a case of a 14-year-old female with a pelvic ABC that was successfully treated by selective arterial embolization. Selective arterial embolization is a cost-efficient way of managing ABC especially in cases where surgical treatment carries high risk.

Cherubism is a rare, non-neoplastic, genetic disorder, characterized by painless bilateral swelling of the jaws. A 5-year-old girl presented with a painless, bilateral symmetrical swelling of both mandible and maxilla. Intraoral examination revealed malocclusion with displacement of teeth and expansion of the alveolar ridges. There was a bilateral expansion of the jaws. In conclusion, cherubism is a genetic disorder that has non-neoplastic bone lesions that affect the jaws. If there is a functional or esthetic problem, it should be treated surgically. The surgical treatment is usually delayed until after puberty. Keywords: Cherubism, Multilocular radiolucency, Jaw expansion, Imaging, Computed tomography

The characteristics of patients with RRMM in the real-world setting often differ from those enrolled in clinical trials, challenging therapeutic decisions in day-to-day practice. We retrospectively analyzed the sociodemographic and clinical characteristics of RRMM patients treated in routine clinical practice and their influence on the prescribing patterns in this setting. Treatment patterns among 276 RRMM patients from multiple hospitals were highly heterogeneous. The prescribed regimen was primarily influenced by the number of previous lines and the presence of osteopenia and extramedullary plasmacytomas. Our results rise awareness on the heterogeneity of the therapeutic landscape of RRMM in the real-world and highlight the complexity of therapeutic decision making in this population. Introduction: Treatment of relapsed and/or refractory multiple myeloma (RRMM) should be established based on multiple factors, including previous treatment and the sociodemographic/clinical characteristics of the patients. However, patients enrolled in randomized-controlled trials often do not mirror the scenario encountered in real-world practice, thus challenging therapeutic decisions in day-to-day practice. Patients and methods: This observational, cross-sectional, multicenter study aimed to investigate the sociodemographic and clinical characteristics of patients with RRMM treated in routine practice in Spain and their influence on treatment regimens. Results: The study included 276 RRMM patients (median age 69 years; no gender predominance). Seventy-four percent of patients had CRAB features at the time of study inclusion, 65.9% bone lesions, 28.7% high-risk cytogenetics, and 27.0% were at ISS stage III; 65.1% were retired and lived in urban areas (75.7%) with their relatives (85.8%); 28.7% had some dependence degree. Patients had experienced their last relapse in a median of 1.61 months before enrollment and had received a median of 2 treatment lines (range 1-10). Second-and third-line therapies were mostly based on immunomodulatory drugs, followed by proteasome inhibitors (PIs), whereas monoclonal antibodies prevailed in later treatment lines. The presence of extramedullary plasmacytomas, the absence of osteopenia, and being in the second or third treatment line (vs. later lines) significantly increased the odds of receiving PIs. Conclusions: RRMM treatment in the real-world setting is highly heterogeneous and is pr imar ily influenced by the number of previous lines. The consideration of patients' clinical and sociodemographic characteristics may support clinicians in making therapeutic decisions.

Background Radiologists have difficulty distinguishing benign from malignant bone lesions because these lesions may have similar imaging appearances. The purpose of this study was to develop a deep learning algorithm that can differentiate benign and malignant bone lesions using routine magnetic resonance imaging (MRI) and patient demographics. Methods 1,060 histologically confirmed bone lesions with T1- and T2-weighted pre-operative MRI were retrospectively identified and included, with lesions from 4 institutions used for model development and internal validation, and data from a fifth institution used for external validation. Image-based models were generated using the EfficientNet-B0 architecture and a logistic regression model was trained using patient age, sex, and lesion location. A voting ensemble was created as the final model. The performance of the model was compared to classification performance by radiology experts. Findings The cohort had a mean age of 30±23 years and was 58.3% male, with 582 benign lesions and 478 malignant. Compared to a contrived expert committee result, the ensemble deep learning model achieved (ensemble vs. experts): similar accuracy (0·76 vs. 0·73, p=0·7), sensitivity (0·79 vs. 0·81, p=1·0) and specificity (0·75 vs. 0·66, p=0·48), with a ROC AUC of 0·82. On external testing, the model achieved ROC AUC of 0·79. Interpretation Deep learning can be used to distinguish benign and malignant bone lesions on par with experts. These findings could aid in the development of computer-aided diagnostic tools to reduce unnecessary referrals to specialized centers from community clinics and limit unnecessary biopsies. Funding This work was funded by a Radiological Society of North America Research Medical Student Grant (#RMS2013) and supported by the Amazon Web Services Diagnostic Development Initiative.

Highlights • Plasma ALP could be used as a discriminating marker in presence of bone lesions in solid tumor or MM. • Multiple Myeloma, ALP values were mainly in the range of normality than those observed in patients with solid cancers and bone lesions. • Lower or normal values, should suggest further investigations such as urinary and serum electrophoresis., Introduction Bone involvement in Multiple Myeloma results from increased osteoclast formation and activity that occurs in proximity to myeloma cells. The role of Alkaline Phosphatse (ALP) in this process and the diagnostic significance of plasma levels in patients with MM are unclear. Aim To compare plasma ALP levels in patients with MM and solid cancers and metastatic lesions to the bone. Results In this observational retrospective study we enrolled 901 patients were enrolled: 440 patients (49%) with Multiple Myeloma, 461 (51%) with solid cancers. All 901 patients had bone lesions. Among patients with Multiple Myeloma, ALP values were mainly in the range of normality than those observed in patients with solid cancers and bone lesions. This difference is independent of stage, number and type of bone lesions. Conclusion This study suggests that plasma ALP has a different clinical significance in MM than in other neoplasms and could be used as a discriminating marker in presence of bone lesions. In particular, lower or normal values, should suggest further investigations such as urinary and serum electrophoresis, associated with bone marrow aspirate in case of the presence of a monoclonal component, in order to confirm or exclude a MM diagnosis.

Langerhans cell histiocytosis (LCH) is a rare disease of the myeloid precursor cells, it predominantly occurs in the skull and long bones as unifocal bone lesions. Aneurysmal bone cysts (ABC) are benign, expansive and lytic bone. Reports of secondary ABC occurring in LCH are rare, having only been reported twice in the skull. Here, we report the first case of LCH masquerading as ABC in a 14-month-old female child who presented with a rapidly growing mass in her left femur. The lesion had typical radiological features of ABC, and only histological examination revealed the presence of cells suggestive of LCH. Keywords: Langerhans cell histiocytosis (LCH), Aneurysmal bone cysts (ABC), Pediatric bone tumors, Magnetic resonance imaging (MRI), Radiograph (X-ray)

Prostate cancer is the most common non-cutaneous malignancy diagnosed in men. When it metastasizes, it usually spreads to bone and/or lymph nodes. A handful of cases have described prostatic metastases to the lung; however, this is usually in the setting of existing bone lesions [1]. Here we describe a unique case in which a patient was found to have both metastatic prostate cancer to the lung and a primary lung cancer in the absence of any other evidence of extra-prostatic disease.

Solid variant aneurysmal bone cyst is a rare benign bone lesion, representing a small fraction of all aneurysmal bone cysts. The imaging appearance and histologic features may overlap with other benign and malignant neoplasms, posing a diagnostic dilemma for clinicians, pathologists, and radiologists. We present a case of solid variant aneurysmal bone cyst of the distal fibula and review the radiologic and histologic features important for diagnosis.

CBCT is an imaging technique consisting of X-ray computed tomography, in which the x-rays are divergent, forming a cone.During 2015, a new model of CBCT, New Tom 5G XL (Verona), was used in the Radiology Department of The University of Verona, in collaboration with the Orthopaedics Department. Our study was carried out from October 2015 to October 2016 (198 patients). We compared CBCT with standard x-ray in the diagnosis of foot and anke fractures (and Lisfranc lesions), tibial plateau fractures, wrist and scaphoid fractures, elbow fractures.All patients were analyzed, of which 143 were positive or had documented bone lesions, while 55 were with no fractures seen.Of the 55 negative patients, 19 were considered positive at Standard RX, thus in 34.5% of cases the X-ray Standard examination overestimated the disease (false positive cases).Similarly, of the 143 positive patients, 21 were negative at RX, resulting in 14.6% of false negatives.We can say that if compared to standard X-ray, CBCT has higher sensitivity and specificity in the proper identification and typing of these kind of lesions, with low exposition dose if compared to MDCT.The most common rx-unrecognized fractures were in small bones of carpus and tarsus. Keywords: Fractures, CT, Scaphoid

Epithelioid hemangioma of bone is a rare vascular neoplasm with a ubiquitous distribution. To date, up to 25% epithelioid hemangioma of bone presents synchronous bone lesions. We report a unique case of epithelioid hemangioma with multifocal metachronous bone lesions without any fatal outcome observed after a long period. Importantly, a strong nuclear expression of FOSB antibody was detected by immunohistochemical analysis. In this case, the pathologic and radiologic findings are also described. We suggest that epithelioid hemangioma can present multifocal metachronous bone lesions without producing a fatal outcome.

Purpose: To investigate the utility of opposed-phase magnetic resonance imaging (OP MRI) in differentiating malignant from benign bone lesions. Materials and methods: MRI scans of musculoskeletal lesions including opposed-phase imaging sequences were reviewed by both an experienced musculoskeletal attending radiologist, and a second year radiology resident. The change in signal from IP to OP images was measured. The reviewers' evaluation of the lesions based on T1 and T2-weighted images was compared to their evaluation with inclusion of the OP sequences. Results: Twenty-seven lesions in bone were analyzed: 4 malignant primary bone lesions, 3 malignant soft tissue lesions to bone, 3 metastases from visceral malignancies, and 17 benign bone lesions. Benign lesions of bone dropped in signal on OP imaging by an average of 37.1%. Five of the benign lesions decreased in signal by less than 20%, and two increased. Malignant bone lesions dropped in signal by an average of 0.69% with one of the ten lesions showing a greater than 20% drop. When OP sequences were included, concern for malignancy decreased in benign lesions and increased in malignant lesions, for both the resident and attending. Compared with standard MRI, inclusion of these sequences increased the overall confidence in diagnosis for both reviewers. Conclusion: Opposed-phase imaging is helpful in differentiating benign from malignant lesions in bone. Confidence in diagnosis rose for both the attending and the resident as result of the inclusion of OP sequences.

The skull base is made of flat bones that separate the intracranial compartment from the extracranial head and neck. Owing to this unique location, it can be affected both by intrinsic lesions originating from the bony elements of the skull base and by lesions originating outside the skull base proper or from trapped embryonic remnants. This chapter specifically focuses on the imaging techniques, developmental anomalies, skull base lesions originating from embryonic remnants, skull base infection, and other diffuse skull base lesions. Diagnostic imaging may require the use of different techniques, most often CT, MRI, bone scintigraphy, and PET-CT and is crucial in patient’s management, as the skull base is hidden from clinical inspection. Awareness of anatomic variants is crucial in surgical planning and to avoid potential confusion with skull base lesions. Moreover, radiologists should also be familiar with embryonic abnormalities affecting the skull base. Often, their particular location and other associated imaging features can be diagnostic. Proximity with sinus cavities (sinonasal and otomastoid) and with the nasopharynx makes the skull base prone to spread of infectious processes when appropriate treatment is delayed. Skull base osteomyelitis from bacterial or fungal agents remains a diagnostic challenge, particularly in the absence of relevant clinical data, and requires a high degree of suspicion. Diffuse bone lesions affecting the skull base result from defects of endochondral ossification, which may also affect the remaining skeleton. Overall, diagnostic imaging of these conditions is similar to that of bone lesions outside the skull base and the same rules for differential diagnosis apply.

We present the case of a 35-year-old man with a hemangioma in the iliac wing that simulated an aggressive bone lesion on CT, MRI, and bone scintigraphy. On CT, the lesion, 12 cm in in maximum dimension, was expansile and septated. On MRI, the lesion was isointense with respect to muscle on T1 weighted images, and hyperintense on T2 images, with focal regions of cortical breach. Radionuclide bone scan showed increased tracer accumulation. The diagnosis was made following surgical biopsy, and the lesion was treated conservatively.

Friedrich Daniel von Recklinghausen's (1833–1910) was a German pathologist whose name is aptly associated with the most commonly occurring neurocutaneous disease. Now known as neurofibromatosis type 1, von Recklinghausen's disease was initially described by the French physician Armand Trousseau (1801–67). It was not until Recklinghausen published his detailed account of the illness in 1882 that his name became associated with the condition. Recklinghausen was a consummate scholar who became President of the University of Strasbourg. Recklinghausen's other important contributions include coining the term ‘hemochromatosis,’ describing osteitis fibrosa cystica (the bone lesions associated with hyperparathyroidism), and developing a silver nitrate stain that aids visualization of cell junctions.

Publisher Summary Imaging plays an important role in the identification and management of bone and soft tissue diseases in children. Of all the imaging techniques, radiography has been established for the longest period. The role of imaging includes confirming that a skeletal lesion is present, defining whether a lesion is single or multiple, defining the features and extent of a lesion so that a diagnosis may be made, differentiating between benign and malignant lesions where possible, and monitoring the effect of treatment and disease. One of the most popular imaging techniques is radiography. In radiography, x-rays are passed through the body; some are absorbed, the amount depending on the atomic number and thickness of the tissue through which the x-rays pass. A differential pattern of x-rays reaches the fluorescent screens of the cassette, in which is held the radiographic film. The fluorescence emitted by the screens is dependent on the incident x-rays and this fluorescence alters the silver crystals in the radiographic film. Radiographs are two-dimensional images of three-dimensional anatomical structures; therefore, two radiographic views at right angles (e.g., anteroposterior [AP] and lateral) are often required to define clearly the anatomical site and extent of a bone lesion.

IMAGING HIGHLIGHTS □ Magnetic resonance imaging (MRI) is the dominant imaging modality for determining intracompartmental and extracompartmental extent of an intraosseous tumor and its relationship to critical neurovascular structures. The routine radiograph remains the most reliable predictor of the histologic nature of a bone lesion.

This chapter discusses about toxicologic pathology of skeletal system (bones and joints). It describes various methods of examining the skeletal system, highlighting gross, histologic, histochemical, and ultrastructural examination. Acute toxicity tests are designed to determine the LD 50 dose and pathologic changes associated with acute toxicity. Test substances must produce profound skeletal alterations for bone lesions to be detected by this procedure. Because only a small amount of osseous tissue is produced or turned over during the acute toxicity test, examination of the metaphysis of a fast-growing bone will give the greatest opportunity to determine a drug related effect. During subacute (subchronic) toxicity tests, there is a greater opportunity for the test compound to have a demonstrable skeletal effect. Many chemical agents affect the skeletal system indirectly via mediator action on cell differentiation or modulation of cell function. Therefore, skeletal effects may be reflected in the rates at which cells function. In the growing animal, any study of skeletal cell function in the metaphysis must distinguish between possible drug action on longitudinal bone growth and metaphyseal cancellous remodeling. Although bone histomorphometry can detect quantitative differences that might be missed by a less rigorous histologic assessment, this methodology has its greatest value in determining mechanisms by which skeletal alterations have occurred.

Primary hyperparathyroidism HPT is associated with generalized skeletal changes, its full-blown osseous manifestations known as . osteitis fibrosa cystica. Fibrous dysplasia FD , a benign bone disorder, is differentiated from generalized fibrocystic disease caused by hyperparathyroidism. The classic triad of McCune-Albright syndrome includes polyostotic FD, patchy skin pigmentation, and sexual precocity. Other associated endocrinopathies are hyperthyroidism, Cushing's syndrome, acromegaly, and HPT. We describe a patient with severe generalized and focal bone lesions and sexual precocity. HPT was diagnosed and treated with persistence of cystic bone lesions. The similarities between HPT and FD are discussed, focusing on a possible genetically determined mechanism to explain the relationship between them. q 1999 Elsevier Science B.V. All rights reserved.

Publisher Summary This chapter describes the effects of cadmium on calcium metabolism in rats. Cadmium is known to influence several metabolic processes including calcium metabolism. It was the Itai–Itai disease that first drew attention to the harmful effects of cadmium on the skeletal system. This disease was described in Japan among middle-aged women exposed to oral cadmium contamination. The main symptoms were osteoporosis, osteomalacia, strong lumbar pains, myalgia, and renal lesions. Similar bone lesions were observed in industrial workers exposed to cadmium. Disturbances of calcium metabolism with bone lesions were produced in experimental animals by cadmium administration. The study discussed in this chapter investigated the effects of relatively low cadmium doses on some parameters of calcium metabolism in rats. In some experiments, cadmium was administered as a single toxic agent, and in others, it was combined with anticonvulsant drugs. The chapter presents the results of these experiments. The results indicate that secondary vitamin D deficiency can be an important factor in the disturbances of calcium metabolism in rats treated with cadmium.

Publisher Summary This chapter describes the diagnosis of bone swelling. The difficulties of diagnosis lie not only in distinguishing the varieties of bone swelling but also in deciding whether the condition is arising from the bone or not, which may be particularly difficult in the case of inflammatory lesions where there is surrounding edema of soft parts and very little enlargement of the bone itself. If careful palpation fails to reveal alteration in the normal bony contour in a patient where a bone lesion is suspected, then the character of any overlying soft-tissue swelling that may be present will sometimes act as a guide. If present, it involves all layers arising from the deep tissues and radiating more or less symmetrically outward. A central bone lesion will result in swelling of the whole contour of the limb in the area at fault. Pain originating in bone is deep and boring in character and often very intense. In all cases, a radiograph is essential and the differential diagnosis of many of these conditions often resolves itself into a question of interpreting the radiograph.

Publisher Summary This chapter discusses the aseptic bone necrosis in Royal Navy divers. Aseptic necrosis of bone is an occupational hazard of naval divers, and although it is reassuring to find that the incidence appears to be a lot less than it is in their civilian counterparts, an annual bone X-ray of all divers is the minimum safeguard that can be recommended. High-quality radiographs with good trabecular bone detail are essential for the detection of early lesions of bone necrosis. Of the 250 divers X-rayed by March 1969, 13 were found to have bone necrosis. It was found that eight had at least one positive lesion, five had only doubtfully positive lesions, and two had associated symptoms. The incidence of radiologically identified lesions in serving Royal Navy divers is provisionally 6%. If a diver has a positive bone lesion that is found to be juxta-articular, whether or not there are accompanying symptoms, it becomes necessary to reconsider his whole future diving career.

Publisher Summary This chapter describes the effects of radiation on bone. Both external and internal radiation might have remarkable and sometimes disastrous, although long-delayed, effects on normal bone. In the treatment of malignant conditions of both the bone itself and adjacent tissues, the risk of osteodysplasia developing later is a risk that should clearly be taken, though it must be minimized as far as possible by careful technique. How far external radiation should be used for nonmalignant conditions in the skeleton, except in old people, is questionable. Long-lived bone-seeking radioactive isotopes should not be administered for therapeutic purposes. The increasing use of radioactive isotopes in all fields of research might well result in accidental ingestion. The possibility of injury because of radiation should not be forgotten in the investigation of obscure bone lesions. Until more is known of the normal physiology of bone, there can be little understanding of its pathology.

The association of alterations in plasma state, renal handling, and kinetics of calcium and inorganic phosphate with malignant bone lesions is a well-established phenomenon. However, the pathogenesis of these alterations is not uniform.