Osteoid osteoma: from diagnosis to treatment

Poster No.: C-1513

Congress: ECR 2013
Type: Educational Exhibit
Authors: 1 2 1 1 1
E. A. Fatone , J. Tuckett , R. Sinha , G. Hide ; Newcastle Upon
2
Tyne/UK, Newcastle-upon-Tyne/UK
Keywords: Ablation procedures, Nuclear medicine conventional, MR, CT,
Oncology, Musculoskeletal system, Interventional non-vascular,
Neoplasia
DOI: 10.1594/ecr2013/C-1513

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 25
Learning objectives

1) To review the imaging features of osteoid osteoma on multiple modalities (radiographs,

CT, MRI and isotope bone scans).

2) To discuss the possible differential diagnoses and therapeutic options.

3) To illustrate clinical cases.

Background

Osteoid osteoma (OO) is a benign tumour, first described by Jaffe in 1935, usually
presenting a typical clinical and radiological picture.

Clinical characteristics:

- mostly male patients

- aged between 7 and 25 years.

- presenting with pain, most intense at night, relieved by salicylates

- skeletal deformity, muscle atrophy, growth aberrations or scoliosis in immature skeleton.

Symptoms:

- pain initially mild and variable

- later becomes more severe, persistent

- may be associated with local tenderness and soft tissue swelling

- if intra-articular can mimic monoarthritis with joint swelling, synovitis and limited range
of motion.

Skeletal distribution:

Page 2 of 25
An analysis of 661 OO cases from seven published series noted 70% of cases occurring
in long tubular bones. Approximately 30% of osteoid osteomas occur in the spine, hands,
or feet.

Long tubular bones (70%):

- approximately 50% of cases occurring in the femur and tibia.

- usually located in the diaphysis, or sometimes in the metaphyseal location in the

proximal femur.

- epiphyseal and intra-articular OO are relatively rare.

Spine, hands and feet (30%):

- typically in posterior elements (unusual in the vertebral body).

- lumbar vertebrae are most commonly affected

- small bones of the hands and feet are often densely sclerotic.

Classification:

Within a bone, OO may occur in cortex, or less frequently in a medullary or

subperiosteal location, and this may have a significant effect on the imaging
appearances.

Images for this section:

Page 3 of 25
Table 1

Page 4 of 25
Imaging findings OR Procedure details

IMAGING APPEARANCES

The diagnosis of osteoid osteoma hinges upon detection of the "nidus", a focus of bone
tissue showing variable mineralization, embedded in a highly vascular connective tissue
stroma (Fig 1).

Fig. 1: Osteoid osteoma of the humerus. Anteroposterior radiograph (left) shows a

round lucent focus representing the nidus (arrows) in the distal humerus. Unenhanced
CT coronal reconstruction (middle) and sagittal PD-FS (right) clearly depict the nidus
without significant mineralization.
References: - Newcastle Upon Tyne/UK

The nidus represents the tumour with the zone of sclerosis representing the host
bone's response to the presence of the lesion.

1. RADIOGRAPHS

Page 5 of 25
 A round or oval radiolucent focus which may contain central mineralization
known as the nidus surrounded by reactive sclerosis, which may obscure it
(Fig 2).

Fig. 2: Lateral radiograph of the distal femur (left) shows intense sclerosis of
the posterior cortex (arrows). No other abnormality seen. Axial unenhanced CT
(right) confirms sclerosis of the posterior cortex and identifies a nidus with some
mineralization (triangle).
References: - Newcastle Upon Tyne/UK
Classic cortical diaphyseal OO in long bones demonstrate a central lucent
area (nidus), usually less than 1cm in diameter surrounded by a zone of
uniform bone sclerosis (Fig 3).

Page 6 of 25
Fig. 3: AP and lateral radiographs of the proximal right tibia demonstrating a typical
cortical osteoid osteoma nidus (arrows) in the proximal diaphysis surrounded by
sclerotic reactive bone changes
References: - Newcastle Upon Tyne/UK

OO in small bones of the hands and feet are often densely sclerotic. (Fig
4).

Page 7 of 25
Fig. 4: AP radiograph showing a sclerotic osteoid osteoma nidus (arrow) in the
proximal phalanx of the index finger of a child.

Page 8 of 25
References: - Newcastle Upon Tyne/UK

Intramedullary OO are uncommon. They may be associated with cortical

and periosteal thickening (Fig 5) but medullary sclerosis around the nidus is
much less prominent such that the nidus can be very difficult to define.

Fig. 5: AP radiograph and coronal CT reconstruction showing an intramedullart

osteoid osteoma. There is a prominent circumferential periosteal reaction and a small
amount of medullary sclerosis on the x-ray. CT shows the medullary changes to
partially outline a faint central nidus (circle).
References: - Newcastle Upon Tyne/UK

2. ISOTOPE BONE SCAN

On bone scans, osteoid osteomas cause increased uptakeand lack of uptake should
cast significant doubt on diagnosis.

Bone scans are sensitive but frequently not specific and supplementary imaging is always
required.

The double density sign is a more distinctive pattern of uptake is observed

in OO, with a small central focus of high uptake surrounded by a less
intense but still abnormal region (Fig 6).

Page 9 of 25
Page 10 of 25
Page 11 of 25
Fig. 6: Isotope bone scan of osteoid osteoma of the talus. Note the intense focus of
increased uptake anteriorly with less intense uptake in the remainder of the bone
References: - Newcastle Upon Tyne/UK

This investigation carries a significant radiation dose and has largely been supplanted by
cross-section evaluation with MRI and CT.

3. MRI

On MRI the nidus may be very difficult to identify, however the frequently
intense bone marrow oedema associated with osteoid osteoma (Fig 7) is
much more easily identified.

Fig. 7: Coronal STIR MR images of a proximal femoral osteoid osteoma

demonstrating intense bone marrow oedema (star) and a joint effusion/synovitis. The
left hand image shows the nidus (arrow).
References: - Newcastle Upon Tyne/UK

Joint effusiuon and intense synovitic response in intra-articular OO (Fig

8-9).

Page 12 of 25


Fig. 8: Axial T2 weighted (left) shows the nidus (arrow) and elbow
joint effusion (dashed line). Post-contrast T1-weighted FS (right) shows
enhancement of the nidus and synovitis (block arrows).
References: - Newcastle Upon Tyne/UK

Fig. 9: Sagittal STIR MR (left) and CT (right) images of an intra-articular osteoid

osteoma of the talus (arrow). The CT image shows the calcified nidus on the dorsal
aspect of the talar neck. The MR image show intense marrow oedema in the talus and
a joint effusion/synovitis.
References: - Newcastle Upon Tyne/UK

4. CT

Page 13 of 25
 CT is the most useful imaging modality to confirm a suspected OO (fig
10).

Fig. 10: AP radiograph showing no significant abnormality (left). CT axial and coronal
reconstruction clearly show the nidus (arrows). No significant sclerosis is seen.
References: - Newcastle Upon Tyne/UK

On CT imaging, the nidus can be seen as an area of low attenuation with

a central high attenuation component, representing mineralization (fig
11).

Page 14 of 25
Fig. 11: Osteoid osteoma of the distal phalanx of the little finger. Anteroposterior
radiograph (left side) shows a round nidus (arrow) with central mineralization. Axial and
coronal unenhanced CT (right side) images show the calcified nidus (block arrows) in
the infero-medial aspect of phalanx, without reactive sclerosis.
References: - Newcastle Upon Tyne/UK

CT can carry a high radiation dose and hence the extent of tissue requiring imaging
should be carefully determined (Fig 12). Low dose CT techniques give good contrast
between the nidus and surrounding sclerotic bone on appropriate window settings.

Page 15 of 25
Fig. 12: AP radiograph of the pelvis showing sclerosis (arrows) on the medial aspect
of the proximal right femoral shaft. Targeted CT scan in this young patient confirms the
presence of sclerosis containing a nidus (dashed arrows) with central mineralization.
References: - Newcastle Upon Tyne/UK
CT is particularly helpful in areas of complex anatomy such as the pelvis and
spine (Fig 13).

Fig. 13: Axial CT images of two patients with pelvic osteoid osteoma. The image on
the left shows a nidus in the left ilium close to the anterior inferior iliac spine. The image
on the right demonstrates a nidus located deep within the acetabulum (arrow).
References: - Newcastle Upon Tyne/UK

Page 16 of 25
 Reconstructions in longitudinal imaging planes allow precise determination
of the nidus dimensions (Fig 14).

Fig. 14: Axial and sagittal CT images of a patient with an osteoid osteoma of the L5
vertebral body.
References: - Newcastle Upon Tyne/UK

DIFFERENTIAL DIAGNOSIS

OO is closely related to an essentially histologically identical tumour,

osteoblastoma.

Differentiation is most commonly made on the basis of size of the

nidus, however authors have used different thresholds as the upper limit
of size for OO varying between 1.0 cm and 2.5 cm (Fig 15). Occasionally,
osteoblastomas are more vascular, possessing more osteoblasts and less
organized than OO.

Osteoblastoma is more common in flat bones and vertebrae.

Page 17 of 25
Fig. 15: Osteoblastoma. Sagittal T1-weighted (left) and CT reconstruction
(right) showing sclerosis and a lesion measuring more than 2 cm (arrows) in the
anterior aspect of the proximal tibia. Biopsy confirmed the suspected diagnosis of
osteoblastoma.
References: - Newcastle Upon Tyne/UK

Stress fractures and other stress injuries of bone can cause similar
appearances to OO on x-rays, bone scans and MRI. CT is usually reliable
at distinguishing the rounded nidus of an OO from the linear lucency seen in
stress fracture (Fig 16) .

Page 18 of 25
Fig. 16: Coronal CT image (left) showing sclerosis in the right femur. Coronal STIR
image showing oedema in the same region of the femur. No nidus identifeid.
References: - Newcastle Upon Tyne/UK
Occasionally, a cortical abscess can cause appearances very similar to
OO and biopsy may be required to determine the diagnosis.

TREATMENT

OO are known to be self-limiting tumours, however, the unpleasant symptoms are usually
too severe and patients frequently exceed recommended doses of analgesics while
attempting to gain relief from their pain.

Surgical excision is not always straightforward, and removal of larger

amounts of bone is associated with a risk of fracture.

The ease with which CT can confirm the diagnosis and display the nidus
helped to promote the use of minimally invasive treatments and most OO
are now treated under CT guidance by percutaneous ablation, usually
radiofrequency (RFA).

RFA (Fig 17) uses an insulated needle with a conducting tip which conducts high
concentration current causing ionic heating in adjacent tissue.

Page 19 of 25
 o
For treatment of OO, a temperature of 90 C is used, typically for 6
minutes.

The area of effect is determined by the length of the non-insulated tip and in most cases,
a 1cm needle tip can be positioned such that an entire nidus can be treated with a single
ablation. Patients may suffer from pain due to thermal injury to other tissues within the
field. However, such pain is readily controlled with analgesics.

Fig. 17: Four images obtained during a CT guided radiofrequency ablation procedure
to treat a proximal femoral osteoid osteoma. 1. The bone biopsy needle being lined
up to ensure it will successfully target the nidus. Once the needle has entered the
bone, it cannot be steered and hence this phase is crucial for success. 2. The needle
advancing into the bone. The needle consists of an outer shaft and a separate inner
needle which can be removed and changed when required. At this stage, the inner
needle chosen has a drill tip which allows it to penetrate the hard bone. 3. The inner
needle drill has been swapped for a biopsy needle which allows the operator to take a
sample of the nidus for histological confirmation of the diagnosis. 4. The biopsy needle
replaced with the radiofrequency needle which performs the treatment.
References: - Newcastle Upon Tyne/UK

Most bone tumour centres offer CT guided RFA and the procedure has very
high levels of success (Table 2).

Page 20 of 25
Table 2: Results of CT guided RFA for osteoid osteomas at our Institution.
References: - Newcastle Upon Tyne/UK

Even a nidus in a technically difficult site to access can be treated (Fig 18).

Page 21 of 25
Fig. 18: CT guided RFA of osteoid osteomas in the sustentaculum tali, carefully
planning was required to approach the nidus by a safe route to avoid vulnerable
structures.
References: - Newcastle Upon Tyne/UK

RFA is not appropriate in cases where vulnerable structures lie within the ablation field,
particularly the cord and nerve roots in the spine.

Rarely, OO may recur following RFA. Further treatments may be offered

with an overall quoted success rate of 98%.

Biopsy may be performed during the RFA procedure, once access to

the nidus has been achieved and prior to insertion of the RFA needle (Fig
17). Biopsy success rates are lower than treatment rates because the biopsy
sample may suffer from severe crush artefact.

Follow up after RFA is based on symptoms with no routine imaging

necessary in asymptomatic patients. Imaging, where patients do
complain of further symptoms, may show progressive sclerosis within the
nidus (Fig 19).

Page 22 of 25
Fig. 19: Axial unenhanced CT before treatment (left) showing a round nidus in the
anterior cortex of the femur. Follow up axial CT image (right) obtained 1 year after
treatment showing complete sclerosis of the nidus indicative of healing.
References: - Newcastle Upon Tyne/UK
However, persisting lucency at the site of the nidus can be seen for months
or even years after successful ablation (fig 20).

Page 23 of 25
Fig. 20: AP radiographs showing persistent lucency (arrow) in the medial aspect of
the proximal tibia 1 year after RFA (right). On the left AP radiograph obtained before
treatment.
References: - Newcastle Upon Tyne/UK

Conclusion

The radiologist's duty is to recognize the imaging features, exclude mimics

and, potentially, offer treatment for osteoid osteomas.

CT represents the modality of choice for detecting the nidus and for guiding
radiofrequency ablation, a valuable and minimally invasive treatment option.

References

1. Jaffe HL. Osteoid-osteoma. Proc R Soc Med 1953; 46(12):1007-1012.

2. Kransdorf MJ, Stull MA, Gilkey FW, Moser RP Jr. Osteoid osteoma.
Radiographics 1991; 11:671-696.
3. Rodallec MH, Feydy A, Larousserie F, et al. Diagnostic imaging of solitary
tumors of the spine: what to do and say. Radiographics 2008; 28:1019-1041.
4. Gangi A, Alizaadeb H, Wong L et al. Osteoid osteoma: percutaneous laser
ablation and follow up in 114 patients. Radiology 2007; 242:293-301.
5. Resnick D, Kyrialos M, Green way GD. Tumor like diseases of bone:
imaging and pathology of specific lesions. In Resnick D, ed Diagnosis
of bone and joint disordes, 4th ed. Philadelphia, Pa: Saunders,
2002;3800-3815.
6. Rosenthal DI, Hornicek FJ, Wolfe MW et al. Percutaneous radiofrequency
coagulation of osteoid osteoma compared with operative treatment. JBJS
Am 1998; 80:815-821.
7. Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW.
Thermal Ablation of Osteoid Osteoma: Overview and Stepby- Step Guide.
Radiographics 2009; 29:2127-2141.
8. Rosenthal D, Callstrom MR, Critical Review and State of the Art in
Interventional Oncology: Benign and Metastatic Disease Involving Bone1.
Radiology 2012; 262:765-780.
9. Liu PT, Spencer Chivers F, Roberts C, Schultz CJ, Beauchamp CP. Imaging
of Osteoid Osteoma with Dynamic Gadolinium enhanced MR Imaging.
Radiology 2003; 227:691-700.

Page 24 of 25
Personal Information

Page 25 of 25