Lucent bone lesions

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Lucent bone lesions

Bone tumors are mostly benign. The most important determinants in imaging of bone tumors are morphology on plain radiograph (well-defined lytic, ill-defined lytic, and sclerotic lesions) and age of the patient at presentation.

Well-defined osteolytic bone tumors and tumor-like lesions have many differentials in different age groups. For simplicity, a widely used mnemonic for lytic bone lesions is extremely helpful: FEGNOMASHIC.

Well-defined, sclerotic margin

1. Nonossifying fibroma —young patients, eccentric metaphyseal location. Consider benign fibrous histiocytoma if patient >25 years or atypical location.
2. Bone cysts — both SBCs and ABCs usually have a thin sclerotic margin. ABCs are more eccentric and expansile.
3. Fibrous dysplasia — variable appearance, typically diaphyseal.
4. Chondroblastoma —epiphyseal location, young patients. If patient >20 years, consider clear cell chondrosarcoma.
5. Brodie’s abscess —typically young patients, most common in metaphysis. Discrete lucency with surrounding ill-defined sclerosis.
6. Healing metastases or primary malignant bone lesions — sclerotic rim indicates a good response to treatment.
7. Osteoblastoma — large lucent nidus with a sclerotic margin. Most common in spine.
8. Intraosseous lipoma — typically in calcaneus or intertrochanteric region of femur. Thin sclerotic margin. Focus of central calcification is pathognomonic but not always present.
9. Liposclerosing myxofibrous tumour — characteristic location: intertrochanteric region of femur. Usually a thick sclerotic margin.
10. Adamantinoma/osteofibrous dysplasia (OFD) — characteristic location: anterior cortex of tibial diaphysis. Both can look identical but OFD occurs in a younger age group (<10 years).
11. Chondromyxoid fibroma— rare; can mimic NOF, BFH and ABC.
12. Haemophilic pseudotumour— usually very expansile + other signs of haemophilia.

Well-defined, nonsclerotic margin

1. Metastasis — usually older patients, in axial or proximal appendicular skeleton.
2. Myeloma/plasmacytoma —older patients, usually in axial or proximal appendicular skeleton. Typically ‘punched-out’ appearance, may be expansile.
3. Low-grade chondral lesions —e.g. enchondroma, low-grade chondrosarcoma. Both can be lytic without chondroid matrix.
4. Giant cell tumour —typically has a well-defined nonsclerotic margin. Adults 20–50 years.
5. Simple/aneurysmal bone cyst —both may have no perceptible sclerotic margin.
6. Eosinophilic granuloma —may appear well-defined.
7. Brown tumour —often expansile. Look for other signs of hyperparathyroidism.
8. Lytic phase of Paget’s disease —well-defined flame-shaped advancing edge without sclerosis.
9. Desmoplastic fibroma —rare. Often contains pseudotrabeculations.

Poorly defined margin

1. Metastasis —usually ill-defined.
2. Myeloma —usually discrete but may appear ill-defined.
3. Osteomyelitis —ill-defined and lytic in the acute phase.
4. Bone lymphoma — typically ill-defined subtle bone destruction with a large soft tissue mass. Can occur at any age but more common in older patients.
5. Primary bone sarcomas —e.g. Ewing sarcoma, osteosarcoma, chondrosarcoma, fibrosarcoma, undifferentiated pleomorphic sarcoma, angiosarcoma. Internal matrix may be absent.
6. Eosinophilic granuloma —patients <30 years. Can occur anywhere, often has an aggressive appearance indistinguishable from infection or malignancy.
7. Giant cell tumour —can appear ill-defined. Adults 20–50 years.

Sources

Subramanian S, Viswanathan VK. Lytic Bone Lesions. [Updated 2024 Sep 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539837/https://www.ncbi.nlm.nih.gov/books/NBK539837/
Chang, Connie & Garner, Hillary & Ahlawat, Shivani & Amini, Behrang & Bucknor, Matthew & Flug, Jonathan & Khodarahmi, Iman & Mulligan, Michael & Peterson, Jeffrey & Riley, Geoffrey & Samim, Mohammad & Lozano-Calderon, Santiago & Wu, Jim. (2022). Society of Skeletal Radiolody– white paper. Guidelines for the diagnostic management of incidental solitary bone lesions on CT and MRI in adults: bone reporting and data system (Bone-RADS). Skeletal Radiology. 51. 10.1007/s00256-022-04022-8.

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