Amit Khera, MD, MSc

• Director, Preventive Cardiology
• Assistant Professor
• Department Inernal Medicine/Cardiology
• UT Southwestern Medical Center
• Dallas, Texas

The phlebolith from the previous image is seen to have developed in one of the slow-flow symptoms vaginal yeast infection , superficial vascular malformations symptoms 1 week before period . This 2-dayold male infant was imaged to evaluate the extent of the lesion for percutaneous sclerotherapy medications errors pictures . The mass surrounds the optic nerve and is producing proptosis of the right globe symptoms just before giving birth , along with bowing of the medial and lateral rectus muscles symptoms copd . High signal within the cystic portions of the mass were present pregadolinium and presumably secondary to elevated protein content. The overall signal intensity is high but not as high as would be expected with simple fluid. Hemangioma and lymphangioma would both be reasonable to include in the differential diagnosis. The lesion has a multiloculated appearance, with a few incomplete septa visible on this image. The increased T1 signal is likely due to proteinaceous or hemorrhagic fluid contents. The mass has heterogeneous signal that is isointense to mildly hyperintense relative to skeletal muscle. This patient has typical demographics for the classic form of Kaposi sarcoma, that being an older adult man of Mediterranean descent. This patient had been treated for over 10 years, utilizing different treatment modalities, without disease control. Differential considerations would include lymphoma, scalp vascular malformation, neurofibroma, and metastasis. Their appearance is suspicious for malignancy but is otherwise fairly nonspecific. Some of the lymph nodes in the groin show intense enhancement, a common feature seen with Kaposi sarcoma involvement. The enlarged soft tissues have heterogeneously isointense to slightly hyperintense signal relative to skeletal muscle. This adult male reported the mass had been present for several decades but recently enlarged. The majority of this mass is isointense to skeletal muscle with low-attenuation regions suggestive of fat or myxoid material and highattenuation, dystrophicappearing calcifications. Note that this infiltrative tumor is superficially located, involving the skin and subcutis. This lesion lacks fat overgrowth, which helps differentiate it from a benign vascular tumor. This mass has heterogeneous signal intensity that is isointense to hyperintense relative to skeletal muscle, with serpiginous low-signal foci around the periphery of the lesion. The previously identified low-signal serpiginous foci correspond to enlarged blood vessels. Demographics · Age All ages; peak incidence in 7th decade ­ Rare in childhood · Gender M > F (2:1) · Epidemiology Very rare soft tissue neoplasm ­ < 1% of sarcomas 17. There is high signal within parts of the mass that could represent either fat or blood (other imaging proved blood rather than fat). Angiosarcoma may often arise from a small subcutaneous lesion; nonetheless the metastatic potential is significant and prognosis is extremely poor. Calcification is most dense around periphery, raising the possibility of myositis ossificans. However, dots of dystrophic calcification are pathognomonic for cartilage calcification. The lesions were resected and confirmed to be soft tissue chondroma, locally invading bone. This lesion later degenerated into a low-grade chondrosarcoma, which is exceptionally unusual for these lesions. The lesion peripherally enhances, contains chondroid matrix, and shows extensive regions of low attenuation. The mass contains hyperattenuating foci of dense calcification or ossification and central low-attenuation regions. The irregular central region of low signal intensity is consistent with fluid from necrosis or remote hemorrhage. The appearance and location of the lesion in this young adult initially favored synovial sarcoma, but extraskeletal osteosarcoma was proven on excision. The lesion abuts bone, but there is no periosteal reaction or cortical involvement. There are scattered small foci of hypointensity that may represent faint mineralization, since no overt mineralization was visible on additional imaging. It contains soft tissue, mostly centrally, with ossification seen mostly peripherally. Myositis ossificans could have this appearance, but extraskeletal osteosarcoma proved to be the diagnosis. Again, the focus of metastatic disease in S1 has similar nonspecific imaging characteristics to the primary lesion. The nodular, solid component is eccentrically located and has a similar attenuation to skeletal muscle. Triangular regions of fat are located along the proximal and distal poles of the lesion. A small amount of high-signal fat is present involving the periphery of the mass, predominantly involving the proximal and distal poles. Although the imaging appearance of this lesion was typical for an intramuscular myxoma, percutaneous biopsy was performed to exclude malignancy. Gross Pathologic & Surgical Features · Lobulated, well-circumscribed mass May have subtly infiltrative borders ± fluid-filled cysts · Gelatinous cut surface 5. Some of the areas of enhancement appear globular, which has been reported in the literature. There is a faint suggestion of fat signal intensity adjacent to the proximal pole of the lesion. This sequence and plane best demonstrate high signal adjacent to the proximal and distal poles of the lesion, which is a typical finding in these lesions and likely reflects leakage of myxomatous tissue. High signal in the soft tissues adjacent to the proximal and distal poles of the lesion (best seen on longitudinal images), without edema involving the midportion of the lesion, is typical. There is high signal, flameshaped extravasation from the mass extending proximally and distally along the muscle fascicles. Ultrasound examination of these lesions is typically nonspecific, with common findings being heterogeneous hypoechogenicity, increased through transmission, focal cystic regions, and absent to mild internal vascularity. Regional lymph nodes were increased in number but not pathologically enlarged in size. Atanaskova Mesinkovska N et al: Ossifying fibromyxoid tumor: a clinicopathologic analysis of 26 subcutaneous tumors with emphasis on differential diagnosis and prognostic factors. These calcifications were initially thought to represent synovial chondromatosis in a popliteal cyst. However, these calcifications do not have the rounded appearance expected for synovial chondromatosis. Bakri A et al: Synovial sarcoma: imaging features of common and uncommon primary sites, metastatic patterns, and treatment response. Postcontrast imaging is not shown, but the lesion showed intense enhancement with a small region of central necrosis, typical of synovial sarcoma. This represents the split fat sign, or displaced fat, that may be seen in synovial sarcomas. Extensively calcified synovial sarcomas have a better prognosis than those that are noncalcified or contain a small amount of calcification. This is worrisome, especially because of the periarticular location in a 20 year old. It is too deep for myositis ossificans and lacks the characteristic zoning seen in that process. As these lesions enlarge, they can produce the split fat sign by peripherally displacing the normal fat that is present in this region. Because the lesion was not easily surgically accessible, the oncologic surgeons were not eager to biopsy or resect it. However, the typical clinical and imaging appearance favoring synovial sarcoma pushed the issue. Although synovial sarcoma is the most frequent sarcoma to contain calcification, it is worth remembering that 2/3 of cases do not have this feature. The patient is a young adult; with the presence of calcification, synovial sarcoma must be strongly suspected. This triple sign is often seen in synovial sarcoma and is due to the combination of areas of solid tumor, hemorrhage, and necrosis. This 18year-old man reported painful swelling in this region for 1 year and an injury to this area 4 years prior. The mass is predominantly isointense to muscle with a focus of high signal, likely representing hemorrhage. There was no evidence of tumor at surgical excision, thus this finding was presumed to be reactive. Despite surgical resection, node-positive status, and adjuvant radiotherapy and chemotherapy, this patient died 1 year later. Wadhwa V et al: Epithelioid sarcoma presenting as radial mononeuropathy: anatomical, magnetic resonance neurography and diffusion tensor imaging appearances. This mass extended along the fascial plane between the gluteus medius and gluteus minimus muscles. This proximal-type epithelioid sarcoma has a predilection to arise in the pelvis, genital tract, and perineum. This mass extended from the region of the spermatic cord into the subcutis and measured less than 2 cm. Also identified is an ill-defined right perineal mass that is isointense to muscle. The patient had a painless mass excised from this region 8 years prior with unclear pathology. Despite the fact that the lesion arises in a subcutaneous position, it does not have other characteristics of the more circumscribed dermatofibrosarcoma protuberans. These lesions often contain hemorrhage of varying ages and necrosis, giving them a variable appearance on imaging. This tumor had metastasized to the intraabdominal soft tissues and lymph nodes at the time of presentation. Oike N et al: Extraskeletal myxoid chondrosarcoma arising in the femoral vein: a case report. The mass has heterogeneous attenuation that is predominantly lower than skeletal muscle with peripheral enhancement of the lobulations. The central regions lacking enhancement histologically corresponded to prominent areas of infarct-like necrosis. Despite the large size of this lesion, no metastases were evident at presentation. This 77-year-old man had been aware of a painless, slowly growing mass for many years, but did not seek medical attention. The mass contains matrix, which is uncommon for extraskeletal myxoid chondrosarcoma. It contains hyperintense material centrally, likely representing hemorrhage (frequently seen in this lesion). There is central high signal in a portion of the lesion that likely represents hemorrhage. The thigh is the most common location of this lesion, and the lobulated appearance is typical. The mass is heterogeneously isointense to hyperintense relative to skeletal muscle. The degenerative, fibrosing changes that involve the plantar digital nerve can also involve the surrounding soft tissue, thus obscuring the borders of the mass. This is centered in the location of the 3rd common digital branch of the medial plantar nerve. Compression is useful for distinguishing between a neuroma and bursitis, as bursal fluid will dissipate with compression. Altered weight-bearing, related to the implant placement, may have contributed to the development of the neuroma. The bulbous mass contour and location at the end of a transected nerve make this typical for a terminal type traumatic neuroma. The enlarged nerve fascicles are faintly visible, giving it a telephone cable or fascicular appearance. Fusiform nerve enlargement over a several centimeter segment of intact nerve is typical for a spindle type traumatic neuroma. The mass is in an intermuscular location, without invasion of the surrounding structures. The mass has mixed signal intensity, being isointense to muscle centrally with a peripheral rim that is faintly hyperintense to muscle. There is a small focus of decreased signal intensity located eccentrically, but this is not large enough to reflect the target sign that can be seen with these lesions. The central portion of the mass more intensely enhances compared with the peripheral portion of the mass. No internal blood flow was visible, nor was the mass clearly contiguous with a nerve. These lesions represent diffuse and localized neurofibromas in a patient with known neurofibromatosis type 1. One of the masses has a central focus of decreased signal, consistent with a target sign. There is prominent bowing of the flexor retinaculum and displacement of the flexor tendons.

The carpal bones and epiphyses are small with irregular margins medications 6 rights , and the metacarpals are short and broad treatment of bronchitis . Spondyloepiphyseal Dysplasia · More severe spine involvement treatment 6th nerve palsy , including platyspondyly · Rhizomelic and mesomelic limb shortening · Small iliac wings medications interactions , horizontal acetabular roofs 777 Multiple Epiphyseal Dysplasia Dysplasias (Left) Lateral radiograph of the spine shows relatively normal findings medications with sulfa , except for mild irregularity of the endplates. The vertebral bodies are otherwise unremarkable; there is no beaking, tongue-like projection, or height loss. The femoral and acetabular articular surfaces are incongruent, which will contribute to premature osteoarthritis. Interestingly, in this hip the acetabular roof is slightly upturned, likely unrelated to the epiphyseal dysplasia. The distal femoral epiphysis & proximal tibial epiphysis are small with margin irregularity. The epiphyses should be more mature in this 13 year old; remember to interpret pediatric images within the context of patient age. Most dramatic is the articular surface of the talar head, which is flattened and broadened, lacking congruity with the navicular bone. At this age, the tarsal bones are quite immature; irregularity is not yet apparent. At one end of the spectrum, the lesions can be extremely expanded while at the other they may be central and only discernible by the presence of punctate matrix. The lesion has the streaky or striated appearance that is commonly seen in the lesions of enchondromatosis. Note the vertical columns of cartilage that cross from the metaphysis into the epiphysis. Crossing the physis often results in growth abnormalities and a unilateral short limb. These linear abnormalities have a spiral orientation, which is a variant growth pattern of the cartilage columns that cross the physis in Ollier disease. Note that similar lesions are present in the ipsilateral fibula, and a small lesion is seen within the tibia. Expanded lytic lesion with arcs & whorls mineralization typical of chondroid matrix is seen in the distal metaphysis. A subperiosteal lesion is present causing pressure erosion on the adjacent cortex. Correlation with the radiographic appearance helps establish the diagnosis of multiple enchondromatosis. Several of the lesions, especially the soft tissue mass, have the lobulated appearance typical of chondroid lesions. The mass has lobulated margins, which is a common finding among lesions of cartilage origin. This mass did not enhance; enhancement within the lesions of enchondromatosis is variable. It represents transformation of enchondroma to chondrosarcoma, as seen in Maffucci syndrome. A nonspecific finding, wormian bones are common in patients with cleidocranial dysplasia. Clavicular anomalies, such as these, lead to the clinical appearance of drooping shoulders and the ability to touch the shoulders together in front of the chest. Evaluation of the left hip suggests a coxa vara deformity with a decreased femoral neck-shaft angle. The mandible appears enlarged; note the distance from the tooth roots to the cortex. As the child continues to grow, the bones will remodel to a more normal appearance. Note also the broad horizontal acetabulae seen in a multitude of skeletal dysplasias. On the left, the lateral femoral condyle is flattened, and the medial femoral condyle is enlarged. The lateral aspect of the joint is abnormal with morphologic distortion of both the radial head and capitellum. While the knee and elbow are most commonly involved in nail patella syndrome, hypoplastic changes may be identified in any joint. Multiple foci of thick linear sclerosis are seen, accompanied by multiple rounded osteoma-like foci. There is intramedullary sclerosis throughout the great toe and the bones along the medial aspect of the midfoot and hindfoot. Involvement of the 2nd toe and the middle cuneiform is confined to the medial aspect of those bones. The uptake is along the surface of the bone, consistent with periosteal hyperostosis. Even on this study, with its low resolution, the dripping candle wax appearance is easily appreciated. The lateral tibia and fibula are spared, typical of the sclerotomal distribution seen with this dysplasia. Pathology showed myositis ossificans; this diagnosis should have been disputed, given the lack of zoning pattern on the x-ray. This proves the overall diagnosis of melorheostosis involving both bone and soft tissues, initially misdiagnosed as myositis ossificans. In addition, the marked canal stenosis with spinal cord compression is easily appreciated. Multiple rounded, completely mineralized soft tissue masses are present in a linear distribution. The ossified body is low signal on all sequences, with thin surrounding enhancement. Ayyavoo A et al: Elimination of pain and improvement of exercise capacity in Camurati-Engelmann disease with losartan. Note that it involves the diaphysis and the thickening extends into the metaphysis, but there is no epiphyseal involvement. It is interesting that the crosssectional involvement of the diaphysis does not appear symmetric; this may occasionally be seen. Note that, as with the previous patient, there is mature endosteal and periosteal thickening of bone. However, the distribution is more symmetric in this case, involving the medial and lateral sides of the bone equally. Thin bones, such as the ulna and fibula, may show later and less complete involvement. As in the femur, the hypertrophy of the endosteal and periosteal bone is circumferential, leaving little marrow centrally. Although only the left femur, forearm, and tibia are shown in this case, the contralateral bones were symmetrically involved. The bilaterally symmetric sclerosis & thickening of both the endosteum & periosteum, resulting in severe cortical thickening, is limited to the diaphyses of the femora, leaving the epiphyses & metaphyses with a normal appearance. However, the appearance is unmistakable, with all the long bones of the hand showing both periosteal and endosteal cortical thickening. Since this is a mature process, the femora and tibias showed mature diaphyseal involvement as well. The proximal femora are not yet involved, but the process will become more smooth, thick, and will involve the entire diaphysis as the child matures. The cranial vault is diffusely thickened, and the vault and skull base are extremely dense. Within the vertebral bodies, sclerosis extends from the endplate almost to the center of the vertebral body. The endobone appearance occurs because the osteoclasts do not remodel properly during skeletal maturation. Osteopetrosis Dysplasias (Left) Lateral radiograph reveals the marked involvement of the skull seen with infantile (autosomal recessive) osteopetrosis. The hyperostosis has lead to encroachment upon and narrowing of the internal auditory canal. The external auditory canals are completely occluded, and the middle ears are narrowed. This appearance is the result of complete replacement of the marrow space by dense bone. Note that sclerosis and trabecular thickening are also present centrally in the vertebral bodies. Without the benefit of radiographs, this finding may not be recognized for what it is. Note how the shape of the apparent sclerotic lesion exactly mirrors the cortical margin. This bump, also seen with bisphosphonate therapy, results from weightbearing stresses. Note the severely restricted medullary space; it is not surprising that these patients develop complications of anemia. There is diminished visualization of the kidneys and bladder due to the diffuse increased uptake in the skeleton (SuperScan). The distal metadiaphysis is widened secondary to impaired remodeling by defective osteoclasts. Transverse metaphyseal bands are present around the knee and are associated with the infantile form of this disease. When associated with resorption of the terminal tufts of the phalanges (not shown), the radiographs are diagnostic of pycnodysostosis. Undertubulation is more pronounced and prevalent in osteopetrosis and is an inconsistent finding in pycnodysostosis. This may be seen in several sclerosing dysplasias, including osteopetrosis and pyknodysostosis. Note that the resorption is not uniform, sparing the 3rd and 4th distal phalanges. Two patterns of resorption can be seen: Band-like resorption in the index finger and tuftal resorption of the 1st and 5th distal phalanges. The spectrum of dense bones in this disease ranges from endosteal thickening, as in this case, to diffusely dense bones, which mimic osteopetrosis. Evaluation of the hands and feet as well as the skull will help to differentiate these entities. Even though the bone is dense, the disorganized architecture and the inability to properly remodel in response to normal stresses places these bones at risk for fracture. Transverse fractures either occur from significant trauma (not the case here), or in abnormal bone. Note how the fracture has occurred along the anterior tibial cortex at the junction of mid and distal 1/3, a site of tension stresses. Normal stress on dense but abnormally remodeled bone in this case of pycnodysostosis has resulted in pathologic fracture. There is bilateral sclerosis limited to the iliac wings adjacent to normal sacroiliac joints. The sclerosis is roughly triangular shaped, with the apex of the triangle pointed cephalad. Changes include periarticular mineralization, subchondral cyst formation, and capsular hypertrophy. Unless symptoms arise from this region, this finding is typically attributed to degenerative disease. This bilateral and predominantly leg abnormality is typical of intramedullary osteosclerosis. This latter finding need not be present in all cases of intramedullary osteosclerosis. Given the concentration in the metaphyses and subchondral regions, this is pathognomonic for osteopoikilosis. Other sclerosing diseases, such as osteoblastic metastases or mastocytosis, are not this uniform and typically spare the epiphyses. Given the time sequence from normal to development of mass with calcification (6 weeks), this is diagnostic of immature heterotopic bone formation in a patient at risk secondary to paraplegia. There is amorphous calcification seen within masses of the left psoas as well as bilateral obturator internus. There is a rectal tube and bladder catheter placed in this patient with new paraplegia. Aebli N et al: Characteristics and surgical management of neuropathic (Charcot) spinal arthropathy after spinal cord injury. Confluent rather than hazy reticulated low signal on T1 strongly suggests osteomyelitis rather than reactive marrow change. There is a clean edge along the ischium from surgical resection of previously infected bone. Although this may represent rapid osteolysis from infection, the rapidity of bone destruction should make one also consider squamous cell carcinoma, which was proven at biopsy. There are chronic changes typical of paraplegia, including resection of the ischii related to chronic osteomyelitis, air in the soft tissues from ongoing infection, and destruction of the iliac wing. However, there is no paraspinous or epidural soft tissue mass to suggest infection. There is osseous destruction and instability of 2 lower levels; these are adjacent sites of neuropathic joints. The spine in paraplegic patients are at risk for both infection and neuropathic changes; differentiation must be made.

Yarmish G et al: Imaging characteristics of primary osteosarcoma: nonconventional subtypes medicine 3 times a day . Note the extremely hemorrhagic appearance medicine journey , with blood clots and also small nodules of tumor symptoms 6dp5dt . It is located in the distal end of the femur and extends to the subarticular surface symptoms 5dpiui . The mass extends into the posterior elements 4 medications walgreens , spinal canal, paraspinous soft tissues, and into the sacrum. The latter finding may suggest aneurysmal bone cyst; however, the mass is more extensive than expected for that diagnosis and contains solid portions. This appearance might be most suggestive of Langerhans cell histiocytosis in this child. There is a mixture of immature osteoid demonstrates a permeative lesion within the diaphysis of and mature regions of bone formation. There is no matrix, cortical breakthrough, sclerotic or defined margin; the lesion is permeative. A moderately aggressive lytic lesion is seen occupying the marrow space of the proximal tibial metadiaphysis. Much of the lesion appears permeative, but more circumscribed regions are also seen. There is a small region of cortical breakthrough, which shows some amorphous osteoid matrix. The overall radiographic picture is of only moderate aggressiveness, but the single site of cortical breakthrough should alert the diagnostician that something more aggressive than fibrous dysplasia must be considered. The cortical breakthrough and soft tissue mass is larger than was suggested by radiograph. There is high signal within much of the cortex, indicating permeation and cortical breakthrough. Therefore one might consider the diagnosis of low-grade intraosseous osteosarcoma, which was confirmed by histology. Fibrous dysplasia is common in the rib, but the matrix should not be this distinct. This patient stated that the mass had been present for several years but was now more bothersome. Statistically, this lesion was expected to be a low-grade chondrosarcoma arising from an underlying enchondroma. The rarity of osteosarcoma relative to cartilage-forming tumors in the ribs led to this diagnosis. There is not obvious periosteal reaction or involvement of the underlying cortex or marrow. Note that the lesion extends beyond the confines of the matrix into the soft tissue. There is subtle high signal within the marrow adjacent to the lesion, indicating intramedullary extension. There is no cortical signal, but subtle marrow signal raises concern for involvement. These are sites that are frequently radiated, or frequent locations for chondrosarcoma or Paget disease. There is a large destructive tumor located proximally, with extension into soft tissue. The tumor blends imperceptibly into the Paget disease, showing typical thickened cortex and disordered trabeculae. This appearance can only represent osteosarcoma; patients of this age with osteosarcoma often have an underlying etiology. Yagishita S et al: Secondary osteosarcoma developing 10 years after chemoradiotherapy for non-small-cell lung cancer. The contrast is unusually well seen in the venogram, indicating proximal obstruction. Superimposed on this is a focal soft tissue mass, which contains faint amorphous osteoid. This image was obtained at presentation and shows a mass with scattered chondroid matrix, typical of chondrosarcoma. There is a severely destructive lesion of the scapula, with a large soft tissue mass containing osteoid matrix. This region had been radiated as treatment of malignant fibrous histiocytoma 31 years earlier. There is a large circumferential soft tissue mass containing some low signal foci as well. Secondary osteosarcomas related to prior radiation, as in this case, may occur several decades following the radiation. Although the lesion appears geographic, there is no sclerotic margin surrounding it. There is an intensely low signal at the site of the chondroid matrix and a more intermediate signal in a lobulated pattern more peripherally. This lobulation is typical of benign cartilage and the combination is that expected in a benign enchondroma. At times, one may also see mild confluent enhancement that is not as strictly related to the lobules. Review of the literature with an emphasis on the clinical behaviour, radiology, malignant transformation and the follow up. This changing pattern over a relatively short time should make one consider the possibility of malignant transformation of the lesion. It is larger, with greater central calcification, and has more peripheral hyperintense lobulation. Although it is difficult to perfectly match the images, the entire study convincingly showed change in the lesion. In this case, the overall change was concerning for malignant transformation, although, no single imaging factor otherwise pointed to such. The lesion was curetted and pathology showed enchondroma without evidence of chondrosarcoma. The metaphyseal location is typical for this diagnosis, and there is no aggressive characteristic to the lesion. There is still no suggestion of aggressiveness, but new lobules of matrix are present. An enchondroma may show change over time, but any change must be considered to potentially represent transformation. Analysis of the curetting demonstrated a few areas of grade 1 chondrosarcoma, with the majority of the lesion representing enchondroma. The lesion is geographic, without sclerotic margin, and causes mild scalloping of the endosteum. All these cases of proven enchondroma show the variable appearance of this lesion. The most common lytic lesion of the hand is enchondroma, even in the absence of chondroid matrix, and was proven in this case. Despite the aggressive appearance, which some phalangeal enchondromas may obtain, transformation to chondrosarcoma is rare in this location. Note the normal marrow and cortex extending from the underlying bone, along the stalk. The apparent widening may be misdiagnosed as a marrow infiltration process or metaphyseal dysplasia. The cartilage cap is high signal and thin and regular, confirming benign osteochondroma. However, this is a 19-yearold man who is just becoming skeletally mature, and this cap thickness falls within the expected range. Because of its large size, the lesion was excised and there were no malignant features seen at pathology. There is marrow and cortical continuity with parent vertebral body, typical for osteochondroma. Though axial location is uncommon for a solitary osteochondroma, it may be surprisingly common in patients with multiple hereditary exostoses. The exostosis, though difficult to see, exhibits standard characteristics of a stalk of normal bone arising from the metaphysis. This growing mass in an adult must generate suspicion of degeneration to chondrosarcoma. The enhancing mass surrounding it suggests that the fluid content is not simple, but it is not typical of an enlarged cartilage cap. Diagnosis of bursal formation over the exostosis was proven by ultrasound and aspiration of 300 cc of extremely thick gelatinous fluid. The large, classic-appearing exostosis is located such that the sciatic nerve is stretched over it. Note the fracture of the exostosis due to trauma, likely accounting for the acute symptoms. A bursa can form over an exostosis, particularly in the context of trauma, as in this case. Therefore, interval "growth" after skeletal maturation does not always imply malignant transformation. Interval growth of an exostosis in a skeletally immature patient is expected, analogous to physeal growth. Note no enlarged cartilage cap, indicated by a thin layer of muscle overlying the cortex of the exostosis. These are not as large and exophytic as the sacral lesion, but represent hundreds of exostoses. Note the very disorganized appearance in a large cartilaginous mass, concerning for degeneration to chondrosarcoma. Given the appearance of deformity without destruction, one can assume the lesion has been present for a long period of time. If one is not careful, this might be misdiagnosed as either a marrow infiltration process, such as Gaucher disease, or a dysplasia, such as Pyle disease. It is not surprising that the diagnosis is often missed or misinterpreted on chest x-ray. There is a combination of sessile and pedunculated exostoses, both of which may normally continue to enlarge until skeletal maturation. The patient complained of "lumps" on the fingers, which correspond to the rounded densities seen on the phalanges. Note the marked displacement of the sciatic nerve by a large posterior osteochondroma. The femoral shaft is seen, with its marrow extending into a large, cauliflower-like exostosis, which is in turn surrounded by an inhomogeneous cartilage cap of variable thickness, > 1 cm at several sites. Note the valgus configuration of the right femoral neck and the associated acetabular dysplasia, resulting from longstanding subluxation of the femoral head. The scapular lesion is particularly large, though not radiodense, causing rib cage deformity that at first looks like an old thoracoplasty; however a discrete scapular mass can be seen. Dense periosteal reaction is seen along the metaphysis, a typical finding in 50% of these lesions. This patient complained of pain & popping with rotation of the shoulder and originally was unnecessarily arthroscoped rather than imaged. There is dense linear periosteal reaction extending along the posterior metaphyseal cortex. Though the sclerosis within the lesion is unusual for chondroblastoma, the other features make the diagnosis. There is a cystic component that contains a fluid level; this appearance is not uncommon in chondroblastoma. Note also that there is edema in the adjacent marrow and periosteal reaction in the nearby posterior femoral metaphysis. Note the mixed signal intensity lesion with lobular high signal portions and inhomogeneous lower signal posteriorly. Except for the reaction, the appearance and patient age are suggestive of giant cell tumor. In this teenager, one might consider diagnoses of giant cell tumor, aneurysmal bone cyst, and chondroblastoma. Chondroblastoma may serve as an underlying lesion for development of aneurysmal bone cyst. The lesion is most frequently found in the tibia, is metaphyseal and eccentric in location, slightly bubbly, and has a sclerotic margin. Aneurysmal bone cyst and chondroblastoma would most likely be considered in this teenager. This diagnosis may be difficult to prospectively suggest because of its rarity and location. The lesion appears geographic although only a portion of it shows significant sclerosis at its margin. However, the lesion does appear to be contained relative to the adjacent iliacus muscle. The most common locations are the proximal metadiaphysis of the humerus and femur (red). Differential includes periosteal chondroma, periosteal osteosarcoma, and early parosteal osteosarcoma.

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