Please cite this article in press as: Errani C, et al. Imaging of bone tumors for the musculoskeletal oncologic surgeon. Eur J Radiol (2011), doi:10.1016/j.ejrad.2011.11.034 ARTICLE IN PRESS G Model EURR-5771; No. of Pages 9 European Journal of Radiology xxx (2011) xxx–xxx Contents lists available at SciVerse ScienceDirect European Journal of Radiology jo ur n al hom epage: www.elsevier.com/locate/ejrad Imaging of bone tumors for the musculoskeletal oncologic surgeon C. Errani a,* , J. Kreshak a,b , P. Ruggieri a , M. Alberghini b , P. Picci b,c , D. Vanel b,c a Department of Orthopaedic Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy b Department of Pathology, Istituto Ortopedico Rizzoli, Bologna, Italy c Department of Research, Istituto Ortopedico Rizzoli, Bologna, Italy a r t i c l e i n f o Keywords: Bone tumor Imaging Surgery Computed tomography Magnetic resonance imaging Computer navigation a b s t r a c t The appropriate diagnosis and treatment of bone tumors requires close collaboration between different medical specialists. Imaging plays a key role throughout the process. Radiographic detection of a bone tumor is usually not challenging. Accurate diagnosis is often possible from physical examination, history, and standard radiographs. The location of the lesion in the bone and the skeleton, its size and margins, the presence and type of periosteal reaction, and any mineralization all help determine diagnosis. Other imaging modalities contribute to the formation of a diagnosis but are more critical for staging, evaluation of response to treatment, surgical planning, and follow-up.When necessary, biopsy is often radioguided, and should be performed in consultation with the surgeon performing the definitive operative procedure. CT is optimal for characterization of the bone involvement and for evaluation of pulmonary metastases. MRI is highly accurate in determining the intraosseous extent of tumor and for assessing soft tissue, joint, and vascular involvement. FDG-PET imaging is becoming increasingly useful for the staging of tumors, assessing response to neoadjuvant treatment, and detecting relapses.Refinement of these and other imaging modalities and the development of new technologies such as image fusion for computer- navigated bone tumor surgery will help surgeons produce a detailed and reliable preoperative plan, especially in challenging sites such as the pelvis and spine. © 2011 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Advances in medical imaging over the last two decades have greatly impacted the management of musculoskeletal tumors. In general, the imaging of musculoskeletal neoplasms can be considered from several standpoints: detection of pathology, diag- nosis, staging, evaluation of treatment, planning of surgery, and follow-up. 2. Detection of pathology Radiographic detection of a bone tumor is usually not challeng- ing and may occur incidentally or in an effort to elucidate the cause of a clinical complaint. Despite the advances in imaging technology that have occurred in recent decades, especially the introduction of cross-sectional imaging modalities, such as computed tomogra- phy (CT) and magnetic resonance imaging (MRI), plain radiographs remain the key in the initial detection of a bone lesion [1]. Occa- sionally, however, small lesions such as osteoid osteoma or large * Corresponding author. E-mail addresses: costantino.errani@ior.it (C. Errani), j.kreshak@yahoo.com (J. Kreshak), pietro.ruggieri@ior.it (P. Ruggieri), marco.alberghini@ior.it (M. Alberghini), piero.picci@ior.it (P. Picci), daniel.vanel@ior.it (D. Vanel). lesions with subtle bone destruction such as Ewing’s sarcoma and lymphoma may be difficult to locate in this manner. When plain radiographs are normal, a technetium bone scan is often helpful in revealing an osseous lesion. It is non-specific but highly sensitive and allows for the evaluation of the entire skeleton. Positron emission tomography using fluorodeoxy-glucose (FDG- PET) has been shown to be more sensitive than CT, MRI, and scintigraphy in detecting primary and metastatic tumors, however, it is relatively nonspecific because FDG may also accumulate in reactive and inflammatory lesions [1]. 3. Diagnosis The age of the patient is the single most important piece of clin- ical information that can be used in conjunction with radiographic findings to establish a diagnosis [1]. Standard radiographs are the single most important imaging diagnostic modality. They reveal the most useful information about location, size, and morphology, including periosteal reaction and matrix of the lesion (calcifications and/or ossifications) [1,2]. Based on a patient’s medical history, physical examination, and plain radiographs, the diagnosis of a bone tumor can be established in over 80% of cases [3]. The location of the lesion within the skeleton and within the involved bone(s) has a major impact on differential diagnosis 0720-048X/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2011.11.034