Adamantinomas are rare primary malignant bone tumours that in the vast majority of cases occur in the tibia of young patients.
In the past, ameloblastomas, which are benign, locally aggressive bone tumours of the mandible, were also known as adamantinomas of the mandible. The two entities are histologically unrelated, and for this reason, adamantinomas are no longer subcategorised as those of the mandible and those of long bones.
Typically presents in the 2nd to 3rd decades as a locally aggressive mass 3 to 15 cm in diameter. There is a slight male predilection (1.3:1). Patients usually present with dull pain of gradual onset.
The occurrence is almost exclusively confined to the tibial diaphysis (especially the anterior cortex) 2,5. Since it is a low-grade malignancy, it has the propensity to metastasise to distant locations including lung, bone, lymph nodes, pericardium, and liver.
Plain radiograph and CT
Typically, it appears as a multilocular or slightly expansile osteolytic cortical lesion. This may be visualised as areas of lysis interspersed with areas of sclerosis 3. Lesions tend to have an eccentric epicentre 4 and a lack of periosteal reaction. There may be locally aggressive disease at presentation.
Some authors have distinguished two morphologic patterns 2:
- solitary lobulated focus
- multiple small nodules in one or more foci
In some patients separated tumour foci may be seen, defined as foci of high signal intensity on either T2- or contrast-enhanced T1-weighted images, interspersed with normal-appearing cortical or cancellous bone 2. A fluid-fluid level may occasionally be seen.
- C+ (Gd): tends to show intense and homogeneous static enhancement, although there is no uniform dynamic enhancement pattern 2
Treatment and prognosis
Surgical, en bloc resection is often performed. It is a locally aggressive tumour with distant metastases reported in around 15% of cases 1.
History and etymology
Adamantinoma is derived from the Greek word 'adamantinos', which means 'very hard'. It was first observed in the shaft of an ulna in 1900 by C Maier 8, who believed it was a carcinoma, although the term 'adamantinoma' was coined by B Fisher in 1913 9.
Imaging differential considerations include 6:
- 1. Kanakaraddi SV, Nagaraj G, Ravinath TM. Adamantinoma of the tibia with late skeletal metastasis: an unusual presentation. J Bone Joint Surg Br. 2007;89 (3): 388-9. doi:10.1302/0301-620X.89B3.18484 - Pubmed citation
- 2. Van der woude HJ, Hazelbag HM, Bloem JL et-al. MRI of adamantinoma of long bones in correlation with histopathology. AJR Am J Roentgenol. 2004;183 (6): 1737-44. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Day DL, Letourneau JG, Crass JR et-al. Musculoskeletal case of the day. AJR Am J Roentgenol. 1987;148 (5): 1048-52. AJR Am J Roentgenol (citation) - Pubmed citation
- 4. Levine SM, Lambiase RE, Petchprapa CN. Cortical lesions of the tibia: characteristic appearances at conventional radiography. Radiographics. 23 (1): 157-77. doi:10.1148/rg.231015088 - Pubmed citation
- 5. Miller TT. Bone tumors and tumorlike conditions: analysis with conventional radiography. Radiology. 2008;246 (3): 662-74. doi:10.1148/radiol.2463061038 - Pubmed citation
- 6. Bloem JL, Van der heul RO, Schuttevaer HM et-al. Fibrous dysplasia vs adamantinoma of the tibia: differentiation based on discriminant analysis of clinical and plain film findings. AJR Am J Roentgenol. 1991;156 (5): 1017-23. AJR Am J Roentgenol (abstract) - Pubmed citation
- 7. Camp MD, Tompkins RK, Spanier SS et-al. Best cases from the AFIP: Adamantinoma of the tibia and fibula with cytogenetic analysis. Radiographics. 28 (4): 1215-20. doi:10.1148/rg.284075173 - Pubmed citation
- 8. Maier C. Ein primers myelogenes platten-epithelkarzinom der ulna. Beitraege zur klinischen Chirurgie 1900;26 : 553-566.
- 9. Fischer B. Uber ein primares adamantinoma der tibia. Virchows Arch [B] 1913;12:422–441
- 10. Imaging of Bone Tumors and Tumor-Like Lesions: Techniques and Applications. Springer. ISBN:3540779825. Read it at Google Books - Find it at Amazon
The differential diagnosis for bone tumours is dependent on the age of the patient, with a very different set of differentials for the paediatric patient.
- bone-forming tumours
- cartilage-forming tumours
- chondromyxoid fibroma
- fibrous bone lesions
- bone marrow tumours
- other bone tumours or tumour-like lesions
- aneurysmal bone cyst
- benign fibrous histiocytoma
- giant cell tumour of bone
- Gorham massive osteolysis
- haemophilic pseudotumour
- intradiploic epidermoid cyst
- intraosseous lipoma
- musculoskeletal angiosarcoma
- musculoskeletal haemangiopericytoma
- primary intraosseous haemangioma
- simple bone cyst
- impending fracture risk