Osteolytic bone lesion

Last revised by Ammar Ashraf on 29 Mar 2023

Osteolytic lesions, lytic or lucent bone lesions are descriptive terms for lesions that replace normal bone or with a vast proportion showing a lower density or attenuation than the normal cancellous bone. This comprises lesions with fatty liquid and solid soft tissue components.

Lucent or osteolytic bone lesions are descriptive radiological terms. Pathologically these findings can be represented by a wide spectrum of conditions including neoplastic, inflammatory and metabolic causes. These lesions are characterized either by the replacement of bone matrix by other types of tissue including soft tissue, fluid or fat. They are the result of uncoupling or imbalance in bone remodeling leading to osteoclast-mediated bone resorption that is triggered by tumor or inflammatory cells and by their surroundings 2,3.

As per definition, osteolytic lesions are radiolucent on plain radiographs and hypodense on CT with lower attenuation than the adjacent trabecular bone 1. This includes lesions with nonsclerotic fatty, liquid or solid soft tissue components. A better and more consistent quantitative definition for the term lucent does not yet exist 1.

Osteolytic lesions can be further characterized by the following 1,4-7:

The radiographic appearance of osteolytic lesions is traditionally classified with the Lodwick classification and more recently with the modified Lodwick-Madewell classification. The classification and its modification primarily look at the pattern of bone destruction and the lesion margin including cortical penetration and reflect the aggressiveness of the lesion 4-7.

The differential diagnosis of lucent or osteolytic bone lesions is vast and can be narrowed down according to the following factors 1, 8,9:

  • aggressive features
  • history of malignancy
  • intralesional fatty components
  • location within the bone and the skeleton:
    • cortical, juxtacortical, centric or eccentric within cancellous bone
    • epiphysis, metaphysis, diaphysis
    • axial skeleton, appendicular skeleton, flat bones
  • typical benign entities

Categorized according to some of the above factors the differential diagnosis includes the following entities 1-3:

On top of that, age plays an important role in differential diagnosis.

Whereas there is generally a plentitude of possible osteolytic lesions <40 years of age, the most likely differential diagnosis of osteolytic lesions in patients ≥40 years includes the following:

  • aggressive features: might require an oncological referral and/or biopsy 1
  • history of malignancy: will almost always require additional imaging, follow-up or oncologic referral
  • intralesional fatty components in the absence of aggressive features and a history of malignancy: almost always indicate a benign entity

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Cases and figures

  • Case 1: osteolytic metastases
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  • Case 2: multiple myeloma
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  • Case 3: large B cell lymphoma
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  • Case 4: subchondral cyst
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  • Case 5: intraosseous lipoma
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  • Case 6: enchondromatosis
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  • Case 7: non-ossifying fibroma
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  • Case 8: metacarpal chondrosarcoma
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  • Case 9: unicameral bone cyst with fracture-femur
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