PMC4897034_01
27-year-old man with multicentric osteoid osteoma. AP (A) and Lateral (B) radiograph of right lower leg demonstrating non-specific sclerosis. When windowed optimally, the AP (C) and lateral (D) radiographs now suggest a lucent, lobulated intramedullary lesion with, serpiginous sclerotic margins surrounding the lucent nidi, which were better demonstrated on the following CT.
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He was initially worked up with conventional radiographs which demonstrated cortical thickening at the junction of the proximal and middle thirds of the tibia without evidence of lucency or fracture (Figs. 1A and 1B). In retrospect, the initial radiograph can be windowed in such a way to demonstrate serpiginous sclerosis about the two discrete lucent nidi within this lesion (Figs. 1C and 1D).
27-year-old man with multicentric osteoid osteoma. Tc-99m MDP bone scan with an intense focus of increased radiopharmaceutical uptake in an ovoid distribution centrally in the proximal right tibia without evidence of cortical involvement. Mild, diffusely increased osseous uptake was observed in the surrounding bone.
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The bone scan showed an intense focus of increased radiopharmaceutical uptake in an ovoid distribution within the proximal right tibia which was centrally located in the lateral projection (Fig. 2).
27-year-old man with multicentric osteoid osteoma. Coronal CT reformations of right lower extremity showing a multi-lobulated, elongate lucent lesion in a medullary, diaphyseal location with a sclerotic margin. Note the linear ossific fragment in both the upper (A) and lower (B) nidus .
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Seen on the CT was an elongated, lobulated appearing, intramedullary lucent lesion with linear ossified or calcified fragments in both the upper and lower aspect of the lucent channel suggestive of a sequestrum (Figure 3, Figure 4).
27-year-old man with multicentric osteoid osteoma. Axial CT through the medullary lesion in the proximal tibia demonstrating a well-circumscribed lucent nidus with small central ossification in both the upper (A) and lower (B) nidus.
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Seen on the CT was an elongated, lobulated appearing, intramedullary lucent lesion with linear ossified or calcified fragments in both the upper and lower aspect of the lucent channel suggestive of a sequestrum (Figure 3, Figure 4).
Sequential coronal T2-weighted MRI (A, B, C) showing increased T2 medullary signal about the lesion consistent with a large area of surrounding marrow edema/hyperemia.
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The MRI showed diffusely increased T2 signal within the proximal tibial diaphysis, with an elongated, slightly lobulated, geographically circumscribed area of increased T2 signal within the medullary aspect of the bone consistent with the nidi (Fig. 5A, 5B, and 5C).
27-year-old man with multicentric osteoid osteoma. Sequential Coronal T1-weighted MRI (A, B) demonstrating the elongate nature of the lesion with two of the adjacent nidi with surrounding low signal sclerosis and adjacent intermediate signal consistent with marrow edema.
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This area demonstrates intermediate to decreased signal on T1-weighted images (Fig 6A and 6B).
27-year-old man with multicentric osteoid osteoma. Axial T1 (A) and STIR (B) MRI demonstrate the medullary location of the nidus with a small central region of low signal consistent with calcification/ossification within the nidus.
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On the axial T1 and T2 images, the medullary nidi can be seen to contain a central area of decreased T1 and T2 signal which may represent a central calcification or sequestrum (Fig 7A and 7B).
27-year-old man with multicentric osteoid osteoma. Indium-111 labeled WBC scan demonstrated subtle increased cortical uptake in the right tibia and was felt to be consistent with chronic osteomyelitis but likely simply reflected the highly vascular connective tissue stroma within the nidus or adjacent marrow hyperemia.
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The WBC scan showed mild uptake in the proximal tibial diaphysis that was felt to be consistent with chronic intramedullary osteomyelitis (Fig. 8).