← All patterns
Aggressive vs non-aggressive bone lesion
MSKRadiograph / CT
A framework rather than a single diagnosis: assessing the margin, periosteal reaction and cortical status to judge how biologically aggressive a bone lesion is.
Differential
Non-aggressive (geographic type IA)
common- •Sharp sclerotic margin, narrow zone of transition
- •No or solid/thick periosteal reaction
- •Intact cortex, no soft-tissue mass
Indeterminate (geographic type IB/IC)
common- •Well-defined but non-sclerotic (IB) or ill-defined (IC) margin
- •Requires correlation and sometimes biopsy
Aggressive (moth-eaten pattern)
less-common- •Multiple small lucencies, wider zone of transition
- •Cortical thinning/endosteal scalloping
Aggressive (permeative pattern)
less-common- •Ill-defined, tiny elongated lucencies infiltrating cortex
- •Round-cell tumours (Ewing, lymphoma), osteomyelitis
Aggressive periosteal reaction
rare- •Sunburst, lamellated (onion-skin) or Codman triangle
- •Associated soft-tissue mass
Key discriminators
- •Zone of transition (narrow non-aggressive vs wide aggressive)
- •Lodwick–Madewell pattern (geographic → moth-eaten → permeative)
- •Periosteal reaction type (solid benign vs interrupted aggressive)
- •Cortical destruction and soft-tissue mass
- •Rate of change on serial imaging
Work-up / next steps
- 1.Grade with the Lodwick–Madewell system on radiograph/CT
- 2.MRI for marrow and soft-tissue extent
- 3.Correlate with age and clinical picture (age remains key)
- 4.Refer aggressive/indeterminate lesions for biopsy at a sarcoma unit
References
- Lodwick GS et al. Determining growth rates of focal lesions of bone. Radiology.
- Radiopaedia: Aggressive vs non-aggressive bone lesions.
Educational clinical decision support only. This differential does not make a diagnosis, is not a medical device, and must never substitute for interpretation by a qualified radiologist correlated with the full clinical picture and prior imaging.