How to Evaluate a Bone Lesion

Abstract

Using a systematic approach is key for evaluating a focal bone lesion. The ultimate goal should be to provide a definitive diagnosis; however, in many instances, this is not possible. Nonetheless, one should aim to provide a short, logical differential diagnosis and to comment on whether the lesion can be left alone as a “do not touch” lesion or whether additional workup is necessary. The analysis should begin with the patient’s age and the location of the lesion, since these two factors play such a significant role in determining the differential diagnosis. Next, assessment of specific lesion characteristics can be used to help narrow the differential, i.e., the lesion’s pattern of bone destruction and lesion margins and the presence of any matrix mineralization, periosteal reaction, or soft tissue component. If multiple lesions are present, that fact can help to refine the diagnosis even further. For example, the presence of multiple lytic lesions in an older individual would lead one to suspect metastatic disease or multiple myeloma. One should also search for relevant secondary findings, such as diffuse osteopenia in multiple myeloma or subperiosteal resorption and acro-osteolysis in hyperparathyroidism, and should consider relevant clinical information, such as a history of malignancy supporting a diagnosis of metastasis or fever and erythema supporting a diagnosis of osteomyelitis.