Radiological Diagnosis of Tumours

Investigations

Imaging Tumours, radiograph of a lytic tumour of the proximal femur
Radiograph of a lytic tumour of the proximal femur. Image by Hellerhoff, Wikimedia Commons, CC BY-SA 3.0.
  • Orthogonal radiographs of the whole bone are the most useful first test
  • Aim to class a lesion as aggressive or non-aggressive with a short differential
  • Narrow zone of transition indicates slow growth, wide indicates rapid growth
  • Chondroid matrix shows rings and arcs or popcorn calcification
  • Osteoid matrix is cloud-like or ivory, as in osteosarcoma
  • Fibrous matrix shows ground glass, as in fibrous dysplasia
  • Absent matrix does not exclude malignancy
  • Solid smooth periosteal reaction indicates a slow process
  • Lamellated onion skin reaction in Ewing sarcoma and infection
  • Sunburst or hair on end spicules indicate aggressive growth
  • Codman triangle indicates aggression but is not specific to malignancy
  • Endosteal scalloping over two thirds of cortex favours chondrosarcoma over enchondroma
  • Soft tissue mass indicates an aggressive process

Classification

Lodwick

GradeDescription
IAGeographic with sclerotic rim
IBGeographic, well defined, no sclerotic rim
ICGeographic with ill defined margin
IIMoth-eaten
IIIPermeative

Original publication Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs. Radiology. 1980;134(3):577-83.

  • IA and IB are non-aggressive
  • Moth-eaten and permeative suggest Ewing sarcoma, lymphoma, osteosarcoma, myeloma or osteomyelitis

Differential Diagnosis

  • Under 5 years, neuroblastoma metastasis, LCH and infection
  • 5 to 20 years, osteosarcoma, Ewing sarcoma, bone cysts, NOF, chondroblastoma and osteochondroma
  • 20 to 40 years, giant cell tumour of bone
  • Over 40 years, metastasis, myeloma, lymphoma and chondrosarcoma
  • Multiple lesions, metastasis, myeloma, lymphoma, LCH, multiple enchondromas and HME
  • Multiple lesions also in fibrous dysplasia, vascular tumours and infection
  • Infection, LCH and ABC can look aggressive
  • Combine imaging with age, history and histology

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.