← All patterns
Sclerotic (blastic) bone lesions
MSKRadiograph / CT
Areas of increased bone density, single or multiple. Multiplicity and clinical context distinguish metastatic disease from benign and marrow-based causes.
Differential
Sclerotic metastases (prostate, breast)
common- •Multiple, axial skeleton; older patient
- •Ill-defined; raised PSA in prostate primary
Bone island (enostosis)
common- •Small, oval with brush-border spiculated margin blending with trabeculae
- •No/low uptake on bone scan; stable
Paget disease
less-common- •Bone expansion with cortical and trabecular thickening
- •Coarsened trabeculae; raised ALP; older patient
Osteoblastic primary (osteosarcoma)
less-common- •Aggressive periosteal reaction, soft-tissue mass, cloud-like osteoid
- •Young patient, metaphysis about the knee
Lymphoma
rare- •Diffuse marrow infiltration, "ivory" vertebra
- •Permeative pattern with a soft-tissue mass
Osteopoikilosis
rare- •Numerous small round sclerotic foci clustered around joints
- •Symmetric, asymptomatic, cold on bone scan
Key discriminators
- •Single vs multiple; symmetry
- •Margin (brush-border enostosis vs ill-defined metastasis)
- •Bone expansion and trabecular coarsening (Paget)
- •Bone-scan uptake
- •Age and biochemistry (PSA, ALP)
Work-up / next steps
- 1.Radiograph and CT to characterise margin and matrix
- 2.Bone scan / whole-body imaging to assess multiplicity
- 3.PSA, ALP and myeloma screen as indicated
- 4.Biopsy for an aggressive or solitary indeterminate lesion
References
- Radiopaedia: Sclerotic bone lesions.
- Greenspan A. Orthopedic Imaging.
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.