Tumor biology and incidence

  • Very rare for this tumor to be primary malignancy of bone
  • Majority of lesions are metastatic when present in bone
  • Combined with non-Hodgkin’s lymphoma, accounts for approximately 10% of malignant bone lesions


Between 20 and 60 years old


Slight male predominance


May present with bone pain, often present before lesion becomes radiographically evident

Physical findings

  • Possible associated swelling if lesion is close to skin
  • Lymphadenopathy may be present; usually precedes detection of osseous lesions

Plain films

  • 50% of lesions found in spine, ribs, pelvis, or femur
  • Thoracolumbar spine most common site of spinal involvement
  • Axial skeleton more commonly affected than appendicular skeleton


Tumor effect on bone
  • Lesion usually presents as lytic lesion with permeative features
  • Check anterolateral vertebral bodies and ribs for “gouge defects” created by pressure erosion of bone by enlarged paravertebral lymph nodes
Bone response to tumor
  • May be sclerotic reaction
  • Vertebral body may become entirely sclerotic, yielding an “ivory vertebra”
  • Periosteal reaction rare



Cortical erosion may be evident

Soft tissue mass

May be present in osseous lesions

Bone scan

Will often show multiple sites of osseous involvement

Gallium scan

  • Tumors often gallium-avid
  • Gallium scan useful as part of systemic staging to delineate bone, soft tissue, and nodal extent of disease
  • Gallium scan has been shown to be accurate, specific modality in evaluation of disease response following therapy

CT and MRI

  • MRI useful for delineating local tumor extent in bone and soft tissues
  • CT scan of affected bone very helpful in determining integrity of cortex
  • CT of mediastinum, abdomen, and pelvis part of the systemic staging for determining nodal and organ involvement

Differential diagnosis

  • Eosinophilic granuloma (younger patients)
  • Ewing’s sarcoma (younger patients)
  • Non-Hodgkin’s lymphoma
  • Multiple myeloma
  • Malignant fibrous histiocytoma
  • Fibrosarcoma
  • Metastasis


  • Gross: Firm tan tissue
  • Microscopic: Identification of Reed-Sternberg cells in appropriate background of eosinophils, lymphocytes, and plasma cells
  • Variable amounts of fibrosis present
  • Immunostaining for CD30 may help identify Reed-Sternberg cells

Diagnosis and treatment

  • Biopsy  required to obtain tissue for diagnosis
    • Gallium scan may demonstrate nodal tissue that may be biopsied in preference to bone
  • Treatment generally involves multi-agent chemotherapy and radiation
  • Radiation may be given to control bone pain or attempt to avert impending pathologic fracture
  • Surgery usually reserved for osseous complications arising secondary to osseous involvement:
    • Treatment of a pathologic fracture
    • Prevention of an impending pathologic fracture