World health organization classification of bone tumors (fifth edition): What a radiologist needs to know?

Abstract

Since 1967, the World Health Organization (WHO) classification of tumors is regarded as a reference standard and practical guide and provides a precious resource not only for the histopathologists and oncosurgeons but also for the radiologists involved in cancer care. Primary bone tumors are a rare and heterogeneous group of neoplasms that have a broad spectrum of morphological, biological, genetic, and radiological features. Appropriate imaging workup and accurate histopathological diagnosis are crucial for appropriate management and prognostication. The fourth edition of the WHO classification of tumors of soft tissue and bone was introduced in 2013. In the past 7 years, there have been considerable advances in the understanding of this large and diverse group of tumors. With technological advances and the introduction of new molecular and genetic data about some bone tumors, there has been reorganization in the classification and introduction of a few new entities. The new WHO classification of soft tissue and bone tumors introduced in 2020 (fifth edition) has made essential refinements in the classification and has also introduced many new entities. Newly identified genetic alterations and corresponding immunohistochemical markers are included in the new classification, and this has helped in the reclassification of the existing tumor entities. These novel genetic alterations not only help in prognostication but are a target for potential therapeutic options which can bring a paradigm shift in the chemotherapeutic regimen for these entities in the future. The sole basis for the classification of bone tumors is histopathological. Although radiologists are not expected to know about the exquisite pathological details of bone tumors, a broad knowledge of the recent updates, including the reclassification of a few entities or the introduction of some, is vital for narrowing the differentials in imaging. A multidisciplinary approach including an orthopedic oncologist, radiologist, pathologist, surgical, and medical oncologist is required for accurate diagnosis and management of primary bone tumors. We hereby present a simplified review for the radiologists comprising the relevant details of the updates in bone tumors along with a simplified diagnostic algorithm to characterize these lesions.