Imaging in Orthopaedic Oncology

Background and Aims: To establish the role of imaging in the diagnosis, staging, treatment planning, and surveillance of musculoskeletal tumours in orthopaedic oncology. Methods: A thorough literature search was carried out into the applications of conventional radiography, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine techniques. The strengths, limitations, and complementary contributions of each modality were reviewed in relation to diagnosis, staging, biopsy guidance, treatment response assessment, and surveillance. Results: A multidisciplinary approach—integrating clinicopathological assessment with multimodality imaging, maximises diagnostic accuracy and guides patient-specific management. Radiography remains the first-line investigation, offering initial lesion characterisation and narrowing the differential. US provides high-resolution evaluation of superficial soft tissue lesions and enables real-time image-guided biopsy. CT offers superior depiction of cortical integrity, osseous destruction, and matrix mineralisation, with advanced dual-energy techniques improving material characterisation and reducing metal artefacts. MRI is the gold standard for local staging, with advanced sequences such as diffusion-weighted imaging, dynamic contrast-enhanced MRI, and chemical shift imaging enhancing lesion characterisation and treatment response assessment. Established and emerging nuclear medicine techniques provide complementary functional information, enabling early detection of metastases and metabolic treatment response evaluation. Conclusion: This review outlines the strengths, limitations, and complementary contributions of these modalities in optimising the diagnostic and treatment pathways for orthopaedic oncology patients. It therefore highlights how imaging in orthopaedic oncology is inherently multimodal, with each modality contributing unique and complementary diagnostic insights.