# Lodwick — Original Lodwick grading of lytic bone-lesion growth rate

> Sequential conventional-radiograph algorithm for an evidently lytic bone lesion using destruction pattern and geographic-margin subtype, cortical penetration, complete sclerotic rim and expanded shell. It estimates relative growth/aggressiveness, not histology, malignancy certainty or a treatment order.

**Situação:** vigente · **Órgão:** Musculoesquelético · **Órgão emissor:** Lodwick et al. / musculoskeletal radiology · **Versão:** Original 1980 IA-III algorithm; variants and evidence reviewed through 2025 · **Ano:** 1980

> ⚠️ Uma versão mais nova pode existir (em revisão).

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: XR
- Fonte primária: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Apply the original ordered truth table to a lytic lesion on radiographs, return every raw descriptor, and keep later variants, histology, management and numeric risk separate.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| IA | Grade IA, single indolent geographic descriptor combination | This is the single original grade-IA combination: an evidently lytic geographic lesion with a regular, lobulated or multicentric margin; absent or partial rather than total cortical penetration; a complete sclerotic rim; and no expanded shell or expansion no greater than 1 cm beyond the expected normal contour. Every element must be supported on adequate radiographs. | Describe the full morphology and compare prior radiographs. A confidently classic benign diagnosis may require no additional workup, but IA itself is not a leave-alone command. Symptoms, age, bone and segment, matrix, periosteal reaction, multiplicity, fracture and any discordant feature determine whether observation, comparison, CT, MRI or specialist review is appropriate. | IA is the slowest-growth end of the original ordinal scale and generally carries the lowest malignancy concern, but it does not prove benignity. The often cited 94% benign figure combines IA and IB in a retrospective modified-system grade-I cohort and must not be presented as an IA-specific probability. | Lodwick et al. 1980, DOI 10.1148/radiology.134.3.6928321, original truth table; Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 item 6 for the only IA combination; Caracciolo et al. 2016 abstract for the non-IA-specific modified grade-I cohort. | ✓ |
| IB | Grade IB, other geographic pattern without total cortical penetration | The lesion is geographic, has no moth-eaten margin and has absent or partial cortical penetration, but fails the unique IA combination. IB includes a ragged or poorly defined geographic margin without total penetration, an absent or incomplete sclerotic rim, or an expanded shell greater than 1 cm when earlier higher-priority destruction-pattern branches do not apply. | Return which descriptor caused IB and integrate the complete lesion and patient context. Because IB spans several morphologies and reader agreement is limited, it cannot alone select surveillance interval or rule out further characterization; discordant clinical or imaging features may warrant CT, MRI or musculoskeletal-oncology review under current workup guidance. | IB denotes faster inferred growth or less secure benign morphology than IA but has no validated subtype-specific malignancy percentage. The 94% benign estimate belongs to IA plus IB combined in the modified Lodwick-Madewell grade-I cohort; using it as an individual IB probability would overstate precision. | Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 4-5 for greater-than 1 cm shell and incomplete rim, plus the direct IB branch for ragged/poorly defined margin without total cortical penetration; Caracciolo et al. 2016 for modified-system context. | ✓ |
| IC | Grade IC, thin moth-eaten margin or total cortical penetration | The lesion remains fundamentally geographic but has either a moth-eaten margin no greater than 1 cm or total cortical penetration. Total penetration assigns IC regardless of a regular, lobulated, multicentric, ragged or poorly defined geographic margin unless an earlier branch already established a moth-eaten margin greater than 1 cm (grade II) or any permeative component (grade III). | Treat IC as an indeterminate-to-aggressive radiographic pattern requiring complete characterization and appropriate specialist workup, not as a histologic diagnosis. Current ACR guidance generally supports MRI or CT after an indeterminate or aggressive radiographic lesion for extent, viability and biopsy or surgical planning; the exact study and need for biopsy depend on the whole case. | IC has greater malignancy concern than IA/IB but no reliable original-IC bedside probability. The 2016 modified system reassigns original IC to its grade II because its cohort showed an approximately even benign/malignant distribution in that modified middle tier; this variant evidence cannot be silently relabeled as an original-IC probability. | Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 2-3 for a thin moth-eaten margin and total cortex penetration; Subsequent works for reclassification of original IC in the 2016 variant; ACR Suspected Primary Bone Tumors 2024 Update, indeterminate/aggressive radiograph variant. | ✓ |
| II | Grade II, moth-eaten pattern or wide moth-eaten margin | The destruction pattern is moth-eaten—multiple randomly distributed lytic holes of nonuniform size—or a dominant geographic lesion has a moth-eaten marginal zone greater than 1 cm. This branch takes priority over geographic cortical, rim and shell assessment, but any permeative component anywhere upgrades the original pattern to grade III. | Report the aggressive destruction pattern and promptly integrate matrix, periosteal reaction, soft-tissue extension, fracture, multiplicity, age and symptoms. Further local staging and specialist referral are commonly appropriate for an indeterminate/aggressive radiographic lesion, but grade II itself does not choose imaging protocol, biopsy route, surgery or oncologic therapy. | Grade II indicates rapid inferred growth and substantial concern for aggressive neoplasm or another aggressive process, but the original scale supplies no universal grade-II malignancy percentage. Infection and other mimics remain possible, and the 2025 reader study demonstrates poor overall interobserver reliability. | Lodwick et al. 1980 original truth table; Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 4 and Pitfalls/Table 2 item 2 for entirely moth-eaten or greater-than 1 cm moth-eaten margin; Willenbring et al. 2025 for reliability limits; ACR 2024 Update for workup context. | ✓ |
| III | Grade III, any permeative component | Multiple uniformly small permeative holes are present anywhere in the lytic lesion. Even a small permeative focus in an otherwise geographic lesion makes the original Lodwick grade III; the more indolent-appearing majority must not erase this highest-priority destruction pattern. | Communicate the permeative component and pursue urgent, appropriately coordinated characterization of an aggressive lesion, including local staging and musculoskeletal-oncology input when indicated. The grade is not proof of malignancy and must not trigger an unplanned biopsy; biopsy trajectory and definitive management require specialist planning. | III is the fastest-growth and highest-concern original category, but some benign or nonneoplastic processes can appear permeative. The cited 81% malignant figure comes from a retrospective modified-system grade III that pooled original II/III with changing-margin and radiographically occult patterns, so it is cohort and variant context rather than an original grade-III individual probability. | Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 3 and Pitfalls/Table 2 item 1 for any permeative component; Caracciolo et al. 2016 abstract for the composition and 81% malignant rate of modified grade III; ACR 2024 Update for aggressive-lesion imaging context. | ✓ |

### Citações por categoria
- **IA**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Lodwick et al. 1980, DOI 10.1148/radiology.134.3.6928321, original truth table; Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 item 6 for the only IA combination; Caracciolo et al. 2016 abstract for the non-IA-specific modified grade-I cohort.
- **IB**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 4-5 for greater-than 1 cm shell and incomplete rim, plus the direct IB branch for ragged/poorly defined margin without total cortical penetration; Caracciolo et al. 2016 for modified-system context.
- **IC**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Figure 1 and Pitfalls/Table 2 items 2-3 for a thin moth-eaten margin and total cortex penetration; Subsequent works for reclassification of original IC in the 2016 variant; ACR Suspected Primary Bone Tumors 2024 Update, indeterminate/aggressive radiograph variant.
- **II**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Lodwick et al. 1980 original truth table; Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 4 and Pitfalls/Table 2 item 2 for entirely moth-eaten or greater-than 1 cm moth-eaten margin; Willenbring et al. 2025 for reliability limits; ACR 2024 Update for workup context.
- **III**: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F. Determining growth rates of focal lesions of bone from radiographs (1980) — https://pubmed.ncbi.nlm.nih.gov/6928321/ · Benndorf et al. 2022, PMC8854272, Table 1, Figure 1, Figure 3 and Pitfalls/Table 2 item 1 for any permeative component; Caracciolo et al. 2016 abstract for the composition and 81% malignant rate of modified grade III; ACR 2024 Update for aggressive-lesion imaging context.

## Referências cruzadas
- _fronteira compartilhada_ → [Bone-RADS — Bone Reporting and Data System](https://radcommons.laudos.ai/systems/bone-rads.md) — Original Lodwick grades radiographic lytic-lesion growth morphology. Bone-RADS is a separate CT/MRI management framework; the numbers are not interchangeable.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 1980-03-01 | published | Lodwick and colleagues published the original IA, IB, IC, II and III radiographic growth-rate truth table for focal lytic bone lesions. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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