Amish Dilip
Patel
Gillian Lieberman M.D.
Advanced Radiology Clerkship
November 2009
Objectives
We will follow the etiologies and outcomes of
three patients with osteosarcoma
A brief discussion on periosteal
reaction
Review of osteosarcoma
and related topics
Menu of tests for diagnosing osteosarcoma
Review of images
Summary
Our Patient: History
Our patient Mr. S presented with a two month
history of progressive worsening of pain and
swelling of the right thigh
No history of trauma, fever, redness over the
swelling, or restriction of movements
No significant past, family, or personal history
Review of systems: weight loss otherwise
unremarkable
Our Patient: Physical Presentation
Vitals: stable
General systems examination: unremarkable
Local examination: edematous right distal
thigh; there is no restriction of right knee joint
movements; there is a large , firm, tender
mass in the right distal thigh circumferentially;
knee effusion +; there is no peripheral
neurovascular deficit; mild inguinal
adenopathy
Our Patient: X‐ray Knee AP View
Periosteal
reaction—distal
femur and
condyles
Soft tissue swelling
BIDMC PACS
Our Patient: X‐ray Knee Lateral View
Periosteal
reaction
Soft tissue swelling
Now lets review the causes of periosteal
reaction
Periosteal
Reaction: Non‐Aggressive
Slowly
progressing
Rana, Rich S., Jim S. Wu, and Ronald L. Eisenberg. "Periosteal
Reaction." American Journal of Roentgenology
(2009): 259‐72. Print.
Periosteal
Reaction: Aggressive
Fast progression
over short period
of time
Rana, Rich S., Jim S. Wu, and Ronald L. Eisenberg. "Periosteal
Reaction." American Journal of Roentgenology
(2009): 259‐72. Print.
Differential of Periosteal
Reaction
Rana, Rich S., Jim S. Wu, and Ronald L. Eisenberg. "Periosteal Reaction." American Journal of Roentgenology (2009): 259-72. Print.
1. Arthritis – psoriasis or reactive arthritis
2. Metabolic – HPOA
3. Congenital –
periosteal
reaction of the newborn
4. Trauma –
stress fracture
5. Drugs – fluoride
6. Vascular
7. Infection –
osteomyelitis
8. Tumors
Osteosarcoma—sunburst, hair on end,
Codman’s triangle
Ewing’s sarcoma—’moth eaten’
appearance
Eosinophilic
granuloma—present as lytic
lesions
Leukemia/Lymphoma—laminated appearance
What is Osteosarcoma?
Malignant tumor where cancerous cells
produce osseous matrix
Most common primary tumor of the bone
(multiple myeloma most common tumor)
Age distribution is bimodal—first peak at 20
years (primary) and second peak at 70 years
(secondary)
Cotran, Ramzi S. Robbins pathologic basis of disease. 7th ed. Philadelphia: Saunders, 1999. Print.
Pathology
Retinoblastoma (RB)
gene most commonly
affected
Most commonly
occurs in the
metaphysis
of long
bones
Distal femur and
proximal tibia is the
most common site
Cotran, Ramzi S. Robbins pathologic basis of disease. 7th ed. Philadelphia: Saunders, 1999. Print.
Radiographic Findings
http://www.orthop.washington.edu/uw/shoulderand/tabID__33
76/ItemID__273/PageID__636/Articles/Default.aspx http://emedicine.medscape.com/article/1257219-overview
TelangiectaticParosteal
Conventional (our patient)
Telangiectatic
–
lytic
lesions with cystic cavities
Multicentric
–
multiple sites leading to a poor prognosis
Parosteal
–
attached to the underlying cortex
Periosteal
–
intermediate grade with cortical thickening
Gnathic
–
affects mandible and maxilla
Radiological Management of Osteosarcoma
Plain radiographs
CT – to assess new bone formation and cortical changes
MRI –
assess bone and soft tissue involvement
Bone scan
Biopsy
Metatstatic
workup—CT chest /CT brain
Back to our Patient
Our Patient: MRI Right Knee T1 with
Contrast
Low intensity tumor
which replaced the
normal hyperintense
bone marrow
Low intensity necrosis
High intensity
hemorrhage
BIDMC PACS
Our Patient: Bone Scan
Increased radiotracer uptake
in the metaphysis
and
diaphysis
of the right femur
Also shows evidence of
metastasis in the lung
Proximal tibia appears ‘hot’
due to reactive hyperemia
BIDMC PACS
Our Patient: Metastatic Workup—CT Chest
Multiple CALCIFIED
metastases
to the lungs
Calcification of lung
metastasis is
pathognomonic
of
osteosarcoma
A few days after admission, our patient
developed chest pain. A AP view chest x‐ray
was taken. Can you locate the abnormality?
Our Patient: Chest X‐ray AP view
Lung nodules
Pneumothorax
Courtesy of Dr. Diana Litmanovtich
BIDMC PACS
BIDMC PACS
Pneumothorax
in Osteosarcoma
Is an unusual but recognized complication of
osteosarcoma
metastasis to the lung
Pathophysiology is unknown
May also be a result of chemotherapy—
necrosis of a subpleural
nodule which may
lead to a fistula between the parenchyma and
pleura
Can also occur in lung metastasis from
melanoma, breast, pancreatic and adrenal
cancers, as well as Wilm’s
tumor
Rastogi, Ruchi. "Unusual thoracic CT manifestations of osteosarcoma: a review of 16 cases." Pediatric Radiology 38.5 (2008): 551-58. Print.
Outcome of our Patient
Pneumothorax
has since
resolved after placement of
a chest tube
Patient is currently on neo‐
adjuvant chemotherapy
with cisplatin
and
doxorubicin
Courtesy of Dr. Diana Litmanovtich
Companion Patient 1: History
Ms. X a 64 year old female with a
longstanding history of Paget’s disease
developed pain and a mass in her right thigh
On examination skin over the mass is red and
looks inflamed
There is bowing of her right thigh with a
circumferential and tender palpable mass
Companion Patient 1: X‐Ray of the Knee 6 months
Before Presentation
Diffuse
demineralization
Thickened trabeculae
Courtesy of Dr. Jim Wu
‘Blade of grass’
appearance
Classic X‐ray Findings
‐Coarsening of trabeculae
‐Thickened cortex
‐Increased size of bone
‐‘Ivory’
vertebrae
Cotran, Ramzi S. Robbins pathologic basis of disease. 7th ed. Philadelphia: Saunders, 1999. Print.
A Quick Word on Paget’s Disease
Companion Patient 1: Presentation to the
ED—X‐Ray Knee
Thickened cortex
Trabecular
coarsening
‘Hair on end’
appearance
Tumor affecting the
diaphysis
of the femur
Bowing of the femur
Courtesy of Dr. Jim Wu
Rana, Rich S., Jim S. Wu, and Ronald L. Eisenberg. "Periosteal
Reaction." American Journal of Roentgenology
(2009): 259‐72. Print.
Paget’s Sarcoma
Is most likely to occur in polyostotic
Paget’s
disease
The pelvis and femur are the most commonly
involved bones
There is a genetic susceptibility –
chromosome 5 and 16
May be difficult to differentiate Paget’s
osteosarcoma
from metastasis of primary
tumors (prostate) to pagetic
bone
Greenspan, Adam, Gernot
Jundt, and Wolfgang Remagen. Differential Diagnosis in Orthopaedic
Oncology. Philadelphia: Lippincott Williams & Wilkins, 2006. Print.
Companion Patient 1: Outcome
Underwent neoadjuvant
chemotherapy with
cisplatin
and doxorubicin
This patient underwent a
reconstruction with total
femur replacement
prosthesis, utilizing
bipolar hemiarthroplasty
proximally and hinged
rotating total knee
replacement
distally
Courtesy of Dr. Jim Wu
Companion Patient 2: History
Ms. Z a 76 year old female presented with
gnawing pain in the right knee which was
worse at night
The pain eventually progressed to the point
where she was unable to walk
Past history: atrial
fibrillation and malignant
melanoma (operated)
X‐ray of the knee showed the following…
Companion Patient 2: X‐Ray Knee
Lytic
lesion
in the left
femoral condyle—
indicative of bone
infarction
Associated with a
cortical defect
Sclerosis in the right
femoral condyle
An MRI was done…
Courtesy of Dr. Mary Hochman
Companion Patient 2: MRI Knee (T2)
Aggressive enhancing
process involving the
distal femur with
cortical destruction
Underlying bone
demonstrates
osteonecrosis
Biopsy of the
underlying mass proved
to be osteosarcoma
Courtesy of Dr. Mary Hochman
Conditions Associated with Bone
Infarction
Alcoholism
Analgesic therapy
Atherosclerosis
Collagen diseases
Cushing’s disease
Hyperlipidemia
Trauma (fractures)
Gauchers
disease
Gout
Pancreatic carcinoma
Pancreatitis
Pheochromocytoma
Polycythemia
vera
Pregnancy
Sickle cell disease
Thromboembolic
heart diseases
Risk factors for our
patient were
Khan, Ali N. "Bone Infarct: eMedicine
Radiology." EMedicine
‐
Medical Reference. Web. 15 Nov. 2009. .
Osteosarcoma
Arising from Bone Infarct
Arise from reactive cells around a necrotic
calcified material
Are usually highly malignant
Have a bleak prognosis—usually worse when
compared to primary osteosarcomas
of the
same histologic
type
Greenspan, Adam, Gernot Jundt, and Wolfgang Remagen. Differential Diagnosis in Orthopaedic Oncology. Philadelphia: Lippincott Williams & Wilkins, 2006. Print.
Companion Patient 2: Outcome
Our patient underwent neoadjuvant
chemotherapy to shrink the tumor
She expired however due her cancer as well
as her complicated past medical history
Summary (1)
Osteosarcoma—cancerous cells produce
osseous matrix
Primary (early onset) and secondary (late
onset—Paget’s disease, bone infarcts,
radiation
Radiological workup includes: x‐rays, CT,
MRIs, bone scans, and chest CTs—for
metastasis
Summary (2)
Osteosarcoma
metastasis to the lungs may
cause pneumothoraces
(also melanoma and
breast cancer metastasis)
Paget’s disease –
excessive breakdown and
formation of bone tissue which at times can
be a cause of secondary osteosarcoma
Classic ‘blade on grass’
appearance of x‐ray with
thickened trabeculae
Ivory vertebrae
Summary (3)
Close attention must be paid in identifying
signs of osteosarcoma
on plain radiograph so
that early intervention may improve patient
outcome
References
1.
Cotran, Ramzi
S. Robbins pathologic basis of disease.
7th ed. Philadelphia:
Saunders, 1999. Print.
2.
Campanacci, Mario. Bone and Soft Tissue Tumors Clinical Features, Imaging,
Pathology and Treatment. New York: Springer, 1999. Print.
3.
Greenspan, Adam, Gernot
Jundt, and Wolfgang Remagen. Differential
Diagnosis in Orthopaedic
Oncology. Philadelphia: Lippincott Williams & Wilkins,
2006. Print.
4.
Khan, Ali N. "Bone Infarct: eMedicine
Radiology." EMedicine
‐
Medical
Reference. Web. 15 Nov. 2009.
.
5.
Rana, Rich S., Jim S. Wu, and Ronald L. Eisenberg. "Periosteal
Reaction."
American Journal of Roentgenology
(2009): 259‐72. Print.
6.
Rastogi, Ruchi. "Unusual thoracic CT manifistations
of osteosarcoma: a review
of 16 cases." Pediatric Radiology
38.5 (2008): 551‐58. Print.
Acknowledgements
Dr. Gillian Lieberman
Dr. Jim Wu
Dr. Mary Hochman
Dr. Suzanne Long
Dr. Justin Kung
Dr. Diana Litmanovitch
Dr. Yulia
Melenevsky
Maria Levantakis
Slide Number 1
Objectives
Our Patient: History
Our Patient: Physical Presentation
Our Patient: X-ray Knee AP View
Our Patient: X-ray Knee Lateral View
Slide Number 7
Periosteal Reaction: Non-Aggressive
Periosteal Reaction: Aggressive
Differential of Periosteal Reaction
What is Osteosarcoma?
Pathology
Radiographic Findings
Radiological Management of Osteosarcoma
Back to our Patient
Our Patient: MRI Right Knee T1 with Contrast
Our Patient: Bone Scan
Our Patient: Metastatic Workup—CT Chest
Slide Number 19
Our Patient: Chest X-ray AP view
Pneumothorax in Osteosarcoma
Outcome of our Patient
Companion Patient 1: History
Companion Patient 1: X-Ray of the Knee 6 months Before Presentation
A Quick Word on Paget’s Disease
Companion Patient 1: Presentation to the ED—X-Ray Knee
Paget’s Sarcoma
Companion Patient 1: Outcome
Companion Patient 2: History
Companion Patient 2: X-Ray Knee
Companion Patient 2: MRI Knee (T2)
Conditions Associated with Bone Infarction
Osteosarcoma Arising from Bone Infarct
Companion Patient 2: Outcome
Summary (1)
Summary (2)
Summary (3)
References
Acknowledgements
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