Osteosarcoma

Key facts

Most common primary malignant bone tumor. 50% around the knee. Presentation: pain, mass, pathologic fracture. Sclerosis is present from either tumor new bone formation or reactive sclerosis. Plain films typically reveal lesions with moth-eaten or permeative pattern of the transition zone with irregular cortical destruction and an interrupted periosteal reaction with soft tissue extension. A periosteal reaction known as Codman's triangle appears as tumor elevates periosteum from underlying bone. Cortical soft tissue extension may produce radiating spicules of bone called sunray appearance. Osteosarcoma (osteogenic sarcoma) is the 2nd most common primary bone tumor and is highly malignant. It is most common among people aged 10 to 25, although it can occur at any age. Osteosarcoma produces malignant osteoid (immature bone) from tumor bone cells. The bone formation dictates the radiographic pictures. When abudant bony tumor matrix is lacking, the osteosarcoma may be of the telangiectatic subtype (which sometimes may mimic aneurysmal bone cyst!), or the differential diagnosis includes Ewings sarcoma or lymphoma, particularly when a large soft tissue mass is present. In older

patients, also chondrosarcoma can be in the differential diagnosis. Osteosarcoma usually develops around the knee (distal femur more often than proximal tibia) or in other long bones (like proximal humerus), particularly the metaphyseal-diaphyseal area, and may metastasize, usually to lung or other bones. Pain and swelling are the usual symptoms. Findings on imaging studies vary and may include sclerotic and/or lytic features. Diagnosis requires biopsy, which shoud always be performed after imaging Patients need a chest x-ray and CT to rule out or detect lung metastases and a bone scan to detect bone metastases. MR imaging is the optimal modality for loco-regional staging. An imaging protocol should at least include T1weighted TSE series in two perpendicular directions for assessment of the intraosseous extent and relationship to joint(s) nearby, and axial T2WI with FS, for assessment of the soft-tissue extension and relationship to important neurovascular structures. Longitudinal imaging of an entire long bone is strongly advocated to rule skip metastases. After administratipn of i.v. contrast, T1-weighted series are repeated in two directions with FS. Treatment is a combination of chemotherapy and surgery. Use of (neo-)adjuvant chemotherapy increases

survival from < 20% to > 65% at 5 yr. Chemotherapy usually begins before any surgery. The goal of neoadjuvant chemotherapy is to eliminate occult distant micrometastases, and to cause tumor volume reduction, in order to make limb-salvage surgery possible. As such, more than 80% of patients can be treated with limb-sparing surgery without decreasing long-term survival rate. The role of imaging during and after neoadjuvant chemotherapy is to assess the rate of response. IN particular, significant reduction of tumor vascularization and perfusion is a strong indicator of good response. Increase in tumor volume strongly suggests poor response, however, volume decrease does not necessarily indicate favourable response. Continuation of (adjuvant) chemotherapy after surgery is usually necessary. If there is nearly complete tumor necrosis (about 99%) from preoperative chemotherapy, 5-yr survival rate is > 90%. Low-grade intraosseous osteosarcoma is a very rare variant of osteosarcoma,which may however have a benign radiographic appearance and therefore can be confused with, for instance,, fibrous dysplasia. Surface osteosarcomas have their origin on the surface of bone and grow primarily into the surrounding soft tissues, but may also infiltrate into the bone marrow. Among these, the parosteal (or juxtacortical)

osteosarcoma is the most frequently encountered variant, most commonly on the posterior side of the distal meta-diaphysis of the femur. Osteosarcoma (2) On the left images of an osteosarcoma in the right femur. It is barely visible, but an agressive periostitis is seen (arrow). Continue with the MR-images.

The MR images show a large tumor mass infiltrating a large portion of the distal femur and extending through the cortex.

Sagittal T1W- and Gd-enhanced T1W-image with fatsat.

Paget disease Stress fractures

Stress fractures occur in normal (fatigue fractures) or metabolically weakened (insufficiency fractures) bones. Usually stress fractures are easy to recognize ...... Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor (7).

Uncommonly it can be difficult to differentiate a stress fracture from a pathologic fracture, that occurs at the site of a bone tumor (7).

Osteoid osteoma versus stress fracture

Stress fractures

Follow up images of stress fracture in medial collum