OSTEOSARCOMA- radiology description.pptx

oncology

1. OSTEOSARCOMA Dr SAMEE UR REHMAN Resident Radiology Rehman Medical Institute

2. CONTENTS DEFINITION EPIDEMIOLOGY RISK FACTORS COMMON LOCATION SKELETAL DISTRIBUTION HISTOLOGICAL TYPES DIAGNOSIS DIFFERENTIALS

3. DEFINITION Osteosarcoma is an aggressive malignant neoplasm arising from primitive transformed cells of mesenchymal origin that exhibit Osteoblastic differentiation and produce malignant Osteoid. Most common primary bone malignancy in 12-25 years age group .

4. EPIDEMIOLOGY Males are effected more than females. 75 % of cases appears at 12- 25 yrs.

5. RISK FACTORS Age specially teen age growth spurt. Height Usually tall for their age. Gender Male> female. Also females develop it a little earlier in their age because of early growth Spurts. Radiation to BONES Treated for other diseases and use of Higher doses of radiation. Other bone diseases P aget's disease of bone Hereditary multiple Osteochondroma Fibrous dysplasia OTHER CANCERS Retinoblastomas Li. Fraumen's Syndrome Rothmund - Thomson syndrome

6. COMMON LOCATIONS Osteosarcoma usually occurs in the metaphysis of the long bones, especially around the knee joint. Bones around knee joint, most common Upper arm bone close to the shoulder, 2nd most common Still, can occur in any bone including pelvic bones , shoulders and jaw. especially in the older adults.

7. SKELETAL DISTRIBUTION

8. HISTOLOGICAL TYPES primary osteosarcoma intramedullary/central conventional osteosarcoma: most common (75-80%) and discussed here. low-grade central osteosarcoma telangiectatic osteosarcoma small cell osteosarcoma surface parosteal osteosarcoma periosteal osteosarcoma high-grade surface osteosarcoma secondary osteosarcoma

9. CONT….. Conventional osteosarcomas can be further divided by histological subtype : osteoblastic (most common) chondroblastic fibroblastic

10. Diagnosis of Osteosarcoma   Clinical Examination Radiological Examination Biopsy for Histopathology

11. Clinical Presentation Patients typically present with  dull, aching pain of several months duration that may suddenly become more severe . The increase in pain severity may correlate with tumor penetration of cortical bone and irritation of the periosteum, or with pathologic fracture . Metastasize early

12. Macroscopic appearance Osteosarcomas are bulky tumors where a heterogeneous cut surface demonstrates areas of hemorrhage, fibrosis, and cystic degeneration. Their extension within the medullary cavity is often much more extensive than the bulky part of the tumor would suggest. Areas of bone formation are characteristic of osteosarcomas, with the degree of bone formation varying widely.

13. Radiographic features P lain radiography can provide a lot of basic information ,  MRI is used for local staging by assessing intraosseous tumor extension (e.g. growth plate/epiphysis, skip lesions) and soft-tissue involvement. Chest CT and bone scanning have a role in distant staging.

14. PLAIN XRAYS Conventional radiography plays an important role in diagnosis. Typical appearances of conventional high-grade osteosarcoma include: medullary and cortical bone destruction wide zone of transition,  permeative  or moth-eaten appearance aggressive periosteal reaction sunburst  type Codman triangle lamellated (onion skin) reaction : less frequently seen soft-tissue mass tumor matrix ossification/calcification lung and nodal metastases may be ossified. spontaneous pneumothorax may occur in patients with lung metastases.

15. Left knee swelling for 2 months. Severe pain after slipping. There is complete fracture at the distal femur with overriding and posteromedial displacement of the distal fracture segment. Small laterally displaced osseous fragment is also observed. The fracture margins are irregular. There are ill-defined lucencies reflective of lytic changes involving the distal shaft, metaphysis and epiphysis of the femur. Interrupted periosteal reaction (Codman triangle) is demonstrated at the distal femoral shaft above the fracture site. Lobulated soft tissue mass density is seen surrounding the fracture and effacing the adjacent fat planes.

16. Red arrow highlights the Codman triangle.

17. Codman triangle periosteal reaction A  Codman triangle  is a type of periosteal reaction seen with aggressive bone lesions. The periosteum does not have time to ossify with shells of new bone in aggressive lesions, so only the edge of the raised periosteum will ossify.

18. CONT…………. The Codman triangle may be seen with the following aggressive lesions: osteosarcoma Ewing sarcoma osteomyelitis active aneurysmal bone cyst giant cell tumor metastasis chondrosarcoma (especially  juxtacortical chondrosarcoma)

19. MRI MRI is proving an essential tool to determine accurate local staging and assessment for limb-sparing resection, particularly for evaluation of intraosseous tumor extension and soft-tissue involvement. Evaluation of the growth plate is also essential as up to 75-88% of metaphyseal tumors do cross the growth plate into the epiphysis  .

20. T1 soft tissue non-mineralized component: intermediate signal intensity mineralized/ossified components: low signal intensity peritumoral edema: intermediate signal intensity scattered regions of hemorrhage will have a variable signal. enhancement: solid components enhance T2 soft tissue non-mineralized component: high signal intensity mineralized/ossified components: low signal intensity peritumoral edema: high signal intensity

21. T1 T2 T1 T2

22. CT The role of CT is predominantly utilized in assisting biopsy and staging. CT adds little to plain radiography and MRI in the direct assessment of the tumor. The exception to this rule is predominantly lytic lesions in which small amounts of mineralized material may be inapparent on both plain film and MRI .

23. TREATMENT AND PROGNOSIS Cure, if achievable, requires aggressive surgical resection often with amputation followed by chemotherapy. If a limb-salvage procedure is feasible, a course of multidrug chemotherapy precedes surgery to downstage the tumor, followed by wide resection of the bone and insertion of an endoprosthesis . T he most important predictor is the histologic degree of necrosis post-induction chemotherapy; 90% histologic necrosis is associated with much better prognosis.  Currently, the 5-year survival rate after adequate therapy is approximately 60-80%  .

24. COMPLICATIONS The most frequent complications of conventional osteosarcoma are a pathologic fracture and the development of metastatic disease, particularly to the bone, lung, and regional lymph nodes.

25. Differential diagnosis O steomyelitis O ther tumors metastatic lesion to bone Ewing sarcoma aneurysmal bone cyst When the lesion is at the posteromedial distal femur, consider cortical desmoid .