Vol 2 ppt
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Volume 2 Classic osteosarcoma-----------------Case 108-9 & 451-490 Bone forming pseudotumors-----Case 491-498
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Transcript of Vol 2 ppt
Volume 2
Classic osteosarcoma-----------------Case 108-9 & 451-490
Bone forming pseudotumors-----Case 491-498
Classic
Osteogenic
Sarcoma
Classic Osteogenic Sarcoma
Osteogenic sarcoma is the most common primary malignant
tumor of bone, making up 20 % of all primary malignancies,
with approximately 500-1000 new cases diagnosed each year in
the United States. The classic or most common form of osteo-
sarcoma is seen typically in children and young adults, with a
male preference. It occurs in the metaphyseal areas of fast growing
bones with the most common location being the distal femur,
second the proximal tibia, and third the proximal humerus.
50% of the lesions will be found around the knee joint. This tumor
is rare in in small bones such as the hand or the foot, or in vertebral
segments. Patients usually present with spontaneous symptoms
of pain in the area, followed several month later with a tumor
mass that is usually diagnosed by biopsy within six months after
onset of symptoms. The radiographic appearance of the lesion
is typically a permeative lytic lesion seen in the metaphyseal area
of a long bone with cortical breakthrough and periosteal elevation
creating a Codman’s reactive triangle, followed later by a sunburst
pattern of chaotic bone formation in the soft tissue outside the peri-
osteal sleeve. In a small percentage of cases, a so-called skip lesion
will appear as a separate nodule of tumor activity totally separate
from the primary lesion which, when found, suggests a very poor
prognosis for survival. Fifty percent of osteosarcomas are of the
osteoblastic type, but in a smaller percentage of cases, there will
be a prominence of cartilage or fibrous tissue that does not seem to
influence the prognosis for survival.
The staging process for this disease includes a MRI study of the
primary tumor that helps identify soft tissue invasion by the tumor
and defines the medullary extent of the tumor which helps the
operating surgeon determine the level of amputation or limb
salvage resection. A bone isotope scan is performed to rule out the
possibility of other bony foci in the skeletal system and a CT scan
of the chest is obtained to rule out the possibility of metastatic
disease to the lung. The final staging process includes a biopsy
of the primary site performed in such a way as to not contaminate
vital structures that might interfere with the potential for a limb
salvage resection at a later date.
Prior to 1970, the prognosis for survival with this disease was
only 20% even though early amputation was performed at a high
level. Pulmonary metastasis was the reason for a fatal outcome in
these early cases, however, with the advent of multi-drug chemo-
therapy the prognosis for survival has now increased to approx-
imately 60%. The drugs most commonly used for systemic control
of the disease include high dose methotrexate, adriamycin,
cysplatin, and ifosfamide. These drugs are administered through
a central venous line on a cyclic basis every three to four weeks
for approximately two months prior to a surgical removal of the
tumor. Chemotherapy is then continued for approximately four
months after surgical treatment.
At the present time, 90% of patients with osteosarcoma are
treated by limb salvage resection. The most common type of
reconstruction consists of a total joint replacement such as a
rotating hinge at the knee. A smaller group of patients are treated
with allograft reconstruction or combinations of the above.
Excisional arthrodesis was a popular technique many years ago
but now patients prefer a reconstruction that involves normal
joint motion. The prognosis for survival is influenced by the
degree of tumor necrosis produced by the preoperative chemo-
therapy protocol, so that at the time of surgical resection if there
is more than 90% necrosis of the tumor, the patient has a much
better prognosis for survival (approximately 85% at five years).
Pulmonary metastasis is still the major concern following treat-
ment for osteosarcoma and, if this does occur, aggressive surgical
resection of the lesions thru the chest wall is frequently performed.
There is a 30% survival rate at five years following this procedure.
As with other forms of cancer, recent molecular genetic studies
have revealed a high incidence of abnormality in the P-53
suppressor genes found in this tumor.
CLASSIC Case #108
16 yr male
classic OGS
femur
Bone scan
Sagittal T-1 MRI
tumor
Coronal T-2 MRI
Axial T-1 MRI
tumor
tumor
vessels
Axial T-2 MRI
tumor
CT scan with pulmonary mets to lung
Amputation
specimen
Macro section
Close up
Codman’s
triangle
tumor margin
Photomic
Higher power
High power
tumor
cells
Case #109
14 yr male
classic OGS
femur tumor
Coronal T-1 MRI
tumor
Coronal T-2 MRI
tumor
Distal femoral resection and reconstruction with
total knee replacement and Compress fixation
femur
measuring device
Widely resected tumor specimen
Reaming the
proximal tibia
Drill guide system
Placing 5 transverse pins
Traction bar protruding from femoral canal
Tightening the compression nut inside spindle
compression cap
compression nut
800 pounds of compressive fixation has been applied
intercalary
segment
spindle
Intercalary segment attached to spindle
Completion of rotating hinge arthroplasty
AP x-ray appearance
following surgery
anchor plug
spindle
Close up lateral
Stable osseointegration
5 years PO in another case
Case #655
16 year female
classic OGS
proximal femur
coronal T-2 MRI
Axial T-2 MRI
tumor
Widely resected specimen
Distal femoral stump being prepared for placement
of the spindle of the Compress reconstruction system
traction bar
Spindle fixed to femur with 800 lbs pressure
Proximal femoral replacement attached to spindle
spindle
Proximal end of modular system with bipolar hip
attachment point for abductor tendon
Hip located and ready for soft tissue attachments
Soft tissue reconstruction completed with two fixation screws
vastus lateralis
abductor tendon
fascia lata
screws
Resected specimen cut in path lab
tumor
Post op x-ray
5 yrs PO
CT scan chest 8/09 -7 yrs Post Op
Recent onset of breast mass
Case #451
17 yr male
classic OGS
femur
Lateral view
Sagittal T-1 MRI
Proper biopsy site
Photomic
Resected specimen
biopsy
site
Specimen cut in
path lab showing
extensive tumor
necrosis
Surgical defect following wide resection
patella
Modular distal
resection system
with rotating hinged
knee
Rotating hinge
components horizontal
axial
vertical
axial
porous pads
Reconstruction
completed and
ready for closure
Radiographic
appearance
7 yrs later
stress
shielding
Case #452
13 year male with
Classic OGS distal femur
tumor
Codman’s
triangle
Sagittal T-1 MRI
tumor
tumor
vessels
Axial T-1 MRI
Photomic
Resected specimen
growth plate
Expandable
prosthesis with
telescoping sleeve
closed down
Telescoping
sleeve opened
Post op X-ray
Case #453
23 yr female
classic OGS
femur
tumor
Resected specimen
Photomic
Partially reconstructed
Completed reconstruction
Side view
Immediate post op
X-ray of cemented
stem prosthesis
13 yrs later with
total failure from
subsidence 2nd to
stress shielding
neck fracture
Surgical specimen
at time of total
femoral reconstruction
stress shielding
X-ray after total
femoral reconstruction
Case #454
17 yr male with classic OGS proximal femur
tumor
Lateral view
tumor
Bone scan
Coronal T-1 MRI
tumor
Axial T-1 MRI
tumor
vessels
Photomic
Modular proximal
femoral resection
system
Properly placed biopsy site over trochanter
incision
Wide resection
specimen
biopsy
site
femoral head
Cut specimen
in path lab
Surgical defect ready for reconstruction
acetabulum
Hyperemic synovium in acetabular notch
Suturing down
abductor tendon
to prosthesis
Final soft tissue
reconstruction
gluteus medius
vastus
lateralis
X-ray 7 yrs later
THA
Case #455
7 yr male classic OGS
distal femur
tumor
Bone scan
Sagittal T-1 MRI tumor
Coronal T-2 MRI
Axial T-1 MRI
vessels
tumor
Surgical incision for turn-up-plasty
Mobilizing prox tibia on vascular pedicle
vessels
tibia
femur
Resected distal femur
laying next to
inverted tibia
plate fixation
tibial plateau
Post op stump
appearance ready
for suction socket
prosthesis
Post op x-ray
prox tibial epiphysis
X-ray 18 mos later
tibial plateau
5 years later
Case #456
17 yr female
classic OGS with
pathologic fracture
and short plate fixation
10 mos post op wide
segmental resection
and double Compress
spacer reconstruction
Proximal Compress
device showing good
osseointegration
10 mos post op
Amputation specimen 10 mos post op
Excellent osseointegration at proximal end
anchor pins
Case #457
32 yr male
classic OGS
mid femur
Coronal T-2 MRI
Large extra
cortical mass
Axial T-2 MRI
fluid
tumor
Pathologic fracture after
6 weeks on chemotherapy
Coronal MRI
thru fracture site tumor
fracture
Gad contrast coronal MRI after 3 cycles of chemotherapy
necrotic
tumor rim
enhancement
Surgical specimen
following wide
resection
Specimen cut
in path lab
necrotic
tumor
fracture
Macro section
necrotic tumor
fracture
Photomic
Post op x-ray following
prosthetic reconstruction
Case #458
13 yr male
classic OGS
distal femur
tumor
Lateral view tumor
Bone scan
CT scan
tumor
T-1 axial MRI
tumor
tumor
edema
Coronal T-1 MRI
tumor
edema
Sagittal T-1 MRI
tumor
edema
Case #458.1
16 year old male with knee pain for 3 months
Cor T-1 T-2 Gad
Sag T-1 T-2 Gad
Axial T-1 T-2
Gad
Wide surgical resection and rotating hinge Compress recon
Case #458.2
8 year female with classic OGS distal femur
Cor T-1 MRI
Cor T-2 Cor Gad
Axial T-2
Axial Gad
Case #459
11 yr male
classic OGS
proximal tibia tumor
Lateral view
tumor
Coronal T-1 MRI tumor
Coronal T-2 MRI
tumor
Axial T-2 MRI
tumor
Photomic
15 year male with classic OGS proximal tibia
tumor
Case #461
Lateral view
tumor
Axial T-1 MRI
tumor
Macro section
tumor
Photomic
Case #461.1 AP & lat x-ray 3-05
17 year female dancer with prox. tibial pain for 3 mos with
early classic OGS looking like monototic fibrous dysplasia
6-05
CT scan 3 months later
Bone scan 7-05
Axial & sagittal T-1 MRI 6-05
Axial T-2 MRI
6-05
Axial T-1 FS Gad
6-05
AP & lat x-ray 5 mos later 11-05 & obvious OGS
Bone scan 11-05 biopsy proven OGS
and placed on preop chemotherapy
Coronal T-1 MRI 1-06 Sagittal T-1 MRI
Post chemo
Axial T-2 MRI 1-06 Sagittal T-2 MRI
following 2 mos of chemotherapy
X-ray following wide resection & Compress TKA
Case #461.2
19 yr female with pain in knee for 3 months
Osteosarcoma prox tibia
Sag T-1 PD FS
Gad
Cor T-1 T-2
Gad
Axial T-2 Gad
Case #462
14 year old female with
Classic OGS distal tibia tumor
AP view tumor
Macro section
tumor
Photomic
Case #463
14 year female
non-ossifying fibroma
tibia with no pain
Incidental finding
4 years later
and no change
14 yrs from 1st x-ray with sudden growth of tumor
Bone scan
Sagittal T-2 MRI tumor
Axial T-2 MRI
tumor
Photomic shows high grade classic OGS
Case #464
14 year female
classic OGS fibula
Another view
tumor
Case # 465
8 year male with classic OGS proximal fibula
Codman’s triangle
tumor
Case # 466
17 year male
classic OGS
proximal humerus
tumor
Coronal T-1 MRI
tumor
Axial T-2 MRI tumor
Widely resected
surgical specimen tumor
bulge
humeral
head
Specimen cut
in path lab
Photomic
Surgical reconsruction
with allograft and long
stem Neer prosthesis allograft
cement
Neer
Post op x-ray
Neer
allograft
Case #467
14 year female with
classic OGS proximal
humerus
Resected specimen
tumor
Cemented custom
prosthesis 5 years
post op
Case 468
16 year male with
classic OGS prox
humerus
Widely resected
surgical specimen
Cut specimen
in path lab
Photomic
Surgical defect
ready for
reconstruction
glenoid
Neer prosthesis
in position
Immediate post op
appearance
Case #468.1
18 year old male with
classic OGS proximal
humerus
tumor
Widely resected
specimen
Surgical defect
ready for
reconstruction
glenoid
Cemented Neer
prosthesis in
position cement
Appearance 9 mos later
with proximal migration
of prosthesis
mets
Case #468.2
14 year male
classic OGS
mid humerus tumor
Close up x-ray
after 1 mo of chemo
T-1 MRI after 2 cycles
of chemotherapy
T-2 MRI after 2 cycles
of chemotherapy
Axial PD MRI
tumor
Surgical specimen
from shoulder
disarticulation
Photomic
Case #468.3
15 year female with
Classic OGS proximal
Humerus with path fracture
Another view
fracture
Case #469 CT scan
27 year female with classic OGS 10th rib
2 years later develops 2nd OGS in R ilium
tumor
CT scan thru tumor
tumor
Another CT cut
tumor
Bone scan
Resected hemipelvis
tumor bulge
acetabulum
Surgical specimen
after 3 mins in
autoclave to kill
tumor ready for
reimplantation sciatic notch
acetabulum
Autoclaved pelvis reimplanted with total hip reconstruction
Post op x-ray appearance
X-ray 2 years later with fracture thru ilium
Case #470
18 year male with classic OGS pelvis
T-2 coronal MRI
tumor
Axial T-2 MRI
tumor
Entire hemipelvic resection specimen
Total hip reconstruction
prior to cementation
Cement construction
completed cement
constrained
total hip
Immediate post op x-ray
CD rod
Immediate post op
X-ray showing CD
rod reconstruction
X-ray 2.5 years later
Case #471
14 year male with classic OGS pelvis
tumor
CT scan
tumor
Axial T-2 MRI
tumor
Coronal T-2 MRI
tumor
spared
acetabulum
Rebar and cement reconstruction sparing hip
cement
X-ray and CT appearance
10 years later
X-ray appearance
Following THA
Case #472
26 year male with incidental fibrous cortical defect in ilium
12 years later with classic OGS in same area
Hemipelvic resection
including hip joint tumor
bulge
sciatic
notch
Reconstruction with
autoclaved hemipelvis
and cemented total hip
autoclaved
bone
THA
Completed
reconstruction
cement
X-ray appearance two years later
One year later the tumor recurred requiring the
removal of the hip reconstruction as we see in
this x-ray following which he died 1 yr later
Case #473
23 year male
classic OGS
lumbo-sacral spine tumor
Lateral X-ray
tumor
L-5
CT scan at L-5 - S-1 level
tumor
Photomic
Case #474
21 year male
classic OGS L-3
Bone scan
CT scan
tumor
L-3
Sagittal T-2 MRI
tumor
Photomic
Post op x-ray following
wide resection of L-3
and reconstruction with
anterior allograft and
pedicle screws and plates
allograft
Case #475
45 year female with classic OGS L-4
Sagittal T-1 MRI
tumor
Axial T-2 MRI
tumor
CT scan
tumor
Case #475.1
30 yr. Female
with mid dorsal
back pain 3 mos
and recent para-
paresis
OGS dorsal spine
Bone scan
CT scan
Sag T-1 T-2 Gad
Axial T-1 T-2
Gad
Post op x-ray Sag CT Axial CT
PO Axial T-2 Gad
PO Sag T-1 T-2
Case #476
20 year male
classic OGS
first metatarsal
Lateral view
Photomic
Case #477
76 year female with classic OGS first metatarsal
Lateral x-ray
tumor
Case #478
17 year male
classic OGS
great toe
18 mos later
without treatment
Bone scan
Post op x-ray following
resection and cancellous
allograft reconstruction
Case #479
18 year female with classic OGS 4th metacarpal
Coronal gad contrast MRI
Axial gad contrast MRI
Another gad contrast cut
2 year post op x-ray with allograft reconstruction
Case #480
70 year male with soft tissue OGS foot
AP view
Photomic
Case #481
55 year male with classic OGS talus
tumor
Mortise view
tumor
Case #482
19 year male with classic OGS os calcis
Macro section
tumor
subtalar joint
Case #483
40 year female with classic OGS mandible
Cut surgical specimen following hemimandibulectomy
tumor
Case #484
75 year female
classic OGS
mandible
tumor
Case #485
36 year male with classic OGS lower rib
18 mos later and no treatment
enlarged
tumor
Bone scan
Case #486
25 year male with classic OGS rib
tumor
CT scan
Another CT cut
tumor
Photomic
Case #487
29 year female with classic OGS clavicle
tumor
Laminogram cut thru tumor
tumor
Immediate post op x-ray following resection
Case #488
21 year male with classic OGS patella
Patellar view of tumor
Case #489
19 year female
classic OGS
ulna
Case #490
38 year male
classic OGS
scapula
tumor
Bone Forming Pseudotumors
Stress fractures
Caffey’s disease
Brown tumor of hyperparathroidism
Hemophilia
Compartment syndrome [late]
Giant bone islands
Osteogenesis imperfecta
Paget’s disease
Heterotopic bone
Case #491
14 year old female with
OGS pseudotumor tibia
(stress fracture)
Bone scan
Coronal T-1 MRI
Axial T-2 MRI
edema
Photomic of callus formation
8/09 9/09
13 yr male runner developed knee pain a month ago
Case #491.1 Stress fracture thru fibroma
Bone scan
Cor gad Sag gad
Axial gad
Case #492
6 mo infant with pseudo OGS ulna which is Caffey’s disease
Photomic of ulnar biopsy
Transverse ulnar cut of amputation specimen
reactive
periostitis
cortex
X-ray showing hypertrophic changes in shoulder girdle
Mandibular hypertrophic changes typical of Caffey’s
Case 493
25 year female with pseudo OGS distal femur
In reality a brown tumor of hyperparathyroidism
Hemorrhagic giant cell response of brown tumor
Thickened osteoid seams of hyperparathyroidism
Case #494
12 year old male with
OGS pseudotumor distal
femur 2nd to pathologic
fracture in hemophilia
Lateral view
pseudotumor
Case #495
44 year male with old
crush injury to leg
25 yrs ago with
ossifying compartment
syndrome looking like
soft tissue OGS
Case #496
64 year female with pseudo OGS distal femur
in fact is a giant bone island
Lateral view
Bone scan
Coronal MRI with low signal lesion
Case #497
10 year female with
OGS pseudotumor from
osteogenesis imperfecta
large fluffy
callus
X-ray 2.5 years later
with healing fracture
Case #498
14 year male with OGS
pseudotumor second to
chronic stress periostitis
proximal femur
Biopsy shows hypertrophic reactive bone and no OGS
Case 498.1
63 year female with aching pain in shoulder for 2 years
07 09 Paget’s disease
Bone scan
Cor T-1 STIR
Alk Phos - 190
Axial T-1 T-2
Gad
Case #498.2
61 yr male with stiff hip and quadriplegia
Sag CT scan
Bone scan
Heterotopic bone
CT scan
CT scan
Case #498.3
9/08
3/09
37 year male with injury
to right hip in 9/08 followed
by painful stiffness in 3/09
Traction spur
Cor CT Cor CT
Axial CT
Sag CT
Axial PD FS
Upper
Lower
