The Unknown CasesThe Unknown Cases
Texas Radiological SocietyTexas Radiological Society
9292ndnd
Annual Scientific Meeting...
CASE 1CASE 1
Male in 20s presenting withMale in 20s presenting with
medial thigh pain and massmedial thigh pain and mass
s...
FindingsFindings
 XR-short segment aggressive periosteal reactionXR-short segment aggressive periosteal reaction
to inclu...
Diagnosis?Diagnosis?
PeriostealPeriosteal
OsteosarcomaOsteosarcoma
DDX (broad; based on XRDDX (broad; based on XR
findings/location)findings/location)
 TraumaTrauma
– Avulsive injuryAvulsi...
OsteosarcomaOsteosarcoma
 Most common primary sarcoma of boneMost common primary sarcoma of bone
 22ndnd
most common pri...
Primary Osteosarcoma:Primary Osteosarcoma:
ClassificationClassification
 Intramedullary-high grade 75%Intramedullary-high...
Juxtacortical OsteosarcomaJuxtacortical Osteosarcoma
 ParParosteal 65%osteal 65%
 PeriPeriosteal 25%osteal 25%
 High-gr...
Murphey MD et al. Imaging ofMurphey MD et al. Imaging of Periosteal OsteosarcomaPeriosteal Osteosarcoma: Radiologic-: Radi...
??
 SurfaceSurface
– ParostealParosteal
 Occurs after skeletal maturityOccurs after skeletal maturity
 Outer layer periost...
Juxtacortical OSAJuxtacortical OSA
– High Grade SurfaceHigh Grade Surface
 Least commonLeast common surface typesurface t...
Juxtacortical LesionsJuxtacortical Lesions
 OSAOSA
– ParParosteal 65% (centrally calcified)osteal 65% (centrally calcifie...
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  • <number>
    Doug Beall PERIOSTEAL OSA
  • <number>
    Murphey MD et al. Imaging of Periosteal Osteosarcoma: Radiologic-Pathologic Comparison. Radiology. 2004;233:129-138.
  • <number>
    Parosteal BEALL
  • <number>
    Figure 16: High-grade surface osteosarcoma of the femoral diaphysis in a 10-year-old boy with clinical symptoms of an enlarging mass. (a, b) Lateral radiograph (Panel A) and axial CT scan (Panel B) show an osteoblastic lesion with aggressive periosteal (hair-on-end) reaction. On the CT scan, the lesion involves the bone surface circumferentially without marrow abnormality (*) and has a peripheral soft-tissue component (arrowheads). (Panel C) Sagittal T1-weighted MR image also shows normal signal intensity in the marrow (*). (Panel D) Axial T2-weighted MR image demonstrates the soft-tissue component peripherally (arrowheads) with the very high signal intensity characteristic of chondroid matrix (which has low attenuation on the corresponding CT scan [b]). (Panel E) Photograph of the sagittally sectioned gross specimen shows extent of involvement on the osseous surface (arrows) and the uninvolved marrow cavity (*).
  • Case 1

    1. 1. The Unknown CasesThe Unknown Cases Texas Radiological SocietyTexas Radiological Society 9292ndnd Annual Scientific MeetingAnnual Scientific Meeting San Antonio, TX; April 1-3, 2005San Antonio, TX; April 1-3, 2005 Justin Q. Ly, MD*+ Douglas P. Beall, MD^ Ernesto Torres, MD+ Daniel H. Duffy* Department of Radiology and Nuclear MedicineDepartment of Radiology and Nuclear Medicine Wilford Hall Medical Center/SAUSHEC Radiology*Wilford Hall Medical Center/SAUSHEC Radiology* Oklahoma University Health Sciences Center^Oklahoma University Health Sciences Center^ Brooke Army Medical Center+Brooke Army Medical Center+
    2. 2. CASE 1CASE 1 Male in 20s presenting withMale in 20s presenting with medial thigh pain and massmedial thigh pain and mass sensationsensation
    3. 3. FindingsFindings  XR-short segment aggressive periosteal reactionXR-short segment aggressive periosteal reaction to include Codman’s triangle (medial distal femoralto include Codman’s triangle (medial distal femoral shaft)shaft)  CT-radiographic findings confirmed, noCT-radiographic findings confirmed, no involvement of the inner cortex or endostealinvolvement of the inner cortex or endosteal surfacesurface  MRI-absence of marrow involvement; nonspecificMRI-absence of marrow involvement; nonspecific ill-defined associated soft tissue mass, aggressiveill-defined associated soft tissue mass, aggressive periosteal reaction/Codman’s triangle again seenperiosteal reaction/Codman’s triangle again seen
    4. 4. Diagnosis?Diagnosis? PeriostealPeriosteal OsteosarcomaOsteosarcoma
    5. 5. DDX (broad; based on XRDDX (broad; based on XR findings/location)findings/location)  TraumaTrauma – Avulsive injuryAvulsive injury (adductor longus(adductor longus insertion)insertion) – Stress fx (location is notStress fx (location is not good)good) – Early myositis ossificansEarly myositis ossificans  TumorTumor – Osteoid osteomaOsteoid osteoma – OsteosarcomaOsteosarcoma  InfectionInfection – In the right clinical settingIn the right clinical setting
    6. 6. OsteosarcomaOsteosarcoma  Most common primary sarcoma of boneMost common primary sarcoma of bone  22ndnd most common primary malignantmost common primary malignant tumor (MM #1)tumor (MM #1)
    7. 7. Primary Osteosarcoma:Primary Osteosarcoma: ClassificationClassification  Intramedullary-high grade 75%Intramedullary-high grade 75%  Juxtacortical 7-10%Juxtacortical 7-10%  Gnathic 6%Gnathic 6%  Low grade sclerosing 4-5%Low grade sclerosing 4-5%  Soft tissue 4%Soft tissue 4%  Osteosarcomatous-multifocal 1-2%Osteosarcomatous-multifocal 1-2%  Intracortical 0.2%Intracortical 0.2%
    8. 8. Juxtacortical OsteosarcomaJuxtacortical Osteosarcoma  ParParosteal 65%osteal 65%  PeriPeriosteal 25%osteal 25%  High-grade surface 10%High-grade surface 10%  Prognosis varies with grade and extent of involvementPrognosis varies with grade and extent of involvement
    9. 9. Murphey MD et al. Imaging ofMurphey MD et al. Imaging of Periosteal OsteosarcomaPeriosteal Osteosarcoma: Radiologic-: Radiologic- Pathologic Comparison.Pathologic Comparison. RadiologyRadiology. 2004;233:129-138.. 2004;233:129-138.  40 cases40 cases  Age range 10-37 years (avg age, 20 years)Age range 10-37 years (avg age, 20 years)  Distinctive imaging appearanceDistinctive imaging appearance  DiaphysealDiaphyseal lesion involvinglesion involving femur or tibiafemur or tibia  Cortical thickening / extrinsically eroded (scalloped) by broad-Cortical thickening / extrinsically eroded (scalloped) by broad- based soft-tissue mass attached to cortexbased soft-tissue mass attached to cortex  Periosteal reaction (perpendicularPeriosteal reaction (perpendicular to long axis of bone)to long axis of bone) extends intoextends into massmass  Additional areas of mineralization are frequently seen on radiographsAdditional areas of mineralization are frequently seen on radiographs  CT and MR imaging show these features and reveal extentCT and MR imaging show these features and reveal extent  CT and MR imaging reflect largely chondroid tissue seen pathologically, which shows low attenuation at CTCT and MR imaging reflect largely chondroid tissue seen pathologically, which shows low attenuation at CT and high T2 signaland high T2 signal  MR reveals foci of marrow replacement in region of tumor (most casesMR reveals foci of marrow replacement in region of tumor (most cases reactive)reactive)  ***Medullary invasion rare and should only be suggested when marrow***Medullary invasion rare and should only be suggested when marrow replacement is in continuity with surface soft-tissue componentreplacement is in continuity with surface soft-tissue component  THIS distinction (reactive vs invasion) important for determining extent of tumorTHIS distinction (reactive vs invasion) important for determining extent of tumor resectionresection
    10. 10. ??
    11. 11.  SurfaceSurface – ParostealParosteal  Occurs after skeletal maturityOccurs after skeletal maturity  Outer layer periosteumOuter layer periosteum  Exophytic growth,Exophytic growth, lobulated osssified masslobulated osssified mass @ post@ post femoral metaphfemoral metaph  Early lesions may have cleavage plane b/n cortex/tumorEarly lesions may have cleavage plane b/n cortex/tumor  Periosteal elevation/new bone formation lackingPeriosteal elevation/new bone formation lacking  Low-grade withLow-grade with very good prognosisvery good prognosis (worse if(worse if medullary invasion)medullary invasion)  DDX: MO, osteochondroma (Parosteal OSA has cartilage cap)DDX: MO, osteochondroma (Parosteal OSA has cartilage cap) JuxtacorticalJuxtacortical OsteosarcomaOsteosarcoma
    12. 12. Juxtacortical OSAJuxtacortical OSA – High Grade SurfaceHigh Grade Surface  Least commonLeast common surface typesurface type  Similar in appearance to periosteal osaSimilar in appearance to periosteal osa, mets, mets more common/more common/ worse prognosisworse prognosis Mark MD, et al. Archives of the AFIP: The Many Faces of Osteosarcoma. RadioGraphics: 1997;17 .
    13. 13. Juxtacortical LesionsJuxtacortical Lesions  OSAOSA – ParParosteal 65% (centrally calcified)osteal 65% (centrally calcified) – PeriPeriosteal 25%osteal 25% – High-grade surface 10%High-grade surface 10%  Myositis Ossificans (peripheral rim ofMyositis Ossificans (peripheral rim of calcification)calcification)

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