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Volume 3            Osteosarcoma VariantsHemorrhagic osteosarcoma------------Case 110 & 499-503Parosteal osteosarcoma-----...
Osteogenic Sarcoma Variants
Hemorrhagic Osteogenic  Sarcoma
Hemorrhagic (Telangiectatic) Osteosarcoma   The hemorrhagic (OGS), an extremely lytic and hemorrhagicvariant of the osteos...
osteosarcoma that is used by many pathologists. There is verylittle evidence of osteoblastic acitivity in the hemorrhagic ...
CLASSICCase #11023 year malehemorrhagic OGSproximal humerusAneurysmal lesion
hemorrhagic                  tumorCoronal T-1 MRI
Coronal T-1 MRI      tumorthru path fracture
Resected tumor cut in path lab
Photomic showing giant cells and malignant cells
osteoid           bloodPhotomic showing hemorrhagic response
Neer                            allograftPost op x-ray withalloprostheticreconstruction
18 year followup x-rays
Case #49915 year malehemorrhagic OGSdistal femur
Lateral view
Bone scan
tumorSagittal T-2 MRI
hemorrhagic tumorCoronal T-2 MRI
tumorAxial T- 2 MRI
bloodPhotomic
osseo-                              integration3 yrs post op Compresstotal knee reconstruction                            ...
Case #50019 year malehemorrhage OGSproximal femurLooks like ABC
Lateral view
Initial biopsy reveals aneurysmal bone cyst
6 weeks latershows lysis ofouter shellRepeat biopsyrevealshemorrhagic OGS
femoral                                head         tumorHip disarticulation specimen
2nd biopsy Photomic
Case #5016 year femalepath fracture thruunicameral bone cyst
cysticlesion         Lateral view
7 weeks after       cyststeroid injection
1 month later andprogressive lyticdestruction
Biopsy here shows hemorrhagic OGS
Case #501.1                  Telangiectatic OGS 19 year old male with acute onset of pain 2 wks ago in right hip
PO      1 mo2 mo   3 mo
Cor T-1   T-2
Axial T-1         T-2            Gad
Sag T-2   Gad
Case #5024 year male                       cysticlooks like                       lesionunicameral bone cyst
Progressive lysisafter steroid injection
2 months laterwith progressivelysis and lookingmalignant
Biopsy reveals hemorrhagic OGS
Clinical appearance before shoulder disarticulation
Case #50317 year femalehemorrhagic OGSC-3
AP view
CT scan
Photomic
6 years later withspontaneous fusionand no tumor
ParostealOstogenic Sarcoma
Parosteal Osteosarcoma  The parosteal (OGS) is a low grade variant arising from the surfaceof a long bone that presents as...
responsive to adjuvant therapy such as chemotherapy orradiation therapy. The treatment consists of a wide surgicalresectio...
CLASSICCase #11132 year maleparosteal OGSdistal femur
AP view
Bone scan
Sagittal T-1 MRI
tumorSagittal STIR MRI
Axial T-1 MRI
tumorAxial STIR MRI
Photomic
Higher power
Case #504 18 year male parosteal OGS distal femur
tumorAP view
Bone scan
tumor        Axial T-2 MRI
tumorSagittal T-2 MRI
tumor   Macro section
Photomic
osseointegration   Compress total knee reconstruction 2 years later
10 years later withrecurrence as a highgrade dedifferentiatedparosteal OGS                         tumor
Another view               tumor
Photomic of recurrence
Close up ofosseointegration ofCompress implant
Case #50532 year maleparosteal OGS      tumorproximal humerus
tumorAxillary view
tumorCT scan
Amputation specimen cut in path lab
Photomic
Case #50625 year maleparosteal OGSdistal femur
Distal femoralresection specimen                     tumor
tumorCut specimenin path lab                       fatty                       marrow
Case #50713 year maleparosteal OGSmid femurAP view
Lateral view
CT scan
Segmental resection specimen
Autoclaved bone replaced with IM nail fixation
Post op x-ray2 years later                autoclaved                bone
Case #508        17 year male with parosteal OGS mid tibia
Lateral x-ray
tumorCT scan
Bone scan
biopsy                      siteSegmental resectionmid tibial lesion
tumorSurgical specimen cut in path lab
Allograft reconstruction over IM nail
X-ray 1 year later
Case #50941 year femaleparosteal OGShumerus
CT scan
tumorResected cut specimen in path lab
Case #509.1           Parosteal OGS pseudotumor M.O.                    10/06                              3/07           ...
Sag T-1   Sag Gad
Axial T-1Axial Gad
Case #510  32 year female with high grade parosteal OGS femur
Macro section                tumor
Photomic
PeriostealOsteogenic Sarcoma
Periosteal Osteosarcoma   The periosteal osteosarcoma is another surface type OGS thattends to be low grade to intermediat...
CLASSIC Case #112      15 year female with periosteal OGS tibia
CT scan
tumorSagittal CT scan
Axial T-2 MRI
Photomic
Post op x-ray followingwide resection andallograft reconstruction
Case #511      30 year male with periosteal OGS prox tibia
CT scan
Sagittal T-2 MRI
edema     tumorAxial T-1 MRI
Wide resectionproximal tibia                 tumor                 bulge
tumorCut specimenin path lab
Photomic
Proximal tibia resected ready for reconstruction
Post op x-ray withalloprosthetic                   TKAreconstruction                     allograft
Case # 5129 year femaleperiosteal OGStibia
AP x-ray
Lateral view
Cut specimen inpath lab followingAK amputation
Photomic
Higher power
Case #51314 year maleperiosteal OGS
Sagittal T-2 MRI
Axial T-1 MRI
Axial T-2 MRI
Case #51426 year femaleperiosteal OGSdistal femur
Lateral view
stress                            shieldingX-ray 10 yearsfollowing wideresection and cementedprosthetic reconstruction
Case #51512 year femaleperiosteal OGStibia
Bone scan
Axial T-1 MRI
Photomic
Case #51615 year maleperiosteal OGSdistal tibia
CT scan
Bone scan
Photomic
Case #51739 year femaleperiosteal OGSpseudotumorIn fact is a Nora’slesion orbizarre parostealosteochondromatousproliferati...
Bone scan
CT scan
edema    Axial Gad contrast MRI
Sagittal PD
Sagittal T-2 MRI                   edema
Axial gad contrast MRI
Pagetic Sarcoma
Pagetic Sarcoma    There are multiple diseases of the skeletal system that can resultin a secondary form of OGS most likel...
of old Pagetic reactive bone. The prognosis for survival in thissecondary form of OGS is extremely poor with only about 8%...
CLASSIC   Case #113          tumor      80 year female with Pagetic sarcoma pelvis
Bone scan
tumor        Axial T-2 MRI
osteoidPhotomic
Post op internal hemipelvectomy
Case#518                  tumor83 year femalePagetic sarcomapelvis
tumor    CT scan
tumorAnother CT cut
Photomic
Case #519       85 year female with Paget’s disease pelvis
Same disease inlumbar spine
Same diseasein skull
Same disease in tibiaAdvancing osteolytic wedge
old Paget’sSame patient withPagetic sarcomahumerus                       new                      tumor
Macro sectionfrom amputationspecimen          tumor
Photomic
Post op x-ray following forequarter amputation
Case # 52073 year femalePagetic sarcoma skullready for resection
Lateral view of skull
Occipital view
Tangential view
tumorResected specimen cut in path lab
Photomic
Case #521                  old Paget’s                  with prior                  fracture82 year malePagetic sarcomadis...
tumorClose up of new tumor
Photomic
Case #52280 year femalePagetic sarcomadistal humerus
Case #523            femur                                         humerus       84 male with multi focal Pagetic sarcoma
Case #52483 year malePagetic sarcomafemur
Case #52560 year malePagetic sarcomafemur
Lateral view
Photomic
Photomic
Case #52678 femalePagetic sarcomaproximal tibia
Lateral view               tumor
Case #52792 year malePagetic sarcoma tibia
Case #52878 year femalePagetic sarcomalumbar spine
Low GradeIntramedullary  Osteogenic    Sarcoma
Low Grade Intramedullary OGS    Low grade intramedullary OGS is another rare low grade fibro-osseous variant of OGS that i...
CLASSICCase #11463 year femaleintramedullary OGSdistal femur
Lateral view
Bone scan
tumor        CT scan
tumorMacro section fromresected specimen
Photomic
Photomic
Case #528.151 year female       tumorlow gradeintramedullary OGSdistal femur
Bone scan
Coronal T-1 MRI                  tumor
tumorAxial T-1 MRI
tumorResected distal femur cut in path lab
Photomic
Case #52932 year female       tumorlow gradeintramedullary OGSdistal femur
Lateral view
CT scan
Photomic
Case #53056 year malelow grade            tumorintramedullary OGSdistal tibia
Lateral view   tumor
Bone scan
Photomic
Radiation-induced   Osteogenic    Sarcoma
Radiation-induced Osteosarcoma   One of the most malignant forms of OGS is the secondary typeinduced by radiation therapy,...
CLASSICCase #11533 year femaleradiation-inducedsarcoma scapula
tumorWidely resected specimen cut in path lab
scapulatumor        Close up
Photomic
Higher power
Post op x-ray following scapular wing resection
Case #531                                          tumor    35 year female with radiation sarcoma prox femur   prior radia...
Frog leg lateral                   tumor
Shortly after withpathologic fracture
tumorBiopsy photomic
Higher power
Case #53272 year maleradiation sarcoma pelvisPrior radiation therapyfor prostate cancer3 years before
Another view at adifferent date withhip dislocation
Photomic
Case #532.1                Radiation induced OGS  79 yr male with prior prostate CA radiation therapy        and now prese...
Coronal Anterior CT   Posterior CT
L Sagittal CT scan   R Sagittal CT scan
Low axial CT                     cut thru L hip                     showing large tumorUpper CT cut thruSI area showingtum...
Metastatic disease seen on chest x-ray
Case #533    56 year female with radiation sarcoma scapula     Prior history of radiation for breast cancer
Oblique view
Bone scan
Photomic
Case #534                           tumor      63 year female with radiation sarcoma scapula  with prior radiation treatme...
Case #53544 year female withradiation sarcomaproximal humerus 2ndto prior radiation for   tumorbreast cancer
Photomic with radiation OGS
Case #53676 year maleradiation sarcomafemurPrior history ofradiation therapyfor soft tissue tumor10 years ago
Bone scan
Photomic radiation OGS
Case #537Elderly M.D. with longhistory working underX-ray fluoroscopeNow skin cancer andradiation sarcomaindex finger
X-ray of indexfinger sarcoma                 tumor
Photomic radiation sarcoma
MulticentricOsteogenic Sarcoma
Multicentric Osteosarcoma    The multicentric variant of OGS is an extremely rare variantoccurring in approximately 1% of ...
CLASSICCase #1168 year femalemulticentric OGS
Close up distal femur
Lateral view
Bone scan
Close upbone scan
Upper bodybone scan
Coronal T-1 MRI
Another coronal cutT-1 MRI
Sagittal T-1 MRI
Photomic
Another photomic
Case #53818 year femalemulticentric OGSpelvis and femur
tumortumorGad contrast coronal MRI
Another Gad contrast cut
pelvictumor         Axial T-2 MRI
Internal HemipelvectomyRecon plate placed across pelvic ring surgical defect
Placement of air screws just prior to cementation
cementPlacement of cement around screws and plate
femoral implant   total   hip Constrained total hip in and securing musclesto custom proximal femoral replacement implant
acetabulum             tumor             bulge           iliumOuter face of resected specimen
tumor          bulgeilium        Inner face
Closure
recon plate                and screwsPost op x-ray
Case #53916 year femalemulticentric OGS         tumorProximal tibial lesion
Lateral view withskip lesion indistal tibia
Bone scan showing two lesions in tibia
Bone scan showingiliac lesion
Bone scan showingsternal lesion
Photomic from tibial biopsy
Proximal tibialresection and     tumortotal knee        bulgereconstruction
Proximal tibialprosthesis in positionready for relocationand closure
Reconstructioncompleted andready for closure
Case #540Multicentric OGSfemur and sacrum20 year male
Lateral view
Coronal T-1 MRIshowing tumor atboth ends of femur
Sagittal T-1 MRIdistal femur                   tumor
tumorAxial T-2 MRI distal femur
Another axial T-2 MRI
Bone scan
Coronal T-1 MRI
Axial T-1 MRI
tumorCoronal gad contrast MRI showing sacral lesion
Photomic from femoral biopsy
Case #541  10 year female with multicentric OGS femur and tibia
tumor        Lateral view
skip                        lesionAP view femur                tumor
tumorCoronal T-2 MRIdistal femur
tumorSagittal T-2 MRIdistal femur                           tibial                           lesions
tumorCoronal T-1 MRIknee joint                   tumor
tumorCoronal T-1 MRI showing multicentric involvement
Case #542                  tumor   15 year male with multicentric OGS tibia and femur
tumorCoronal T-1 MRI                   tumor
Coronal T-2 MRI                  tumor
Sagittal T-1 MRI                   tumor
tumorAxial T-2 MRI view of distal femur
Soft TissueOsteogenic Sarcoma
Soft Tissue Osteosarcoma    OGS can be seen in soft tissue outside the skeletal system. Itaccounts for 4% of all OGS and i...
CLASSICCase #118                  tumor67 year malesoft tissue OGScalf
AP view
Sagittal T-1 MRI                   tumor
Axial T-1 MRI
Cut surgical specimen in path lab
Photomic
Case #54376 year femalesoft tissue OGScalf
Lateral view
CT scan
Bone scan
Axial T-1 MRI
Sagittal T-1 MRI                   tumor
Photomic
Case #54460 year female withsoft tissue OGS leg
Oblique view
Bone scan
Case #54563 year malesoft tissue OGShand              tumor
Lateral view
tumorAxial T-1 MRI
tumorAxial T-2 MRI
tumorCoronal T-2 MRI
Multiple pulmonary mets
Intracortical Osteogenic  Sarcoma
Intracortical Osteosarcoma   The intracortical OGS is perhaps the rarest variant of OGS withonly 14 cases described in the...
CLASSIC    Case #119     42 year female with intracortical OGS femur
Bone scan
Axial PD MRI
Sagittal T-2 MRI
Early biopsy photomic
X-ray 18 monthsafter curettementwith recurrence
Bone scan at time of recurrence
Axial Gad contrast MRI same time
tumorSagittal PD MRIsame time
tumorUnicortical segmental wide resection
Photomic of resected specimen
Post op x-ray following   allograftunicortical resectionand allograft recon
PD                       T-2                   tumorSagittal PD & T-2 MRI 18 months later with met to C-spine
Case #54643 year femaleintracortical OGSdistal femur
Lateral view
Sagittal T-1 MRI
tumorSagittal T-2 MRI
Biopsy photomic
Photomic
Case #54747 year femaleintracortical OGShumerus
Lateral view
CT scan
tumorSagittal T-1 MRI
Post op x-ray afterwide resection andallograft recon
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An Atlas of Musculoskeletal Oncology: Volume 3

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An Atlas of Musculoskeletal Oncology: Volume 3

  1. 1. Volume 3 Osteosarcoma VariantsHemorrhagic osteosarcoma------------Case 110 & 499-503Parosteal osteosarcoma-----------------Case111 & 504-510Periosteal osteosarcoma----------------Case 112 & 511-517Pagetic sarcoma-------------------------Case 113 & 518-528Low grade intramedullary OGS------Case 114 & 528.1-530Radiation induced OGS---------------Case 115 & 531-537Multicentric osteosarcoma------------Case 116 & 538-542Soft tissue osteosarcoma--------------Case 118 & 543-545Intracortical osteosarcoma------------Case 119 & 546-547
  2. 2. Osteogenic Sarcoma Variants
  3. 3. Hemorrhagic Osteogenic Sarcoma
  4. 4. Hemorrhagic (Telangiectatic) Osteosarcoma The hemorrhagic (OGS), an extremely lytic and hemorrhagicvariant of the osteosarcoma, presents in the same age group andlocation as a classic osteosarcoma but has a radiographicappearance almost identical to that of an aggressive aneurysmalbone cyst, making for a very difficult differential considerationfor the radiologist. At the time of biopsy the tumor is veryhemorrhagic and has the gross appearance of an aneurysmalbone cyst. Even microscopically, many areas of the hemorrhagicOGS will have the appearance of an aneurysmal bone cyst withonly an occasional mitotic figure. For this reason, it is veryimportant for the surgeon who performs the biopsy to obtainan adequate specimen with good sampling by means of an openbiopsy as apposed to a simple needle biopsy. The microscopicfeatures of the hemorrhagic OGS is a large number of benign-appearing giant cells and thus the terminology “giant cell rich”
  5. 5. osteosarcoma that is used by many pathologists. There is verylittle evidence of osteoblastic acitivity in the hemorrhagic OGSand, because it is so lytic in character, it frequently presents witha pathologic fracture early in the course of the disease and with thatcome potential problems for the treating orthopedic surgeon whomust deal with the major contamination that occurs during thefracture. Because of the possible complications, one might consideran early limb salvage procedure before the fracture occurs. It was once felt that the prognosis for the hemorrhagic OGSwas worse than that of the classic OGS because of its lytic dest-uctive nature. However, since the advent of systemic chemotherapy,the prognosis for survival is no different than for a classic OGS.
  6. 6. CLASSICCase #11023 year malehemorrhagic OGSproximal humerusAneurysmal lesion
  7. 7. hemorrhagic tumorCoronal T-1 MRI
  8. 8. Coronal T-1 MRI tumorthru path fracture
  9. 9. Resected tumor cut in path lab
  10. 10. Photomic showing giant cells and malignant cells
  11. 11. osteoid bloodPhotomic showing hemorrhagic response
  12. 12. Neer allograftPost op x-ray withalloprostheticreconstruction
  13. 13. 18 year followup x-rays
  14. 14. Case #49915 year malehemorrhagic OGSdistal femur
  15. 15. Lateral view
  16. 16. Bone scan
  17. 17. tumorSagittal T-2 MRI
  18. 18. hemorrhagic tumorCoronal T-2 MRI
  19. 19. tumorAxial T- 2 MRI
  20. 20. bloodPhotomic
  21. 21. osseo- integration3 yrs post op Compresstotal knee reconstruction CPS
  22. 22. Case #50019 year malehemorrhage OGSproximal femurLooks like ABC
  23. 23. Lateral view
  24. 24. Initial biopsy reveals aneurysmal bone cyst
  25. 25. 6 weeks latershows lysis ofouter shellRepeat biopsyrevealshemorrhagic OGS
  26. 26. femoral head tumorHip disarticulation specimen
  27. 27. 2nd biopsy Photomic
  28. 28. Case #5016 year femalepath fracture thruunicameral bone cyst
  29. 29. cysticlesion Lateral view
  30. 30. 7 weeks after cyststeroid injection
  31. 31. 1 month later andprogressive lyticdestruction
  32. 32. Biopsy here shows hemorrhagic OGS
  33. 33. Case #501.1 Telangiectatic OGS 19 year old male with acute onset of pain 2 wks ago in right hip
  34. 34. PO 1 mo2 mo 3 mo
  35. 35. Cor T-1 T-2
  36. 36. Axial T-1 T-2 Gad
  37. 37. Sag T-2 Gad
  38. 38. Case #5024 year male cysticlooks like lesionunicameral bone cyst
  39. 39. Progressive lysisafter steroid injection
  40. 40. 2 months laterwith progressivelysis and lookingmalignant
  41. 41. Biopsy reveals hemorrhagic OGS
  42. 42. Clinical appearance before shoulder disarticulation
  43. 43. Case #50317 year femalehemorrhagic OGSC-3
  44. 44. AP view
  45. 45. CT scan
  46. 46. Photomic
  47. 47. 6 years later withspontaneous fusionand no tumor
  48. 48. ParostealOstogenic Sarcoma
  49. 49. Parosteal Osteosarcoma The parosteal (OGS) is a low grade variant arising from the surfaceof a long bone that presents as an exophytic mass with dense fibro-osseous tissue. It carries an excellent five year survival prognosisof 85% and accounts for about 4% of all osteosarcomas. Thistumor has very little, if any, medullary involvement which clearlyseparates it from the classic OGS. It is seen more commonly infemales than males and is found in a slightly older age groupthan the classic OGS. By far the most common location for thistumor is in the posterior aspect of the distal femur where it isfrequently presents with minimal symptoms of pain but with apalpable tumor mass that might have been present many yearsbefore medical advise was sought. Histologically, this tumor has avery low mitotic index and in many cases can be confused witha normal healing fracture callous with occasional areas of cartilagebeing seen. Because this tumor is extremely low grade, it is not
  50. 50. responsive to adjuvant therapy such as chemotherapy orradiation therapy. The treatment consists of a wide surgicalresection that must have safe margins, otherwise the recurrencerate will be quite high. Recurrence can occur 10 to 15 years afterthe surgery. In many cases the lesion can be resected withoutsacrificing the adjacent joint, but in larger lesions the bestapproach is a total joint replacement similar to that used for theclassic OGS.
  51. 51. CLASSICCase #11132 year maleparosteal OGSdistal femur
  52. 52. AP view
  53. 53. Bone scan
  54. 54. Sagittal T-1 MRI
  55. 55. tumorSagittal STIR MRI
  56. 56. Axial T-1 MRI
  57. 57. tumorAxial STIR MRI
  58. 58. Photomic
  59. 59. Higher power
  60. 60. Case #504 18 year male parosteal OGS distal femur
  61. 61. tumorAP view
  62. 62. Bone scan
  63. 63. tumor Axial T-2 MRI
  64. 64. tumorSagittal T-2 MRI
  65. 65. tumor Macro section
  66. 66. Photomic
  67. 67. osseointegration Compress total knee reconstruction 2 years later
  68. 68. 10 years later withrecurrence as a highgrade dedifferentiatedparosteal OGS tumor
  69. 69. Another view tumor
  70. 70. Photomic of recurrence
  71. 71. Close up ofosseointegration ofCompress implant
  72. 72. Case #50532 year maleparosteal OGS tumorproximal humerus
  73. 73. tumorAxillary view
  74. 74. tumorCT scan
  75. 75. Amputation specimen cut in path lab
  76. 76. Photomic
  77. 77. Case #50625 year maleparosteal OGSdistal femur
  78. 78. Distal femoralresection specimen tumor
  79. 79. tumorCut specimenin path lab fatty marrow
  80. 80. Case #50713 year maleparosteal OGSmid femurAP view
  81. 81. Lateral view
  82. 82. CT scan
  83. 83. Segmental resection specimen
  84. 84. Autoclaved bone replaced with IM nail fixation
  85. 85. Post op x-ray2 years later autoclaved bone
  86. 86. Case #508 17 year male with parosteal OGS mid tibia
  87. 87. Lateral x-ray
  88. 88. tumorCT scan
  89. 89. Bone scan
  90. 90. biopsy siteSegmental resectionmid tibial lesion
  91. 91. tumorSurgical specimen cut in path lab
  92. 92. Allograft reconstruction over IM nail
  93. 93. X-ray 1 year later
  94. 94. Case #50941 year femaleparosteal OGShumerus
  95. 95. CT scan
  96. 96. tumorResected cut specimen in path lab
  97. 97. Case #509.1 Parosteal OGS pseudotumor M.O. 10/06 3/07 17 year male with football injury 9/06
  98. 98. Sag T-1 Sag Gad
  99. 99. Axial T-1Axial Gad
  100. 100. Case #510 32 year female with high grade parosteal OGS femur
  101. 101. Macro section tumor
  102. 102. Photomic
  103. 103. PeriostealOsteogenic Sarcoma
  104. 104. Periosteal Osteosarcoma The periosteal osteosarcoma is another surface type OGS thattends to be low grade to intermediate with potential for pulmonarymetastasis in about 25% of cases. It accounts for 2% of all OGS’sand, compared to the parosteal OGS, has a much higher percentageof cartilagenous tissue in the tumor to the point where it can looklike a periosteal chondroma but with a much higher mitotic index.One must find a few areas of osteoid formation to classify this asa periosteal OGS. It is seen typically in the second decade of lifeand is slightly more common in females than males. It arises fromlong bones, typically the tibia or femur, and has a higher incidencein diaphyseal bone than does OGS. Like the parosteal OGS, thislesion is treated by aggressive wide local resection that often canspare the adjacent joint. In most cases chemotherapy is not utilizedunless the clinical picture is more aggressive than usual.
  105. 105. CLASSIC Case #112 15 year female with periosteal OGS tibia
  106. 106. CT scan
  107. 107. tumorSagittal CT scan
  108. 108. Axial T-2 MRI
  109. 109. Photomic
  110. 110. Post op x-ray followingwide resection andallograft reconstruction
  111. 111. Case #511 30 year male with periosteal OGS prox tibia
  112. 112. CT scan
  113. 113. Sagittal T-2 MRI
  114. 114. edema tumorAxial T-1 MRI
  115. 115. Wide resectionproximal tibia tumor bulge
  116. 116. tumorCut specimenin path lab
  117. 117. Photomic
  118. 118. Proximal tibia resected ready for reconstruction
  119. 119. Post op x-ray withalloprosthetic TKAreconstruction allograft
  120. 120. Case # 5129 year femaleperiosteal OGStibia
  121. 121. AP x-ray
  122. 122. Lateral view
  123. 123. Cut specimen inpath lab followingAK amputation
  124. 124. Photomic
  125. 125. Higher power
  126. 126. Case #51314 year maleperiosteal OGS
  127. 127. Sagittal T-2 MRI
  128. 128. Axial T-1 MRI
  129. 129. Axial T-2 MRI
  130. 130. Case #51426 year femaleperiosteal OGSdistal femur
  131. 131. Lateral view
  132. 132. stress shieldingX-ray 10 yearsfollowing wideresection and cementedprosthetic reconstruction
  133. 133. Case #51512 year femaleperiosteal OGStibia
  134. 134. Bone scan
  135. 135. Axial T-1 MRI
  136. 136. Photomic
  137. 137. Case #51615 year maleperiosteal OGSdistal tibia
  138. 138. CT scan
  139. 139. Bone scan
  140. 140. Photomic
  141. 141. Case #51739 year femaleperiosteal OGSpseudotumorIn fact is a Nora’slesion orbizarre parostealosteochondromatousproliferation (BPOP)
  142. 142. Bone scan
  143. 143. CT scan
  144. 144. edema Axial Gad contrast MRI
  145. 145. Sagittal PD
  146. 146. Sagittal T-2 MRI edema
  147. 147. Axial gad contrast MRI
  148. 148. Pagetic Sarcoma
  149. 149. Pagetic Sarcoma There are multiple diseases of the skeletal system that can resultin a secondary form of OGS most likely brought about by a secondmutation at a later age in a patient with chronic benign disease.These diseases include Paget’s disease, osteoblastoma, fibrousdysplasia, benign giant cell tumor of bone, bone infarcts, andchronic osteomyelitis. The most common of this group is Paget’sdisease, a non-specific inflammatory osteomyelitis of bone seenin older patients that may be induced by a virus infection. Approx-imately 1% of patients with Paget’s disease can go on to PageticOGS which accounts for 3% of all OGS. The most commonlocation for this secondary form of OGS is in the humerus,followed next by the pelvis and femur. The patients typically have along history of dull, aching pain from their inflammatory Paget’sdisease but then suddenly develop an acute new pain in the area ofthe older pain with x-ray evidence of recent lysis and destruction
  150. 150. of old Pagetic reactive bone. The prognosis for survival in thissecondary form of OGS is extremely poor with only about 8%surviving, mainly because the older age group in which the diseaseoccurs make it impractical to implement the aggressive protocolsused in younger age groups.
  151. 151. CLASSIC Case #113 tumor 80 year female with Pagetic sarcoma pelvis
  152. 152. Bone scan
  153. 153. tumor Axial T-2 MRI
  154. 154. osteoidPhotomic
  155. 155. Post op internal hemipelvectomy
  156. 156. Case#518 tumor83 year femalePagetic sarcomapelvis
  157. 157. tumor CT scan
  158. 158. tumorAnother CT cut
  159. 159. Photomic
  160. 160. Case #519 85 year female with Paget’s disease pelvis
  161. 161. Same disease inlumbar spine
  162. 162. Same diseasein skull
  163. 163. Same disease in tibiaAdvancing osteolytic wedge
  164. 164. old Paget’sSame patient withPagetic sarcomahumerus new tumor
  165. 165. Macro sectionfrom amputationspecimen tumor
  166. 166. Photomic
  167. 167. Post op x-ray following forequarter amputation
  168. 168. Case # 52073 year femalePagetic sarcoma skullready for resection
  169. 169. Lateral view of skull
  170. 170. Occipital view
  171. 171. Tangential view
  172. 172. tumorResected specimen cut in path lab
  173. 173. Photomic
  174. 174. Case #521 old Paget’s with prior fracture82 year malePagetic sarcomadistal humerus
  175. 175. tumorClose up of new tumor
  176. 176. Photomic
  177. 177. Case #52280 year femalePagetic sarcomadistal humerus
  178. 178. Case #523 femur humerus 84 male with multi focal Pagetic sarcoma
  179. 179. Case #52483 year malePagetic sarcomafemur
  180. 180. Case #52560 year malePagetic sarcomafemur
  181. 181. Lateral view
  182. 182. Photomic
  183. 183. Photomic
  184. 184. Case #52678 femalePagetic sarcomaproximal tibia
  185. 185. Lateral view tumor
  186. 186. Case #52792 year malePagetic sarcoma tibia
  187. 187. Case #52878 year femalePagetic sarcomalumbar spine
  188. 188. Low GradeIntramedullary Osteogenic Sarcoma
  189. 189. Low Grade Intramedullary OGS Low grade intramedullary OGS is another rare low grade fibro-osseous variant of OGS that is unique because it is totally confinedwithin the cortical anatomy of a long bone, most typically aroundthe knee joint. It is found in an older age group than the classicOGS and is typically seen between the ages of 15 and 55 years;it affects males and females equally. The radiologic picture is thatof a diffuse sclerotic change within the metaphysis of the longbone with no periosteal response or lytic destruction of the corticalanatomy. The smoky appearance of metaphyseal bone suggeststhe diagnosis of chronic osteomyelitis or perhaps fibrous dysplasia.Microscopically, the tumor has a histological appearance similarto parosteal OGS and because of this carries the same excellentprognosis for survival as we see in parosteal sarcoma. Likewise,treatment is similar without the use of chemotherapy or radiation.These lesions must be treated with complete wide resection thatfrequently involves a TKA, similar as in the classic OGS.
  190. 190. CLASSICCase #11463 year femaleintramedullary OGSdistal femur
  191. 191. Lateral view
  192. 192. Bone scan
  193. 193. tumor CT scan
  194. 194. tumorMacro section fromresected specimen
  195. 195. Photomic
  196. 196. Photomic
  197. 197. Case #528.151 year female tumorlow gradeintramedullary OGSdistal femur
  198. 198. Bone scan
  199. 199. Coronal T-1 MRI tumor
  200. 200. tumorAxial T-1 MRI
  201. 201. tumorResected distal femur cut in path lab
  202. 202. Photomic
  203. 203. Case #52932 year female tumorlow gradeintramedullary OGSdistal femur
  204. 204. Lateral view
  205. 205. CT scan
  206. 206. Photomic
  207. 207. Case #53056 year malelow grade tumorintramedullary OGSdistal tibia
  208. 208. Lateral view tumor
  209. 209. Bone scan
  210. 210. Photomic
  211. 211. Radiation-induced Osteogenic Sarcoma
  212. 212. Radiation-induced Osteosarcoma One of the most malignant forms of OGS is the secondary typeinduced by radiation therapy, usually over 3000 rads, for sometype of either benign or malignant disease process in the past.One of the most common types of radiation-induced OGS isseen in patients with breast cancer who receive local radiationfollowing radical mastectomy and than develop OGS in theshoulder girdle area. Other malignant diseases that can result inOGS after radiation therapy include Ewing’s sarcoma andlymphomas. Benign diseases that can result in OGS fromradiation therapy include GCT,ABC, and fibrous dysplasia. Theaverage delay for the occurrence of secondary OGS is 15 years,with a range from 3 to 55 years. The prognosis for this variant isextremely poor, similar to Pagetic OGS. It has a very high rateof metastasis to the lung for which chemotherapy is not veryeffective.
  213. 213. CLASSICCase #11533 year femaleradiation-inducedsarcoma scapula
  214. 214. tumorWidely resected specimen cut in path lab
  215. 215. scapulatumor Close up
  216. 216. Photomic
  217. 217. Higher power
  218. 218. Post op x-ray following scapular wing resection
  219. 219. Case #531 tumor 35 year female with radiation sarcoma prox femur prior radiation treatment for Hodgkin’s 20 yrs ago
  220. 220. Frog leg lateral tumor
  221. 221. Shortly after withpathologic fracture
  222. 222. tumorBiopsy photomic
  223. 223. Higher power
  224. 224. Case #53272 year maleradiation sarcoma pelvisPrior radiation therapyfor prostate cancer3 years before
  225. 225. Another view at adifferent date withhip dislocation
  226. 226. Photomic
  227. 227. Case #532.1 Radiation induced OGS 79 yr male with prior prostate CA radiation therapy and now presents with radiation OGS
  228. 228. Coronal Anterior CT Posterior CT
  229. 229. L Sagittal CT scan R Sagittal CT scan
  230. 230. Low axial CT cut thru L hip showing large tumorUpper CT cut thruSI area showingtumor R post ilium
  231. 231. Metastatic disease seen on chest x-ray
  232. 232. Case #533 56 year female with radiation sarcoma scapula Prior history of radiation for breast cancer
  233. 233. Oblique view
  234. 234. Bone scan
  235. 235. Photomic
  236. 236. Case #534 tumor 63 year female with radiation sarcoma scapula with prior radiation treatment for breast CA 12 yrs ago
  237. 237. Case #53544 year female withradiation sarcomaproximal humerus 2ndto prior radiation for tumorbreast cancer
  238. 238. Photomic with radiation OGS
  239. 239. Case #53676 year maleradiation sarcomafemurPrior history ofradiation therapyfor soft tissue tumor10 years ago
  240. 240. Bone scan
  241. 241. Photomic radiation OGS
  242. 242. Case #537Elderly M.D. with longhistory working underX-ray fluoroscopeNow skin cancer andradiation sarcomaindex finger
  243. 243. X-ray of indexfinger sarcoma tumor
  244. 244. Photomic radiation sarcoma
  245. 245. MulticentricOsteogenic Sarcoma
  246. 246. Multicentric Osteosarcoma The multicentric variant of OGS is an extremely rare variantoccurring in approximately 1% of all OGS. It has two distinctcategories: (1) Synchronous multicentric OGS occurring in child-hood and adolescence. This is the more severe variant, consideredto be extremely high grade with a very poor prognosis associatedwith it. This form presents with multiple sclerotic lesions seen in afairly symmetrical fashion in long bones, mostly in the lowerextremities and because of the heavy tumor burden associatedwith multiple lesions throughout the skeleton, the alkaline phos-phatase is frequently elevated. (2) Metachronous multicentric OGSoccurring mainly in adults is less aggressive than the synchronousform seen in children, presenting usually with a solitary lesion.Then, later on, more lesions develop that are considered multi-focal in nature. The possibility of metastasis can not be ruled out.These forms of OGS are quite resistant to chemotherapy andsurgical treatment is frustrating because of the multi focal disease.
  247. 247. CLASSICCase #1168 year femalemulticentric OGS
  248. 248. Close up distal femur
  249. 249. Lateral view
  250. 250. Bone scan
  251. 251. Close upbone scan
  252. 252. Upper bodybone scan
  253. 253. Coronal T-1 MRI
  254. 254. Another coronal cutT-1 MRI
  255. 255. Sagittal T-1 MRI
  256. 256. Photomic
  257. 257. Another photomic
  258. 258. Case #53818 year femalemulticentric OGSpelvis and femur
  259. 259. tumortumorGad contrast coronal MRI
  260. 260. Another Gad contrast cut
  261. 261. pelvictumor Axial T-2 MRI
  262. 262. Internal HemipelvectomyRecon plate placed across pelvic ring surgical defect
  263. 263. Placement of air screws just prior to cementation
  264. 264. cementPlacement of cement around screws and plate
  265. 265. femoral implant total hip Constrained total hip in and securing musclesto custom proximal femoral replacement implant
  266. 266. acetabulum tumor bulge iliumOuter face of resected specimen
  267. 267. tumor bulgeilium Inner face
  268. 268. Closure
  269. 269. recon plate and screwsPost op x-ray
  270. 270. Case #53916 year femalemulticentric OGS tumorProximal tibial lesion
  271. 271. Lateral view withskip lesion indistal tibia
  272. 272. Bone scan showing two lesions in tibia
  273. 273. Bone scan showingiliac lesion
  274. 274. Bone scan showingsternal lesion
  275. 275. Photomic from tibial biopsy
  276. 276. Proximal tibialresection and tumortotal knee bulgereconstruction
  277. 277. Proximal tibialprosthesis in positionready for relocationand closure
  278. 278. Reconstructioncompleted andready for closure
  279. 279. Case #540Multicentric OGSfemur and sacrum20 year male
  280. 280. Lateral view
  281. 281. Coronal T-1 MRIshowing tumor atboth ends of femur
  282. 282. Sagittal T-1 MRIdistal femur tumor
  283. 283. tumorAxial T-2 MRI distal femur
  284. 284. Another axial T-2 MRI
  285. 285. Bone scan
  286. 286. Coronal T-1 MRI
  287. 287. Axial T-1 MRI
  288. 288. tumorCoronal gad contrast MRI showing sacral lesion
  289. 289. Photomic from femoral biopsy
  290. 290. Case #541 10 year female with multicentric OGS femur and tibia
  291. 291. tumor Lateral view
  292. 292. skip lesionAP view femur tumor
  293. 293. tumorCoronal T-2 MRIdistal femur
  294. 294. tumorSagittal T-2 MRIdistal femur tibial lesions
  295. 295. tumorCoronal T-1 MRIknee joint tumor
  296. 296. tumorCoronal T-1 MRI showing multicentric involvement
  297. 297. Case #542 tumor 15 year male with multicentric OGS tibia and femur
  298. 298. tumorCoronal T-1 MRI tumor
  299. 299. Coronal T-2 MRI tumor
  300. 300. Sagittal T-1 MRI tumor
  301. 301. tumorAxial T-2 MRI view of distal femur
  302. 302. Soft TissueOsteogenic Sarcoma
  303. 303. Soft Tissue Osteosarcoma OGS can be seen in soft tissue outside the skeletal system. Itaccounts for 4% of all OGS and is typically in large muscle groupsaround the pelvis and thigh area. It occurs most often in patientsover 40 years of age and hits males and females equally. Softtissue OGS, with its mature appearing bone in the central area ofthe lesion and aggressive, poorly mineralized tissue at theperiphery, must be differentiated from myositis ossificans, whichhas a typical zonal pattern with peripheral maturation of boneformation. As with any soft tissue sarcoma, the treatment consistsof wide local resection. Because of the poor prognosis, worsethan that of bone osteosarcoma, systemic chemotherapy is utilizedextensively as one would use for a typical medullary OGS.
  304. 304. CLASSICCase #118 tumor67 year malesoft tissue OGScalf
  305. 305. AP view
  306. 306. Sagittal T-1 MRI tumor
  307. 307. Axial T-1 MRI
  308. 308. Cut surgical specimen in path lab
  309. 309. Photomic
  310. 310. Case #54376 year femalesoft tissue OGScalf
  311. 311. Lateral view
  312. 312. CT scan
  313. 313. Bone scan
  314. 314. Axial T-1 MRI
  315. 315. Sagittal T-1 MRI tumor
  316. 316. Photomic
  317. 317. Case #54460 year female withsoft tissue OGS leg
  318. 318. Oblique view
  319. 319. Bone scan
  320. 320. Case #54563 year malesoft tissue OGShand tumor
  321. 321. Lateral view
  322. 322. tumorAxial T-1 MRI
  323. 323. tumorAxial T-2 MRI
  324. 324. tumorCoronal T-2 MRI
  325. 325. Multiple pulmonary mets
  326. 326. Intracortical Osteogenic Sarcoma
  327. 327. Intracortical Osteosarcoma The intracortical OGS is perhaps the rarest variant of OGS withonly 14 cases described in the world literature since 1960. Itoccurs between the ages of 10 and 47 years, equally betweenmales and females, and is seen most typically in the femur ortibia as a metadiaphyseal lesion with a radiographic appearancevery similar to that of osteoid oasteoma. The prognosis is usuallyquite good with a total of three deaths in the world literature. Itis usually treated by wide resection without chemotherapy. Afew cases are higher grade and carry a poor prognosis similarto the classic OGS.
  328. 328. CLASSIC Case #119 42 year female with intracortical OGS femur
  329. 329. Bone scan
  330. 330. Axial PD MRI
  331. 331. Sagittal T-2 MRI
  332. 332. Early biopsy photomic
  333. 333. X-ray 18 monthsafter curettementwith recurrence
  334. 334. Bone scan at time of recurrence
  335. 335. Axial Gad contrast MRI same time
  336. 336. tumorSagittal PD MRIsame time
  337. 337. tumorUnicortical segmental wide resection
  338. 338. Photomic of resected specimen
  339. 339. Post op x-ray following allograftunicortical resectionand allograft recon
  340. 340. PD T-2 tumorSagittal PD & T-2 MRI 18 months later with met to C-spine
  341. 341. Case #54643 year femaleintracortical OGSdistal femur
  342. 342. Lateral view
  343. 343. Sagittal T-1 MRI
  344. 344. tumorSagittal T-2 MRI
  345. 345. Biopsy photomic
  346. 346. Photomic
  347. 347. Case #54747 year femaleintracortical OGShumerus
  348. 348. Lateral view
  349. 349. CT scan
  350. 350. tumorSagittal T-1 MRI
  351. 351. Post op x-ray afterwide resection andallograft recon

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