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  1. 1. Case Report #0648 Submitted by: Susanna Spence, M.D. Faculty reviewer: Manickam Kumaravel, M.D Date accepted: 11 January 2010 Radiological Category: Principal Modality (1): Principal Modality (2): This case report presented at noon conference, Case-Based Radiology-Pathology Correlation, July 2009. Musculoskeletal MRI, nuclear medicine Plain film
  2. 2. Case History 20 year old male with left forearm pain for 3 months.
  3. 3. Radiological Presentations
  4. 4. Radiological Presentations
  5. 5. Radiological Presentations Coronal T1
  6. 6. Radiological Presentations Coronal T2
  7. 7. Radiological Presentations Axial T1 + C
  8. 8. •Ewing’s sarcoma •Osteogenic osteosarcoma •Lymphoma •Eosinophilic granulomatosis •Metastatic disease Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Test Your Diagnosis
  9. 9. There is an ill-defined lesion with a wide zone of transition centered at the metaphysis of the distal ulna with surrounding new bone formation and periosteal reaction. There is increased tracer uptake on the bone scan images. There is no evidence of additional lesions on the bone scan (mild uptake at the left hindfoot was found to be due to tarsal coalition). MR images demonstrate low signal intensity consistent with the areas of ossification, and surrounding edema. There are patchy areas of contrast enhancement. •Ewing’s sarcoma •Osteogenic osteosarcoma •Lymphoma •Eosinophilic granulomatosis •Metastatic disease Findings: Differentials: Findings and Differentials
  10. 10. Discussion Age (y) Possible Diagnoses 1–30 Ewing sarcoma, osteogenic sarcoma 30–40 Giant cell tumor, parosteal sarcoma, fibrosarcoma, malignant fibrous histiocytoma, 1° lymphoma of bone Over 40 Chondrosarcoma, metastatic disease, myeloma The most likely histologic diagnosis for a given bone lesion can be broken down by its imaging appearance and the patient’s age. In this case, the lesion has aggressive features, with a wide-zone of transition, cortical breakthrough and a soft tissue component, favoring a malignant process. In this 20 year old patient, the most likely diagnoses would be either Ewing sarcoma or osteogenic osteosarcoma (these diagnoses will be discussed further).
  11. 11. Osteogenic Osteosarcoma • Most common primary malignant tumor of bone in adolescents and young adults. Several types: • Intramedullary (high grade, telangiectatic, low grade, small cell, osteosarcomatosis, and gnathic), • Surface (intracortical, parosteal, periosteal, and high-grade surface), • Extraskeletal (rare). Osteosarcoma may also occur as a secondary lesion in association with underlying benign conditions (e.g. Paget’s, fibrous dysplasia, previous radiation) Discussion Murphey et al. The many faces of osteosarcoma. RadioGraphics 1997; 17: 1205-1231.
  12. 12. Osteogenic osteosarcoma: Clinical features: •Male: female ratio 1.5-2:1 •White > black •Most commonly presents around the knee, with the distal femur (40- 45%) and proximal tibia (16-20%) being the most common sites. •Most common type is intramedullary, which occurs most commonly within the metaphysis (90-95%) Imaging features •Majority (~90%) demonstrate “fluffy” or “cloud-like” areas characteristic of osteoid formation •Tends to violate the cortex without altering osseous contours •May occasionally be primarily lytic •Associated with aggressive periosteal reaction, which may be lamellated, sunburst, or feature a Codman’s triangle (*). Discussion *
  13. 13. In this case: The appearance of the lesion, with fluffy surrounding new bone formation, periosteal reaction and violation of the cortex without alteration in osseous contours, along with the age of the patient, all strongly favor osteogenic osteosarcoma as the primary diagnosis. Discussion
  14. 14. The patient went on the biopsy (shown below). Low power and high power views demonstrate pleomorphic, atypical cells are shown producing areas of pink osteoid, consistent with osteogenic osteosarcoma. Discussion
  15. 15. Ewing’s sarcoma: Clinical features: •10% or all primary bone tumors •Male: female ratio 2:1 •95% between ages 4 and 25 •95% in whites •Most common locations: pelvis, humerus, femur, distal extremities •Average time to diagnosis: 6 months Imaging features: •~59% metadiaphyseal, 35% diaphyseal •Permeative lesion located in the medullary cavity •Aggressive periosteal reaction, may be amorphous, sunburst or lamellated •Often associated with a large soft tissue mass Discussion Reinus WR, Gilula LA, IESS Committee. Radiology of Ewing Sarcoma: Intergroup Ewing’s Sarcoma Study (IESS). RadioGraphics 1984; 4 (6): 929-944.
  16. 16. Ewing’s sarcoma: In this case: The prominent finding of new bone formation, along with the cortical breakthrough without disturbance of the osseous contours, is typical of osteogenic osteosarcoma. While some periosteal reaction was present in our case, it is often a very much more prominent feature of Ewing’s sarcoma. Therefore, Ewing’s sarcoma is not the favored diagnosis in this case. Discussion Reinus WR, Gilula LA, IESS Committee. Radiology of Ewing’s Sarcoma :Intergroup Ewing’s Sarcoma Study (IESS). RadioGraphics 1984; 4 (6): 929-944.
  17. 17. Osteogenic osteosarcoma. Diagnosis
  18. 18. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Fundamentals of Diagnostic Radiology. 3rd ed. Lippincott, Williams & Wilkins; 2006. Levine SM et al. Cortical Lesions of the Tibia: Characteristic Appearances at Conventional Radiography RadioGraphics 2003; 23: 157-177. Reinus WR, Gilula LA, IESS Committee. Radiology of Ewing Sarcoma :Intergroup Ewing’s Sarcoma Study (IESS). RadioGraphics 1984; 4 (6): 929-944. References