Volume 2
Classic osteosarcoma-----------------Case 108-9 & 451-490 Bone forming pseudotumors-----Case 491-498
Classic Classic Osteogenic Osteogenic SarcomaSarcoma
Classic Osteogenic Sarcoma Osteogenic sarcoma is the most common primary malignanttumor of bone, making up 20 % of all primary malignancies,with approximately 500-1000 new cases diagnosed each year inthe United States. The classic or most common form of osteo-sarcoma is seen typically in children and young adults, with amale preference. It occurs in the metaphyseal areas of fast growingbones 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 symptomsof 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 lesionis 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 sunburstpattern 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 separatefrom 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 tumorand 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 thepossibility of other bony foci in the skeletal system and a CT scanof the chest is obtained to rule out the possibility of metastatic
disease to the lung. The final staging process includes a biopsyof the primary site performed in such a way as to not contaminatevital structures that might interfere with the potential for a limbsalvage resection at a later date. Prior to 1970, the prognosis for survival with this disease wasonly 20% even though early amputation was performed at a high level. Pulmonary metastasis was the reason for a fatal outcome inthese 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 controlof the disease include high dose methotrexate, adriamycin, cysplatin, and ifosfamide. These drugs are administered througha central venous line on a cyclic basis every three to four weeksfor approximately two months prior to a surgical removal of the tumor. Chemotherapy is then continued for approximately fourmonths after surgical treatment. At the present time, 90% of patients with osteosarcoma are
treated by limb salvage resection. The most common type ofreconstruction consists of a total joint replacement such as a rotating hinge at the knee. A smaller group of patients are treatedwith 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 thereis more than 90% necrosis of the tumor, the patient has a muchbetter 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 studieshave revealed a high incidence of abnormality in the P-53 suppressor genes found in this tumor.
CLASSICCase #108
16 yr maleclassic OGSfemur
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
Amputationspecimen
Macro section
Close up
Codman’striangle
tumor margin
Photomic
Higher power
High power
tumorcells
Case #109
14 yr maleclassic OGSfemur 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
intercalarysegment
spindle
Intercalary segment attached to spindle
Completion of rotating hinge arthroplasty
AP x-ray appearancefollowing surgery
anchor plug
spindle
Close up lateral
Stable osseointegration5 years PO in another case
Case #655
16 year femaleclassic OGSproximal femur
coronal T-2 MRI
Axial T-2 MRI
tumor
Widely resected specimen
Distal femoral stump being prepared for placementof 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 tendonfascia lata
screws
Resected specimen cut in path lab
tumor
Post op x-ray
5 yrs PO
Case #451
17 yr maleclassic OGSfemur
Lateral view
Sagittal T-1 MRI
Proper biopsy site
Photomic
Resected specimenbiopsysite
Specimen cut inpath lab showingextensive tumornecrosis
Surgical defect following wide resection
patella
Modular distal resection systemwith rotating hingedknee
Rotating hingecomponents horizontal
axial
vertical axial
porous pads
Reconstructioncompleted and ready for closure
Radiographicappearance 7 yrs later
stress shielding
Case #452
13 year male withClassic OGS distal femur
tumor
Codman’striangle
Sagittal T-1 MRI
tumor
tumor
vessels
Axial T-1 MRI
Photomic
Resected specimen
growth plate
Expandable prosthesis with telescoping sleeveclosed down
Telescopingsleeve opened
Post op X-ray
Case #453
23 yr femaleclassic OGSfemur
tumor
Resected specimen
Photomic
Partially reconstructed
Completed reconstruction
Side view
Immediate post opX-ray of cementedstem prosthesis
13 yrs later with total failure fromsubsidence 2nd tostress shielding
neck fracture
Surgical specimenat time of totalfemoral reconstruction
stress shielding
X-ray after totalfemoral reconstruction
Case #454
17 yr male with classic OGS proximal femur
tumor
Lateral view
tumor
Bone scan
Coronal T-1 MRItumor
Axial T-1 MRI
tumor
vessels
Photomic
Modular proximalfemoral resectionsystem
Properly placed biopsy site over trochanter
incision
Wide resectionspecimen
biopsysite
femoral head
Cut specimenin path lab
Surgical defect ready for reconstruction
acetabulum
Hyperemic synovium in acetabular notch
Suturing downabductor tendonto prosthesis
Final soft tissuereconstruction
gluteus medius
vastus lateralis
X-ray 7 yrs later
THA
Case #455
7 yr male classic OGSdistal femur
tumor
Bone scan
Sagittal T-1 MRItumor
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 femurlaying next toinverted tibia
plate fixation
tibial plateau
Post op stumpappearance readyfor suction socketprosthesis
Post op x-ray
prox tibial epiphysis
X-ray 18 mos later
tibial plateau
5 years later
Case #456
17 yr femaleclassic OGS withpathologic fractureand short plate fixation
10 mos post op widesegmental resectionand double Compressspacer reconstruction
Proximal Compressdevice showing goodosseointegration10 mos post op
Amputation specimen 10 mos post op
Excellent osseointegration at proximal end
anchor pins
Case #457
32 yr maleclassic OGSmid femur
Coronal T-2 MRI
Large extracortical mass
Axial T-2 MRI
fluid
tumor
Pathologic fracture after6 weeks on chemotherapy
Coronal MRIthru fracture site
tumorfracture
Gad contrast coronal MRI after 3 cycles of chemotherapy
necrotictumor rim
enhancement
Surgical specimenfollowing wideresection
Specimen cut in path lab
necrotictumor
fracture
Macro section
necrotictumor
fracture
Photomic
Post op x-ray followingprosthetic reconstruction
Case #458
13 yr maleclassic OGSdistal femur
tumor
Lateral viewtumor
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 OGSproximal tibia tumor
Lateral view
tumor
Coronal T-1 MRItumor
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 #461.1AP & lat x-ray 3-05
17 year female dancer with prox. tibial pain for 3 mos withearly 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 #462
14 year old female withClassic OGS distal tibia tumor
AP view tumor
Macro section
tumor
Photomic
Case #463
14 year femalenon-ossifying fibromatibia with no pain
Incidental finding
4 years laterand 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 femaleclassic OGS fibula
Another view
tumor
Case # 465
8 year male with classic OGS proximal fibula
Codman’s triangle
tumor
Case # 466
17 year maleclassic OGSproximal humerus
tumor
Coronal T-1 MRI
tumor
Axial T-2 MRItumor
Widely resectedsurgical specimen
tumorbulge
humeralhead
Specimen cut in path lab
Photomic
Surgical reconsructionwith allograft and longstem Neer prosthesis allograft
cement
Neer
Post op x-ray
Neer
allograft
Case #467
14 year female with classic OGS proximal humerus
Resected specimentumor
Cemented customprosthesis 5 years post op
Case 468
16 year male withclassic OGS proxhumerus
Widely resected surgical specimen
Cut specimen in path lab
Photomic
Surgical defectready forreconstruction
glenoid
Neer prosthesisin position
Immediate post opappearance
Case #468.1
18 year old male withclassic OGS proximalhumerus
tumor
Widely resectedspecimen
Surgical defectready forreconstruction
glenoid
Cemented Neerprosthesis inposition
cement
Appearance 9 mos laterwith proximal migrationof prosthesis
mets
Case #468.2
14 year maleclassic OGSmid humerus
tumor
Close up x-rayafter 1 mo of chemo
T-1 MRI after 2 cyclesof chemotherapy
T-2 MRI after 2 cyclesof chemotherapy
Axial PD MRI
tumor
Surgical specimenfrom shoulderdisarticulation
Photomic
Case #468.3
15 year female with Classic OGS proximalHumerus 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 specimenafter 3 mins inautoclave to killtumor ready forreimplantation
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 reconstructionprior to cementation
Cement constructioncompleted
cement
constrainedtotal hip
Immediate post op x-ray
CD rod
Immediate post opX-ray showing CDrod 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
sparedacetabulum
Rebar and cement reconstruction sparing hip
cement
X-ray and CT appearance 10 years later
X-ray appearanceFollowing THA
Case #472
26 year male with incidental fibrous cortical defect in ilium
12 years later with classic OGS in same area
Hemipelvic resectionincluding hip joint
tumorbulge
sciaticnotch
Reconstruction withautoclaved hemipelvisand cemented total hip
autoclavedbone
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 maleclassic OGSlumbo-sacral spine
tumor
Lateral X-ray
tumor
L-5
CT scan at L-5 - S-1 level
tumor
Photomic
Case #474
21 year maleclassic OGS L-3
Bone scan
CT scan
tumor
L-3
Sagittal T-2 MRI
tumor
Photomic
Post op x-ray followingwide resection of L-3and reconstruction withanterior allograft andpedicle 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 #476
20 year male classic OGSfirst metatarsal
Lateral view
Photomic
Case #477
76 year female with classic OGS first metatarsal
Lateral x-ray
tumor
Case #478
17 year male classic OGSgreat toe
18 mos laterwithout treatment
Bone scan
Post op x-ray followingresection and cancellousallograft 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 femaleclassic OGS mandible
tumor
Case #485
36 year male with classic OGS lower rib
18 mos later and no treatment
enlargedtumor
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 femaleclassic OGSulna
Case #490
38 year maleclassic OGSscapula
tumor
Bone Forming Bone Forming PseudotumorsPseudotumors
Stress fracturesCaffey’s diseaseBrown tumor of hyperparathroidismHemophiliaCompartment syndrome [late]Giant bone islandsOsteogenesis imperfecta
Case #491
14 year old female withOGS pseudotumor tibia(stress fracture)
Bone scan
Coronal T-1 MRI
Axial T-2 MRI
edema
Photomic of callus formation
Case #492
6 mo infant with pseudo OGS ulna which is Caffey’s disease
Photomic of ulnar biopsy
Transverse ulnar cut of amputation specimen
reactiveperiostitis
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 withOGS pseudotumor distalfemur 2nd to pathologicfracture in hemophilia
Lateral view
pseudotumor
Case #495
44 year male with oldcrush injury to leg 25 yrs ago with ossifying compartmentsyndrome looking likesoft 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 withOGS pseudotumor fromosteogenesis imperfecta
large fluffycallus
X-ray 2.5 years laterwith healing fracture
Case #498
14 year male with OGSpseudotumor second tochronic stress fractureproximal femur
Biopsy shows hypertrophic reactive bone and no OGS
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