Vol 2 ppt
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This document describes several cases of classic osteosarcoma. It begins with an overview of classic osteosarcoma, including that it most commonly affects children and young adults, occurs in long bones like the femur and tibia, and patients typically present with pain followed by a tumor mass. It then describes the staging process and treatments, including chemotherapy and surgical resection. Multiple patient cases are then described in detail, with imaging findings, surgical procedures, outcomes, and in some cases, recurrence of disease.
![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](https://image.slidesharecdn.com/vol2ppt-130130180435-phpapp02/85/Vol-2-ppt-299-320.jpg)
Vol 2 ppt
- 1. Volume 2 Classic osteosarcoma-----------------Case 108-9 & 451-490 Bone forming pseudotumors-----Case 491-498
- 3. 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
- 4. 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
- 5. 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
- 6. 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.
- 7. CLASSIC Case #108 16 yr male classic OGS femur
- 8. Bone scan
- 10. Coronal T-2 MRI
- 11. tumor tumor vessels Axial T-1 MRI
- 13. CT scan with pulmonary mets to lung
- 15. Macro section
- 16. Codman’s triangle tumor margin Close up
- 17. Photomic
- 18. Higher power
- 19. tumor cells High power
- 20. Case #109 14 yr male classic OGS femur tumor
- 22. Coronal T-2 MRI tumor
- 23. measuring device femur Distal femoral resection and reconstruction with total knee replacement and Compress fixation
- 24. Widely resected tumor specimen
- 27. Placing 5 transverse pins
- 28. Traction bar protruding from femoral canal
- 29. Tightening the compression nut inside spindle
- 30. compression nut compression cap 800 pounds of compressive fixation has been applied
- 31. spindle intercalary segment Intercalary segment attached to spindle
- 32. Completion of rotating hinge arthroplasty
- 33. AP x-ray appearance following surgery
- 34. anchor plug Close up lateral spindle
- 35. Stable osseointegration 5 years PO in another case
- 36. Case #655 16 year female classic OGS proximal femur coronal T-2 MRI
- 39. traction bar Distal femoral stump being prepared for placement of the spindle of the Compress reconstruction system
- 40. Spindle fixed to femur with 800 lbs pressure
- 41. spindle Proximal femoral replacement attached to spindle
- 42. attachment point for abductor tendon Proximal end of modular system with bipolar hip
- 43. Hip located and ready for soft tissue attachments
- 44. abductor tendon fascia lata vastus lateralis screws Soft tissue reconstruction completed with two fixation screws
- 45. tumor Resected specimen cut in path lab
- 46. Post op x-ray
- 47. 5 yrs PO
- 48. CT scan chest 8/09 -7 yrs Post Op Recent onset of breast mass
- 49. Case #451 17 yr male classic OGS femur
- 50. Lateral view
- 51. Sagittal T-1 MRI
- 53. Photomic
- 54. biopsy Resected specimen site
- 55. Specimen cut in path lab showing extensive tumor necrosis
- 56. patella Surgical defect following wide resection
- 57. Modular distal resection system with rotating hinged knee
- 58. porous pads Rotating hinge components horizontal axial vertical axial
- 59. Reconstruction completed and ready for closure
- 60. stress shielding Radiographic appearance 7 yrs later
- 61. Case #452 Codman’s triangle 13 year male with Classic OGS distal femur tumor
- 62. Sagittal T-1 MRI tumor
- 63. tumor vessels Axial T-1 MRI
- 64. Photomic
- 68. Post op X-ray
- 69. Case #453 tumor 23 yr female classic OGS femur
- 71. Photomic
- 74. Side view
- 75. Immediate post op X-ray of cemented stem prosthesis
- 76. 13 yrs later with total failure from neck fracture subsidence 2nd to stress shielding
- 77. stress shielding Surgical specimen at time of total femoral reconstruction
- 78. X-ray after total femoral reconstruction
- 79. Case #454 tumor 17 yr male with classic OGS proximal femur
- 81. Bone scan
- 82. Coronal T-1 MRI tumor
- 83. vessels tumor Axial T-1 MRI
- 84. Photomic
- 86. incision Properly placed biopsy site over trochanter
- 87. femoral head Wide resection specimen biopsy site
- 88. Cut specimen in path lab
- 89. acetabulum Surgical defect ready for reconstruction
- 90. Hyperemic synovium in acetabular notch
- 91. Suturing down abductor tendon to prosthesis
- 92. gluteus medius Final soft tissue reconstruction vastus lateralis
- 93. THA X-ray 7 yrs later
- 94. Case #455 7 yr male classic OGS distal femur tumor
- 95. Bone scan
- 97. Coronal T-2 MRI
- 99. Surgical incision for turn-up-plasty
- 100. tibia vessels femur Mobilizing prox tibia on vascular pedicle
- 101. plate fixation Resected distal femur laying next to inverted tibia tibial plateau
- 102. Post op stump appearance ready for suction socket prosthesis
- 103. Post op x-ray prox tibial epiphysis
- 104. X-ray 18 mos later tibial plateau
- 105. 5 years later
- 106. Case #456 17 yr female classic OGS with pathologic fracture and short plate fixation
- 107. 10 mos post op wide segmental resection and double Compress spacer reconstruction
- 108. Proximal Compress device showing good osseointegration 10 mos post op
- 109. Amputation specimen 10 mos post op
- 110. anchor pins Excellent osseointegration at proximal end
- 111. Case #457 32 yr male classic OGS mid femur
- 112. Coronal T-2 MRI Large extra cortical mass
- 113. tumor fluid Axial T-2 MRI
- 114. Pathologic fracture after 6 weeks on chemotherapy
- 115. Coronal MRI thru fracture site tumor fracture
- 116. necrotic rim tumor enhancement Gad contrast coronal MRI after 3 cycles of chemotherapy
- 118. necrotic Specimen cut tumor in path lab fracture
- 119. necrotic tumor Macro section fracture
- 120. Photomic
- 121. Post op x-ray following prosthetic reconstruction
- 122. Case #458 tumor 13 yr male classic OGS distal femur
- 123. tumor Lateral view
- 124. Bone scan
- 125. tumor CT scan
- 126. edema tumor tumor T-1 axial MRI
- 127. edema Coronal T-1 MRI tumor
- 128. Sagittal T-1 MRI edema tumor
- 129. Case #458.1 16 year old male with knee pain for 3 months
- 130. Cor T-1 T-2 Gad
- 131. Sag T-1 T-2 Gad
- 132. Axial T-1 T-2 Gad
- 133. Wide surgical resection and rotating hinge Compress recon
- 134. Case #458.2 8 year female with classic OGS distal femur
- 135. Cor T-1 MRI
- 136. Cor T-2 Cor Gad
- 137. Axial Gad Axial T-2
- 138. Case #459 11 yr male classic OGS proximal tibia tumor
- 139. Lateral view tumor
- 140. Coronal T-1 MRI tumor
- 141. Coronal T-2 MRI tumor
- 142. tumor Axial T-2 MRI
- 143. Photomic
- 144. Case #461 tumor 15 year male with classic OGS proximal tibia
- 145. tumor Lateral view
- 146. tumor Axial T-1 MRI
- 147. tumor Macro section
- 148. Photomic
- 149. 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
- 150. 6-05 CT scan 3 months later
- 151. Bone scan 7-05
- 152. Axial & sagittal T-1 MRI 6-05
- 153. Axial T-2 MRI Axial T-1 FS Gad 6-05 6-05
- 154. AP & lat x-ray 5 mos later 11-05 & obvious OGS
- 155. Bone scan 11-05 biopsy proven OGS and placed on preop chemotherapy
- 156. Post chemo Coronal T-1 MRI 1-06 Sagittal T-1 MRI
- 157. Axial T-2 MRI 1-06 Sagittal T-2 MRI following 2 mos of chemotherapy
- 158. X-ray following wide resection & Compress TKA
- 159. Case #461.2 Osteosarcoma prox tibia 19 yr female with pain in knee for 3 months
- 160. Sag T-1 PD FS Gad
- 161. Cor T-1 T-2 Gad
- 162. Axial T-2 Gad
- 163. Case #462 14 year old female with Classic OGS distal tibia tumor
- 164. AP view tumor
- 165. Macro section tumor
- 166. Photomic
- 167. Case #463 14 year female non-ossifying fibroma tibia with no pain Incidental finding
- 168. 4 years later and no change
- 169. 14 yrs from 1st x-ray with sudden growth of tumor
- 170. Bone scan
- 171. Sagittal T-2 MRI tumor
- 172. tumor Axial T-2 MRI
- 173. Photomic shows high grade classic OGS
- 174. Case #464 14 year female classic OGS fibula
- 175. Another view tumor
- 176. Case # 465 tumor Codman’s triangle 8 year male with classic OGS proximal fibula
- 177. Case # 466 17 year male tumor classic OGS proximal humerus
- 179. Axial T-2 MRI tumor
- 180. humeral head Widely resected surgical specimen tumor bulge
- 181. Specimen cut in path lab
- 182. Photomic
- 183. Neer cement Surgical reconsruction with allograft and long stem Neer prosthesis allograft
- 184. Neer Post op x-ray allograft
- 185. Case #467 14 year female with classic OGS proximal humerus
- 186. Resected specimen tumor
- 187. Cemented custom prosthesis 5 years post op
- 188. Case 468 16 year male with classic OGS prox humerus
- 190. Cut specimen in path lab
- 191. Photomic
- 195. Case #468.1 tumor 18 year old male with classic OGS proximal humerus
- 198. Cemented Neer prosthesis in cement position
- 199. Appearance 9 mos later with proximal migration of prosthesis mets
- 200. Case #468.2 14 year male classic OGS mid humerus tumor
- 201. Close up x-ray after 1 mo of chemo
- 202. T-1 MRI after 2 cycles of chemotherapy
- 203. T-2 MRI after 2 cycles of chemotherapy
- 204. tumor Axial PD MRI
- 206. Photomic
- 207. Case #468.3 15 year female with Classic OGS proximal Humerus with path fracture
- 208. Another view fracture
- 209. Case #469 CT scan 27 year female with classic OGS 10th rib
- 210. tumor 2 years later develops 2nd OGS in R ilium
- 211. tumor CT scan thru tumor
- 212. tumor Another CT cut
- 213. Bone scan
- 214. acetabulum tumor bulge Resected hemipelvis
- 215. Surgical specimen after 3 mins in autoclave to kill tumor ready for reimplantation sciatic notch acetabulum
- 216. Autoclaved pelvis reimplanted with total hip reconstruction
- 217. Post op x-ray appearance
- 218. X-ray 2 years later with fracture thru ilium
- 219. Case #470 T-2 coronal MRI tumor 18 year male with classic OGS pelvis
- 220. tumor Axial T-2 MRI
- 221. Entire hemipelvic resection specimen
- 222. Total hip reconstruction prior to cementation
- 223. Cement construction cement completed constrained total hip
- 224. CD rod Immediate post op x-ray
- 225. Immediate post op X-ray showing CD rod reconstruction
- 226. X-ray 2.5 years later
- 227. Case #471 tumor 14 year male with classic OGS pelvis
- 228. tumor CT scan
- 229. tumor Axial T-2 MRI
- 230. tumor spared acetabulum Coronal T-2 MRI
- 231. cement Rebar and cement reconstruction sparing hip
- 232. X-ray and CT appearance 10 years later
- 235. Case #472 26 year male with incidental fibrous cortical defect in ilium
- 236. 12 years later with classic OGS in same area
- 237. Hemipelvic resection tumor including hip joint bulge sciatic notch
- 238. autoclaved Reconstruction with bone autoclaved hemipelvis and cemented total hip THA
- 239. Completed reconstruction cement
- 240. X-ray appearance two years later
- 241. 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
- 242. Case #473 23 year male classic OGS lumbo-sacral spine tumor
- 243. tumor L-5 Lateral X-ray
- 244. tumor CT scan at L-5 - S-1 level
- 245. Photomic
- 246. Case #474 21 year male classic OGS L-3
- 247. Bone scan
- 248. L-3 tumor CT scan
- 249. Sagittal T-2 MRI tumor
- 250. Photomic
- 251. Post op x-ray following wide resection of L-3 and reconstruction with allograft anterior allograft and pedicle screws and plates
- 252. Case #475 Sagittal T-1 MRI tumor 45 year female with classic OGS L-4
- 253. tumor Axial T-2 MRI
- 254. tumor CT scan
- 255. Case #475.1 OGS dorsal spine 30 yr. Female with mid dorsal back pain 3 mos and recent para- paresis
- 256. Bone scan
- 257. CT scan
- 258. Sag T-1 T-2 Gad
- 259. Axial T-1 T-2 Gad
- 260. Post op x-ray Sag CT Axial CT
- 261. PO Axial T-2 Gad
- 262. PO Sag T-1 T-2
- 263. Case #476 20 year male classic OGS first metatarsal
- 264. Lateral view
- 265. Photomic
- 266. Case #477 76 year female with classic OGS first metatarsal
- 267. tumor Lateral x-ray
- 268. Case #478 17 year male classic OGS great toe
- 269. 18 mos later without treatment
- 270. Bone scan
- 271. Post op x-ray following resection and cancellous allograft reconstruction
- 272. Case #479 18 year female with classic OGS 4th metacarpal
- 273. Coronal gad contrast MRI
- 274. Axial gad contrast MRI
- 275. Another gad contrast cut
- 276. 2 year post op x-ray with allograft reconstruction
- 277. Case #480 70 year male with soft tissue OGS foot
- 278. AP view
- 279. Photomic
- 280. Case #481 tumor 55 year male with classic OGS talus
- 281. tumor Mortise view
- 282. Case #482 Macro section subtalar joint tumor 19 year male with classic OGS os calcis
- 283. Case #483 40 year female with classic OGS mandible
- 284. tumor Cut surgical specimen following hemimandibulectomy
- 285. Case #484 75 year female classic OGS mandible tumor
- 286. Case #485 36 year male with classic OGS lower rib
- 287. enlarged tumor 18 mos later and no treatment
- 288. Bone scan
- 289. Case #486 CT scan tumor 25 year male with classic OGS rib
- 290. tumor Another CT cut
- 291. Photomic
- 292. Case #487 tumor 29 year female with classic OGS clavicle
- 293. tumor Laminogram cut thru tumor
- 294. Immediate post op x-ray following resection
- 295. Case #488 21 year male with classic OGS patella
- 296. Patellar view of tumor
- 297. Case #489 19 year female classic OGS ulna
- 298. Case #490 38 year male classic OGS scapula tumor
- 299. 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
- 300. Case #491 14 year old female with OGS pseudotumor tibia (stress fracture)
- 301. Bone scan
- 302. Coronal T-1 MRI
- 303. edema Axial T-2 MRI
- 304. Photomic of callus formation
- 305. Case #491.1 Stress fracture thru fibroma 8/09 9/09 13 yr male runner developed knee pain a month ago
- 306. Bone scan
- 307. Cor gad Sag gad
- 308. Axial gad
- 309. Case #492 6 mo infant with pseudo OGS ulna which is Caffey’s disease
- 310. Photomic of ulnar biopsy
- 311. cortex reactive periostitis Transverse ulnar cut of amputation specimen
- 312. X-ray showing hypertrophic changes in shoulder girdle
- 313. Mandibular hypertrophic changes typical of Caffey’s
- 314. Case 493 25 year female with pseudo OGS distal femur In reality a brown tumor of hyperparathyroidism
- 315. Hemorrhagic giant cell response of brown tumor
- 316. Thickened osteoid seams of hyperparathyroidism
- 317. Case #494 12 year old male with OGS pseudotumor distal femur 2nd to pathologic fracture in hemophilia
- 319. Case #495 44 year male with old crush injury to leg 25 yrs ago with ossifying compartment syndrome looking like soft tissue OGS
- 320. Case #496 64 year female with pseudo OGS distal femur in fact is a giant bone island
- 321. Lateral view
- 322. Bone scan
- 323. Coronal MRI with low signal lesion
- 324. Case #497 10 year female with large fluffy OGS pseudotumor from callus osteogenesis imperfecta
- 325. X-ray 2.5 years later with healing fracture
- 326. Case #498 14 year male with OGS pseudotumor second to chronic stress periostitis proximal femur
- 327. Biopsy shows hypertrophic reactive bone and no OGS
- 328. Case 498.1 Paget’s disease 07 09 63 year female with aching pain in shoulder for 2 years
- 329. Bone scan
- 330. Cor T-1 STIR Alk Phos - 190
- 331. Axial T-1 T-2 Gad
- 332. Case #498.2 Sag CT scan Heterotopic bone Bone scan 61 yr male with stiff hip and quadriplegia
- 333. CT scan
- 334. CT scan
- 335. Case #498.3 Traction spur 9/08 37 year male with injury to right hip in 9/08 followed by painful stiffness in 3/09 3/09
- 336. Cor CT Cor CT Axial CT Sag CT
- 337. Axial PD FS Lower Upper