Osteosarcoma Profile - Hospital Number 024728-56 - years old male student - Ht 170 cm Bw 50 kg Chief Complaint - Painful and swelling at right ankle for 1 year Present illness • 1 year PTA, the patient went to Chao Phya Abhaibhubejhr hospital with an ankle pain from the accident during playing football. Being able to walk but cannot run. Normal x- ray finding. Tendinitis was diagnosed. The pain wasn’t relieved. The right ankle kept being swollen. Present illness • 6 months PTA, the patient went to Chakkraphong hospital. Diagnosis was bone fracture, the bone had splinted for a month. The symptoms, pain and swelling, were still exist. • 1 month PTA, the patient went to MHMC. Chronic osteomyelitis was diagnosed. The patient was treated by IV antibiotics and not getting better a month after. Physical examination • Vital sign : BP 120/80 BT 37.3 PR 86 RR20 • General appearance : Good consciousness, no jaundice • Lung: Clear both • LN : no groin lymph node enlargement • EXT : painful mass size 9 cm. at distal tibia and limit ROM of right ankle Problem list 1. Painful right ankle mass for 1 year Differential diagnosis • Bone tumor • Osteomyelitis Provisional diagnosis Bone tumor Lab investigation • CBC : Hb 10.6 Hct 32.5 WBC 9,540 N72.3% L21% Mo4% E3% B0% Plt 427,000 • CRP 39.6 mg/L • ESR 102 mm/hr Approach film 6/1/14 Film : At right ankle joint, AP view : Permeative osteolytic lesion at metaphysis extend to diaphysis of right distal tibia with soft tissue swelling 6/1/14 Film : At right ankle, lateral view : Osteoid matrix; Homogeneous opacity : Osteolyic lesion; permeative : Soft tissue swelling Disuse osteoporosis : Decrease cortex density and prominent trabeculae Osteoid matrix : Homogeneous opacity : Soft tissue swelling 27/3/14 27/3/14 Film : At right ankle joint : Osteoid matrix : Cortical erosion : Periosteal reaction; Codman’s triangle Conclusion • 18 years old male present with painful right ankle mass for 1 year • X-ray finding : - Permeative osteolytic lesion at metaphysis extend to diaphysis of right distal tibia with soft tissue swelling Conclusion • X-ray finding : - Osteoid matrix - Soft tissue mass - Codman's triangle • Ddx : - osteosarcoma - Ewing’s sarcoma Definited diagnosis • Biopsy : - Osteosarcoma Treatment Treatment • Surgery • Chemotherapy • Radiation Therapy (in certain cases) Bone Tumors • classified by Location Longitudinal Plane • EPIPHYSEAL METAPHYSEAL • DIAPHYSEAL – Chondroblastoma ◦ Nonossifying fibroma – Adamantinoma (close to growth plate) – Clear cell ◦ Chondromyxoid fibroma – Leukemia, chondrosarcoma (abutting growth plate) Lymphoma, – Giant cell tumor ◦ Solitary bone cyst, ABC, Reticulum cell GCT sarcoma – Aneurysmal bone ◦ Osteochondroma cyst – Ewing sarcoma ◦ Brodie abscess – – Geode ◦ Osteogenic sarcoma, Metastasis (subchondral cyst) chondrosarcoma – Osteoblastoma/ – Infection osteoid osteoma – Eosinophilic – Nonossifying fibroma granuloma Transverse Plane • Central: Enchondroma • Eccentric: Giant cell tumor , Chrondomyxiod fibroma, Osteosarcoma • Cortical: Osteoid osteoma, Nonossifying fibroma • Parosteal: Osteochondroma, Parosteal osteosarcoma • classified by The lesion doing to the bone Patterns of bone destruction Osteolytic lesion • Geographic osteolytic lesion • Moth-eaten osteolytic lesion • Permeative osteolytic lesion 1. Geograhic •Well-defined smooth/irregular margin •Short zone of transition •Implies a less-aggressive, slow- growing, benign process Examples : Non-ossifying fibroma, Chondromyxoid fibroma, Eosinophilic granuloma 2. Moth-eaten •Areas of destruction with ragged borders •Less well defined •Implies more rapid growth •Malignant tumor, Osteomyelitis •Some benign ex.Eosinophillic granuloma Examples : Myeloma Metastasis Lymphoma Ewing’s sarcoma Infection 3. Permeative •Poorly demarcated lesion imperceptibly merging with uninvolved bone •Long zone of transition •Run parallel to long axis of bone •Implies an aggressive malignancy •Malignant tumor, Osteomyelitis Examples : Ewing’s sarcoma infection Myeloma, metastasis Lymphoma Osteomyelitis Neuroblastoma Osteosarcoma • classified by Age Periosteal Reactions •Benign None Solid •More aggressive or malignant Lamellated or onion-skinning Sunburst Codman’s triangle Take home message.