Refleksi Kasus Osteosarkoma

8/11/2019 Refleksi Kasus Osteosarkoma

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Laporan Pagi

30 Juni 2014

Rona Kartika/13166


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Identitas

Nama: Nn. V

Usia: 12 tahun

Alamat: Sleman, Yogyakarta No. Rm 01689xxx

Keterangan Klinis: suspek trauma ankle

Jenis Foto: Ankle joint, AP dan Lateral


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R


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R


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R


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Hasil Pemeriksaan

Foto ankle joint, AP dan lateral view, kondisi

cukup.

Tampak soft tissue swelling

Trabekulasi tulang baik

Tampak lesi sklerotik dan litik pada os tibia sinistra

1/3 distal, periosteal reaction (+), sun burst (+)

Tak tampak osteofit maupun subchondral sclerotic

Joint space tak melebar maupun menyempit


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Kesan

Suspek osteosarcoma os tibia sinistra 1/3

distal


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Teori


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Osteosarcoma

Definitions:

A mesenchymal malignancy (malignant spindle cells)

that differentiates to produce osteoid/immature bone

Second most common primary malignant tumor ofbone (first most common=multiple myeloma)

15% of all biopsied primary bone tumors

Sites: Metaphysis: 90% ;Diaphysis: 8-10% Sex: male > female 1,52 : 1

Age : 75% patients 12 - 25 yo, 30% patient > 40 yo


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Predilection

Major sites of origin of osteosarcomas:

Metaphysis (90%), diaphysis (10%)

femur distal,

tibia prox,

humerus prox Jaws,

skull,

pelvis,

vertebra


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Classification

Intramedullary Osteosarcoma: Lesion arising

within the medullary space of the bone (most

common type)

Juxtacortical Osteosarcoma: Lesion arising on thesurface of the bone in apposition to the cortex

Intracortical Osteosarcoma: Lesion arising from

the cortex of the bone


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Juxtacortical Osteosarcoma

Parosteal Osteosarcoma (65%)

Periosteal Osteosarcoma (25%)

High Grade Surface (10%)


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Parosteal Osteosarcoma

Origin: Arises from outer layer of periosteum

Usually a low grade tumor with fibroblastic stroma andosteoid/woven bone

Age: 20-30 yrs; usually about a decade older thanconventional osteosarcoma

Location:

Posterior distal femur metaphysis (65%)

Proximal humerus (15%); Tibia (10%); Fibula (3%)

Clinical: painless mass in posterior distal thigh; may bepresent for several yrs; decreased ROM of adjacent joint

Sex: Female>Male 2:1


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Radiology:

XR:

Lobulated and ossified exophytic mass (cauliflower-like)

adjacent to the cortex with a lucent cleavage plane betweenlesion and the cortex

Radiodense centrally

Cortical thickening

Large tumors encircle the bone

Growth may obliterate cleavage plane between lesion and

cortex and will appear to have broad attachment

Invasion of the medullary canal with long standing disease


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Periosteal Osteosarcoma

Low to intermediate grade bone forming sarcomawith predominant chondroblastic differentiationtumor (>90% of tumor); 85%);ulna and humerus (10%)


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Radiology:

XR:

Diaphyseal lesion on surface of bone; medullary canal isuninvolved

Saucerized cortex with chondroblastic soft tissue mass

Cortical thickening at margins of erosion (40%)

May have Codmans triangle

Spiculated or sunburst periosteal reaction (elevates the

periosteum) Partial matrix mineralization may be seen consistent with

chondroblastic nature

Rarely, intramedullary invasion


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High Grade Surface Osteosarcoma

High grade osteosarcoma that develops on the

surface of the bone without any medullary

involvement; very rare (


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Radiology:

Appearance similar to periosteal osteosarcoma

but matrix mineralization is similar to

conventional osteosarcoma with cloudlikeopacities

Broad based lesion arising on surface

Codmans triangle; periosteal new bone Cortical erosion/destruction but medullary cavity

usually uninvolved


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Bone tumordifferential diagnosis

Abbreviations used:ABC = Aneurysmal bone cyst

CMF = Chondromyxoid fibroma

EG = Eosinophilic Granuloma

GCT = Giant cell tumour

FD = Fibrous dysplasia

HPT = Hyperparathyroidismwith Brown tumor

NOF = Non Ossifying Fibroma

SBC = Simple Bone Cyst


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Differential Diagnosis: Site


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Differential Diagnosis: Sclerotic type

www.radiologyassistant.nl/en/p4bc9a97980036/sclerotic-bone-tumors-and-tumor-like-lesions.html


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Radiologic Findings

Metaphyseal lesion

Eccentric extraosseous mass

Sclerotic and lytic lesion

Codmans

triangle

Eccentric

extraosseous

mass

Lytic lesion

Sclerotic lesion

http://www.mypacs.net/cases/OSTEOSARCO

MA-4172660.html


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Codman triangleis the

triangular area of new

subperiosteal bone that

is created when alesion, often a tumor,

raises the periosteum

away from the bone.

http://www.radiologyassistant.nl/en/p494e15cbf0d8d/bone-tumor-systematic-approach-and-differential-diagnosis.html


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sunburst appearance

due to the tumor

spicules of calcified

bone radiating in rightangles

www.studyblue.com/notes/note/n/efmh-pdiatrie/deck/3217062


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Periosteal reaction

cortical bone reacts to one of many possibleinsults (tumor, infection, trauma, certain drugs,and some arthritic conditions) can elevate theperiosteum from the cortex

Classification:Non-aggresive:

Thin, solid, thick irregular, septated

Aggressive:Lamilated, spiculated (sunburst, hair on

end), codman triangle, disorganize


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Periosteal reaction: Non Aggresive

Thin Solid Thick irregular Septated

Healed fracture, osteoid osteoma, osteomyelitis

http://www.ajronline.org/doi/full/10.2214/AJR.09.3300
http://www.ajronline.org/doi/full/10.2214/AJR.09.3300http://www.ajronline.org/doi/full/10.2214/AJR.09.3300


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Periosteal reaction: Aggresive

Multilamilated

cycles of rapid and slow injury to bone

led to the formation of concentric

layers.

modulation of sheets of fibroblasts in

the adjacent soft tissue, whichdevelop osteoblastic potential and

give rise to sheets of new bone.

the new layer of bone is lifted off the

cortex, the inner cambium layer is

stimulated to form a new bone layer

below Lesion in slow periodic growth

E.q: sarcomas, osteomyelitis, and chondroblastomas


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Periosteal reaction: Spiculated

Hair on end Sunburst Hair on end and codman

triangle in ewing sarcoma

an aggressive form of periosteal reaction.

The linear spicules of new bone form along newly formed vascular channels

and fibrous bands (Sharpey fibers).

due to the tumor spicules of calcified bone radiating in divergent


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Periosteal reaction:

Disorganized & Codman triangle

A Codman triangle

develops when a portion

of periosteum is lifted

off of the cortex by

tumor, pus, or

hemorrhage at a leading

edge

Lamillated & disorganized Codman Triangle


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Matrix Mineralization

Chondral calcification: LINEAR, CURVILINEAR, RING-LIKE, PUNCTATE,

NODULAR

e.q enchondroma, chondrosarcoma, chondromyxoidfibroma

Osseous mineralization: FLUFFY, CLOUD-LIKE, POORLY DEFINED.

e.q. osteosarcoma

DIFUSE : GROUND-GLASS APPEARANCE E.q. fibrous dysplasia


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CHONDRAL CALCIFICATION OSSEOUS MINERALIZATION


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GROUND-GLASS CALCIFIED MEDULLARY BONE INFARCT

Refleksi Kasus Osteosarkoma

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