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. 2014 May;48(3):238-46.
doi: 10.4103/0019-5413.132491.

Classification, imaging, biopsy and staging of osteosarcoma

Affiliations

Classification, imaging, biopsy and staging of osteosarcoma

Zile Singh Kundu. Indian J Orthop. 2014 May.

Abstract

Osteosarcoma is the most common primary osseous malignancy excluding malignant neoplasms of marrow origin (myeloma, lymphoma and leukemia) and accounts for approximately 20% of bone cancers. It predominantly affects patients younger than 20 years and mainly occurs in the long bones of the extremities, the most common being the metaphyseal area around the knee. These are classified as primary (central or surface) and secondary osteosarcomas arising in preexisting conditions. The conventional plain radiograph is the best for probable diagnosis as it describes features like sun burst appearance, Codman's triangle, new bone formation in soft tissues along with permeative pattern of destruction of the bone and other characteristics for specific subtypes of osteosarcomas. X-ray chest can detect metastasis in the lungs, but computerized tomography (CT) scan of the thorax is more helpful. Magnetic resonance imaging (MRI) of the lesion delineates its extent into the soft tissues, the medullary canal, the joint, skip lesions and the proximity of the tumor to the neurovascular structures. Tc99 bone scan detects the osseous metastases. Positron Emission Tomography (PET) is used for metastatic workup and/or local recurrence after resection. The role of biochemical markers like alkaline phosphatase and lactate dehydrogenase is pertinent for prognosis and treatment response. The biopsy confirms the diagnosis and reveals the grade of the tumor. Enneking system for staging malignant musculoskeletal tumors and American Joint Committee on Cancer (AJCC) staging systems are most commonly used for extremity sarcomas.

Keywords: Enneking staging; Osteosarcoma; biopsy; imaging.

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Conflict of interest statement

Conflict of Interest: None.

Figures

Figure 1
Figure 1
(a) X-ray anteroposterior and lateral views of proximal tibia and knee joint showing diaphyseal osteosarcoma of tibia with sclerosis (arrow), cortical destruction on posteromedial side (arrow heads) and new bone formation in the soft tissues (b) x-ray distal end of femur (anteroposterior and lateral views) showing sclerosis/radio-opacity in sclerosing osteosarcoma
Figure 2
Figure 2
X-ray of humerus anteroposterior view showing osteosarcoma of the proximal humerus- typical sun burst or sun ray appearance, new bone formation in soft tissues, and Codman's triangles (arrows)
Figure 3
Figure 3
Telangiectatic type of osteosarcoma of the proximal tibia: (a) X-ray anteroposterior and lateral views showing lysis and expansion (b) MRI showing fluid levels
Figure 4
Figure 4
X-ray of knee joint anteroposterior views showing surface osteosarcoma: (a) parosteal (b) periosteal. See the under lying cortex is visibly intact in ‘a’ and lifting of periosteum in ‘b’ (red arrow). However, both are on the surface of the bone
Figure 5
Figure 5
X-ray anteroposterior and lateral views showing that after chemotherapy the tumor becomes well defined with better capsulation: (a) before chemotherapy and (b) after chemotherapy
Figure 6
Figure 6
(a) Plain X-ray chest of a patient of osteosarcoma showing multiple metastatic lung nodules (b) CT scan (axial section) demonstrating multiple metastases in both lungs (c) Tc-99m bone scan of osteosarcoma in the proximal humerus with hot spot at this site and in spine, ribs and a focus in the skull bone
Figure 7
Figure 7
Osteosarcoma in the distal end of femur: (a) X-ray thigh with knee anteroposterior view showing big soft tissue component on the medial side; (b) MRI-coronal section showing the medullary extent (arrow); (c) MRI-axial section showing the proximity of the popliteal vessels
Figure 8
Figure 8
Open biopsies taken through small two cm incisions without making different planes. The incisions were placed such that these can be well resected with definitive resection of the tumor
Figure 9
Figure 9
Core needle biopsy: (a) Jamshidi needle with trochar and stylet. (b) Biopsy being taken through stab incision. (c) Five good cores taken
Figure 10
Figure 10
Poorly performed biopsies: (a) Avoid transverse incision in the extremity because this is difficult to excise with definitive resection. (b) Never biopsy through buttock as this is the flap for the coverage in the hind quarter amputation if required. (c) Never biopsy through rectus femoris; very important for knee extension (d) Poor biopsy: Long incision and widely placed sutures marks will require excision of wide area of skin and under lying tissues if salvage surgery is contemplated and the wound closure may be compromised

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