8-year-old with osteosarcoma of the right humerus amy millar march 2013 james cameron, md
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8-year-old with osteosarcoma of the right humerus
Amy Millar
March 2013
James Cameron, MD
• 8 yo F diagnosed w/ resectable, localized osteosarcoma of R humerus 4/19/12 at OSH
• Family refused treatment; received non-conventional therapy in AZ (ozone, IV vitamin C)
• When patient did not improve, parents took her to a hospital in NY where new pulmonary mets were seen. She received “palliative radiation” to humerus and lungs
• Presented to Rush on 8/19/12 due to severe pain in right arm
• Limb salavage not feasible/pulmonary mets not resectable at this time
Patient Presentation
2
• Most common malignant bone tumor
• Rare in pts <5 yo, increases with age
• Most common in long bones near metaphyseal growth plate
• Femur (42%), tibia (19%), humerus (10%) are most common locations
• Classic/conventional OS is most common subtype
• Most commonly presents with pain with activity
Osteosarcoma
Ddx solitary lucent bone lesions
FEGNOMASHICF - fibrous dysplasia OR fibrous cortical defect (FCD)E - enchondroma OR eosinophilic granuloma (EG)G - giant cell tumour (GCT)N - non-ossifying fibroma (NOS)O - osteoblastomaM - metastasis(es)A - aneurysmal bone cyst (ABC)S - simple (unicameral) bone cystH - hyperparathyroidism (brown tumour)I - infection (osteomyelitis)C - chondroblastoma OR chondromyxoid fibroma
1º Bone Tumors: ACR Appropriateness Criteria
Radiologic Procedure
Rating Comments Relative Radiation Level
Xray area of interest 9 Absolute requirement in pt with suspected bone lesion
Varies
US area of interest 1 0
MRI area of interest 1 0
Tc-99m bone scan whole body
1 ☢ ☢ ☢
CT area of interest w/o contrast
1 Varies
FDG-PET/CT whole body 1 ☢ ☢ ☢ ☢
Screening, First Study
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
1º Bone Tumors: ACR Appropriateness Criteria
Radiologic Procedure
Rating Comments Relative Radiation Level
MRI area of interest w/ or w/o contrast
9 Contrast can provide more information.Useful for vascularity and necrotic areas.
0
CT area of interest w/o contrast
5 May be useful if MRI not available orpossible. Useful for evaluation ofcalcification, cortical breakthrough andpathological fractures.
Varies
FDG-PET/CT whole body 5 Can be useful for problem solving. ☢☢☢☢
Tc-99m bone scan whole body
3 Probably not indicated, except to look foradditional lesions.
☢☢☢
US area of interest 1 0
Suspicious for malignant characteristics on radiograph
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Radiographic findings of OS
7
Elevation of periosteum 2/2 reactive bone formation (“Codman triangle”)
Mixed sclerotic/lytic appearance is common Mineralized osteoid
may be seen in adjacent soft tissue
Radiographic findings of OS
Intramedullary skip lesions may be present
Occasionally may present as a pathologic fx
Radiographic findings, cont.
9
- Abnormal medullary signal intensity - Soft tissue mass
- Decr signal intensity- Soft tissue mass- Extension into
epiphysis
• Evaluate for longitudinal extent of interosseous disease, involvement of adjacent epiphyses, presence of skip lesions• Evaluate for extent
of extraosseous disease
• MRI to assess tumor distribution and associated soft tissue mass (staging)
Normal comparison
Right Shoulder AP
Mixed sclerotic and lytic lesion
Soft tissue mass and swelling
Right Humerus AP and Lateral
Periosteal reaction
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Pre Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Axillary vasculature
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Coronal MRI Post Contrast
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
Right Shoulder T1 Axial MRI
• Court-ordered chemo started on 9/6/12
• Underwent resection of several small pulmonary mets in 2/2012 and 3/2012
• Primary tumor remains unresectable
Pt MRN 6331959
Hospital Course to Date