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