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Parosteal Osteosarcoma:

Parosteal Osteosarcoma Latoya Carson & Victoria Honeysucker October 12, 2011

General Description:

General Description Typically low-grade tumor Location: metaphyses of long bone Lobular / exophytic mass on radiographs Bone Matrix with chondroid tissue Central ossificatiation Common site: posterior distal aspect of femur 1

Possible Signs and Symptoms:

Possible Signs and Symptoms Painless to severe pain Night pain Growing mass- Space occupying lesion Swelling Decreased ROM Local tenderness upon palpation 2,3 Varies based on location, severity & pain

Incidence :

Incidence ≈ 5% of all osteosarcomas 1 Age: 20 – 40 years old 1 Gender: Female > Males 4

Diagnosis :

Diagnosis Radiograph, MRI, CT all used Biopsy for tissue evaluation CT and MRI effective for extent of tumor & surgical preparation MRI- Superior for bone marrow impaction 2

Prognosis :

Prognosis Good prognosis with surgical intervention 4 No chemotherapy required for low grade Chemotherapy for high grade lesions 5 Reoccurrence at the same site in about 1/3 of affected individuals 3 5 year survival rate of 86-91% 1 Rarely Metastasizes 1

Functional Impact:

Functional Impact Gait- e.g. antalgic, decreased cadence/step length Transfers ADLs/IADLs- e.g. cooking, cleaning, grooming, shopping, driving Varies according to severity of symptoms

Role of Imaging :

Role of Imaging Primary tool for the diagnosis! Important for differential diagnosis 1 Myositis Ossificans, Osteochondroma, Fibrous malignancy Important for surgical planning Adequate resection  ’ s risk for reoccurrence 6

Management of Disease:

Management of Disease Surgical Intervention- resection tumor 4 Chemotherapy may be indicated for the high grade lesions 5

Best Imaging- MRI:

Best Imaging- MRI T1- BEST for intramedullary extension T2- Greater detail of soft tissue & neurovascular structures Multiple angle views Allows T1/T2 comparison of tumor characteristics 5,7

Differential Diagnosis:

Differential Diagnosis These conditions may mimic Parosteal osteosarcoma: Myositis Ossificans Osteochondroma Periosteal Chondroma * Imaging plays a key role in differentiating these conditions and their interventions. 1

Lateral Radiograph :

Lateral Radiograph A: Normal tibiofemoral alignment. Patellar femoral and tibiofibular joints appear to be in normal alignment . Exostosis : lobular centrally calcified tumor formation at distal post. femur; cortex and tumor separated by radiolucent line B: increased radiodensity of post. distal 1/3 femur Minimal increased radiodensity at tibial plateau C: Normal S: Muscles indistinct, Radiolucent periosteal line Image Source 8 :

Radiograph Findings:

Radiograph Findings Biomechanical impairments : Limited knee flex/ ext Abnormal HS length-tension relationship Physical Impairments : Decreased ROM Decreased Strength Decreased HS length Decreased Functional Mobility

Parosteal OS Radiograph:

Parosteal OS Radiograph Arrow points to cleavage plane- commonly referred to as “ string sign ” Arrow heads point to radiolucent line indicating periosteum 1

CT Scan of Parosteal Osteosarcoma :

CT Scan of Parosteal Osteosarcoma Radiographic Findings Tumor formation posterior aspect of the femur Increase radiodensity of tumor centrally No intramedullary extension Minimal bone formation along the medial/post. aspect of the femur Image source 9: http ://

Questions :

Questions 1) Clinically how would you differentiate between Parosteal Osteosarcoma and myositis ossificans? What would be the differences between the two on radiographs? 2) Although parosteal osteosarcoma rarely metastasizes, in the event of metastasis to the distal femur resulting in limb amputation, what would be your treatment approach for early rehabilitation post surgery?

References :

References Yarmish G, Klein MJ, Landa J, Lefkowitz RA, Hwang S. Imaging characteristics of primary osteosarcoma: nonconventional Subtypes. RadioGraphics 2010; 30:1653-1672. Accessed October 10, 2011 2. Dönmez FY, Tüzün U, Başaran C, Tunacı M, Bilgiç B, Acunaş G. MRI findings in parosteal osteosarcoma: Correlation with histopathology. Diagn Intev Radiol 2008; 14: 147-152. Accessed October 10, 2011 Zafivoski SM, Tolevska ZG, Konstandinova-Kunovaska S, Vasilevska V. Parosteal Osteosarcoma. Bratisl Lek Listy 2009;110(4): 240-244. Accessed October 10, 2011 Arslan JS, Aydin O, Derisoglu S, Oksuz DC, Kantarci F, Hiz M, Dincbac FO, Mandel NM. Low-grade osteosarcoma: review of 15 cases in a series of 156 osteosarcoma cases. Turkish Journal of Pathology. 2011; 27(2): 138-143. Accessed October 10, 2011


References Buecker PJ, Gebhardt M, Weber K. Electronic Sarcoma Update Newsletter. 2005; 2(1) . Accessed October 11, 2011 Lau TW, Wong JWK, Yip DKH, Chien EP, Shek TWH,Wong LLS. Local reoccurrence of parosteal osteosarcoma adjacent to a prosthesis after 20 years: A case report. Joun of Ortho Surg 2004: 12(2): 263-266 Donmez FY, Tuzun U, Baaran C, Tunaci M, Bilgic B, Acunas G. MRI Findings in paosteal osteosarchoma : correlations with histopathology. Diag and Interven Radiog 2008; 14(3): 142-152 The American Roentgen Ray Society. Accessed October 10, 2011 Hunter J. Accessed October 10, 2011

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