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Second Malignancies in Pediatric Patients: Imaging Findings and Differential Diagnosis¹

¹ From the Department of Pediatric Radiology and Institut de Diagnòstic per la Imatge (E.V., A.C., J.P., P.O., J.L.), the Department of Pediatric Oncology (J.S.T.), and the Department of Pediatric Neurosurgery (P.N.), Hospital Materno-Infantil Vall d’Hebron, Psg Vall d’Hebron 112-119, Barcelona E-08035, Spain. Recipient of a Cum Laude award for an education exhibit at the 2002 RSNA scientific assembly. Received February 21, 2003; revision requested April 8 and received June 6; accepted June 6. Address correspondence to E.V. (e-mail: evazquez@cs.vhebron.es).

View larger version (115K): [in a new window]   Figure 1a.  Meningioma after medulloblastoma. (a) CT scan of a 4-year-old child shows a posterior mass. Follow-up CT over the next several years was unremarkable. (b) CT scan obtained 7 years later shows a high-attenuation, asymptomatic extraaxial mass. (c, d) T2-weighted (c) and contrast-enhanced T1-weighted (d) MR images show a well-defined, extraparenchymal left occipital mass that is isointense relative to gray matter (c) and anterior hyperintense white matter edema and homogeneous enhancement (d), findings that are consistent with meningioma. Surgery and posterior histologic analysis revealed anaplastic tumor foci with a typical whorl of bland meningothelial cells. (e) Follow-up MR image demonstrates tumor recurrence with dural venous sinus invasion and transcalvarial extension. Two other resections were performed, but the tumor progressed and the patient died.

View larger version (131K): [in a new window]   Figure 1b.  Meningioma after medulloblastoma. (a) CT scan of a 4-year-old child shows a posterior mass. Follow-up CT over the next several years was unremarkable. (b) CT scan obtained 7 years later shows a high-attenuation, asymptomatic extraaxial mass. (c, d) T2-weighted (c) and contrast-enhanced T1-weighted (d) MR images show a well-defined, extraparenchymal left occipital mass that is isointense relative to gray matter (c) and anterior hyperintense white matter edema and homogeneous enhancement (d), findings that are consistent with meningioma. Surgery and posterior histologic analysis revealed anaplastic tumor foci with a typical whorl of bland meningothelial cells. (e) Follow-up MR image demonstrates tumor recurrence with dural venous sinus invasion and transcalvarial extension. Two other resections were performed, but the tumor progressed and the patient died.

View larger version (138K): [in a new window]   Figure 1c.  Meningioma after medulloblastoma. (a) CT scan of a 4-year-old child shows a posterior mass. Follow-up CT over the next several years was unremarkable. (b) CT scan obtained 7 years later shows a high-attenuation, asymptomatic extraaxial mass. (c, d) T2-weighted (c) and contrast-enhanced T1-weighted (d) MR images show a well-defined, extraparenchymal left occipital mass that is isointense relative to gray matter (c) and anterior hyperintense white matter edema and homogeneous enhancement (d), findings that are consistent with meningioma. Surgery and posterior histologic analysis revealed anaplastic tumor foci with a typical whorl of bland meningothelial cells. (e) Follow-up MR image demonstrates tumor recurrence with dural venous sinus invasion and transcalvarial extension. Two other resections were performed, but the tumor progressed and the patient died.

View larger version (107K): [in a new window]   Figure 1d.  Meningioma after medulloblastoma. (a) CT scan of a 4-year-old child shows a posterior mass. Follow-up CT over the next several years was unremarkable. (b) CT scan obtained 7 years later shows a high-attenuation, asymptomatic extraaxial mass. (c, d) T2-weighted (c) and contrast-enhanced T1-weighted (d) MR images show a well-defined, extraparenchymal left occipital mass that is isointense relative to gray matter (c) and anterior hyperintense white matter edema and homogeneous enhancement (d), findings that are consistent with meningioma. Surgery and posterior histologic analysis revealed anaplastic tumor foci with a typical whorl of bland meningothelial cells. (e) Follow-up MR image demonstrates tumor recurrence with dural venous sinus invasion and transcalvarial extension. Two other resections were performed, but the tumor progressed and the patient died.

View larger version (119K): [in a new window]   Figure 1e.  Meningioma after medulloblastoma. (a) CT scan of a 4-year-old child shows a posterior mass. Follow-up CT over the next several years was unremarkable. (b) CT scan obtained 7 years later shows a high-attenuation, asymptomatic extraaxial mass. (c, d) T2-weighted (c) and contrast-enhanced T1-weighted (d) MR images show a well-defined, extraparenchymal left occipital mass that is isointense relative to gray matter (c) and anterior hyperintense white matter edema and homogeneous enhancement (d), findings that are consistent with meningioma. Surgery and posterior histologic analysis revealed anaplastic tumor foci with a typical whorl of bland meningothelial cells. (e) Follow-up MR image demonstrates tumor recurrence with dural venous sinus invasion and transcalvarial extension. Two other resections were performed, but the tumor progressed and the patient died.

View larger version (116K): [in a new window]   Figure 2a.  Meningioma after medulloblastoma. (a) CT scan of a 3-month-old boy shows a hypoattenuating mass in the cerebellar vermis with associated hydrocephalus. Surgical resection helped confirm medulloblastoma. (b) Contrast-enhanced CT scan obtained 12 years later shows an enhancing mass with calcifications and increased size posteriorly. (c) Sagittal T1-weighted MR image shows two hypointense masses of different sizes (arrows). (d) Axial contrast-enhanced T1-weighted MR image shows the larger mass with heterogeneous enhancement and peripheral cystic or necrotic areas (arrow) that represent meningioma. (e) Coronal T2-weighted MR image shows the smaller mass with heterogeneous intensity (arrow). The mass proved to be basal cell carcinoma. Several resections were performed for recurrence of meningioma, but the patient died.

View larger version (132K): [in a new window]   Figure 2b.  Meningioma after medulloblastoma. (a) CT scan of a 3-month-old boy shows a hypoattenuating mass in the cerebellar vermis with associated hydrocephalus. Surgical resection helped confirm medulloblastoma. (b) Contrast-enhanced CT scan obtained 12 years later shows an enhancing mass with calcifications and increased size posteriorly. (c) Sagittal T1-weighted MR image shows two hypointense masses of different sizes (arrows). (d) Axial contrast-enhanced T1-weighted MR image shows the larger mass with heterogeneous enhancement and peripheral cystic or necrotic areas (arrow) that represent meningioma. (e) Coronal T2-weighted MR image shows the smaller mass with heterogeneous intensity (arrow). The mass proved to be basal cell carcinoma. Several resections were performed for recurrence of meningioma, but the patient died.

View larger version (159K): [in a new window]   Figure 2c.  Meningioma after medulloblastoma. (a) CT scan of a 3-month-old boy shows a hypoattenuating mass in the cerebellar vermis with associated hydrocephalus. Surgical resection helped confirm medulloblastoma. (b) Contrast-enhanced CT scan obtained 12 years later shows an enhancing mass with calcifications and increased size posteriorly. (c) Sagittal T1-weighted MR image shows two hypointense masses of different sizes (arrows). (d) Axial contrast-enhanced T1-weighted MR image shows the larger mass with heterogeneous enhancement and peripheral cystic or necrotic areas (arrow) that represent meningioma. (e) Coronal T2-weighted MR image shows the smaller mass with heterogeneous intensity (arrow). The mass proved to be basal cell carcinoma. Several resections were performed for recurrence of meningioma, but the patient died.

View larger version (143K): [in a new window]   Figure 2d.  Meningioma after medulloblastoma. (a) CT scan of a 3-month-old boy shows a hypoattenuating mass in the cerebellar vermis with associated hydrocephalus. Surgical resection helped confirm medulloblastoma. (b) Contrast-enhanced CT scan obtained 12 years later shows an enhancing mass with calcifications and increased size posteriorly. (c) Sagittal T1-weighted MR image shows two hypointense masses of different sizes (arrows). (d) Axial contrast-enhanced T1-weighted MR image shows the larger mass with heterogeneous enhancement and peripheral cystic or necrotic areas (arrow) that represent meningioma. (e) Coronal T2-weighted MR image shows the smaller mass with heterogeneous intensity (arrow). The mass proved to be basal cell carcinoma. Several resections were performed for recurrence of meningioma, but the patient died.

View larger version (114K): [in a new window]   Figure 2e.  Meningioma after medulloblastoma. (a) CT scan of a 3-month-old boy shows a hypoattenuating mass in the cerebellar vermis with associated hydrocephalus. Surgical resection helped confirm medulloblastoma. (b) Contrast-enhanced CT scan obtained 12 years later shows an enhancing mass with calcifications and increased size posteriorly. (c) Sagittal T1-weighted MR image shows two hypointense masses of different sizes (arrows). (d) Axial contrast-enhanced T1-weighted MR image shows the larger mass with heterogeneous enhancement and peripheral cystic or necrotic areas (arrow) that represent meningioma. (e) Coronal T2-weighted MR image shows the smaller mass with heterogeneous intensity (arrow). The mass proved to be basal cell carcinoma. Several resections were performed for recurrence of meningioma, but the patient died.

View larger version (146K): [in a new window]   Figure 3.  Meningioma after acute lymphoblastic leukemia in a 17-year-old girl who presented with headaches. The patient had undergone chemotherapy and craniospinal irradiation at 2 years of age. Coronal contrast-enhanced T1-weighted MR image demonstrates a posterior fossa mass. The tumor was resected, and no residual or recurrent meningioma was seen at follow-up MR imaging.

View larger version (123K): [in a new window]   Figure 4a.  Primitive neuroectodermal tumor in a 17-year-old girl. The patient had been treated for acute lymphoblastic leukemia at 5 years of age. Axial contrast-enhanced CT scan (a), axial T2-weighted MR image (b), and coronal contrast-enhanced T1-weighted MR image (c) show a heterogeneous right hemispheric cerebral mass with cystic-necrotic components (arrow in a). Partial surgical resection demonstrated a primitive neuroectodermal tumor with posterior tumor progression. The patient did not survive.

View larger version (113K): [in a new window]   Figure 4b.  Primitive neuroectodermal tumor in a 17-year-old girl. The patient had been treated for acute lymphoblastic leukemia at 5 years of age. Axial contrast-enhanced CT scan (a), axial T2-weighted MR image (b), and coronal contrast-enhanced T1-weighted MR image (c) show a heterogeneous right hemispheric cerebral mass with cystic-necrotic components (arrow in a). Partial surgical resection demonstrated a primitive neuroectodermal tumor with posterior tumor progression. The patient did not survive.

View larger version (150K): [in a new window]   Figure 4c.  Primitive neuroectodermal tumor in a 17-year-old girl. The patient had been treated for acute lymphoblastic leukemia at 5 years of age. Axial contrast-enhanced CT scan (a), axial T2-weighted MR image (b), and coronal contrast-enhanced T1-weighted MR image (c) show a heterogeneous right hemispheric cerebral mass with cystic-necrotic components (arrow in a). Partial surgical resection demonstrated a primitive neuroectodermal tumor with posterior tumor progression. The patient did not survive.

View larger version (154K): [in a new window]   Figure 5a.  Pontine glioma after medulloblastoma. (a) Sagittal T1-weighted MR image obtained in a 2-year-old girl shows a posterior fossa mass with homogeneous hypointensity (arrow), an enlarged Silvian aqueduct, and hydrocephalus. The postsurgical diagnosis was medulloblastoma. (b) Follow-up axial contrast-enhanced T1-weighted MR image shows postoperative deformity of the fourth ventricle with no residual tumor. (c) Contrast-enhanced T1-weighted MR image obtained 5 years later reveals a hypointense pontine mass with nodular enhancement. Biopsy revealed anaplastic glioma. The family decided against therapy, and the patient died.

View larger version (140K): [in a new window]   Figure 5b.  Pontine glioma after medulloblastoma. (a) Sagittal T1-weighted MR image obtained in a 2-year-old girl shows a posterior fossa mass with homogeneous hypointensity (arrow), an enlarged Silvian aqueduct, and hydrocephalus. The postsurgical diagnosis was medulloblastoma. (b) Follow-up axial contrast-enhanced T1-weighted MR image shows postoperative deformity of the fourth ventricle with no residual tumor. (c) Contrast-enhanced T1-weighted MR image obtained 5 years later reveals a hypointense pontine mass with nodular enhancement. Biopsy revealed anaplastic glioma. The family decided against therapy, and the patient died.

View larger version (118K): [in a new window]   Figure 5c.  Pontine glioma after medulloblastoma. (a) Sagittal T1-weighted MR image obtained in a 2-year-old girl shows a posterior fossa mass with homogeneous hypointensity (arrow), an enlarged Silvian aqueduct, and hydrocephalus. The postsurgical diagnosis was medulloblastoma. (b) Follow-up axial contrast-enhanced T1-weighted MR image shows postoperative deformity of the fourth ventricle with no residual tumor. (c) Contrast-enhanced T1-weighted MR image obtained 5 years later reveals a hypointense pontine mass with nodular enhancement. Biopsy revealed anaplastic glioma. The family decided against therapy, and the patient died.

View larger version (156K): [in a new window]   Figure 6a.  Brainstem glioma after craniopharyngioma. (a, b) Sagittal (a) and axial contrast-enhanced (b) T1-weighted MR images obtained in a 10-year-old girl show an isointense, heterogeneously enhancing suprasellar mass (arrow), a finding that is suggestive of craniopharyngioma. The tumor was partially resected. (c) Follow-up sagittal T1-weighted MR image demonstrates no progression of the mass. Residual calcifications were seen at CT. (d) Axial contrast-enhanced T1-weighted MR image obtained 8 years later shows a heterogeneously enhancing mass that involves the upper brainstem. Stereotactic biopsy revealed high-grade glioma.

View larger version (136K): [in a new window]   Figure 6b.  Brainstem glioma after craniopharyngioma. (a, b) Sagittal (a) and axial contrast-enhanced (b) T1-weighted MR images obtained in a 10-year-old girl show an isointense, heterogeneously enhancing suprasellar mass (arrow), a finding that is suggestive of craniopharyngioma. The tumor was partially resected. (c) Follow-up sagittal T1-weighted MR image demonstrates no progression of the mass. Residual calcifications were seen at CT. (d) Axial contrast-enhanced T1-weighted MR image obtained 8 years later shows a heterogeneously enhancing mass that involves the upper brainstem. Stereotactic biopsy revealed high-grade glioma.

View larger version (152K): [in a new window]   Figure 6c.  Brainstem glioma after craniopharyngioma. (a, b) Sagittal (a) and axial contrast-enhanced (b) T1-weighted MR images obtained in a 10-year-old girl show an isointense, heterogeneously enhancing suprasellar mass (arrow), a finding that is suggestive of craniopharyngioma. The tumor was partially resected. (c) Follow-up sagittal T1-weighted MR image demonstrates no progression of the mass. Residual calcifications were seen at CT. (d) Axial contrast-enhanced T1-weighted MR image obtained 8 years later shows a heterogeneously enhancing mass that involves the upper brainstem. Stereotactic biopsy revealed high-grade glioma.

View larger version (139K): [in a new window]   Figure 6d.  Brainstem glioma after craniopharyngioma. (a, b) Sagittal (a) and axial contrast-enhanced (b) T1-weighted MR images obtained in a 10-year-old girl show an isointense, heterogeneously enhancing suprasellar mass (arrow), a finding that is suggestive of craniopharyngioma. The tumor was partially resected. (c) Follow-up sagittal T1-weighted MR image demonstrates no progression of the mass. Residual calcifications were seen at CT. (d) Axial contrast-enhanced T1-weighted MR image obtained 8 years later shows a heterogeneously enhancing mass that involves the upper brainstem. Stereotactic biopsy revealed high-grade glioma.

View larger version (167K): [in a new window]   Figure 7a.  Osteosarcoma after bilateral retinoblastoma. (a, b) Axial T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images obtained in an 8-month-old boy with leukocoria show extensive bilateral retinal tumors (arrows). (c) Follow-up contrast-enhanced CT scan obtained postoperatively shows residual soft tissue in the left orbit and an ocular prosthesis in the right orbit, without evidence of tumor. (d, e) CT scans obtained 4 years later (e obtained caudad to d) demonstrate a maxillary mass with bone destruction and matrix mineralization. Follow-up MR imaging performed after chemotherapy and radical surgery demonstrated no tumor recurrence.

View larger version (129K): [in a new window]   Figure 7b.  Osteosarcoma after bilateral retinoblastoma. (a, b) Axial T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images obtained in an 8-month-old boy with leukocoria show extensive bilateral retinal tumors (arrows). (c) Follow-up contrast-enhanced CT scan obtained postoperatively shows residual soft tissue in the left orbit and an ocular prosthesis in the right orbit, without evidence of tumor. (d, e) CT scans obtained 4 years later (e obtained caudad to d) demonstrate a maxillary mass with bone destruction and matrix mineralization. Follow-up MR imaging performed after chemotherapy and radical surgery demonstrated no tumor recurrence.

View larger version (95K): [in a new window]   Figure 7c.  Osteosarcoma after bilateral retinoblastoma. (a, b) Axial T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images obtained in an 8-month-old boy with leukocoria show extensive bilateral retinal tumors (arrows). (c) Follow-up contrast-enhanced CT scan obtained postoperatively shows residual soft tissue in the left orbit and an ocular prosthesis in the right orbit, without evidence of tumor. (d, e) CT scans obtained 4 years later (e obtained caudad to d) demonstrate a maxillary mass with bone destruction and matrix mineralization. Follow-up MR imaging performed after chemotherapy and radical surgery demonstrated no tumor recurrence.

View larger version (103K): [in a new window]   Figure 7d.  Osteosarcoma after bilateral retinoblastoma. (a, b) Axial T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images obtained in an 8-month-old boy with leukocoria show extensive bilateral retinal tumors (arrows). (c) Follow-up contrast-enhanced CT scan obtained postoperatively shows residual soft tissue in the left orbit and an ocular prosthesis in the right orbit, without evidence of tumor. (d, e) CT scans obtained 4 years later (e obtained caudad to d) demonstrate a maxillary mass with bone destruction and matrix mineralization. Follow-up MR imaging performed after chemotherapy and radical surgery demonstrated no tumor recurrence.

View larger version (121K): [in a new window]   Figure 7e.  Osteosarcoma after bilateral retinoblastoma. (a, b) Axial T2-weighted (a) and contrast-enhanced fat-saturated T1-weighted (b) MR images obtained in an 8-month-old boy with leukocoria show extensive bilateral retinal tumors (arrows). (c) Follow-up contrast-enhanced CT scan obtained postoperatively shows residual soft tissue in the left orbit and an ocular prosthesis in the right orbit, without evidence of tumor. (d, e) CT scans obtained 4 years later (e obtained caudad to d) demonstrate a maxillary mass with bone destruction and matrix mineralization. Follow-up MR imaging performed after chemotherapy and radical surgery demonstrated no tumor recurrence.

View larger version (114K): [in a new window]   Figure 8a.  Osteosarcoma after bilateral retinoblastoma in a 13-year-old girl who presented with a nasopharyngeal mass. The patient had undergone treatment for bilateral retinoblastoma at a young age. (a) CT scan shows a heterogeneous mass with areas of iso- and hypoattenuation that involves the maxillary antrum on the right side. Associated osseous destruction of the posterior maxillary sinus wall and nasopharyngeal protrusion are also seen (arrows). (b, c) Axial fat-saturated T2-weighted (b) and coronal contrast-enhanced fat-saturated T1-weighted (c) MR images demonstrate an extensive soft-tissue mass that arises from the right maxilla. Biopsy revealed undifferentiated osteosarcoma. Chemotherapy and surgery produced very good results, although the follow-up period has been very short.

View larger version (109K): [in a new window]   Figure 8b.  Osteosarcoma after bilateral retinoblastoma in a 13-year-old girl who presented with a nasopharyngeal mass. The patient had undergone treatment for bilateral retinoblastoma at a young age. (a) CT scan shows a heterogeneous mass with areas of iso- and hypoattenuation that involves the maxillary antrum on the right side. Associated osseous destruction of the posterior maxillary sinus wall and nasopharyngeal protrusion are also seen (arrows). (b, c) Axial fat-saturated T2-weighted (b) and coronal contrast-enhanced fat-saturated T1-weighted (c) MR images demonstrate an extensive soft-tissue mass that arises from the right maxilla. Biopsy revealed undifferentiated osteosarcoma. Chemotherapy and surgery produced very good results, although the follow-up period has been very short.

View larger version (133K): [in a new window]   Figure 8c.  Osteosarcoma after bilateral retinoblastoma in a 13-year-old girl who presented with a nasopharyngeal mass. The patient had undergone treatment for bilateral retinoblastoma at a young age. (a) CT scan shows a heterogeneous mass with areas of iso- and hypoattenuation that involves the maxillary antrum on the right side. Associated osseous destruction of the posterior maxillary sinus wall and nasopharyngeal protrusion are also seen (arrows). (b, c) Axial fat-saturated T2-weighted (b) and coronal contrast-enhanced fat-saturated T1-weighted (c) MR images demonstrate an extensive soft-tissue mass that arises from the right maxilla. Biopsy revealed undifferentiated osteosarcoma. Chemotherapy and surgery produced very good results, although the follow-up period has been very short.

View larger version (151K): [in a new window]   Figure 9a.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (131K): [in a new window]   Figure 9b.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (90K): [in a new window]   Figure 9c.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (128K): [in a new window]   Figure 9d.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (162K): [in a new window]   Figure 9e.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (157K): [in a new window]   Figure 9f.  Calvarial osteosarcoma after cerebral astrocytoma and surface femoral osteosarcoma. (a) Coronal T1-weighted MR image obtained in a 12-year-old girl shows a surface femoral osteosarcoma (arrow). The patient underwent surgery and chemotherapy. (b) Coronal contrast-enhanced T1-weighted MR image obtained 2 years later for seizures demonstrates a left hemispheric mass. The presumptive imaging diagnosis was a metastatic lesion, but surgical resection revealed anaplastic glioma. The patient underwent cranial irradiation. (c, d) Brain CT scans obtained 3 years later (d obtained at a lower level with bone windowing) reveal a calcified mass with new bone formation and a permeative pattern. (e, f) Axial T2-weighted (e) and coronal contrast-enhanced T1-weighted (f) MR images demonstrate the bone lesion with an accompanying soft-tissue mass. Histologic analysis demonstrated a highly atypical proliferation of mesenchymal cells with osteoid and trabecular bone differentiation.

View larger version (132K): [in a new window]   Figure 10a.  Lingual epidermoid carcinoma after Wilms tumor in a 15-year-old boy. The patient had been treated for Wilms tumor with pulmonary metastases at the age of 5 years. Axial T2-weighted (a) and contrast-enhanced T1-weighted (b) MR images demonstrate a hyperintense enhancing mass (arrow) that involves the middle and posterior thirds of the right side of the tongue. The tongue carcinoma was surgically resected, and radiation therapy was administered. Follow-up MR imaging performed 5 years later showed no tumor recurrence.

View larger version (136K): [in a new window]   Figure 10b.  Lingual epidermoid carcinoma after Wilms tumor in a 15-year-old boy. The patient had been treated for Wilms tumor with pulmonary metastases at the age of 5 years. Axial T2-weighted (a) and contrast-enhanced T1-weighted (b) MR images demonstrate a hyperintense enhancing mass (arrow) that involves the middle and posterior thirds of the right side of the tongue. The tongue carcinoma was surgically resected, and radiation therapy was administered. Follow-up MR imaging performed 5 years later showed no tumor recurrence.

View larger version (162K): [in a new window]   Figure 11a.  Parotid gland carcinoma after acute lymphoblastic leukemia in a 14-year-old boy. The patient had been treated for acute lymphoblastic leukemia with chemotherapy and radiation therapy at the age of 5 years. Axial T1-weighted (a) and fat-saturated T2-weighted (b) MR images demonstrate a left parotid gland mass (arrows in a). The lesion is well defined and hypointense in a, with conspicuously higher homogeneous signal intensity in b. Surgical resection and posterior histologic examination demonstrated a low-grade mucoepidermoid carcinoma. Follow-up MR imaging showed no tumor recurrence.

View larger version (149K): [in a new window]   Figure 11b.  Parotid gland carcinoma after acute lymphoblastic leukemia in a 14-year-old boy. The patient had been treated for acute lymphoblastic leukemia with chemotherapy and radiation therapy at the age of 5 years. Axial T1-weighted (a) and fat-saturated T2-weighted (b) MR images demonstrate a left parotid gland mass (arrows in a). The lesion is well defined and hypointense in a, with conspicuously higher homogeneous signal intensity in b. Surgical resection and posterior histologic examination demonstrated a low-grade mucoepidermoid carcinoma. Follow-up MR imaging showed no tumor recurrence.

View larger version (183K): [in a new window]   Figure 12.  Thyroid carcinoma after acute lymphoblastic leukemia in the same patient as in Figure 3, who developed a cervical mass at age 15 years. Axial US image shows an enlarged, heterogeneous thyroid gland. Histologic analysis revealed papillary carcinoma. Follow-up US showed no tumor recurrence.