DOI: 10.1148/rg.281075015
Osteosarcoma of the Femur with Skip, Lymph Node, and Lung Metastases1
Tjeerd Zwaga, MD,
Judith V. M. G. Bovée, MD, PhD, and
Herman M. Kroon, MD, PhD
1 From the Department of Radiology, Kennemer Gasthuis, Teaching Hospital, Boerhaavelaan 22, 2035 RC Haarlem, the Netherlands (T.Z.); and Departments of Pathology (J.V.M.G.B.) and Radiology (H.M.K.), Leiden University Medical Center, Leiden, the Netherlands. Received February 1, 2007; revision requested March 16 and received May 15; accepted May 16. All authors have no financial relationships to disclose.
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Figure 1a. Initial lateral (presented in mirror view for correlation with MR images) (a) and anteroposterior (b) radiographs of the left knee show extensive mineralized osteoid throughout the osteoblastic lesion in the distal femur with involvement of the anterior, posterior, and medial cortex (arrowheads). Areas of opacity suggestive of skip lesions are seen in the epiphysis (curved arrow), and mineralized osteoid is seen in the posterior soft tissues (straight arrows in a).
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Figure 1b. Initial lateral (presented in mirror view for correlation with MR images) (a) and anteroposterior (b) radiographs of the left knee show extensive mineralized osteoid throughout the osteoblastic lesion in the distal femur with involvement of the anterior, posterior, and medial cortex (arrowheads). Areas of opacity suggestive of skip lesions are seen in the epiphysis (curved arrow), and mineralized osteoid is seen in the posterior soft tissues (straight arrows in a).
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Figure 2. Bone scan demonstrates increased focal radionuclide uptake in the distal femoral diaphysis, metaphysis, and epiphysis (arrowhead), as well as in the left inguinal region (arrow).
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Figure 4. Radiograph of the left hip demonstrates mineralized osteoid in the inguinal region (arrows). The lesion projects over the medial part of the acetabulum. Findings from bone scintigraphy, US, and radiography are suggestive of a lymph node metastasis. At pathologic analysis, the surgical specimen showed osteoid-producing cells with pre-existing lymphoid tissue.
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Figure 5a. (a) Sagittal T1-weighted MR image (repetition time msec/echo time msec = 600/7) shows the predominantly low signal intensity of the mineralized osteoid in the medulla; the posterior cortex shows destruction (arrowhead). Distally, the tumor is bordered by the physis. Skip lesions with almost identical signal intensity are located in the epiphysis (curved arrow). An oval soft-tissue lesion with intermediate signal intensity (straight arrow) corresponding to the mineralized lesion visible on the lateral conventional radiograph, and compatible with a lymph node metastasis, is seen. The joint space is not involved. (b) Sagittal gadolinium-enhanced fat-suppressed T1-weighted MR image (500/7) shows an oval tumor with peripheral enhancement in the soft tissues, indicating a lymph node metastasis (straight arrow). The areas with low signal intensity in the metaphysis represent the areas of dense bone formation (*). The high signal intensity surrounding the tumor reflects areas of nonossified tumor and edema in the bone marrow and surrounding soft tissues (arrowheads).
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Figure 5b. (a) Sagittal T1-weighted MR image (repetition time msec/echo time msec = 600/7) shows the predominantly low signal intensity of the mineralized osteoid in the medulla; the posterior cortex shows destruction (arrowhead). Distally, the tumor is bordered by the physis. Skip lesions with almost identical signal intensity are located in the epiphysis (curved arrow). An oval soft-tissue lesion with intermediate signal intensity (straight arrow) corresponding to the mineralized lesion visible on the lateral conventional radiograph, and compatible with a lymph node metastasis, is seen. The joint space is not involved. (b) Sagittal gadolinium-enhanced fat-suppressed T1-weighted MR image (500/7) shows an oval tumor with peripheral enhancement in the soft tissues, indicating a lymph node metastasis (straight arrow). The areas with low signal intensity in the metaphysis represent the areas of dense bone formation (*). The high signal intensity surrounding the tumor reflects areas of nonossified tumor and edema in the bone marrow and surrounding soft tissues (arrowheads).
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Figure 6. Lateral radiograph obtained after 2 months of preoperative chemotherapy shows progressive sclerosis of the lesions in the metaphysis, skip metastases in the epiphysis (curved arrows), and a lymph node metastasis in the soft tissues (straight arrow). Small soft-tissue calcification is seen dorsal to the femoral diaphysis (arrowhead), a finding indicative of lymphatic spread.
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Figure 9. Photomicrograph (original magnification, x200) of the inguinal lymph node metastasis of osteosarcoma shows the deposition of osteoid (arrowheads) by tumor cells and pre-existing lymphoid tissue (*).
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Figure 10. Photograph of the resected specimen of the left distal femur shows a white tumor resulting from osteoid formation. The bulk of the tumor is located in the marrow (*). Soft-tissue extension by way of cortical destruction is seen posteriorly (straight arrows), and multiple skip lesions are found below the epiphyseal plate (white arrowheads). At least one of the skip lesions does not contact the physis (black arrowheads). In addition, a separate tumor nodule is found in soft tissues more dorsally, representing a lymph node metastasis (curved arrow).
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Copyright © 2008 by the Radiological Society of North America.
