8-year-old with osteosarcoma of the right humerus amy millar march 2013 james cameron, md
TRANSCRIPT
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8-year-old with osteosarcoma of the right humerus
Amy Millar
March 2013
James Cameron, MD
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• 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
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• 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
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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
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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
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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
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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
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Radiographic findings of OS
Intramedullary skip lesions may be present
Occasionally may present as a pathologic fx
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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)
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Normal comparison
Right Shoulder AP
Mixed sclerotic and lytic lesion
Soft tissue mass and swelling
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Right Humerus AP and Lateral
Periosteal reaction
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Pre Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
Axillary vasculature
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Coronal MRI Post Contrast
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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Right Shoulder T1 Axial MRI
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• 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