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Postradiation Sarcoma Workup

  • Author: Nagarjun Rao, MD, FRCPath; Chief Editor: Harris Gellman, MD  more...
Updated: Jul 19, 2016

Laboratory Studies

No specific laboratory blood tests are used to diagnose postradiation sarcoma (PRS). Routine laboratory investigations may be ordered.

Cytogenetic studies on PRS tumor cells do not have much value, because the tumor cells can have numerous quantitative (numerical) and qualitative abnormalities that lack specificity. However, the value of cytogenetic analysis lies in excluding other conditions that may have specific anomalies and that may present a challenge in light-microscopic examination.


Imaging Studies

Plain radiographs should be obtained in two planes. Cortical bone destruction is the most common finding. A mineralized soft-tissue mass is seen in most patients. Changes such as osteopenia and sclerosis are seen in a minority of patients.

If plain radiography yields normal findings and the patient has significant pain, computed tomography (CT) and magnetic resonance imaging (MRI) are useful for identifying abnormal areas in the medullary cavity, cortical bone destruction, and the presence of an extramedullary soft-tissue mass. MRI is the best modality for detecting soft-tissue involvement in PRS. Chest CT is performed to detect pulmonary metastases.

Technetium bone scanning is performed to detect bone metastases.



Fine-needle aspiration (FNA) biopsies or Tru-Cut core biopsies can be obtained from the lesion for histopathologic/cytopathologic confirmation of diagnosis and for typing and grading of the lesion. In the case of a deep-seated lesion, CT-guided biopsies can be obtained. The biopsy should be the final diagnostic procedure because it can distort the findings from imaging studies, especially MRI.

Careful preoperative planning is required before biopsy is attempted. Imaging studies aid the surgeon in selecting the best site for tissue diagnosis. Usually, the best diagnostic site is at the interface between the tumor and adjacent normal tissue; this also prevents the occurrence of fracture at the biopsy site, in that biopsy in this location usually does not violate cortical bone.

A frozen section can be obtained to determine whether adequate representative tissue has been obtained. A definitive diagnosis usually is delayed until permanent sections are analyzed.

Olson et al conducted a retrospective review of 13 patients (median age, 61 years) who underwent FNA in the treatment of PRS.[24]  Patients generally presented with large tumors (median, 8 cm; range, 3-12 cm), and median survival was 14 months (range, 6-46 months). Nine of the 13 patients died of their disease, and one was lost to follow-up. The tumors were morphologically heterogeneous. The researchers concluded that PRS can be diagnosed by means of FNA and that immunohistochemistry is often required to rule out locally recurrent malignancy.


Histologic Findings

PRS in bone and soft tissue usually is a high-grade lesion, and this partly accounts for the almost uniformly grim prognosis.[4, 7] In a study of 130 patients with PRS of bone and soft tissue, osteosarcoma was the most common type, constituting 61.5% of all cases.[10] This was followed by fibrosarcoma (23.7%), malignant fibrous histiocytoma (MFH; 9.6%), chondrosarcoma (3.7%), and rare cases of angiosarcoma and Ewing sarcoma. No difference in the histologic type of PRS was demonstrated between orthovoltage and megavoltage groups.

Among soft-tissue PRS lesions, the most common histologic type is MFH (70%), followed by osteosarcoma, fibrosarcoma, malignant peripheral nerve sheath tumor (MPNST), chondrosarcoma, and angiosarcoma.[25]

Grossly, these tumors are soft and fleshy, with extension into adjacent soft tissue and formation of a soft-tissue mass. Hemorrhagic/necrotic foci and matrix production (osteoid/chondroid) may be seen. Degenerative calcific changes also may be noted. Microscopically, whereas specific characteristics such as osteoid production (in osteosarcomas) may be seen, these tumors generally show pleomorphic high-grade spindle cell features with marked nuclear pleomorphism, mitotic activity, and variable necrosis. (See the image below.)

Light-microscopic appearance of postradiation oste Light-microscopic appearance of postradiation osteosarcoma; tumor is composed of pleomorphic plump spindle cells with focal presence of neoplastic osteoid (pink areas) in between tumor cells. This meningeal tumor occurred 10 years after radiation therapy in patient who had received such therapy for recurrent pituitary neoplasm.


Careful staging is a prerequisite for appropriate management of PRS. The marrow extent and soft-tissue involvement of PRS should be gauged by using radiologic modalities, of which MRI is the best choice. Biopsies may be obtained to confirm the diagnosis and to type and grade the lesion. CT of the chest is obtained to detect pulmonary metastases. A technetium bone scan is performed to detect bone metastases.

On the basis of the results of imaging and histopathologic/cytopathologic studies, the lesion may be staged. The American Joint Committee on Cancer (AJCC) and Musculoskeletal Tumor Society (MSTS) staging systems generally are used.

AJCC staging system

The AJCC staging system is based on the TNM staging system and uses the following categories:

  • Size and extension of primary tumor (T)
  • Involvement of lymph nodes (N)
  • Presence of metastases (M)
  • Type and grade of sarcoma (G)

T categories in the AJCC TNMG staging system are as follows:

  • T1 - Tumor smaller than 5 cm
  • T2 - Tumor 5 cm or larger

N categories in the AJCC TNMG staging system are as follows:

  • N0 - No histologically verified regional node metastasis
  • N1 - Histologically verified regional node metastasis

M categories in the AJCC TNMG staging system are as follows:

  • M0 - No distant metastasis
  • M1 - Distant metastasis

G categories in the AJCC TNMG staging system are as follows:

  • G1 - Well differentiated
  • G2 - Moderately well differentiated
  • G3 - Poorly differentiated
  • G4 – Undifferentiated

MSTS staging system

The MSTS staging system classifies tumors as follows:

  • Stage IA - Low grade, intracompartmental
  • Stage IB - Low grade, extracompartmental
  • Stage IIA - High grade, intracompartmental
  • Stage IIB - High grade, extracompartmental
  • Stage III - Systemic or regional metastases

In the MSTS staging system, the margins are classified as follows:

  • Intralesional - Margin through tumor tissue
  • Marginal - Margin through reactive zone around tumor consisting of edema, inflammatory cells, fibrous tissue, and tumor cell satellites
  • Wide - Margin through normal tissue outside reactive zone
  • Radical – Removal of entire compartment containing tumor
Contributor Information and Disclosures

Nagarjun Rao, MD, FRCPath Pathologist, Great Lakes Pathologists, Aurora Clinical Laboratories

Nagarjun Rao, MD, FRCPath is a member of the following medical societies: American Society for Clinical Pathology, United States and Canadian Academy of Pathology, College of American Pathologists, Royal College of Pathologists

Disclosure: Nothing to disclose.


Vinod B Shidham, MD, FRCPath Professor, Vice-Chair-AP, and Director of Cytopathology, Department of Pathology, Wayne State University School of Medicine, Karmanos Cancer Center and Detroit Medical Center; Co-Editor-in-Chief and Executive Editor, CytoJournal

Vinod B Shidham, MD, FRCPath is a member of the following medical societies: American Association for Cancer Research, American Society of Cytopathology, College of American Pathologists, International Academy of Cytology, Royal College of Pathologists, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Donald A Hackbarth, Jr, MD, FACS Professor of Clinical Orthopedic Surgery, Division Chief, Musculoskeletal Oncology, Department of Orthopedic Surgery, Medical College of Wisconsin

Donald A Hackbarth, Jr, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Tissue Banks, American College of Surgeons, Christian Medical and Dental Associations, Clinical Orthopaedic Society, Children's Oncology Group, Wisconsin Medical Society

Disclosure: Received honoraria from Musculoskeletal Transplant Foundation for board membership.

Vivek Panikkar, MBBS, MS, MCh, FRCS Consulting Surgeon, Departments of Trauma and Orthopedics, Doncaster Royal Infirmary, UK

Disclosure: Nothing to disclose.

Stuart Wong, MD Assistant Professor, Department of Medicine, Section of Hematology/Oncology, Froedert Memorial Lutheran Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Sean P Scully, MD 

Sean P Scully, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, Society of Surgical Oncology

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

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Light-microscopic appearance of postradiation osteosarcoma; tumor is composed of pleomorphic plump spindle cells with focal presence of neoplastic osteoid (pink areas) in between tumor cells. This meningeal tumor occurred 10 years after radiation therapy in patient who had received such therapy for recurrent pituitary neoplasm.
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