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Low-Grade Central Osteosarcoma Workup

  • Author: Barnaby Dedmond, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 30, 2015
 

Laboratory Studies

No laboratory studies have been shown to be helpful for the physician in diagnosing low-grade central osteosarcoma, with the exception of histologic examination.

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Imaging Studies

Standard radiography

Standard radiography may be helpful. Radiographs show a large amount of radiographic variation among low-grade osteosarcomas, as in the image below.

Standard radiographs of a low-grade central osteos Standard radiographs of a low-grade central osteosarcoma of the distal femur.

Characteristic features include the following:

  • Location within the bone - Metaphyseal, 67%; at the junction of the diaphysis and the metaphysis, 17%; diaphyseal, 16%
  • Degree of margination - Poor, 50-68%; intermediate, 11-20%; sharp, 22-30%

Other features seen on standard radiographs include the following:

  • Cortical destruction - 55-70%
  • Expansive lesion - 40-51%
  • Soft-tissue extension - 40-55%
  • Periosteal new bone formation - 22-50%
  • Crossing of previously fused physes - 60% (In one study, 0 of 11 cases crossed radiographically open physes.)

Radiographic findings may be suggestive of malignancy.

Enneking reported that the main radiologic feature that distinguishes low-grade central osteosarcoma from fibrous dysplasia is increased radiopacity.[16]

At least 2 of 3 of the following radiographic signs were present in 8 of 8 cases presented by Ellis et al; thus, these signs are thought to be suggestive of malignancy: (1) cortical discontinuity (the radiographic sign that was considered to be the most useful feature for distinguishing low-grade central osteosarcoma from benign entities), (2) poorly marginated soft-tissue extension, and (3) a cloudlike tumor matrix pattern.

Standard anteroposterior and lateral chest radiographs are used to assess pulmonary metastases.

Computed tomography

Computed tomography (CT) scanning is useful for evaluating the degree of cortical destruction. On CT scans, 85% of low-grade central osteosarcomas show cortical destruction (compared with 55% on plain radiographs). CT scans show the trabecular pattern of the lesion and its relationship to adjacent healthy bone more clearly than do other images. CT scanning of the chest is also used to evaluate pulmonary metastases.

Magnetic resonance imaging

Compared with other techniques, magnetic resonance imaging (MRI) enables better assessment of potential soft-tissue and marrow extension, as in the images below.

Magnetic resonance image (MRI) of low-grade centra Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.
Magnetic resonance image (MRI) of low-grade centra Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.
Magnetic resonance image (MRI) of low-grade centra Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.

Bone scanning

Bone scanning reveals intense radioisotope uptake by the lesion, demonstrates the approximate local extent of the lesion, and may depict distant metastatic lesions to bone, as in the image below.

Bone scan of a low-grade central osteosarcoma of t Bone scan of a low-grade central osteosarcoma of the distal femur.

Angiography

Angiography is usually not necessary. Angiographic findings are normal until soft-tissue extension (which typically occurs late) is present.

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Diagnostic Procedures

Biopsy of the lesion may be necessary to obtain tissue for histologic diagnosis.

Core-needle biopsy may be performed to obtain tissue when sufficient soft-tissue extension is present. In most cases, a Craig needle or an equivalent biopsy needle is necessary to enter the bone to obtain tissue for diagnosis.

Formal open biopsy also may be performed. The authors recommend sealing the site of biopsy with bone cement to prevent local extension of the tumor. However, because of the risk of tumoral dissemination into the venous circulation and lungs, this technique is controversial.

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Histologic Findings

General histologic characteristics of low-grade central osteosarcomas include the following (see the images below):

  • Spindle cell tumor
  • Irregular bone production - Chinese-characters pattern of fibrous dysplasia (14%); desmoid pattern with scanty osteoid production and many collagen fibers (33%); parosteal sarcoma pattern with heavy, irregular osteoid seams (40%)
  • Low cellularity - Small foci of cartilage differentiation (18%); small clusters of benign-appearing giant cells (36%)
  • Few mitotic figures - In 82% of low-grade central osteosarcomas, 1-2 mitotic figures are present per 10 high-power fields; in 18% of low-grade central osteosarcomas, 3-4 mitotic figures are present per 10 high-power fields
  • Minimal cytologic atypia
  • Other - Low-grade central osteosarcomas are often indistinguishable from parosteal osteosarcoma at histologic analysis. [17, 18, 19, 20, 21] ; differentiation of these two osteosarcomas is often based on whether a tumor is located within bone (low-grade central osteosarcoma) or has a juxtacortical presence (parosteal osteosarcoma; see also Juxtacortical Tumors)
Photomicrograph of a low-grade central osteosarcom Photomicrograph of a low-grade central osteosarcoma (original magnification, X40). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.
Photomicrograph of a low-grade central osteosarcom Photomicrograph of a low-grade central osteosarcoma (original magnification, X100). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.
Photomicrograph of a low-grade central osteosarcom Photomicrograph of a low-grade central osteosarcoma (original magnification, X400). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.

Detection of GNAS mutations in primary bone tumors has been useful in clinical practice for diagnosing fibrous dysplasia; however, a study by Salinas-Souza et al found that GNAS mutations are highly specific for fibrous dysplasia and rarely, if ever, occur in low-grade osteosarcomas.[21]

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Staging

Two staging systems are used to stage sarcomas of bone: the American Joint Committee on Cancer staging protocol and the Musculoskeletal Tumor Society (MSTS) staging system.[22]

  • The American Joint Committee on Cancer staging system is based on tumor grade, size, and location (specifically, whether the tumor is within the cortex or extends beyond it), as well as on the presence of regional nodal or distant metastases.
  • The MSTS system is based on tumor grade, site (ie, extracompartmental vs intracompartmental), and metastases.
  • In both systems, low-grade central osteosarcoma is, by definition, a stage I tumor unless metastasis has occurred.
  • In the MSTS system, stage IA includes intracompartmental low-grade tumors without metastases, whereas stage IB includes extracompartmental low-grade tumors. Tumors that have metastasized are classified as stage III lesions.
  • In the American Joint Committee on Cancer system, stage IA includes low-grade tumors that are confined within the cortex without metastases, whereas stage IB includes low-grade tumors that have extended beyond the cortex. Tumors that have metastasized to regional lymph nodes are classified as stage IVA lesions, and those with distant metastasis are classified as stage IVB tumors.
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Contributor Information and Disclosures
Author

Barnaby Dedmond, MD Orthopedic Traumatologist, Lexington Orthopedics, Lexington Medical Center

Barnaby Dedmond, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Coauthor(s)

John Eady, MD Chief of Orthopedic Surgery, Dorn Veterans Affairs Hospital

John Eady, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Southern Medical Association

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.

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, 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

Disclosure: Nothing to disclose.

Additional Contributors

Timothy A Damron, MD David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse

Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Society for Experimental Biology and Medicine, Orthopaedic Research Society, Children's Oncology Group, Musculoskeletal Tumor Society, American College of Surgeons, American Medical Association, Connective Tissue Oncology Society

Disclosure: Received research grant from: National Institutes of Health NIAMS; Orthopaedic Research and Education Foundation; Stryker; Cempra; Wright Medical<br/>Received income in an amount equal to or greater than $250 from: Stryker, Inc (Educational travel to Stryker sponsored meetings)<br/>Received royalty from Lippincott, Williams, and Wilkins for editing/writing textbook; Received grant/research funds from Genentech for clinical research; Received grant/research funds from Orthovita for clinical research; Received grant/research funds from National Institutes of Health for clinical research; Received royalty from UpToDate for update preparation author; Received grant/research funds from Wright Medical, Inc. for clinical research.

References
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  20. Yoshida A, Ushiku T, Motoi T, Shibata T, Beppu Y, Fukayama M, et al. Immunohistochemical analysis of MDM2 and CDK4 distinguishes low-grade osteosarcoma from benign mimics. Mod Pathol. 2010 Sep. 23(9):1279-88. [Medline].

  21. Salinas-Souza C, De Andrea C, Bihl M, Kovac M, Pillay N, Forshew T, et al. GNAS mutations are not detected in parosteal and low-grade central osteosarcomas. Mod Pathol. 2015 Oct. 28 (10):1336-42. [Medline].

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Standard radiographs of a low-grade central osteosarcoma of the distal femur.
Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.
Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.
Magnetic resonance image (MRI) of low-grade central osteosarcoma of the distal femur.
Bone scan of a low-grade central osteosarcoma of the distal femur.
Photomicrograph of a low-grade central osteosarcoma (original magnification, X40). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.
Photomicrograph of a low-grade central osteosarcoma (original magnification, X100). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.
Photomicrograph of a low-grade central osteosarcoma (original magnification, X400). Courtesy of Dr Ronald Burns, Palmetto Richland Department of Pathology.
 
 
 
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