History
Symptoms of osteosarcoma may be present for weeks or months (occasionally longer) before patients are diagnosed. The most common presenting symptom is pain, particularly pain with activity. Patients may be concerned that their child has a sprain, arthritis, or growing pains. Often, there is a history of trauma, but the precise role of trauma in the development of osteosarcoma is unclear.
Pathologic fractures are not particularly common. The exception is the telangiectatic type of osteosarcoma, which is more commonly associated with pathologic fractures. The pain in an extremity may result in a limp. There may or may not be a history of swelling (see the image below), depending on the size of the lesion and its location. Systemic symptoms, such as fever and night sweats, are rare.
Clinical appearance of a teenager who presented with osteosarcoma of the proximal humerus (same patient as in the following images). Note the impressive swelling throughout the deltoid region, as well as the disuse atrophy of the pectoral musculature.
Tumor spread to the lungs only rarely results in respiratory symptoms and usually indicates extensive lung involvement. Metastases to other sites are extremely rare, and therefore, other symptoms are unusual.
Physical Examination
Physical examination findings are usually limited to the site of the primary tumor, as follows:
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Mass - A palpable mass may or may not be present; the mass may be tender and warm, though these signs are indistinguishable from osteomyelitis; increased skin vascularity over the mass may be discernible; pulsations or a bruit may be detectable
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Decreased range of motion - Involvement of a joint should be obvious on physical examination
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Lymphadenopathy - Involvement of local or regional lymph nodes is unusual
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Respiratory findings - Auscultation is usually uninformative unless the disease is extensive
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Chest radiograph of patient with osteosarcoma who died from pulmonary metastatic disease. Note the presence of a pneumothorax as well as radiodense (bone-forming) metastatic lesions.
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Clinical appearance of a teenager who presented with osteosarcoma of the proximal humerus (same patient as in the following images). Note the impressive swelling throughout the deltoid region, as well as the disuse atrophy of the pectoral musculature.
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Radiographic appearance (plain radiograph) of a proximal humeral osteosarcoma (same patient as previous image). Note the radiodense matrix of the intramedullary portion of the lesion, as well as the soft-tissue extension and aggressive periosteal reaction.
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Intense radionuclide uptake of the proximal humerus is noted on a bone scan (same patient as previous 2 images).
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A comparison bone scan of the involved shoulder (right image) with the uninvolved shoulder (left image) (same patient as previous 3 images).
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Magnetic resonance image appearance (T1-weighted image) of osteosarcoma of the proximal humerus (same patient as previous 4 images). Note the dramatic tumor extension into the adjacent soft-tissue regions.
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Core needle biopsy instruments commonly used for bony specimens. Craig needle set.
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Close-up view of Craig needle biopsy instruments. Cutting cannula with T-handle attached (top) and sheath through which the cutting cannula passes (bottom).
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Resected specimen of a proximal tibia osteosarcoma. The primary lesion was such that the knee joint was resected with the primary lesion. Note that the previous longitudinal biopsy tract was completely excised with the specimen.
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Intraoperative consultation with the pathologist, in which the surgeon and pathologist view the microscopic appearance of the biopsy specimen.
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Intraoperative consultation with the pathologist. A frozen section of the biopsy specimen is being performed.
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Intraoperative photograph of a Van Ness rotationplasty procedure. Osteosynthesis of the tibia to the residual femur is being performed. Courtesy of Alvin H. Crawford MD, FACS.
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Clinical photograph taken at the conclusion of a Van Ness rotationplasty procedure (same patient as previous image). Note that the new "knee" of the operative side (left side) is purposely reconstructed distal to the normal right knee. This is in anticipation of the future growth potential of the unoperated limb. Courtesy of Alvin H. Crawford MD, FACS.
