Osteosarcoma x ray

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

On x-ray, osteosarcoma is characterized by medullary and cortical bone destruction, periosteal reaction, tumor matrix calcification and soft tissue mass.

X Ray

Conventional radiography continues to play an important role in diagnosis of osteosarcoma. Typical appearances of conventional high grade osteosarcoma include:

• Medullary and cortical bone destruction.
• Wide zone of transition, permeative or moth-eaten appearance.
• Aggressive periosteal reaction characterized by:

• Sunburst appearance
• Codman triangle
• Lamellated (onion skin) reaction: less frequently seen

• Soft-tissue mass.
• Tumor matrix ossification/calcification.

• Variable: reflects a combination of the amount of tumor bone production, calcified matrix, and osteoid.
• Ill-defined fluffy or cloud-like cf. to the rings and arcs of chondroid lesions.

Images courtesy of RadsWiki

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  Plain film: Osteosarcoma

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  Plain film: Osteosarcoma

Subtype	X-Ray findings
Intracortical osteosarcoma	Presents as an oval intracortical geographic osteolytic lesion in the diaphysis with surrounding sclerosis Measures approximately 4 cm in length Multiple calcific foci can be seen within the lytic region, suggesting osteoid matrix.
Parosteal osteosarcoma	Large lobulated exophytic, 'cauliflower-like' mass with central dense ossification adjacent to the bone. String sign: Thin radiolucent line separating the tumor from cortex, observed in 30% of cases. Tumor stalk: Grows within tumor in late stages and obliterates the radiolucent cleavage plane. +/- soft tissue mass. Cortical thickening without aggressive periosteal reaction is often seen. Tumor extension into medullary cavity is frequently observed.
Oncocytoma	May contain fat
Wilm's tumor	May contain fat
Retroperitoneal sarcoma	Liposarcoma Leiomyosarcoma
Renal cell carcinoma	Sarcomatoid differentiation
Renal leiomyoma	Very rare Desmin +ve HMB-45 -ve
Perirenal fat entrapment	Renal junctional parenchymal defect
Adrenal myelolipoma	Fat in renal parenchyma

Extra skeletal osteosarcoma

On X-ray, extra skeletal osteosarcoma appears as soft tissue density with variable amount of calcification which represents osteoid matrix formation, and is seen in approximately 50% of cases.

Parosteal osteosarcoma

• Large lobulated exophytic, 'cauliflower-like' mass with central dense ossification adjacent to the bone.
• String sign: Thin radiolucent line separating the tumor from cortex, observed in 30% of cases.
• Tumor stalk: Grows within tumor in late stages and obliterates the radiolucent cleavage plane.
• +/- soft tissue mass.
• Cortical thickening without aggressive periosteal reaction is often seen.
• Tumor extension into medullary cavity is frequently observed.

Intracortical osteosarcoma

• It typically presents as an oval intracortical geographic osteolytic lesion in the diaphysis with surrounding sclerosis and usually measures about 4 cm in length. *Multiple calcific foci can be seen within the lytic region, suggesting osteoid matrix.

Periosteal osteosarcoma

• Typically seen as a broad-based surface soft-tissue mass causing extrinsic erosion of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into the soft-tissue component.

Low grade osteosarcoma

• Because the fibrous dysplasia and central low-grade osteosarcoma are so similar histologically, the radiographic features are an extremely important part of the diagnosis.
• Radiographic features of low grade osteosarcomas are variable.
• Most common pattern is as a large intracompartmental expansile lytic fibro-osseous lesion with coarsely thick or thin incomplete trabeculations. Another less common pattern is as a dense sclerotic lesion.
• Cortical erosion and soft tissue extension is also a common feature.

Telangiectatic osteosarcoma

• Typically seen as an expansile lytic metaphyseal bony lesion.
• Geographic bony destruction with wide zone of transition tends to be more common than permeative bony destruction.
• Less osteoid matrix compared from conventional type.