CASE 31
By: Dr. Waleed Althobaity, MD
HISTORY: 18-year-old complaining of shoulder pain.
What are your findings?
What is the differential diagnosis?
What is next step?
FINDINGS:
Plain radiograph (A) of the left shoulder demonstrates meta-epiphyseal expansile lytic lesion with aggressive features which including wide zone of transition, thin destructed cortices and aggressive periosteal reaction (Codman triangle). Subtle matrix mineralization at the periphery is also seen.
Axial T2 FS image (B) shows multilocular lesion with fluid /fluid appearance in addition to peri lesional edematous changes.
Axial T1 FS post contrast image (C)shows peripheral and septal enhancement.
DIFFERENTIAL DIAGNOSIS:
Telangiectatic Osteosarcoma.
Giant cell tumor (GCT): Aggressive periosteal reaction is not a feature GCT.
Aneurysmal bone cyst (ABC): Also, aggressive features are against this.
DIAGNOSIS:
Telangiectatic Osteosarcoma.
Next step:
Orthopedic oncology referral.
Tumor work-up which usually including MRI for local staging, bone scan and chest X-ray +/- CT thoracic.
PEARLS AND DISCUSSION:
Telengectatic osteosearcoma is malignant bone forming tumor characterized by large spaces with or without septa, filled with blood. It is characterized by osteolytic lesion on radiograph. Most lesions are in metaphysis and usually extend into the epiphysis. Tumor often expands and disrupts the cortex, extending into the soft tissues. Periosteal reaction including Codman triangle is common. MRI, T1-weighted images may show increased signal intensity due to the presence of methemoglobin, and T2-weighted images show high signal intensity with several cystic areas and fluid– fluid levels, associated with an extra skeletal extension.
It is like ABC in MRI, but the hint is the aggressive features of the lesion by radiograph and extra-osseous extension in MRI.
FURTHER READINGS
Greenspan, Adam; Borys, Dariusz (2015-09-21). Radiology and Pathology Correlation of Bone Tumors: A Quick Reference and Review (Kindle Locations 1807-1811). LWW. Kindle Edition.
