Pediatric Radiology I
Case note
9 Springer-Verlag
(1991) 21:226
Osteosarcoma with isolated metastases to the pleura D. J. Shanley and M. E. Mulligan Department of Radiology, Tripler Army Medical Center, Honolulu, Hawaii, USA Received: 2 July 1990; accepted: 18 September 1990
Abstract. O s t e o s a r c o m a is the most c o m m o n primary skeletal malignancy of childhood, typically occurring b e t w e e n the ages of 10 and 20. The classic radiographic a p p e a r a n c e is that of a mixed lyric and sclerotic lesion originating in the metaphysis of the long bones with cortical destruction, periostitis, and an associated soft tissue mass. Metastatic disease to the lungs is an important prognostic indicator and is found in the maj ority of patients dying of the disease [1]. We present a child with osteosarcoma of the distal femur who d e v e l o p e d extensive metastatic disease involving the chest pleura bilaterally with no other sites of involvement.
Case report A 9-year-old girl presented with persistent left knee pain after a fall approximately one month prior. Physical examination revealed
an 8 x 9 cm mass in her left distal thigh. Radiographs of the left femur showed an eccentric osteoblastic lesion with cortical destruction in the distal metaphysis, consistent with osteosarcoma. Staging CT and MR scans demonstrated the metaphyseal lesion and an associated soft tissue mass [Fig. 1]. A biopsy of the lesion confirmed the diagnosis of osteosarcoma. Subsequent examinations revealed no evidence of metastatic disease on bone scan, chest radiographs, and chest CT. A limb salvage procedure was planned and the patient underwent high dose methotrexate therapy followed by an above-the-knee amputation. During the eighth postoperative month the patient presented with a 4 day history of low grade fever, tachypnea, and a minimally productive cough. A chest radiograph was obtained which showed complete opacification of the right hemithorax. Thoracentesis was performed and 2.5 liters of exudative serosanguinous fluid were removed with positive cytology for malignant cells. A CT scan demonstrated extensive pleural metastases encasing the right lung and involving the left hemithorax to a lesser extent [Fig. 2]. No evidence
of parenchymal metastases was identified. Her condition rapidly deteriorated and she subsequently died.
Discussion P u l m o n a r y metastases are a frequent finding in patients with osteosarcoma and significantly influences their prognosis. Involvement of the chest pleura usually results from local extension of the p a r e n c h y m a l disease though rare cases of osteosarcoma arising from the pleura have b e e n r e p o r t e d [2]. Pleural metastases have only been described previously in patients with known pulm o n a r y or e x t r a p u l m o n a r y involvement. CT was invaluable in demonstrating this unusual presentation of metastatic osteosarcoma involving only the chest pleura.
References 1. Jefffee GM, Price HG, Sissons H A (1975) The metastatic patterns of osteosarcoma. Br J Cancer 32:87 2. Stark R Smith DC, Watkins GE, Chun KE (1990) Primary intrathoracic extraosseous osteogenic sarcoma: report of three cases. Radiology 174:725
Fig. 1. Coronal MR image (SE 600/20) shows extent of tumor involvement of the medullary space and the associated soft tissue mass Fig.2. CT scan of the chest demonstrates extensive calcified pleural metastases (arrowheads) encasing the right lung
D. J. Shanley, D.O. Department of Radiology Tripler Army Medical Center Honolulu, Hawaii 96859 USA
Case note
9 Springer-Verlag
(1991) 21:226
Osteosarcoma with isolated metastases to the pleura D. J. Shanley and M. E. Mulligan Department of Radiology, Tripler Army Medical Center, Honolulu, Hawaii, USA Received: 2 July 1990; accepted: 18 September 1990
Abstract. O s t e o s a r c o m a is the most c o m m o n primary skeletal malignancy of childhood, typically occurring b e t w e e n the ages of 10 and 20. The classic radiographic a p p e a r a n c e is that of a mixed lyric and sclerotic lesion originating in the metaphysis of the long bones with cortical destruction, periostitis, and an associated soft tissue mass. Metastatic disease to the lungs is an important prognostic indicator and is found in the maj ority of patients dying of the disease [1]. We present a child with osteosarcoma of the distal femur who d e v e l o p e d extensive metastatic disease involving the chest pleura bilaterally with no other sites of involvement.
Case report A 9-year-old girl presented with persistent left knee pain after a fall approximately one month prior. Physical examination revealed
an 8 x 9 cm mass in her left distal thigh. Radiographs of the left femur showed an eccentric osteoblastic lesion with cortical destruction in the distal metaphysis, consistent with osteosarcoma. Staging CT and MR scans demonstrated the metaphyseal lesion and an associated soft tissue mass [Fig. 1]. A biopsy of the lesion confirmed the diagnosis of osteosarcoma. Subsequent examinations revealed no evidence of metastatic disease on bone scan, chest radiographs, and chest CT. A limb salvage procedure was planned and the patient underwent high dose methotrexate therapy followed by an above-the-knee amputation. During the eighth postoperative month the patient presented with a 4 day history of low grade fever, tachypnea, and a minimally productive cough. A chest radiograph was obtained which showed complete opacification of the right hemithorax. Thoracentesis was performed and 2.5 liters of exudative serosanguinous fluid were removed with positive cytology for malignant cells. A CT scan demonstrated extensive pleural metastases encasing the right lung and involving the left hemithorax to a lesser extent [Fig. 2]. No evidence
of parenchymal metastases was identified. Her condition rapidly deteriorated and she subsequently died.
Discussion P u l m o n a r y metastases are a frequent finding in patients with osteosarcoma and significantly influences their prognosis. Involvement of the chest pleura usually results from local extension of the p a r e n c h y m a l disease though rare cases of osteosarcoma arising from the pleura have b e e n r e p o r t e d [2]. Pleural metastases have only been described previously in patients with known pulm o n a r y or e x t r a p u l m o n a r y involvement. CT was invaluable in demonstrating this unusual presentation of metastatic osteosarcoma involving only the chest pleura.
References 1. Jefffee GM, Price HG, Sissons H A (1975) The metastatic patterns of osteosarcoma. Br J Cancer 32:87 2. Stark R Smith DC, Watkins GE, Chun KE (1990) Primary intrathoracic extraosseous osteogenic sarcoma: report of three cases. Radiology 174:725
Fig. 1. Coronal MR image (SE 600/20) shows extent of tumor involvement of the medullary space and the associated soft tissue mass Fig.2. CT scan of the chest demonstrates extensive calcified pleural metastases (arrowheads) encasing the right lung
D. J. Shanley, D.O. Department of Radiology Tripler Army Medical Center Honolulu, Hawaii 96859 USA
