Laporan Pagi

30 Juni 2014
Rona Kartika/13166
Identitas
Nama: Nn. V
Usia: 12 tahun
Alamat: Sleman, Yogyakarta
No. Rm 01689xxx
Keterangan Klinis: suspek trauma ankle
Jenis Foto: Ankle joint, AP dan Lateral
R
R
R
Hasil Pemeriksaan
Foto ankle joint, AP dan lateral view, kondisi
cukup.
Tampak soft tissue swelling
Trabekulasi tulang baik
Tampak lesi sklerotik dan litik pada os tibia sinistra
1/3 distal, periosteal reaction (+), sun burst (+)
Tak tampak osteofit maupun subchondral sclerotic
Joint space tak melebar maupun menyempit
Kesan
Suspek osteosarcoma os tibia sinistra 1/3
distal
Teori
Osteosarcoma
Definitions:
A mesenchymal malignancy (malignant spindle cells)
that differentiates to produce osteoid/immature bone
Second most common primary malignant tumor of
bone (first most common=multiple myeloma)
15% of all biopsied primary bone tumors
Sites: Metaphysis: 90% ;Diaphysis: 8-10%
Sex: male > female 1,5 2 : 1
Age : 75% patients 12 - 25 yo, 30% patient > 40 yo



Predilection
Major sites of origin of osteosarcomas:
Metaphysis (90%), diaphysis (10%)
femur distal,
tibia prox,
humerus prox
Jaws,
skull,
pelvis,
vertebra

Classification
Intramedullary Osteosarcoma: Lesion arising
within the medullary space of the bone (most
common type)
Juxtacortical Osteosarcoma: Lesion arising on the
surface of the bone in apposition to the cortex
Intracortical Osteosarcoma: Lesion arising from
the cortex of the bone

Juxtacortical Osteosarcoma
Parosteal Osteosarcoma (65%)
Periosteal Osteosarcoma (25%)
High Grade Surface (10%)

Parosteal Osteosarcoma
Origin: Arises from outer layer of periosteum
Usually a low grade tumor with fibroblastic stroma and
osteoid/woven bone
Age: 20-30 yrs; usually about a decade older than
conventional osteosarcoma
Location:
Posterior distal femur metaphysis (65%)
Proximal humerus (15%); Tibia (10%); Fibula (3%)
Clinical: painless mass in posterior distal thigh; may be
present for several yrs; decreased ROM of adjacent joint
Sex: Female>Male 2:1


Radiology:
XR:
Lobulated and ossified exophytic mass (cauliflower-like)
adjacent to the cortex with a lucent cleavage plane between
lesion and the cortex
Radiodense centrally
Cortical thickening
Large tumors encircle the bone
Growth may obliterate cleavage plane between lesion and
cortex and will appear to have broad attachment
Invasion of the medullary canal with long standing disease

Periosteal Osteosarcoma
Low to intermediate grade bone forming sarcoma
with predominant chondroblastic differentiation
tumor (>90% of tumor); <2% of osteosarcomas
Origin: Arises from the inner layer of the
periosteum
Age: 10-20 yrs; similar to conventional
osteosarcoma
Sex: Slight male predominance
Location: Diaphysis of femur and tibia (>85%);
ulna and humerus (10%)
Radiology:
XR:
Diaphyseal lesion on surface of bone; medullary canal is
uninvolved
Saucerized cortex with chondroblastic soft tissue mass
Cortical thickening at margins of erosion (40%)
May have Codmans triangle
Spiculated or sunburst periosteal reaction (elevates the
periosteum)
Partial matrix mineralization may be seen consistent with
chondroblastic nature
Rarely, intramedullary invasion
High Grade Surface Osteosarcoma
High grade osteosarcoma that develops on the
surface of the bone without any medullary
involvement; very rare (<1% of osteosarcomas)
Histology is the same as a conventional
osteosarcoma with the same potential for mets
Age: 2
nd
decade
Sites: Femur (45%); Humerus (26%); Fibula (10%);
arises usually on the metaphyseal surface

Radiology:
Appearance similar to periosteal osteosarcoma
but matrix mineralization is similar to
conventional osteosarcoma with cloudlike
opacities
Broad based lesion arising on surface
Codmans triangle; periosteal new bone
Cortical erosion/destruction but medullary cavity
usually uninvolved

Bone tumor differential diagnosis
Abbreviations used:
ABC = Aneurysmal bone cyst
CMF = Chondromyxoid fibroma
EG = Eosinophilic Granuloma
GCT = Giant cell tumour
FD = Fibrous dysplasia
HPT = Hyperparathyroidism
with Brown tumor
NOF = Non Ossifying Fibroma
SBC = Simple Bone Cyst
Differential Diagnosis: Site

Differential Diagnosis: Sclerotic type
www.radiologyassistant.nl/en/p4bc9a97980036/sclerotic-bone-tumors-and-tumor-like-lesions.html
Radiologic Findings
Metaphyseal lesion
Eccentric extraosseous mass
Sclerotic and lytic lesion
Codmans
triangle
Eccentric
extraosseous
mass
Lytic lesion
Sclerotic lesion
http://www.mypacs.net/cases/OSTEOSARCO
MA-4172660.html
Codman triangle is the
triangular area of new
subperiosteal bone that
is created when a
lesion, often a tumor,
raises the periosteum
away from the bone.

http://www.radiologyassistant.nl/en/p494e15cbf0d8d/bone-tumor-systematic-approach-and-differential-
diagnosis.html
sunburst appearance
due to the tumor
spicules of calcified
bone radiating in right
angles

www.studyblue.com/notes/note/n/efmh-pdiatrie/deck/3217062
Periosteal reaction
cortical bone reacts to one of many possible
insults (tumor, infection, trauma, certain drugs,
and some arthritic conditions) can elevate the
periosteum from the cortex
Classification:
Non-aggresive:
Thin, solid, thick irregular, septated
Aggressive:
Lamilated, spiculated (sunburst, hair on
end), codman triangle, disorganize
Periosteal reaction: Non Aggresive
Thin Solid Thick irregular Septated
Healed fracture, osteoid osteoma, osteomyelitis
http://www.ajronline.org/doi/full/10.2214/AJR.09.3300

Periosteal reaction: Aggresive
Multilamilated
cycles of rapid and slow injury to bone
led to the formation of concentric
layers.
modulation of sheets of fibroblasts in
the adjacent soft tissue, which
develop osteoblastic potential and
give rise to sheets of new bone.
the new layer of bone is lifted off the
cortex, the inner cambium layer is
stimulated to form a new bone layer
below
Lesion in slow periodic growth


E.q: sarcomas, osteomyelitis, and chondroblastomas
Periosteal reaction: Spiculated
Hair on end Sunburst Hair on end and codman
triangle in ewing sarcoma
an aggressive form of periosteal reaction.
The linear spicules of new bone form along newly formed vascular channels
and fibrous bands (Sharpey fibers).
due to the tumor spicules of calcified bone radiating in divergent

Periosteal reaction:
Disorganized & Codman triangle
A Codman triangle
develops when a portion
of periosteum is lifted
off of the cortex by
tumor, pus, or
hemorrhage at a leading
edge



Lamillated & disorganized Codman Triangle
Matrix Mineralization
Chondral calcification:
LINEAR, CURVILINEAR, RING-LIKE, PUNCTATE,
NODULAR
e.q enchondroma, chondrosarcoma, chondromyxoid
fibroma
Osseous mineralization:
FLUFFY, CLOUD-LIKE, POORLY DEFINED.
e.q. osteosarcoma
DIFUSE : GROUND-GLASS APPEARANCE
E.q. fibrous dysplasia
Matrix Mineralization
CHONDRAL CALCIFICATION OSSEOUS MINERALIZATION
Matrix Mineralization
GROUND-GLASS

CALCIFIED MEDULLARY BONE INFARCT