belajar ujian magang

bull Tampak lesi blastik di metafisis hingga proksimal diafisis tibia kanan disertai dengan zone transisi lebar dan gambaran reaksi periosteal tipe agresif di sisi posterior dan tampak perluasan ke jaringan lunak di sekitarnya dengan gambaran matriks osteoid

bull Osteosarcomas are malignant bone forming tumours and the second most common primary bone tumour after multiple myeloma They account for ~20 of all primary bone tumours

bull Patients usually present with bone pain occasionally accompanied by a soft-tissue mass or swelling At times the first symptoms are related to pathologic fracture

osteosarcoma

The distribution of primary and secondary osteosarcomas is also different

bull Primary tumours typically occur in the metaphyseal regions of long bones and have a striking predilection for the knee with up to 60 occurring there

bull Secondary tumours on the other hand have a much wider distribution largely mirroring the combined incidence of their underlying condition and thus much have a higher incidence in flat bones especially the pelvis (a favourite site of Pagets disease)

Clinical presentation

bull Osteosarcomas can be divided into a number of sub types according to degree of differentiation location within the bone and histological variants 3

bull These sub types vary in imaging findings demographics and biological behaviour and include

bull Intramedullary ~ 80ndash conventional high-grade - most common and discussed in this articlendash telangiectatic osteosarcomandash low-grade osteosarcoma

bull Surface or juxtacortical ~ 10-15ndash intracortical osteosarcomandash parosteal osteosarcomandash periosteal osteosarcoma

bull Extra skeletal ~ 5ndash extra skeletal osteosarcoma

Pathology

bull They typically occur at the metadiaphysis of tubular bones in the appendicular skeleton Common sites include

bull femur ~ 40 (especially distal femur)bull tibia ~ 16 (especially proximal tibia)bull humerus ~ 15 bull Other less common sites includebull fibulabull innominate bonebull mandible (gnathic osteosarcoma)bull maxillabull vertebrae

Location

Plain Filmbull Conventional radiography continues to play an important role in

diagnosis Typical appearances of conventional high grade osteosarcoma include

bull medullary and cortical bone destructionbull wide zone of transition permeative or moth-eaten appearancebull aggressive periosteal reaction

ndash sunburst typendash Codman trianglendash lamellated (onionskin) reaction - less frequently seen

bull soft-tissue massbull tumour matrix ossification calcification

ndash variable reflects a combination of the amount of tumour bone production calcified matrix and osteoid

Radiological Features

bull The role of CT is predominantly in assisting biopsy and staging but adds little to plain radiography and MRI in direct assessment of the tumour The exception to this rule is predominantly lytic lesions in which small amounts of mineralized material may be inapparent on both plain film and MRI

CT

bull MRI is proving essential in accurate local staging and assessment for limb sparing resection particularly for evaluation of intraosseous tumour extension and soft-tissue involvement Assessment of the growth plate is also essential as up to 75 - 88 of metaphyseal tumours do cross the growth plate into the epiphysis

bull T1ndash soft tissue non-mineralized component intermediate signal intensityndash mineralised ossified components low signal intensityndash peri-tumoural oedema intermediate signal intensityndash scattered regions of haemorrhage will have variable signal (see ageing

blood on MRI)ndash enhancement solid components enhance

bull T2ndash soft tissue non-mineralized component high signal intensityndash mineralised ossified components low signal intensityndash peri-tumoural oedema high signal intensity

MRI

bull General differential considerations includebull osteomyelitisbull Other tumoursndashmetastatic lesion to bonendash Ewing sarcomandash aneurysmal bone cyst

Differential diagnosis

bull Identified in 1921 by James Ewingbull 2nd most common bone tumor in childrenbull Ewingrsquos Sarcoma Family of tumorsndash Ewingrsquos sarcoma (Bone ndash87) ndash Extraosseous Ewingrsquos sarcoma (8)ndash Peripheral PNET(5) ndash Askinrsquos tumor

13

Ewing sarcoma

2 of cancer childhood malignancyOccurs most commonly in 2nd decade80 occur between ages 5 and 25MF 131 lt 10 yrs

161 gt 10 yrsRare in African-Americans and Asians

Epidemiology

bull Pain amp swelling of affected area

bull May also have systemic symptomsndash Feverndash Anemiandash Weight loss ndash Elevated WBC amp ESRLDH

bull Longest lag time in diagnosis for any pediatric solid tumor (mean of 146 days)

bull Pathological fracture

Clinical Presentation

Location more common in diaphysis or

metadiaphysis

central axis (47) pelvis chest wall spine head amp

neck

extremities (53)

Scapula (38)

Skull(38)

bull direct extension into adjacent bone or soft tissuebull Metastases generally spread through bloodstreambull 25 present with metastatic diseasendash Lungs (38)ndash Bone (31)ndash Bone Marrow (11)

bull Nearly all pts have micromets at diagnosis so all Need chemo

Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1

Imagingbull X-RAYndash Moth eaten lesionndash Lytic or mixed lytic-sclerotic areas

presentndash Multi-Layered subperiosteal reaction

(onion skinning)ndash Lifting of perioteum (codmanrsquos triangle)

bull CT SCAN bone destruction best seenbull Intramedullary spacebull extraosseous involvement

19

bull Bone scan ndash To detect polyostotic involvementndash to detect bone metastasis

bull Bone marrow biopsy

bull CXRCT of chest lung mets

bull Tampak erosi disisi medial metatarsal digiti 1 dan basis phalang proksimal digiti 1 dengan gambaran overhanging edge dan tampak pula penebalan jaringan lunak di sertai kalsifikasi di regio tersebut

Gout

Radiological features of gout

ClassificationBladder rupture be divided into three broad typesbull extra-peritonealbull intra-peritonealbull combined

Extraperitoneal bladder rupturebull Extraperitoneal rupture is the most common type of

bladder injury accounting for ~85 (range 80-90) of cases It is usually the result of pelvic fractures or penetrating trauma Cystography reveals a variable path of extravasated contrast material Treatment is with an indwelling catheter (IDCFoley)

Intraperitoneal bladder rupturebull Occurs in approximately ~15 (range 10-20) of major

bladder injuries and typically is the result of a direct blow to the already distended bladder Cystography demonstrates intraperitoneal contrast material around bowel loops between mesenteric folds and in the paracolic gutters Treatment is surgical repair

Combined bladder rupturebull Simultaneous intraperitoneal and extraperitoneal

injury Cystography usually demonstrates extravasation patterns that are typical for both types of injury

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osteosarcoma


Pathology

Location

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CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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bull Osteosarcomas are malignant bone forming tumours and the second most common primary bone tumour after multiple myeloma They account for ~20 of all primary bone tumours

bull Patients usually present with bone pain occasionally accompanied by a soft-tissue mass or swelling At times the first symptoms are related to pathologic fracture

osteosarcoma










Pathology



Location









CT





MRI




13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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Pathology



Location









CT





MRI




13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









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osteosarcoma


Pathology

Location

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CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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Location









CT





MRI




13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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CT





MRI




13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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MRI




13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









Slide 1

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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Gout


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13

Ewing sarcoma



Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









Slide 1

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Slide 3

osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Slide 22

Gout


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Epidemiology







metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









Slide 1

Slide 2

Slide 3

osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

Slide 19

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Slide 22

Gout


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metadiaphysis


neck

extremities (53)

Scapula (38)

Skull(38)



Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









Slide 1

Slide 2

Slide 3

osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

Slide 19

Slide 20

Slide 21

Slide 22

Gout


Slide 25

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Routes of spread

No mets75

Lu+BoneBM 4

Lung 13

BoneBM 7

Other 1





19





Gout









Slide 1

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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Slide 22

Gout


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19





Gout









Slide 1

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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Slide 22

Gout


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Gout









Slide 1

Slide 2

Slide 3

osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Slide 22

Gout


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Slide 1

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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

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Slide 21

Slide 22

Gout


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Slide 2

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osteosarcoma


Pathology

Location

Slide 8


CT

MRI


Ewing sarcoma


Location

Routes of spread

Imaging

Slide 19

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Slide 21

Slide 22

Gout


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