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Osteosarcoma and its Osteosarcoma and its VariantsVariants
James C. Wittig, MDJames C. Wittig, MDAssociate Professor of Orthopedic OncologyAssociate Professor of Orthopedic Oncology
Chief, Orthopedic OncologyChief, Orthopedic OncologyMount Sinai Medical Mount Sinai Medical CenterCenter
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OsteosarcomaOsteosarcoma
Definitions:Definitions:A mesenchymal malignancy (malignant spindle cells) A mesenchymal malignancy (malignant spindle cells) that differentiates to produce osteoid/immature that differentiates to produce osteoid/immature boneboneConsidered an osteosarcoma no matter how much Considered an osteosarcoma no matter how much osteoid is producedosteoid is producedSecond most common primary malignant tumor of Second most common primary malignant tumor of bone (first most common=multiple myeloma)bone (first most common=multiple myeloma)15% of all biopsied primary bone tumors15% of all biopsied primary bone tumors
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OsteosarcomaOsteosarcomaDefinitions:Definitions:
Primary Osteosarcoma: arises from the bone in the Primary Osteosarcoma: arises from the bone in the absence of a benign precursor lesion or treatmentabsence of a benign precursor lesion or treatmentSecondary Osteosarcoma: arises from a precursor Secondary Osteosarcoma: arises from a precursor lesion to one that is metastatic from a primary lesion to one that is metastatic from a primary osteosarcomaosteosarcomaSynchronous Osteosarcoma: Lesions that affect Synchronous Osteosarcoma: Lesions that affect multiple bones discovered within 6 mos of each othermultiple bones discovered within 6 mos of each otherMetachronous Osteosarcoma: Lesions involving Metachronous Osteosarcoma: Lesions involving multiple bones discovered more than 6 mos apartmultiple bones discovered more than 6 mos apart
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OsteosarcomaOsteosarcoma
Definitions:Definitions:Intramedullary Osteosarcoma: Lesion arising within Intramedullary Osteosarcoma: Lesion arising within the medullary space of the bone (most common the medullary space of the bone (most common type)type)Juxtacortical Osteosarcoma: Lesion arising on the Juxtacortical Osteosarcoma: Lesion arising on the surface of the bone in apposition to the cortexsurface of the bone in apposition to the cortexIntracortical Osteosarcoma: Lesion arising from the Intracortical Osteosarcoma: Lesion arising from the cortex of the bonecortex of the bone
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OsteosarcomaOsteosarcomaClassificationClassification
Intramedullary (75%)Intramedullary (75%)ConventionalConventional
Osteoblastic (82%)Osteoblastic (82%)Mixed and SclerosingMixed and Sclerosing
Chondroblastic (5%)Chondroblastic (5%)Fibroblastic (3Fibroblastic (3--4%)4%)MFHMFH--like (3like (3--4%)4%)OsteoblastomaOsteoblastoma--like (.5%)like (.5%)Giant CellGiant Cell--rich (.5%)rich (.5%)SmallSmall--cell (1%)cell (1%)Epithelioid (.5%)Epithelioid (.5%)
Telangiectatic Telangiectatic (3%)(3%)WellWell--differentiateddifferentiated (low (low grade intraosseous; 4%grade intraosseous; 4%--5%)5%)
Juxtacortical/SurfaceJuxtacortical/Surface (7(7--10%)10%)ParostealParostealPeriostealPeriostealHighHigh--grade surfacegrade surface
IntracorticalIntracortical (.2%)(.2%)Secondary (older population)Secondary (older population)
Pagets (67Pagets (67--90%); Post RT (690%); Post RT (6--22%); Bone infarct; Fibrous 22%); Bone infarct; Fibrous dysplasia; Metallic implant; dysplasia; Metallic implant; OsteomyelitisOsteomyelitis
OS with specific syndromesOS with specific syndromesFamilial; Retinoblastoma; Familial; Retinoblastoma; RothmundRothmund--Thomson Thomson Syndrome; Multifocal; OISyndrome; Multifocal; OI
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General RadiologyGeneral Radiology
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General Radiology: Plain General Radiology: Plain Radiographic PresentationRadiographic Presentation
Osteoid/Ossification production on XOsteoid/Ossification production on X--RayRayMixed Sclerotic and Lytic LesionMixed Sclerotic and Lytic Lesion——Most Most common radiographic presentationcommon radiographic presentationPurely LyticPurely LyticPurely BlasticPurely Blastic
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Mixed Sclerosis and Lysis
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Purely Lytic
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BlasticTumor
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OsteosarcomaOsteosarcoma
General Pathology:General Pathology:OsteoidOsteoid and/or immature bone production by and/or immature bone production by tumor cellstumor cellsMalignant stromal cellsMalignant stromal cellsGraded on degree of anaplasia IGraded on degree of anaplasia I--IVIV
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Osteoid Deposition
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OsteosarcomaOsteosarcomaPrimary, High Grade, Intramedullary (Conventional)Primary, High Grade, Intramedullary (Conventional)
About 75% of all osteosarcomasAbout 75% of all osteosarcomasAges: 15Ages: 15--25 years (rare <6y or >60y)25 years (rare <6y or >60y)Sex: Male>Female 1.5Sex: Male>Female 1.5--2:12:1Sites:Sites:
Long Bones: 70%Long Bones: 70%--80%80%Distal Femur (40%; about twice as common as proximal tibia)Distal Femur (40%; about twice as common as proximal tibia)Proximal Tibia (20%)Proximal Tibia (20%)Proximal Humerus (10Proximal Humerus (10--15%)15%)
Axial SkeletonAxial SkeletonPelvisPelvisJawJaw
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OsteosarcomaOsteosarcoma
Sites: Sites: Metaphysis: 90%Metaphysis: 90%Diaphysis: 8Diaphysis: 8--10%10%
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Telangiectatic OsteosarcomaTelangiectatic Osteosarcoma
Tumor largely composed of cystic cavities Tumor largely composed of cystic cavities containing necrosis and hemorrhagecontaining necrosis and hemorrhageABCABC-- like which can lead to a misdiagnosis on like which can lead to a misdiagnosis on XX--raysraysSites: Similar to conventionalSites: Similar to conventional
Distal femur, proximal tibia, proximal humerusDistal femur, proximal tibia, proximal humerusMetaphyseal (90%), diaphyseal (10%)Metaphyseal (90%), diaphyseal (10%)
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Telangiectatic OsteosarcomaTelangiectatic Osteosarcoma
Radiology:Radiology:Osteolytic and expansile on XOsteolytic and expansile on X--rayraySmall areas of osteoid (more easily detected with Small areas of osteoid (more easily detected with CT)CT)Pathologic fracture (25%Pathologic fracture (25%--30%)30%)MRI/CT: FluidMRI/CT: Fluid--fluid levels; soft tissue massfluid levels; soft tissue massBone scan: Donut signBone scan: Donut sign
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Juxtacortical OsteosarcomaJuxtacortical Osteosarcoma
Parosteal Osteosarcoma (65%)Parosteal Osteosarcoma (65%)Periosteal Osteosarcoma (25%)Periosteal Osteosarcoma (25%)High Grade Surface (10%)High Grade Surface (10%)
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Parosteal OsteosarcomaParosteal OsteosarcomaOrigin: Arises from outer layer of periosteumOrigin: Arises from outer layer of periosteumUsually a low grade tumor with fibroblastic stroma and Usually a low grade tumor with fibroblastic stroma and osteoid/woven boneosteoid/woven boneAge: 20Age: 20--30 yrs; usually about a decade older than conventional 30 yrs; usually about a decade older than conventional osteosarcomaosteosarcomaLocation:Location:
Posterior distal femur metaphysis (65%)Posterior distal femur metaphysis (65%)Proximal humerus (15%); Tibia (10%); Fibula (3%)Proximal humerus (15%); Tibia (10%); Fibula (3%)
Clinical: painless mass in posterior distal thigh; may be presenClinical: painless mass in posterior distal thigh; may be present t for several yrs; decreased ROM of adjacent jointfor several yrs; decreased ROM of adjacent jointSex: Female>Male 2:1Sex: Female>Male 2:1
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Tumor
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Parosteal OsteosarcomaParosteal Osteosarcoma
Radiology:Radiology:XR: XR:
Lobulated and ossified exophytic mass (cauliflowerLobulated and ossified exophytic mass (cauliflower--like) like) adjacent to the cortex with a lucent cleavage plane between adjacent to the cortex with a lucent cleavage plane between lesion and the cortexlesion and the cortexRadiodense centrallyRadiodense centrallyCortical thickening Cortical thickening Large tumors encircle the boneLarge tumors encircle the boneGrowth may obliterate cleavage plane between lesion and Growth may obliterate cleavage plane between lesion and cortex and will appear to have broad attachmentcortex and will appear to have broad attachmentInvasion of the medullary canal with long standing diseaseInvasion of the medullary canal with long standing disease
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Periosteal OsteosarcomaPeriosteal Osteosarcoma
Low to intermediate grade bone forming sarcoma Low to intermediate grade bone forming sarcoma with predominant chondroblastic differentiation with predominant chondroblastic differentiation tumor (>90% of tumor); <2% of osteosarcomastumor (>90% of tumor); <2% of osteosarcomasOrigin: Arises from the inner layer of the Origin: Arises from the inner layer of the periosteumperiosteumAge: 10Age: 10--20 yrs; similar to conventional 20 yrs; similar to conventional osteosarcomaosteosarcomaSex: Slight male predominanceSex: Slight male predominanceLocation: Diaphysis of femur and tibia (>85%); Location: Diaphysis of femur and tibia (>85%); ulna and humerus (10%)ulna and humerus (10%)
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Tumor
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Periosteal OsteosarcomaPeriosteal OsteosarcomaRadiology:Radiology:
XR: XR: Diaphyseal lesion on surface of bone; medullary canal is Diaphyseal lesion on surface of bone; medullary canal is uninvolveduninvolvedSaucerized cortex with chondroblastic soft tissue massSaucerized cortex with chondroblastic soft tissue massCortical thickening at margins of erosion (40%)Cortical thickening at margins of erosion (40%)May have CodmanMay have Codman’’s triangles triangleSpiculated or sunburst periosteal reaction (elevates the Spiculated or sunburst periosteal reaction (elevates the periosteum)periosteum)Partial matrix mineralization may be seen consistent with Partial matrix mineralization may be seen consistent with chondroblastic naturechondroblastic natureRarely, intramedullary invasionRarely, intramedullary invasion
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High Grade Surface OsteosarcomaHigh Grade Surface Osteosarcoma
High grade osteosarcoma that develops on the High grade osteosarcoma that develops on the surface of the bone without any medullary surface of the bone without any medullary involvement; very rare (<1% of osteosarcomas)involvement; very rare (<1% of osteosarcomas)Histology is the same as a conventional Histology is the same as a conventional osteosarcoma with the same potential for metsosteosarcoma with the same potential for metsAge: 2Age: 2ndnd decadedecadeSites: Femur (45%); Humerus (26%); Fibula (10%); Sites: Femur (45%); Humerus (26%); Fibula (10%); arises usually on the metaphyseal surface arises usually on the metaphyseal surface
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High Grade Surface OsteosarcomaHigh Grade Surface Osteosarcoma
Radiology:Radiology:Appearance similar to periosteal osteosarcoma but Appearance similar to periosteal osteosarcoma but matrix mineralization is similar to conventional matrix mineralization is similar to conventional osteosarcoma with cloudlike opacitiesosteosarcoma with cloudlike opacitiesBroad based lesion arising on surfaceBroad based lesion arising on surfaceCodmanCodman’’s triangle; periosteal new bones triangle; periosteal new boneCortical erosion/destruction but medullary cavity Cortical erosion/destruction but medullary cavity usually uninvolvedusually uninvolved
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Low Grade Intramedullary Low Grade Intramedullary OsteosarcomaOsteosarcoma
Intramedullary low grade fibroblastic osteoid Intramedullary low grade fibroblastic osteoid producing sarcoma characterized by benign producing sarcoma characterized by benign cytologic features of spindle cells and maturity cytologic features of spindle cells and maturity of tumor boneof tumor bone1% of all osteosarcomas1% of all osteosarcomasAge: peakAge: peak—— 33rdrd decade; individual cases in 2decade; individual cases in 2ndnd
decade and 50sdecade and 50sSites: Metaphysis of femur and tibia most Sites: Metaphysis of femur and tibia most commoncommon
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Low Grade IntramedullaryLow Grade Intramedullary
Radiology:Radiology:XR: XR:
MetaMeta--epiphysealepiphysealCentral ossification/sclerosis with expansile remodelingCentral ossification/sclerosis with expansile remodelingGround glass density and internal trabeculation (simulates Ground glass density and internal trabeculation (simulates fibrous dysplasia)fibrous dysplasia)Usually no soft tissue mass and not as aggressive Usually no soft tissue mass and not as aggressive appearingappearingUsually no periosteal reactionUsually no periosteal reaction
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Intracortical OsteosarcomaIntracortical Osteosarcoma
High grade osteosarcoma confined to the cortex of a High grade osteosarcoma confined to the cortex of a long bonelong boneVery rare; handful of casesVery rare; handful of casesAge: 10Age: 10--30 yrs30 yrsSites: Diaphysis of femur or tibiaSites: Diaphysis of femur or tibiaRadiology: Radiology:
Intracortical lucency with surrounding sclerosis of boneIntracortical lucency with surrounding sclerosis of boneNo intramedullary or soft tissue involvementNo intramedullary or soft tissue involvementMinimal or no periosteal reactionMinimal or no periosteal reaction
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Conventional Osteosarcoma of Distal Conventional Osteosarcoma of Distal Femur XFemur X--RayRay
Permeative Lesion
Codman’s Triangle
Ossification in Soft Tissue Component
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Conventional Osteosarcoma of Conventional Osteosarcoma of Proximal TibiaProximal Tibia
Permeative Lesion with Fluffy White Ossification (sclerosis)
Cortical Destruction
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Cortical Destruction and Hair on End Periosteal Reaction
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OsteosarcomaOsteosarcomaConventionalConventional
Radiographic Differential Diagnosis:Radiographic Differential Diagnosis:Ewing sarcomaEwing sarcomaFibrosarcoma/MFHFibrosarcoma/MFHChondrosarcomaChondrosarcomaOsteomyelitisOsteomyelitisOsteoblastomaOsteoblastomaGiant Cell TumorGiant Cell Tumor
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Examples of Conventional Examples of Conventional Osteosarcomas including Gross and Osteosarcomas including Gross and
Microscopic PathologyMicroscopic Pathology
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Chondroblastic Subtype of a Chondroblastic Subtype of a Conventional Osteosarcoma of Distal Conventional Osteosarcoma of Distal
TibiaTibia
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Microscopic PathologyMicroscopic Pathology——Malignant Malignant Appearing Cartilaginous TissueAppearing Cartilaginous Tissue
Cells in Lacunae
Ground Glass Matrix—Intercellular Matrix (Non-cellular Substance)
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Hypercellular, Disorganized, Hypercellular, Disorganized, Crowded Cells, Multinucleated Cells, Crowded Cells, Multinucleated Cells,
Large Bizarre NucleiLarge Bizarre Nuclei
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Bone Production Identified which Bone Production Identified which Categorizes it as an OsteosarcomaCategorizes it as an Osteosarcoma
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OsteosarcomaOsteosarcomaConventionalConventional
Pathologic Differential Diagnosis:Pathologic Differential Diagnosis:OsteoblastomaOsteoblastomaOsteoid OsteomaOsteoid OsteomaGiant Cell TumorGiant Cell TumorFracture CallusFracture CallusFibrosarcomaFibrosarcomaChondrosarcomaChondrosarcomaMFHMFH
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OsteosarcomaOsteosarcomaTreatment:Treatment:
Preoperative (induction) chemotherapy:Preoperative (induction) chemotherapy:Adriamycin (doxorubicin)Adriamycin (doxorubicin)Cisplatinum (cisplatin)Cisplatinum (cisplatin)High Dose Methotrexate (HDMTX)High Dose Methotrexate (HDMTX)Ifosfamide/Etoposide in some regimensIfosfamide/Etoposide in some regimens
(2 cycles and then surgery)(2 cycles and then surgery)
Surgery:Surgery:Wide surgical resection /Limb Salvage(95% of extremity lesions)Wide surgical resection /Limb Salvage(95% of extremity lesions)Amputation (5% of extremity lesions)Amputation (5% of extremity lesions)
Postoperative (adjuvant) chemotherapy:Postoperative (adjuvant) chemotherapy:Same regimen as preop; usually 4 cyclesSame regimen as preop; usually 4 cycles
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Limb Salvage: Radical Resection of Distal Limb Salvage: Radical Resection of Distal Femur Osteosarcoma and Reconstruction with Femur Osteosarcoma and Reconstruction with
Distal Femur Tumor ProsthesisDistal Femur Tumor Prosthesis
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Radical Resection of proximal Humerus Radical Resection of proximal Humerus Osteosarcoma with Metastasis to Scapula: Osteosarcoma with Metastasis to Scapula:
Reconstruction with total Scapula Prosthetic Reconstruction with total Scapula Prosthetic ReplacementReplacement
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Telangiectatic Osteosarcoma of Telangiectatic Osteosarcoma of Distal RadiusDistal Radius
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MRI Demonstrating Multiple fluidMRI Demonstrating Multiple fluid--Fluid LevelsFluid Levels
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Gross Pathology: Telangiectatic OsteosarcomaGross Pathology: Telangiectatic Osteosarcoma
Multiple Cystic and Necrotic Spaces/Cavities
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Microscopic PathologyMicroscopic Pathology
Wall of Cyst Cavity
Cavity
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Osteoid Production
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Telangiectatic OsteosarcomaTelangiectatic Osteosarcoma
Radiographic Differential Dx:Radiographic Differential Dx:Conventional osteosarcomaConventional osteosarcomaFibrosarcomaFibrosarcomaMFHMFHAneurysmal Bone CystAneurysmal Bone Cyst
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Telangiectatic OsteosarcomaTelangiectatic Osteosarcoma
Treatment and Prognosis same as conventional Treatment and Prognosis same as conventional osteosarcomaosteosarcoma
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Parosteal OsteosarcomaParosteal Osteosarcoma
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Parosteal OsteosarcomaParosteal Osteosarcoma
Radiology:Radiology:MRI/CT: MRI/CT:
Medullary invasionMedullary invasionAny areas that may be high gradeAny areas that may be high gradeLocal extentLocal extent------circumference of femurcircumference of femurCT of chest for detecting pulmonary metsCT of chest for detecting pulmonary mets
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CT Scan of Distal Femur Parosteal CT Scan of Distal Femur Parosteal OsteosarcomaOsteosarcoma
Cortex of Bone
Medullary Canal
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Gross and Microscopic PathologyGross and Microscopic Pathology
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Tumor
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Tumor on Surface of Bone
Medullary Canal of Bone
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PathologyPathology
Microscopic pathology demonstrates a Microscopic pathology demonstrates a fibroblastic tumor that is producing bone and fibroblastic tumor that is producing bone and osteoidosteoidThe islands of bone are interspersed amongst The islands of bone are interspersed amongst fibrous appearing tissuefibrous appearing tissueThere is minimal nuclear atypia and a minimal There is minimal nuclear atypia and a minimal number of mitotic figuresnumber of mitotic figuresThe tumor is typically a low grade tumorThe tumor is typically a low grade tumor
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Bone Production
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Parosteal OsteosarcomaParosteal Osteosarcoma
Radiographic Differential Diagnosis:Radiographic Differential Diagnosis:Myositis ossificansMyositis ossificansPeriosteal osteosarcomaPeriosteal osteosarcomaPeriosteal chondrosarcomaPeriosteal chondrosarcomaHighHigh--grade surface osteosarcomagrade surface osteosarcomaConventional osteosarcomaConventional osteosarcomaOsteochondromaOsteochondroma
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Parosteal OsteosarcomaParosteal Osteosarcoma
Pathologic Differential Diagnosis:Pathologic Differential Diagnosis:OsteochondromaOsteochondromaMyositis ossificansMyositis ossificansHigh grade surface osteosarcomaHigh grade surface osteosarcomaPeriosteal osteosarcomaPeriosteal osteosarcoma
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Parosteal OsteosarcomaParosteal Osteosarcoma
Typically a parosteal osteosarcoma is a low grade type Typically a parosteal osteosarcoma is a low grade type of tumor with little risk of metastasizing or spreadingof tumor with little risk of metastasizing or spreadingMost patients are cured with surgery alone. Most patients are cured with surgery alone. Chemotherapy is usually not used for treatment.Chemotherapy is usually not used for treatment.Occasionally, parosteal osteosarcomas that are present Occasionally, parosteal osteosarcomas that are present for prolonged periods of time before being identified, for prolonged periods of time before being identified, can dedifferentiate and develop high grade areas. These can dedifferentiate and develop high grade areas. These higher grade variants have a higher likelihood of higher grade variants have a higher likelihood of spreading and may be treated with chemotherapy in spreading and may be treated with chemotherapy in addition to surgery.addition to surgery.
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Parosteal OsteosarcomaParosteal Osteosarcoma
Treatment:Treatment:Wide surgical resection and reconstructionWide surgical resection and reconstructionChemotherapy only if grade 3 components or Chemotherapy only if grade 3 components or dedifferentiated components identified on biopsy or after dedifferentiated components identified on biopsy or after resection (Same regimen as conventional)resection (Same regimen as conventional)Radiation: Not used in treatment of this tumorRadiation: Not used in treatment of this tumor
Prognosis:Prognosis:8080--90% cure rate90% cure rateMets more common with medullary invasion and high grade Mets more common with medullary invasion and high grade componentscomponentsMedullary invasion more common with high grade Medullary invasion more common with high grade componentscomponents
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Periosteal Osteosarcoma of TibiaPeriosteal Osteosarcoma of Tibia
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Hair on End Periosteal Reaction
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Pathology: Primarily a Chondroblastic Pathology: Primarily a Chondroblastic (Cartilaginous) Tumor with Bone (Osteoid) (Cartilaginous) Tumor with Bone (Osteoid)
ProductionProduction
Malignant Appearing Cartilage
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Osteoid Production Identified in Various Areas of Tumor
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Periosteal OsteosarcomaPeriosteal Osteosarcoma
Radiographic Differential Diagnosis:Radiographic Differential Diagnosis:Parosteal osteosarcomaParosteal osteosarcomaHigh grade surface osteosarcomaHigh grade surface osteosarcomaPeriosteal chondrosarcomaPeriosteal chondrosarcomaMyositis ossificansMyositis ossificans
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Periosteal OsteosarcomaPeriosteal Osteosarcoma
Pathologic Differential Diagnosis:Pathologic Differential Diagnosis:Periosteal chondromaPeriosteal chondromaPeriosteal chondrosarcomaPeriosteal chondrosarcomaHigh grade surface osteosarcomaHigh grade surface osteosarcomaConventional osteosarcoma with chondroblastic Conventional osteosarcoma with chondroblastic componentcomponent
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Periosteal OsteosarcomaPeriosteal Osteosarcoma
Treatment:Treatment:En bloc resection and reconstructionEn bloc resection and reconstruction
Prognosis:Prognosis:1515--25% metastatic rate to lungs25% metastatic rate to lungsRole of chemotherapy is questionableRole of chemotherapy is questionable
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High Grade Surface Osteosarcoma of High Grade Surface Osteosarcoma of Distal TibiaDistal Tibia
Ossification in Tumor
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Necrotic Cystic Cavity
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PathologyPathology
Microscopically, a high grade surface Microscopically, a high grade surface osteosarcoma looks the same as a conventional osteosarcoma looks the same as a conventional intramedullary osteosarcomaintramedullary osteosarcoma
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Osteoid Production
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High Grade Surface OsteosarcomaHigh Grade Surface Osteosarcoma
Radiographic Differential Diagnosis:Radiographic Differential Diagnosis:Periosteal osteosarcomaPeriosteal osteosarcomaParosteal osteosarcomaParosteal osteosarcomaPeriosteal chondrosarcomaPeriosteal chondrosarcoma
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High Grade Surface OsteosarcomaHigh Grade Surface Osteosarcoma
Pathologic Differential Diagnosis:Pathologic Differential Diagnosis:Myositis ossificansMyositis ossificansPeriosteal osteosarcomaPeriosteal osteosarcomaConventional osteosarcoma with prominent soft Conventional osteosarcoma with prominent soft tissue extensiontissue extensionParosteal osteosarcomaParosteal osteosarcoma
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High Grade Surface OsteosarcomaHigh Grade Surface Osteosarcoma
Treatment and Prognosis:Treatment and Prognosis:Same as conventional osteosarcomaSame as conventional osteosarcoma
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Low Grade Intramedullary Low Grade Intramedullary Osteosarcoma of Distal FemurOsteosarcoma of Distal Femur
Ossification
Breaking through Cortex
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PathologyPathology
Microscopically, low grade intramedullary Microscopically, low grade intramedullary osteosarcoma looks similar to a parosteal osteosarcoma looks similar to a parosteal osteosarcomaosteosarcomaFibroblastic tumor producing bone Fibroblastic tumor producing bone (osteoid/immature bone)(osteoid/immature bone)Minimal nuclear atypia, mildly hypercellular, Minimal nuclear atypia, mildly hypercellular, minimal mitotic figuresminimal mitotic figures
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Osteoid Production
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Low Grade IntramedullaryLow Grade Intramedullary
Radiographic Differential Diagnosis:Radiographic Differential Diagnosis:Fibrous dysplasiaFibrous dysplasiaGiant cell tumorGiant cell tumorOrdinary osteosarcomaOrdinary osteosarcomaFibrosarcomaFibrosarcomaMalignant fibrous histiocytomaMalignant fibrous histiocytoma
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Low Grade IntramedullaryLow Grade Intramedullary
Pathologic Differential Diagnosis:Pathologic Differential Diagnosis:Fibrous dysplasiaFibrous dysplasiaOsteofibrous dysplasiaOsteofibrous dysplasiaConventional osteosarcomaConventional osteosarcomaParosteal osteosarcomaParosteal osteosarcoma
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Low Grade IntramedullaryLow Grade Intramedullary
Treatment:Treatment:Surgical resection and reconstructionSurgical resection and reconstructionNo chemotherapy unless dedifferentiation is presentNo chemotherapy unless dedifferentiation is present
Prognosis:Prognosis:90% cure rate (<10% metastatic rate)90% cure rate (<10% metastatic rate)
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Intracortical OsteosarcomaIntracortical Osteosarcoma
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Osteoid Production
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Intracortical OsteosarcomaIntracortical Osteosarcoma
Differential Diagnosis:Differential Diagnosis:Stress fractureStress fractureOsteoid osteomaOsteoid osteomaOsteoblastomaOsteoblastomaIntracortical abscessIntracortical abscessFibrous dysplasiaFibrous dysplasiaNonossifying fibromaNonossifying fibromaAdamantinomaAdamantinoma
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Intracortical OsteosarcomaIntracortical Osteosarcoma
Treatment:Treatment:En bloc resectionEn bloc resectionChemotherapyChemotherapy
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Osteosarcoma vs OsteoblastomaOsteosarcoma vs Osteoblastoma
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Osteosarcoma vs OsteoblastomaOsteosarcoma vs Osteoblastoma
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Parosteal Osteosarcoma vs OsteomaParosteal Osteosarcoma vs Osteoma
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Parosteal Osteosarcoma vs OsteomaParosteal Osteosarcoma vs Osteoma
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Surface Lesions of Bone: Differential Diagnosis of Surface Lesions of Bone: Differential Diagnosis of Parosteal OsteosarcomaParosteal Osteosarcoma