Phalangeal intraosseous well-differentiated osteosarcoma of the hand

Osteogenic sarcomas of the hands: A case series with emphasis in its peculiarities and literature review

AIM

To present our experience on osteosarcomas of the hands and review the existing literature pertaining osteosarcomas in this extremely rare location.

METHODS

and results: Seven cases of osteosarcomas of the hands were reviewed, and a literature search of all primary osteosarcomas of the hands was performed. All tumors occurred in adults (mean age, 41 years) and were located mainly around the metacarpophalangeal joints. All patients presented with localized long-lasting pain as main symptom. The mean size at diagnosis was 33 mm. Three tumors were low-grade central osteosarcomas, 1 low-grade central chondroblastoma-like osteosarcoma and 3 high-grade osteosarcomas. All tumors were positive for mouse double-minute 2 homolog (MDM2) immunohistochemistry. Three cases yielded results with fluorescence in-situ amplification for MDM2 (12q15)/CEP12. At last follow-up, one patient with a high-grade osteosarcoma was dead of disease. The literature review revealed similar demographic and site distribution of osteosarcomas within the hands than our series and an unusually high proportion of low-grade central and parosteal osteosarcomas when compared to the proportion of these infrequent neoplasms in the whole skeleton.

CONCLUSIONS

osteosarcomas of hands present in older individuals compared to the population affected by conventional osteosarcomas of all sites. Importantly from a diagnostic, therapeutic and prognostic points of view, around 40% of osteosarcomas of the hands are low-grade osteosarcomas of the central or parosteal types.

Intramedullary Well-differentiated Osteosarcoma: Imaging and Pathologic Findings in 17 Patients

BACKGROUND

Intramedullary well-differentiated osteosarcoma (IMWDOS) is rare and may easily be misdiagnosed.

OBJECTIVE

This study aimed at investigating the clinical, imaging, and pathological features of IMWDOS for correct diagnosis.

MATERIALS AND METHODS

Seventeen patients with IMWDOS were enrolled, and their clinical, imaging, and pathological data were analyzed.

RESULTS

Total 13 males and 4 females aged 19-55 years (mean 36. 1) were selected. The lesion was located at long bones in 16 patients and the second region of the acetabulum in one patient. Except for three patients with limited areas of lesions, all the other patients had a wide distribution of tumor, and the lesion in long bones involved the metaphysis area with possible extension towards the diaphysis. In imaging, the lesion usually had an unclear boundary with the destruction of bone cortex, uneven thickness of the bone cortex, thick and coarse trabecula in the lesion, but few periosteal reactions and soft tissue masses. The lesion was histologically composed of spindle cells with slight atypia. Follow-up was performed 2-101 months (mean 31.9m) in 14 cases, 10 years in one case, and 26 years in the remaining two. At follow-up, 12 patients (12/17 or 70.6%) who had a complete resection, including amputation (n=2), wide excision (n=8), and endoprosthetic replacement (n=2), showed no recurrence or metastasis. Among five patients who underwent curettage, three (3/17 or 17.6%) had recurrent lesions, leading to death in two of them, and the third one died during post-operation chemotherapy.

CONCLUSION

Intramedullary well-differentiated osteosarcoma tends to occur at the metaphysis of long bones, especially at the distal femur. Histological, clinical, and imaging findings lack specific characteristics and should be examined collectively to reach a correct diagnosis. The prognosis of patients with complete lesion resection is good, while incomplete lesion curettage or resection will lead to recurrence and transformation into a highly malignant tumor.

Well-Differentiated Intramedullary Osteosarcoma

Well-differentiated intraosseous osteosarcoma (WDIOS) is a rare tumor and histologically similar to parosteal osteosarcoma. This study reports the clinicopathological features of five patients with WDIOS tumor seen at the Instituto Nacional de Cancerologia in Mexico City. The patients' ages ranged from 29 to 42 years with a median age of 32 years. Four of the five patients presented with pain and a mass that had been present for more than 3 years prior to the diagnosis. Radiologically, four of the lesions were present in the long bones and showed a predominantly trabeculated appearance with some small ill-defined lytic areas. The bony sclerosis was more prominent within the medullary cavity than in the soft tissue extension. The majority of the tumors were large, averaging 21 cm in size. Histologically, the tumors were characterized by spindle cells with areas of cytologic atypia and presence of mature bone formation. In two patients a high-grade sarcoma component was found in addition to WDIOS component: in both patients the high-grade sarcoma component was identified in the amputation specimens, and in one of these it was also recognized in the pulmonary metastasis. This study demonstrated that WDIOS is a slowgrowing malignant neoplasm that may show a histologic progression to dedifferentiation (dedifferentiated osteosarcoma) and an aggressive behavior with distant metastasis.

Smooth muscle actin expression in primary bone tumours

Alpha isoform of smooth muscle actin (SMA) expression has been reported in giant cell tumour of bone (GCTB) and other benign and malignant bone tumours, but the pattern of SMA expression and the precise nature of SMA-expressing cells in these lesions is uncertain. We determined by immunohistochemistry the expression of SMA and other muscle and vascular markers in normal bone, GCTB and a wide range of primary benign and malignant bone tumours. Cultured stromal cells of GCTB, chondroblastoma (CB), and aneurysmal bone cyst (ABC) were also analysed for SMA expression. SMA was only noted in blood vessels in normal bone. SMA was expressed by mononuclear stromal cells (MSC) cultured from GCTB, ABC and CB. SMA was strongly and diffusely expressed by MSC in non-ossifying fibroma, fibrous dysplasia, and "brown tumour" of hyperparathyroidism. SMA expression was also noted in GCTB, ABC, CB, chondromyxoid fibroma, malignant fibrous histiocytoma of bone and osteosarcoma. Little or no SMA was noted in Langerhans cell histiocytosis, simple bone cyst, Ewing's sarcoma, osteoblastoma, osteoid osteoma, enchondroma, osteochondroma, chondrosarcoma, myeloma, lymphoma, chordoma and adamantinoma. Our findings show that there is differential SMA expression in primary bone tumours and that identifying the presence or absence of SMA is useful in the differential diagnosis of these lesions. The nature of SMA-expressing cells in bone tumours is uncertain but they are negative for desmin and caldesmon and could represent either myofibroblasts or perivascular cells, such as pericytes.

Ultrastructure of Low-grade Intraosseous Osteosarcoma of Bone: A Comparative Study with Fibrous Dysplasia and Parosteal Osteosarcoma

The ultrastructure of low-grade intraosseous osteosarcoma (LGOS) is not well documented in the literature. Four cases of LGOS are described with an emphasis on its distinguishing characteristics as well those it shares with other lesions. The predominant cells of LGOS are fibroblasts with well-developed rough endoplasmic reticulum and mild focal immunoreactivity to SMA and MSA. Few osteoblasts and myofibroblasts are present. Transition cells between fibroblasts and osteoblasts are also noted. The fibroblasts are closely related to osteoblasts from a histological and functional point of view, and phenotypically are probably modified osteoblasts. Comparative ultrastructural studies between LGOS and fibrous dysplasia (FD) reveal basic similarities, although the cells in LGOS are larger with more of an abundance of organelles. Therefore, accurate differentiation between these two lesions rests at the histological and radiological levels. LGOS and parosteal osteosarcomas (PO) also share similar ultrastructural features. In the case samples in this study, an unusual type of multilayered amorphous material was found in the osteoid matrix of a case of LGOS and one of PO. This probably emphasizes the morphologic similarities between these 2 tumors.

High-grade surface osteosarcoma of the hand

A 32-year-old woman presented with a 1-year history of mild pain in the right ring finger. Radiographs and CT revealed a calcified lesion with cortical erosion on the surface of the proximal aspect of the right ring finger proximal phalanx. On magnetic resonance imaging (MRI), the lesion showed low signal intensity on T1- and T2-weighted images and slight enhancement with gadolinium. Clinically, it was diagnosed as a benign bone-forming lesion such as florid reactive periostitis, and excision was accordingly performed. However, histological examination revealed proliferation of atypical osteoblastic cells among irregularly arranged osteoid seams. Taking the imaging findings into account, a pathological diagnosis of high-grade surface osteosarcoma was established. In general, bone- and cartilage-forming lesions of the hands and feet are benign. Osteosarcoma of short tubular bones in the hands and feet is extremely rare; moreover, high-grade surface osteosarcoma is one of the rarest subtypes of osteosarcoma. Nonetheless, high-grade surface osteosarcoma should be included in the differential diagnosis, particularly if the radiological findings or clinical course are not entirely typical of a more common benign process, to avoid incorrect clinicoradiological and pathological diagnosis.

Case Reports: osteosarcoma of the hand: one case and a literature review

Osteosarcoma of the hand is rare. We present a case report and a literature review that indicates an older median age of onset than conventional osteosarcoma. The predilection for these lesions to manifest in the metacarpophalangeal joints, particularly in the second and third digits, is in contrast to the more symmetrical distribution of metastatic cancer and correlates with the sites of most active growth during development of conventional osteosarcoma.

Osteosarcoma of the hand and forearm: experience of the Cooperative Osteosarcoma Study Group

BACKGROUND

Osteosarcoma is extremely rare in the hand and forearm. Therefore, only limited data are available for planning treatment or predicting the outcome and prognosis of osteosarcoma in the peripheral upper extremity.

METHODS

Epidemiological, clinical, and histopathologic data were analyzed in 39 patients with osteosarcoma of the forearm or hand who were enrolled in studies of the Cooperative German-Austrian-Swiss Osteosarcoma Study Group from 1977 to December 2000. In patients with high-grade osteosarcoma, the treatment entailed surgical resection in combination with chemotherapy, whereas patients with low-grade osteosarcoma underwent only surgery.

RESULTS

The 5-year overall survival rate among the 33 patients with high-grade central osteosarcoma of the distal upper extremity was 86.2% +/- 6.4%. The 5-year event-free survival rate was 65.4% +/- 9.6%. Five of the eight patients with secondary metastases were in remission at the time of analysis. Four patients died of their disease, and two patients died of chemotherapy-related complications. The mean overall survival rate was 88.0% +/- 6.5% in patients treated by wide or radical tumor resection and was 75.0% +/- 21.7% in patients with nonwide margins of resection. Whether amputation or local resection was performed had no significant influence on the prognosis. All six patients whose osteosarcoma was not classified as high-grade central osteosarcoma were in remission at the time of analysis.

CONCLUSIONS

The results demonstrate a remarkably high survival rate for patients with high-grade osteosarcoma of the hand and forearm and confirm that multiagent chemotherapy in combination with wide excision is a highly effective treatment for this malignant tumor.

Primary osteogenic sarcoma of a finger proximal phalanx: a case report and literature review

Osteogenic sarcoma of the small bones of the hand is rare with only 15 cases documented. We describe a 12-year-old boy with an osteogenic sarcoma of the proximal phalanx of the middle finger. Wide excision in the form of ray amputation with a wide surgical margin was performed after neoadjuvant chemotherapy consisting of combined high-dose methotrexate, doxorubicin, ifosfamide, and cisplatin. To restore maximum function the index ray was transferred to the base of the third metacarpal. Adjuvant chemotherapy was administered subsequently. At 28-month follow-up evaluation there was no evidence of local recurrence of disease or distant metastasis and both function and appearance were good.

Primary osteosarcoma of metatarsal bone

Primary osteosarcomas of the short tubular bones of hands and feet are rare. We describe a 46-year-old woman with osteosarcoma of the left metatarsal bone with pulmonary metastases. This is the first reported case of osteosarcoma at this site.

Anaplastic osteosarcoma with abundant eosinophilic cytoplasm and minimal osteoid production

A case of osteosarcoma with unusual microscopic features, occurring in the right proximal tibial metaphysis of a 12-year-old boy is reported. Radiographically, the tumor was ill-defined and purely osteolytic. On gross examination, the tumor was soft, fragile, spongy and red to brown in color. Microscopically, the tumor consisted of pleomorphic cells possessing abundant eosinophilic cytoplasm, including cells larger than 100 microm in diameter. The cells were arranged in a sheet, with few extracellular collagen fibers. Multiple sectioning of the specimens revealed a small amount of osteoid production. Immunohistochemical study revealed a positive reaction for vimentin and osteocalcin. Electron microscopic study suggested the fibroblastic or osteoblastic origin of the cells.

h-Caldesmon as a specific marker for smooth muscle tumors. Comparison with other smooth muscle markers in bone tumors

Caldesmon is a protein widely distributed in smooth and non-smooth muscle cells and is thought to regulate cellular contraction. Its isoform, high-molecular-weight caldesmon (h-CD), was demonstrated to be specific for smooth muscle cells and smooth muscle tumors of the soft tissue and to never be expressed in myofibroblasts. We performed an immunohistochemical study to examine h-CD expression in the following bone tumors: conventional and non-conventional osteosarcoma, 13; malignant fibrous histiocytoma of bone, 5; giant cell tumors of bone, 5; chondroblastoma, 3; metastatic leiomyosarcoma, 2; and rhabdomyosarcoma, 1. Frequent immunoreactivity for muscle actin (alpha-smooth muscle actin or muscle-specific actin) was seen in 11 of 13 osteosarcomas and all other tumors, whereas h-CD was expressed intensely only in 2 leiomyosarcomas. h-CD is considered a specific and useful marker to distinguish smooth muscle tumor from bone tumors with myoid differentiation.

Well-differentiated intraosseous osteosarcoma of the jaws: experience of two cases from the Instituto Nacional de Cancerología, México

Osteosarcomas of the jaws represent less than 10% of all osteosarcomas, and most of them are high-grade neoplasms. Prognostic factors in overall survival include tumor size, location and histologic grade. Examples of well-differentiated (low-grade) intraosseous osteosarcomas of the jaws (WDIOJ) have been rarely reported. This article presents two cases of this unusual lesion, one of which was located in the maxilla of a 17-year-old man and the other developed in the mandible of a 37-year-old woman. CT scan was necessary to detect the small foci of penetration into the thinned cortical bone and the reactive periosteal bone formation, which are important findings to establish the correct diagnosis of WDIOJ and help to exclude other benign intraosseous lesions that may be very similar histologically, such as fibrous dysplasia, ossifying and desmoplastic fibromas. In spite of tumor size (mean 5.2 cm), their well-demarcated borders allowed complete removal of both tumors. There is no evidence of tumoral activity in any of our patients after follow-up periods of 15 months and 5 years. Wide excision seems to be the treatment of choice for this subgroup of osteosarcomas.