Intracranial osteosarcomas: report of four cases and review of the literature

Primary and radiation induced skull base osteosarcoma: a systematic review of clinical features and treatment outcomes

PURPOSE

We aim to systematically review and summarize the demographics, clinical features, management strategies, and clinical outcomes of primary and radiation-induced skull-base osteosarcoma (SBO).

METHODS

PubMed, Scopus, and Cochrane databases were used to identify relevant articles. Papers including SBO cases and sufficient clinical outcome data were included. A comprehensive clinical characteristic review and survival analysis were also conducted.

RESULTS

Forty-one studies describing 67 patients were included. The median age was 31 years (male = 59.7%). The middle skull-base was most commonly involved (52.7%), followed by anterior (34.5%) and posterior (12.7%) skull-base. Headache (27%), exophthalmos (18%), and diplopia (10%) were common presenting symptoms. Sixty-eight percent of patients had primary SBO, while 25% had radiation-induced SBO. Surgery was the main treatment modality in 89% of cases. Chemotherapy was administered in 65.7% and radiotherapy in 50%. Median progression-free survival (PFS) was 12 months, and the overall 5-year survival was 22%. The five-year survival rates of radiation-induced SBO and primary SBO were 39% and 16%, respectively (P < 0.05).

CONCLUSION

SBO is a malignant disease with poor survival outcomes. Surgical resection is the primary management modality, in conjunction with chemotherapy and radiotherapy. Radiation-induced SBO has a superior survival outcome as compared to its primary counterpart. Complete surgical resection showed a statistically insignificant survival benefit as compared to partial resection.

Sarcomas of the sellar region: a systematic review

PURPOSE AND METHODS

Sarcomas of the sellar region are uncommon and unexpected tumors. Here, we review the cases reported in literature via a systematic search.

RESULTS

Ninety-four patients, 58.5% male with mean age of 39.2 ± 17.2 years were included. Fifty-seven (62%) had soft tissue sarcomas (STS) and 35 (38%) bone sarcomas (BS). Sarcoma was a primary tumor in 66%, developed after radiotherapy in 31.9% and 7.4% were metastatic. Median time between radiotherapy and sarcoma development was 10.5 (11) years. Main presentation symptoms were visual disorders (87.9%), headache (61.5%) and III cranial nerve palsy (24.1%). After surgery, sarcoma persisted or recurred in 82.3% and overall mortality reported was 44.6% with 6.5 (14) months of median survival. Tumor appeared earlier in BS compared to STS (34.4 ± 15.1 vs. 42.6 ± 17.6 years), p = 0.034 and complete tumor resection was achieved more often (41.3% vs. 4.4%), p =  < 0.001. Condrosarcoma and rhabdomyosarcoma were more frequent subtypes among primary tumors while fibrosarcoma was among post-radiation sarcomas. Tumor size was larger in radiation associated sarcomas (mean maximum diameter 46.3 ± 9.3 vs. 29.1 ± 8.0 mm, p = 0.004) and persistency/recurrence was similar in both groups (70.1 vs. 73.3%, p = 0.259).

CONCLUSION

Sarcomas appear as mass effect symptoms in the middle aged population, mainly as primary tumors, but one third is associated with radiotherapy. Surgery is commonly not curative, mortality rate is high and death ensues shortly after diagnosis.

Primary osteogenic sarcoma of the skull: Report of two cases with review of literature

Primary calvarial (excluding jaw) osteosarcoma is rare. We report two cases highlighting their unusual presentation and histopathologic variability – a 30-year-old female who presented with progressively increasing headache and a rapidly growing frontal swelling and a 16-year-old girl who had a rapidly growing mass in the left frontoparietal region which had recurred thrice but was otherwise asymptomatic. The lesions were osteolytic on neuroimaging and histopathological examination confirmed osteosarcoma. These two unusual cases are discussed along with a brief review of literature.

Treatment and survival of osteosarcoma and Ewing sarcoma of the skull: a SEER database analysis

Background

Common primary bone tumors include osteosarcomas (OSC) and Ewing sarcomas (EWS). The skull is a rare site, and literature about their treatment and survival is scarce. Using the Surveillance, Epidemiology, and End Results (SEER) database, this study aims to assess the treatment and survival of skull OSC and skull EWS, as well as predictors for survival.

Methods

Skull OSC and EWS cases were obtained from the SEER database. Patient and tumor characteristics, treatment modalities, and survival were extracted. Overall survival (OS) was assessed using multivariable Cox proportional hazard regression stratified by tumor histology. Kaplan-Meier curves were constructed for OS comparing OSC and EWS, as well as histological subtypes in OSC.

Results

A total of 321 skull OSC and 80 skull EWS patients were registered from 1973 to 2013. EWS was more common in younger patients (p < 0.001). Resection was the predominant treatment strategy (80.1%), frequently in combination with adjuvant radiotherapy (30.4%). The 5-year survival rate varied significantly between OSC and EWS (51.0% versus 68.5%, p = 0.02). Kaplan-Meier curves show that EWS had a significantly better survival compared to OSC. Comparing histological subtypes of skull OSC, chondroblastic OSC had the best OS, Paget OSC the worst. Older age, tumor advancement, no surgical treatment, and the use of radiotherapy were identified as independent predictors of decreased OS in skull OSC.

Conclusion

Overall prognosis is better for EWS compared to OSC. Chondroblastic OSC have the best overall survival, while OSC associated with Paget’s disease of the bone has the poorest overall survival.

Central nervous system metastasis from osteosarcoma: Case report and literature review

Osteosarcoma is the most common primary malignancy of bone in children and young adults, the highest incidence peak is during adolescence and doesn't have any gender predominance. The main site of metastasis are the lungs and extrapulmonary cases are occasional. The incidence of metastasis in the Central Nervous System (CNS) is 2-6.5%, increase to 10-15% in patients with pulmonary metastases. Therefore, metastatic disease of the CNS is rare and the information on such patients is limited. Here, we describe a case of a 20-year old patient diagnosed with osteosarcoma in the left distal femur stage IIB, he developed pulmonary disease, during palliative chemotherapy experienced relapse to the brain classified as recursive partitioning analysis (RPA) class II, and was treated with external radiotherapy (30 Gy in 10 fractions) and later he had a poor evolution and died.

Primary osteosarcoma of frontal bone: A case report and review of literature

RATIONALE

Primary osteosarcomas of the skull and skull base are rare, comprising <2% of all skull tumors. Primary osteosarcomas of the skull are aggressive neoplasms composed of spindle cells producing osteoid which have poor outcome.

PATIENT CONCERNS

A 33-year-old woman was admitted to our hospital with a major complaint of a growing mass on her left frontal region of the skull for 10 months. Prior to the accurate diagnosis, the mass on her skull was considered to be eosinophilic granuloma.

DIAGNOSES

Computerized tomogram (CT) scan of skull revealed a lytic lesion causing destruction of left frontal bone with surrounding soft tissue mass. The histological examination of the lesion showed typical features of osteosarcoma.

INTERVENTIONS

The patient received 3 surgeries and adjuvant chemotherapy and radiotherapy for the frontal bone lesion.

OUTCOMES

At the last follow-up, after 4 years, the patient was free of disease both clinically and on imaging by magnetic resonance imaging (MRI) scan after 4 years.

LESSONS

Because osteosarcoma of skull is a rare disease, the early recognition and correct diagnosis are very important for a better prognosis. It is therefore imperative that clinicians recognize osteosarcoma early to make an accurate diagnosis and complete surgical resection followed by combined chemo-radiation is proved to be one of the most optimal treatment regimens.

Primary intraventricular osteosarcoma in a 3-year-old boy: report of a case and review of literature

INTRODUCTION

Extraskeletal osteosarcoma (ExOS) is a rare and well-known entity. Three to 4% of ExOSs occur in the head and neck region but anecdotally in the central nervous system (CNS). Primary intracranial osteosarcoma (PIOS) can originate from the skull, brain parenchyma, or meninges.

CASE PRESENTATION

A 3-year-old boy with history of head trauma 2 weeks before admission is presented harboring an ExOS in the left temporoparietal region. He was operated with the impression of intraventricular meningioma but turned to be a PIOS without any sources in his skeleton. Tumor recurred after 5 months and patient died in 2 weeks with tumor seeding to the brain stem.

CONCLUSION

This case is reported to show failure of surgery as the only treatment for these tumors, highlighting the need for more aggressive treatment.

Calcified Middle Cranial Fossa Mass

A 21-year-old male presented for evaluation of transient loss of consciousness and was found to have a hyperdense mass in the left middle fossa. He underwent craniotomy for tumor resection. Intra- and extradural invasion was noted. Gross total resection was achieved. Pathology demonstrated a densely cellular neoplasm with predominately spindle cell morphology in a collagen-containing stroma, areas of vascular proliferation, focal mineralization, and regions of cartilage formation. High mitotic index and regions of necrosis were seen. Based on the final diagnosis of osteosarcoma, the patient was referred for chemotherapy and radiation. Intracranial osteosarcoma is a nonmeningiomatous mesenchymal tumor. Most osteosarcomas are meningeal-based and supratentorial. Presentation depends on tumor location and may include focal neurologic deficits, cranial neuropathy, seizures, or symptoms of increased intracranial pressure. Given the relative rarity of intracranial osteosarcoma, there are no established guidelines for treatment, and therapy is guided by experience with systemic osteosarcoma. Gross total resection is recommended whenever feasible. Both chemotherapy and radiation therapy are used as adjuvant therapy. Regardless of treatment, osteosarcoma remains a highly aggressive malignancy with a poor prognosis. Morbidity and mortality may be the result of local recurrence or development of pulmonary or skeletal metastasis.

Primary intracerebral osteosarcoma: a rare case report and review

Background

Primary intracranial osteosarcoma is a extremely rare disease entity. We describe a case of primary intracerebral osteosarcoma in an adult brain.

Case description

A patient who presented with a 1-week history of headaches, and MRI examination was performed. The immunohistochemical diagnosis confirmed primary intracerebral osteosarcoma. The patient was treated with a surgical resection of the tumor.

Conclusion

Primary osteosarcomas occurring in the brain are extremely rare. The MRI images did not provide a specific pretreatment diagnosis, and the histopathology was the mainstay in establishing the diagnosis.

[Cerebral primitive osteosarcoma, a radiological and histological atypia]

INTRODUCTION

Osteosarcoma is a malignant mesenchymal tumor including cells that present an osteoblastic differentiation. On the skull, it has often extra-axial development associated with bone reaction. We report an atypical and rare case of intracranial or cerebral osteosarcoma underline the radiological and pathological diagnostic difficulties.

CASE REPORT

Our case concerns a primary osteosarcoma without bone involvement in a 10-year old boy who was admitted for intracranial hypertension with progressive worsening and brachial monoparesis. Subtotal resection was performed but the postoperative course was not favorable. The child died five months after the initial surgery. Its radiological aspect prompted us evoke several diagnoses including glioma or meningioma. On the histological level, osteosarcoma, especially with poorly differentiated cells, can be deceiving with other processes, including a gliosarcoma that was revealed by simple microscopic reading before being confirmed by an immunohistochemical study.

CONCLUSION

In the absence of any bone reaction or known extra-cranial location, it can be difficult to suggest the diagnosis of osteosarcoma based on imagery alone. Immunohistochemistry is essential for an accurate diagnosis.

Primary Bone Tumors of the Skull: Spectrum of 125 Cases, with Review of Literature

AIMS

Primary skull bone tumors, benign or malignant, are rare, and include a vast repertoire of lesions. These tumors are not reported systematically in the literature, with most studies being on individual entities or as single case reports.

METHODS

Primary bone tumors diagnosed over a period of 12 years were retrieved, histological diagnoses reviewed, and clinical parameters noted.

RESULTS

We identified 125 primary skull bone tumors. The mean age at diagnosis was 32 years (range: 2-65 years). Majority of patients were adults (82.4%); male preponderance was noted (72.8%). Malignant tumors were more frequent than benign tumors. Most common malignant tumor was chordoma (n = 37), while most common benign tumor was osteoma (n = 7). Tumors were most frequently located at the skull base, of which clivus was most common location. Chordomas accounted for majority of clival tumors, while chondrosarcoma predominated at other skull base locations. Benign tumors were extremely rare in skull base. Tumors of the vault bones were infrequent; with chondrosarcoma and osteoma being the most common malignant and benign tumors, respectively.

CONCLUSIONS

This is the largest series of primary skull bone tumors from India. Documentation of such a series will aid in approaching differential diagnosis of skull tumors in a systematic manner.

Osteosarcoma of the cranial vault and skull base in pediatric patients

Cranial osteosarcoma is very rare in children, rendering the development of optimal treatment algorithms challenging. The authors present 3 cases of pediatric cranial osteosarcoma: a primary calvarial tumor, a cranial metastasis, and a primary osteosarcoma of the cranial base. A review of the literature demonstrates significant variation in the management of cranial osteosarcomas and the outcome for patients with these tumors. This series and literature review is presented to improve the understanding of pediatric cranial osteosarcoma and to reinforce the importance of maximal resection in optimizing outcome.

Primary undifferentiated spindle-cell sarcoma of sella turcica: successful treatment with adjuvant temozolomide

Sellar tumours in adults are most commonly pituitary adenomas. Primary spindle cell sarcoma of the sella turcica without a prior history of cranial radiation is extremely rare. We report a case of a large sellar mass with suprasellar and cavernous sinus extension in a geriatric male patient who presented with complete left oculomotor nerve palsy and panhypopituitarism. The patient underwent partial resection of the sellar mass through transcranial route. The pathology of the mass revealed a poorly differentiated spindle cell neoplasm most consistent with a sarcoma. Postoperatively, the size of the residual sellar mass decreased significantly following six cycles of external beam radiation in conjunction with temozolomide.

Undifferentiated sarcoma of the sellar region

Malignancies lacking specific features of cellular maturation are termed "undifferentiated" and represent 5-10% of all human tumors. They are encountered at a variety of sites but do not, as a rule, arise in the sellar region. A 39-year-old male with a history of testicular seminoma and an unsuccessful biopsy of a third ventricular neoplasm, presented with visual disturbances and memory loss. Light microscopically, the tumor consisted entirely of undifferentiated spindle cells. No germ cell component was noted. An exhaustive immunohistochemical study found immunoreactivity for vimentin and desmin, but for no other myoid markers. Polymerase chain reaction showed no X;18 translocation. Based upon these studies, a diagnosis of "undifferentiated sarcoma" was made. Our case, being highly unusual among reported sellar neoplasms, underscores the difficulties inherent in the differential diagnosis of undifferentiated neoplasms.

Multiple malignancies in a child with de novo TP53 mutation

The authors present the case of an 8.5-year-old boy diagnosed with embryonal rhabdomyosarcoma of the infratemporal fossa at 21 months old. Five years later he developed an osteosarcoma of the tibia, for which he was treated with standard chemotherapy and resection. Soon after completing this treatment, ptosis of the right eye developed. A mass in the cavernous sinus was found, interpreted as an osteogenic metastatsis, although a third primary tumor could not be ruled out. Molecular genetic investigation revealed a de novo germline TP53 mutation, and heralded an aggressive clinical progression of multiple malignancies in a child.

A 57-year-old female with a cerebellar mass

A 57-year-old female presented with recurrent episodes of nausea and vomit, as well as instability during walking. The patient had a history of uterine leiomyosarcoma, for which she underwent a hysterectomy and oophorectomy 8 months ago. CT scan revealed a calcified mass that was located in the left cerebellar hemisphere which was resected. Histologically, multiple tissue fragments displayed infiltration of cerebellar tissue by polymorphic spindle-shaped cells. The Ki-67 proliferation index was approximately 20%. The morphological and immunohistochemical data, in association with the past clinical history, were consistent with cerebellar metastasis of uterine leiomyosarcoma. Although adjuvant radiotherapy was introduced, the patient died of cardiopulmonary arrest 6 weeks after the surgical procedure. The present case adds to the body of literature being the second report of uterine leiomyosarcoma metastatic to the cerebellum.

Radiation-induced meningeal osteosarcoma of tentorium cerebelli with intradural spinal metastases

BACKGROUND

Primary meningeal osteosarcomas and radiation-induced extraosseous tumors are extremely rare. We encountered a patient with a radiation-induced meningeal osteosarcoma with metastatic spread.

CASE DESCRIPTION

A 54-year-old man presented with a 2-week history of nausea, vomiting, and ataxia. CT and MRI studies revealed an extra-axial, dural-based mass in the posterior fossa arising from the tentorium cerebelli. The patient underwent complete resection of the tumor with adjuvant chemotherapy. Histopathologic analysis revealed chondroblastic osteosarcoma. Tumor recurrence was observed 9 months after initial diagnosis, and adjuvant radiation therapy was administered. The intracranial disease stabilized; however, multiple cervico-thoracic spinal metastases were discovered 15 months after initial diagnosis. The patient expired 16 months after initial diagnosis.

CONCLUSION

Meningeal osteosarcomas are rare lesions that can metastasize and should be considered in the differential diagnosis for dural-based lesions, especially in the case of previous radiation therapy.

Osteosarcoma presenting as hemorrhagic cerebellar metastasis

PURPOSE

Osteosarcoma is the most common malignant bone tumor in children and adolescents. Brain metastasis from osteosarcoma was once uncommon; however, with the advent of chemotherapeutic agents and improved imaging modalities, it has become a more common and recognized finding. Brain metastases are, rarely, the initial presenting symptom, but instead are a late and preterminal event in the disease process. When osteosarcomas manifest in the central nervous system, they tend to occur in the gray-white junction in the anterior circulation akin to other metastatic lesions in the brain.

CASE REPORT

The authors report a case of a 16-year-old boy who presented with acute neurological deterioration due to a posterior fossa hemorrhage and was subsequently found to have a primary site localizing to the metaphysis of the right femur with florid metastatic disease.

CONCLUSIONS

This is the first case reported in the literature in which an osteosarcoma initially presented as cerebral metastasis in the form of a posterior fossa hemorrhage with a rapidly deteriorating course.

Synovial sarcoma of the sellar region

Primary sarcomas of the sellar region are uncommon, although a wide variety have been reported. To date, no cases of primary synovial sarcoma have been described as occurring at this site. We report an immunohistochemically and molecular genetically confirmed primary synovial sarcoma involving the sellar/parasellar region and cavernous sinus in an adult male. Subtotal resection and radiosurgery proved to be efficacious. The spectrum of primary sellar region sarcomas is summarized.

Low-grade central osteosarcoma of the skull

A case of low-grade central osteosarcoma of the skull in a 36-year-old male is described. A 10cm mass of the left temporo-occipital bone, which was incidentally found 6 years previously on the occasion of a head trauma, was osteolytic and osteoplastic, affecting soft tissues and the subdural space. The patient was treated with intralesional curettage. Histologically, the tumor was characterized by spindle cell proliferation with woven and lamellar bone formation, resembling fibrous dysplasia, parosteal osteosarcoma, low-grade fibrosarcoma, or desmoplastic fibroma. The spindle cells were fairly uniform with mild atypia and low-mitotic activity (3 per 50 high power fields), and cellularity varied from low to high. Clinicians and pathologists should be aware of this type of low-grade osteosarcoma of the skull and distinguish it from its mimics, including fibrous dysplasia, parosteal osteosarcoma, and low-grade fibrosarcoma. Careful microscopic correlation with radiographic findings is the clue to the correct diagnosis.

Osteosarcoma arising from the skull--case report

A 20-year-old male presented with an osteosarcoma in the right parieto-occipital bone occurring as a painless occipital lump which had rapidly enlarged in the 6 months prior to admission. The neuroimaging appearance resembled intraosseous meningioma. Gross total resection of the tumor was achieved. The final histological diagnosis was osteosarcoma. Osteosarcomas of craniofacial region have a better prognosis than those of the skeletal bones, and distant metastasis is rare. Local recurrence is the most significant factor contributing to poor outcome. Complete excision with negative margins is the key to a better outcome. Adjuvant therapy may be an option in cases of incomplete excision. Advances in target chemotherapy may diminish the significant morbidity associated with these lesions.