Bone sarcomas in Paget disease

Imaging of Paget's Disease of Bone

Paget's disease is a metabolic bone disorder affecting the elderly and characterized by bone resorption followed by compensatory bone formation. Radiography is the imaging modality of choice for the diagnosis whereas bone scintigraphy helps stage the extent of the disease and assess response to treatment. MRI and CT are important imaging methods in the assessment of complications and surgical planning. Osteolytic lesions of Paget's first phase present with well-defined margins on radiographs, most commonly in the femur, pelvis, and skull. Cortical thickening, trabecular coarsening, bone marrow sclerosis, and deformities of long bones are present in the mixed- and late-sclerotic phases.

An update on imaging of Paget's sarcoma

Paget's sarcoma is a rare and particularly aggressive tumour arising within pagetic bone, affecting approximately 1% of patients with Paget's disease during the course of their disease. Most of these tumours are osteosarcomas, but the age profile, skeletal distribution and clinical outcomes differ considerably from conventional osteosarcoma. In this review, we outline the clinical, radiographic/CT, scintigraphic and magnetic resonance imaging features of Paget's sarcoma. We also review the neoplastic and non-neoplastic mimics of Paget's sarcoma that should be considered in the differential diagnosis when encountering an aggressive lesion within pagetic bone.

Hypercalcemia in a patient with a bowing femur

Hypercalcemia in PDB is rare; its occurrence requires thorough investigations as it may reveal several diseases, such as primary hyperparathyroidism, malignant transformation, metastases, or myeloma.

TP53 in bone and soft tissue sarcomas

Genomic and functional study of existing and emerging sarcoma targets, such as fusion proteins, chromosomal aberrations, reduced tumor suppressor activity, and oncogenic drivers, is broadening our understanding of sarcomagenesis. Among these mechanisms, the tumor suppressor p53 (TP53) plays significant roles in the suppression of bone and soft tissue sarcoma progression. Although mutations in TP53 were thought to be relatively low in sarcomas, modern techniques including whole-genome sequencing have recently illuminated unappreciated alterations in TP53 in osteosarcoma. In addition, oncogenic gain-of-function activities of missense mutant p53 (mutp53) have been reported in sarcomas. Moreover, new targeting strategies for TP53 have been discovered: restoration of wild-type p53 (wtp53) activity through inhibition of TP53 negative regulators, reactivation of the wtp53 activity from mutp53, depletion of mutp53, and targeting of vulnerabilities in cells with TP53 deletions or mutations. These discoveries enable development of novel therapeutic strategies for therapy-resistant sarcomas. We have outlined nine bone and soft tissue sarcomas for which TP53 plays a crucial tumor suppressive role. These include osteosarcoma, Ewing sarcoma, chondrosarcoma, rhabdomyosarcoma (RMS), leiomyosarcoma (LMS), synovial sarcoma, liposarcoma (LPS), angiosarcoma, and undifferentiated pleomorphic sarcoma (UPS).

Disappearing hemipelvis: Low grade osteosarcoma, an unusual and poorly described variant of Paget's Sarcoma

Paget's sarcomatous transformation is a rare and potentially fatal complication of Paget's disease. Histologically, it is typically described as a high-grade and extremely aggressive malignancy. We present an unusual radiographic series from a patient diagnosed with a low-grade Paget's osteosarcoma, a very rare and poorly described variant of the disease.

Comparative Aspects of Osteosarcoma Pathogenesis in Humans and Dogs

Osteosarcoma (OS) is a primary and aggressive bone sarcoma affecting the skeleton of two principal species, human beings and canines. The biologic behavior of OS is conserved between people and dogs, and evidence suggests that fundamental discoveries in OS biology can be facilitated through detailed and comparative studies. In particular, the relative genetic homogeneity associated with specific dog breeds can provide opportunities to facilitate the discovery of key genetic drivers involved in OS pathogenesis, which, to-date, remain elusive. In this review, known causative factors that predispose to the development OS in human beings and dogs are summarized in detail. Based upon the commonalities shared in OS pathogenesis, it is likely that foundational discoveries in one species will be translationally relevant to the other and emphasizes the unique opportunities that might be gained through comparative scientific approaches.

Pathological femoral fracture caused by primary bone tumour: a population-based study

This population-based study aimed to analyse the demographic, clinical and histological features of patients with a malignant primary bone tumour of the femur presenting with a pathological fracture. Eighty-four patients were identified from a prospectively gathered national tumour database between 1960 and 2004. Demographic data, presenting features, tumour location, histological diagnosis, treatment, local recurrence, metastasis and survival data were gathered. An estimate of the annual incidence was obtained using population data from the General Register Office and was 0.4 per million population per annum. The mean age was 56 years (range 4-87 years) with a bimodal distribution and 46% were men or boys. Forty-one percent of patients presented with a history of trauma. The average duration of symptoms before presentation was 1-3 months. The most common histological diagnoses were osteosarcoma (14 patients) and Paget's sarcoma (12 patients). The local recurrence rate was 38% and the overall five-year survival was 22%. The prognosis was made worse by local tumour recurrence, the development of metastasis and age at diagnosis greater than 21 years. Limb salvage surgery did not alter the prognosis. Patients who present with pathological fracture of a primary malignant bone tumour, carry a poor prognosis in all tumour types and no improvement in survival was identified over the period of the study.

Paget's Osteosarcoma - no Cure in Sight

Purpose Paget' s osteosarcoma has a fearful reputation with a quoted survival of at best 5% at 5 years.We therefore reviewed our experience of 26 patients treated over the last 25 years using modern staging and limb salvage techniques to see if there had been any improvement in survival.

Subjects: We identified 26 patients on the Royal Orthopaedic Hospital Oncological database with a diagnosis of sarcoma secondary to Paget's disease.

Results: The survival rate was 53% at 1 year, 25% at 2 years and no patient survived for 5 years.The median survival was 21 months for those treated with curative intent and 7 months for those treated palliatively. Four of the five patients treated with limb-sparing surgery developed local recurrence between 5 and 12 months, the fifth died at 14 months.There was no difference in survival between amputation and limb salvage.

Discussion: The development of sarcomatous change in Paget's disease is well recognised. It represents an important segment of primary bone tumours in patients over 40 years of age.The prognosis is appalling. Indeed only 15 of 368 cases (4%) from a number of historical series have survived more than 5 years. Our results are similarly disappointing with no survivors at 5 years despite modern methods of management of bone tumours.While there is no difference in local recurrence rates or survival between limb reconstruction and limb ablation the poor prognosis for both means that neither can be recommended at present. Sarcomatous change in Pagetoid bone should therefore be regarded as a different disease to primary osteosarcoma. It remains an incurable disease with a poor prognosis.

Genetic variation in the TNFRSF11A gene encoding RANK is associated with susceptibility to Paget's disease of bone

RANK (receptor activator of nuclear factor-κB), encoded by TNFRSF11A, is a key protein in osteoclastogenesis. TNFRSF11A mutations cause Paget's disease of bone (PDB)-like diseases (ie, familial expansile osteolysis, expansile skeletal hyperphosphatasia, and early-onset PDB) and an osteoclast-poor form of osteopetrosis. However, no TNFRSF11A mutations have been found in classic PDB, neither in familial nor in isolated cases. To investigate the possible relationship between TNFRSF11A polymorphisms and sporadic PDB, we conducted an association study including 32 single-nucleotide polymorphisms (SNPs) in 196 Belgian sporadic PDB patients and 212 control individuals. Thirteen SNPs and 3 multimarker tests (MMTs) turned out to have a p value of between .036 and 3.17 × 10(-4) , with the major effect coming from females. Moreover, 6 SNPs and 1 MMT withstood the Bonferroni correction (p < .002). Replication studies were performed for 2 nonsynonymous SNPs (rs35211496 and rs1805034) in a Dutch and a British cohort. Interestingly, both SNPs resulted in p values ranging from .013 to 8.38 × 10(-5) in both populations. Meta-analysis over three populations resulted in p = .002 for rs35211496 and p = 1.27 × 10(-8) for rs1805034, again mainly coming from the female subgroups. In an attempt to identify the underlying causative SNP, we performed functional studies for the coding SNPs as well as resequencing efforts of a 31-kb region harboring a risk haplotype within the Belgian females. However, neither approach resulted in significant evidence for the causality of any of the tested genetic variants. Therefore, further studies are needed to identify the real cause of the increased risk to develop PDB shown to be present within TNFRSF11A.

The role of surgery and adjuvants to survival in Pagetic osteosarcoma

BACKGROUND

Osteosarcoma is a rare complication of Paget's disease with a very poor prognosis. Treatment is controversial: the older age of the patients affected by Paget's disease may limit the use of chemotherapy and axial involvement may limit the practicality of surgery.

QUESTIONS/PURPOSES

The purposes of this study are (1) to report the survival in patients treated for osteosarcoma in Paget's disease; (2) to identify correlations between type of treatment and survival comparing our data with those in the literature; (3) to determine if the extent of Paget's disease and risk of malignant transformation are associated; (4) to assess if prognosis is related with site; and (5) to identify the variations of histologic subtypes of these osteosarcomas.

METHODS

We retrospectively reviewed the medical records of 26 patients treated between 1961 and 2006 who had bone sarcoma arising from a site of Paget's disease. Twenty two of the 26 patients had surgery. In six surgery only was performed; three had surgery, adjuvant chemotherapy, and radiotherapy; one surgery and radiotherapy; 12 underwent surgery and chemotherapy, adjuvant in 10 patients and neoadjuvant in two; two had only radiotherapy and two had only chemotherapy. We performed survival analyses between various combinations of treatment.

RESULTS

At last followup four patients had no evidence of disease (NED) at a minimum followup of 42.6 months (mean, 139 months; range, 42.6-257.4 months) and 22 died with disease (DWD) at a minimum time of 1 month (mean, 20.2 months; range, 1-84 months). One of the six patients (11%) treated with surgery only had NED at 10 years; the other five died from disease at a mean of 30 months. Three of 12 patients (25%) treated with surgery and chemotherapy are NED at a mean followup of 12 years; nine died of disease at a mean of 24 months. All patients treated without surgery died at a mean of 7.5 months (range, 1-13.7 months).

CONCLUSIONS

Despite improvements in surgery and medical treatments the prognosis remains poor in patients with Paget's sarcoma.

Advances in the identification of molecular markers for bone neoplasia

IMPORTANCE OF THE FIELD

Bone tumors represent a heterogeneous and poorly understood group of neoplasms affecting patients of all ages. This review is intended to highlight recent advances in the identification of diagnostically relevant molecular biomarkers.

AREAS COVERED IN THIS REVIEW

This review offers a summary of basic techniques in molecular pathology. In the case of primary bone tumors with diagnostically applicable molecular markers, an overview of the tumor is provided incorporating the germane background and advances in the identification of molecular markers.

WHAT THE READER WILL GAIN

The reader will gain an understanding of the techniques governing the discovery of biomarkers, and their applicability in diagnostic bone pathology.

TAKE HOME MESSAGE

Molecular analysis has identified key diagnostic biomarkers in only a small proportion of bone tumors. Many of these findings owe their existence to earlier karyotype-based cytogenetic studies. In cases where characteristic cytogenetic findings are absent, there remains a tremendous need to interrogate rigorously these lesions using emerging techniques such as whole genome sequencing. It is assumed that with a more precise understanding of the tumor genetic code, more accurate diagnostic, prognostic and therapeutic markers will emerge.

Somatic mutations in SQSTM1 detected in affected tissues from patients with sporadic Paget's disease of bone

Paget's disease of bone (PDB) is a focal disorder of bone remodeling that leads to overgrowth of affected bone, with rare progression to osteosarcoma. Extensive studies of familial PDB showed that a majority of cases harbor germline mutations in the Sequestosome1 gene (SQSTM1). In contrast, little is known about the mutational status of SQSTM1 in sporadic PDB. We hypothesized that somatic SQSTM1 mutations might occur in the affected tissues of sporadic PDB and pagetic osteosarcoma. We used laser capture microdissection to capture homogeneous populations of cells from the affected bone or tumor of patients with sporadic PDB or pagetic osteosarcoma, respectively. DNA from these samples and appropriate controls was used for sequence analysis and allelic discrimination analysis. Two of five patients with sporadic PDB had SQSTM1(C1215T) mutations detected in their affected bone but not in their blood samples, indicating a somatic origin of the mutations. Samples from three of five sporadic pagetic osteosarcoma patients had the SQSTM1(C1215T) mutation, whereas the normal adjacent tissue from two of these tumors clearly lacked the mutation, again indicating an occurrence of somatic events. No SQSTM1 mutations were found in primary adolescent osteosarcomas. The discovery of somatic SQSTM1 mutations in sporadic PDB and pagetic osteosarcoma shows a role for SQSTM1 in both sporadic and inherited PDB. The discovery of somatically acquired mutations in both the diseased bone and tumor samples suggests a paradigm shift in our understanding of this disease.

Osteogenic sarcoma (osteosarcoma) in the elderly: tumor delineation and predisposing conditions

Osteogenic sarcoma (OS), the most common primary bone cancer, is conventionally a primary intramedullary (conventional OS) high-grade malignant tumor characterized by malignant cells forming immature bone or osteoid. The age distribution data for primary bone sarcomas are bimodal. OS is largely a disease of the young but about one-third of OS occurs in patients over 40 years of age. Thus, though considered as rare occurrences, bone tumors occur also in the geriatric population. In this report, tumor delineation and the significance of predisposing conditions to the occurrence of OS are reviewed.

Degeneration of Paget's disease into sarcoma: clinical and therapeutic influencing factors

We analysed a series of 119 patients presenting with Paget's bone disease treated at the Istituto Ortopedico Rizzoli (Bologna Italy) over 35 years (from 1970 to 2006). Among these, we found 18 cases that had degenerated into sarcoma. The first goal of this study was to underline the potential factors of Paget's disease transformation into sarcoma. In detail we considered: age, gender, duration of disease, clinical expression, levels of total alkaline phosphatase and type of therapy. The results highlighted an interesting correlation between therapy and degeneration into sarcoma; more specifically, malignant transformation occurred both in patients who had not received any therapy and those who had received regular calcitonin treatment; otherwise, no sarcoma degeneration occurred in the patients treated with bisphosphonates. These data seem to indicate a preventing effect of bisphosphonates towards the degeneration of Paget's disease into sarcoma.

Giant cell tumor complicating Paget disease of long bone

Giant cell tumor (GCT) is a rare complication of Paget disease of bone. It usually occurs in the skull or pelvic bones of patients with long-standing polyostotic disease. This report describes a 62-year-old patient who presented with monostotic Paget disease of the distal femur complicated by GCT. He had a 2-year history of discomfort and pain in his left knee. Conventional plain films and MRI demonstrated the characteristic bone changes of Paget disease and an associated lytic lesion involving the epiphyseal and metaphyseal regions of the distal femur. A diagnostic curettage showed the characteristic histopathologic features of Paget disease and GCT. There was no evidence of malignancy. The clinicopathologic features of this rare lesion are described and correlated with a review of the literature.

Sarcomas arising in Paget disease of bone: a clinicopathologic analysis of 70 cases

CONTEXT

Sarcomatous transformation is a rare complication of Paget disease of bone. Prognosis in patients with other types of sarcomas arising in bone has improved in the last several decades because of therapeutic advances. However, because of the rarity of Paget sarcoma, outcome studies in these patients are limited.

OBJECTIVE

To determine whether prognosis for Paget sarcoma has improved.

DESIGN

Seventy cases of sarcomas arising in the setting of Paget disease were collected, and the histologic and clinical findings were reviewed. Clinical follow-up was obtained in 67 cases.

RESULTS

Sarcoma arising in Paget disease tended to arise in older men (46 men, 24 women; age range, 31-88 years; mean age, 66 years) and predominated in the axial skeleton (n = 37), especially in the pelvis. Thirty-three patients had a clinical history of Paget disease ranging in duration from 16 months to 30 years (mean, 15 years). No significant difference in incidence between monostotic (n = 33) and polyostotic (n = 36) disease was noted. Most tumors were osteosarcomas (88%). All tumors were high grade. Follow-up information was obtained in 67 of 70 cases (range of follow-up, 1-252 months). Survival ranged from 1 month to 20 years, with a 5-year survival rate of 10%.

CONCLUSIONS

Prognosis remains poor in patients with Paget sarcoma. There is no significant correlation between the number of bones involved with Paget disease or the duration of disease and development of Paget sarcoma. Poor prognosis in Paget sarcoma is unrelated to site or stage at presentation.

Neoadjuvant chemotherapy for osteosarcoma of the extremities in patients aged 41-60 years: outcome in 34 cases treated with adriamycin, cisplatinum and ifosfamide between 1984 and 1999

BACKGROUND

It is unclear whether adult patients with high-grade non-metastatic osteosarcoma of the extremities, treated with neoadjuvant chemotherapy according to protocols designed for adults, have a different outcome than younger patients treated with conventional protocols.

PATIENTS AND METHODS

From 1994 through 1999, we treated 34 patients with non-metastatic osteosarcoma of the extremities. These patients were aged mean 50 years (41-60), and received 4 cycles of multidrug chemotherapy (1 preoperatively and 3 postoperatively). Each cycle consisted of a combination of Cisplatin/Adriamycin, Ifosfamide/Cisplatinum and Ifosfamide/Adriamycin. 30 patients had limb salvage and 3 underwent amputation. During preoperative treatment, 1 died of toxicity. 16 patients had a good histological response to chemotherapy (> or = 90% tumor necrosis) and 17 had a poor response.

RESULTS AND INTERPRETATION

With a median follow-up of 8 (5-11) years, 19/33 patients remained continuously disease-free and 14 relapsed (10 with metastases, 3 with local recurrence and metastases, and 1 with local recurrence alone). After further treatments, 2/14 relapsed patients are alive and disease-free, 11 died of tumor, and 1 is alive with uncontrolled disease. 5-year event-free survival and overall survival were 56% and 70%, respectively. These results, which are similar to those of 296 patients under 40 years of age who were treated with conventional chemotherapy (5-year EFS 59% and 5-year OS 70%), indicate that neoadjuvant chemotherapy improves prognosis and also reduces amputations in patients aged over 40 with osteosarcoma of the extremities.

Osteosarcoma in Paget's disease of bone

Paget's disease of bone (PDB) is a focal disorder of bone metabolism first described by Sir James Paget in 1876. It is presumed benign in nature and mediated by abnormal osteoclast function. The incidence of osteosarcomas complicating PDB is estimated at <1%. These cancers occur mostly in persons with long-standing, polyostotic disease and affect patients in their seventh decade or when osteosarcoma is remarkably rare in the general population. Epidemiological studies suggest that this late peak of osteosarcomas is absent in regions where Paget's is infrequently reported. Whereas PDB has a predilection for the axial skeleton, skull, femurs, and tibias, pagetic osteosarcoma tend to spare the spine, and are reported more commonly in the pelvis, femur, humerus, and skull. A molecular basis for the association of osteosarcoma with Paget's disease is unclear. These osteosarcomas are osteogenic in origin, consistently arise in sites of pagetic bone, and may present as metachronous, multifocal lesions. On histopathology, the lesions are usually osteoblastic, and the tumor phenotype is sometimes characterized as an exaggerated, chaotic form of the accelerated bone remodeling that characterizes PDB. New insights from the biology of adolescent osteosarcomas, VCP and SQSTM1 mutations now defined in patients with Paget's disease, and emerging evidence that stromal lesions are present in patients with Paget's disease are changing the way we think about the pathogenesis of PDB and the rare complication of pagetic osteosarcomas.

Prevalence and clinical features of Paget's disease of bone in Japan

The present study aimed to evaluate the prevalence and clinical presentation of Paget's disease of bone (PDB) in Japan. As PDB is a very rare disease in Japan, a nationwide mail survey was conducted targeting doctors in the specialty most frequently diagnosing and treating PDB patients in Japan. First, the literature for all case reports in Japan published between January 1990 and December 2002 was reviewed to determine who was diagnosing and treating PDB in Japan. This literature review for all case reports in Japan revealed that 72.1% of cases in Japan were reported from departments of orthopedic surgery. A nationwide two-phase mail survey was conducted for the departments of orthopedic surgery of 2,320 general hospitals accredited by the Japanese Orthopaedic Association. Phase 1 involved determining how many patients with PDB were followed at each hospital. If the answer was one or more, phase 2 of the survey gathered information on the clinical presentation of current patients. The mail survey yielded a final response rate of 75.4% for phase 1 and 87.6% for phase 2. Phase 1 indicated that the prevalence of PDB in Japan is about 2.8 cases per million capita. Phase 2 revealed a slight female predominance, lower frequency of familial clustering, higher frequency of femoral fracture in the affected femur, and a higher ratio of symptomatic PDB in Japan compared with findings in countries displaying a higher prevalence of PDB. The present epidemiological study revealed that the disorder is extremely rare in Japanese individuals, and that some differences exist with regard to the clinical features of PDB between Japanese patients and patients from high-prevalence countries.

Subperiosteal ganglion associated with Paget's disease of bone

Tumoral lesions related to Paget's disease may be classified as malignant, benign or pseudotumoral. While sarcomatous degeneration is the most feared complication, awareness of benign and pseudotumoral lesions is essential for assisting in accurate histological interpretation of the biopsy sample, which may avoid unnecessary repeat biopsies. We present the first case of a juxta-articular subperiosteal ganglion associated with Paget's disease, with classic imaging characteristics, especially on CT examination. The well-defined soft tissue mass at the medial aspect of the obturator rim, adjacent to a small fracture in pagetic quadrilateral plate, showed an ossified rim and internal gas lucencies, these being the hallmarks of a juxta-articular subperiosteal ganglion. On MRI, the lesion was of intermediate signal intensity on T1-weighted sequences, increased signal intensity on T2-weighted sequences, with rim enhancement after gadolinium contrast injection and preservation of fatty marrow signal of the underlying pagetic bone. Identification of the entity avoided an unnecessary biopsy or surgical intervention.

Paget's sarcoma: limb salvage by custom mega prosthesis: four case reports

Of 4 Paget's sarcoma patients (age range, 55-68 years) underwent limb salvage surgery by custom mega prosthesis, 3 had lesions in the upper extremity and one in the proximal femur. Three of the patients were at stage IIB of the disease, according to Enneking's system of staging musculoskeletal tumours. All 4 patients underwent wide resection with a mean length of 152.5 mm. The defects were reconstructed with custom-made prostheses: proximal humeral prostheses in 2 of the patients, total elbow prosthesis in one, and total hip prosthesis in one. During a mean postoperative follow-up period of 40 months, one died of disseminated disease 14 months after surgery; one remained disease-free; 2 had local recurrence and required amputation, of whom one died of disseminated disease one year after amputation, the other had no further evidence of the disease. We report the functional outcomes of the 2 patients who were alive at the latest follow-up. The 2-year patient survival rate was 50%.

Neoplastic transformation and tumour-like lesions in Paget's disease of bone: a pictorial review

The development of a sarcoma is the most serious complication of Paget's disease of bone. Although its incidence is <1% of those with the underlying disease, it is important to recognise the imaging features of these tumours as Paget's disease of bone is relatively common in the ageing population in certain parts of the world. The purpose of this pictorial review is to present the imaging features of Paget's sarcoma based on one orthopaedic oncology centres experience in 49 patients; however, not all masses or destructive lesions arising in association with Paget's disease are sarcomas and not all the tumours are malignant. This review also includes other malignancies which may arise in pagetic bone as well as tumour-like manifestations of Paget's disease.

Osteosarcoma over the age of forty

The European Musculo Skeletal Oncology Society (EMSOS) has carried out a retrospective review of patients over the age of 40 years with osteosarcoma. 481 patients from 12 centres or multicentric groups were included. 42 patients had osteosarcoma arising in Paget's disease, median survival was 9 months. Patients with axial or metastatic tumours also did badly whilst 41 patients with radiation-induced osteosarcoma had a prognosis paralleling conventional osteosarcoma matched for patient age and site of the tumour. 238 patients had high grade non-metastatic osteosarcoma and had a survival of 46% at 5 years. Older patients had less chemotherapy and fared worse. Osteosarcoma in the elderly is a curable condition and warrants intensive treatment with chemotherapy and surgical resection.

Osteosarcoma arising in Paget's disease of the mandible

Although osteosarcoma is a well-known complication of Paget's disease of bone, it uncommonly develops in the jaw bones. We present an osteosarcoma arising in Paget's disease of the mandible with unique features of a normal serum alkaline phosphatase level, and histologic features of telangiectatic change in the osteosarcoma and association with cemento-osseous dysplasia. Sixteen reported cases of osteosarcoma arising in Paget's disease of the jaw bones (OPJ) are also reviewed and compared to osteosarcoma arising in Paget's disease occurring in the entire skeleton (OPS) and osteosarcoma arising de novo in the jaw bones (OJ). Females are more commonly involved in OPJ in contrast to a male predominance in OPS and OJ. OPJ also has a distinctively higher percentage involving blacks compared to OPS. The prognosis of OPJ is poor, with 69% of patients dying within two years after diagnosis. Early recognition, early and aggressive treatment are important to improve the prognosis and are hence emphasized.

From the archives of the AFIP. Radiologic spectrum of Paget disease of bone and its complications with pathologic correlation

Paget disease of bone is a common disorder affecting approximately 3%-4% of the population over 40 years of age. The pathologic abnormality in Paget disease is excessive and abnormal remodeling of bone. Three pathologic phases have been described: the lytic phase (incipient-active), in which osteoclasts predominate; the mixed phase (active), in which osteoblasts cause repair superimposed on the resorption; and the blastic phase (late-inactive) in which osteoblasts predominate. Radiographic appearance of Paget disease reflects these pathologic changes and is often characteristic. Initially, there is osteolysis, particularly affecting the skull (osteoporosis circumscripta) and subchondral long bones, with subsequent development of trabecular and cortical thickening and enlargement of bone in the mixed phase of the disease. Finally, areas of sclerosis may develop in the blastic phase. Frequent sites of involvement include the skull (25%-65% of cases), spine (30%-75%), pelvis (30%-75%), and proximal long bones (25%-30%). Bone scintigraphy typically demonstrates marked increased uptake of radionuclide in all phases of Paget disease. Computed tomography and magnetic resonance imaging often show changes similar to those seen radiographically in noncomplicated Paget disease with maintenance of yellow marrow. Complications of Paget disease include the effects of osseous weakening (deformity and fracture), arthritis, neurologic symptoms, and neoplastic involvement. Sarcomatous transformation is the most feared complication, occurring in approximately 1% of cases, and is seen on images as focal bone destruction extending through the cortex with an associated soft-tissue mass. Recognition of the radiologic spectrum of the appearances of Paget disease usually allows prospective diagnosis and differentiation of its associated complications, which helps guide therapy and improve patient management.

Incidence and natural history of Paget's disease of bone in England and Wales

This study used a large, primary care, record-linkage resource (the General Practice Research Database [GPRD]) to evaluate the incidence, clinical presentation, and natural history of Paget's disease of bone in England and Wales. Between 1988 and 1999, we identified 2465 patients with the recorded diagnosis of Paget's disease of bone, within the five million subjects > or = 18 years old who were registered in the GPRD. The validity of diagnostic recording was assessed by questionnaire to individual general practitioners (GPs) in 150 patients; the diagnosis was confirmed in 93.8% of responders. The mean age of patients with Paget's disease was 75 years and 51% were men. The prevalence of the disorder was 0.3% among men and women aged > or = 55 years; incidence rates for clinically diagnosed Paget's disease rose steeply with age (men, 5 per 10,000 person-years; women, 3 per 10,000 person-years at the age of 75 years). Over the 11-year period of the study, the age- and sex-adjusted incidence rate of clinically diagnosed Paget's disease declined from 1.1 per 10,000 person-years to 0.7 per 10,000 person-years. Each patient with Paget's disease was matched to three controls matched by age, gender, and general practice. Cases had a greater risk of back pain (relative risk [RR], 2.1; 95% CI, 1.9-2.3), osteoarthritis (OA; RR, 1.7; 95% CI, 1.5-1.9), hip arthroplasty (RR, 3.1; 95% CI, 2.4-4.1), knee arthroplasty (RR, 1.6; 95% CI, 1.0-2.6), fracture (RR, 1.2; 95% CI, 1.0-1.5), and hearing loss (RR, 1.6; 95% CI, 1.3-1.9). Seven patients with Paget's disease developed a malignant bone neoplasm (0.3%). Using life table methodology, the estimated number of people who died within 5 years of follow-up was 32.7% among the patients with Paget's disease and 28.0% among the control patients.

Inheritance of osteosarcoma and Paget's disease of bone: a familial loss of heterozygosity study

Pagetoid osteosarcoma is a complication of Paget's disease of bone. Sarcomatous transformation is most often seen in severe, long-standing Paget's disease. Familial clustering of Paget's disease has been described with apparent autosomal dominant inheritance with high penetrance by the sixth decade. Although definitive proof of the specific gene involved remains elusive, some researchers have shown loss of heterozygosity in a region of chromosome 18q in a relatively high percentage of studied patients affected with either Paget's disease alone, in Pagetoid osteosarcoma, and in uncomplicated osteosarcoma. Our patient was diagnosed with Pagetoid osteosarcoma and had a first-degree relative with history of the same. We hypothesized that our patient's tumor samples might contain a similar genetic abnormality. Our analysis of several polymorphic markers from the chromosome 18q21-22 region showed loss of maternally inherited alleles throughout the region. This finding is similar to those described previously and provides further evidence of a susceptibility region relating to this disease. This report describes a father and son, their young ages at diagnosis of Pagetoid sarcoma, the identical sites of disease involvement, and a loss of heterozygosity study illustrating the inheritance of the presumed defective gene.

Primary osteogenic sarcoma arising from the dura mater: case report

A 42-year-old woman who sought treatment for left drop foot was found to have a right frontoparietal parasagittal mass. Gross total resection of the tumor was performed and pathologic analysis revealed high grade osteoblastic osteosarcoma. The patient received adjuvant chemotherapy and continues to do well with no evidence of metastases or local recurrence 3 years after initial presentation.

Common mechanisms of osteosarcoma and Paget's disease

One of the most serious complications of Paget's disease is a significant increase in the incidence of osteosarcoma. Approximately 1% of Paget's patients develop osteosarcoma, an increase in risk that is several thousand-fold higher than the general population. This risk contributes significantly to the mortality and morbidity of Paget's disease patients. We examined several cases of pagetic and sporadic osteosarcoma for tumor-specific loss of constitutional heterozygosity (LoH) on chromosome 18q. Our analysis found that both pagetic and sporadic osteosarcoma tumors showed LoH for all or part of the distal portion of chromosome 18q. The pattern of LoH in both types of tumors identified a region between loci D18S60 and D18S42 that must contain the putative tumor suppressor locus. This region is tightly linked to familial Paget disease and familial expansile osteolysis (FEO). Our hypothesis is that the predisposition locus for Paget's disease and the tumor suppressor locus for osteosarcoma are either the same gene or that osteosarcoma in Paget's disease represents a deletion affecting two adjacent genes. In either model, localization of the osteosarcoma tumor suppressor gene would be of benefit in the eventual isolation of the predisposition locus for Paget's disease. We have begun to isolate and test candidate genes from within the region defined by both the familial Paget's disease families and the minimal region of LoH in osteosarcomas for evidence that one or more of them is responsible for predisposition to Paget's disease and/or osteosarcoma.

Malignant spindle cell tumor arising in the mandible of a patient with florid osseous dysplasia

Florid osseous dysplasia is a non-neoplastic condition of the alveolar processes of the jaws characterized by the replacement of multiple foci of bone by fibrous connective tissue, accompanied by gradual deposition of cementum, bone, or both. The lesions are not associated with inflammatory diseases of the dental pulp or periodontal tissues. In fully developed florid osseous dysplasia, there are multiple lobulated masses in the alveolar bone bilaterally in the mandible and sometimes in the maxilla. This is the first report of a malignancy originating within the jaws of a patient with florid osseous dysplasia. A spindle cell malignancy was diagnosed in the mandible of a 54-year-old black woman whose jaw was affected by florid osseous dysplasia bilaterally. Despite extensive surgery and radiotherapy, the patient died 20 months after diagnosis of the malignancy.

Pseudosarcoma in Paget's disease of bone

The appearance of a sarcoma of bone is a well-recognized complication of Paget's disease. The most common type of such a sarcoma is osteosarcoma. Much less common are soft tissue lesions adjoining the pagetic bone that clinically and radiologically simulate sarcoma but histologically represent exaggerated periosteal bone formation as a manifestation of the basic pathologic process. We present a case of a bulky juxtacortical soft tissue mass in the thigh arising from a pagetic femur in a 62-year-old patient with polyostotic Paget's disease that was clinically and radiologically suspected to be a juxtacortical osteosarcoma. Microscopically, the lesion showed features of florid Paget's disease without any evidence of sarcomatous growth. It is important to be aware of this rare manifestation of Paget's disease to avoid unnecessary overtreatment.

Giant-cell tumor in soft parts in a patient with osseous Paget's disease: diagnosis by fine-needle aspiration

In this report, the cytological features and differential diagnosis of a case of giant-cell tumor (GCT) in soft tissues in a patient with osseous Paget's disease (PD) are described, with histological confirmation. Characteristic cytological findings include a diffuse cellular population of neoplastic cells composed of two types: one group of polygonal or round mononuclear small cells, exhibiting a thin-rim, dense cytoplasm and single hyperchromatic nuclei; and the second group of multinucleated, osteoclast-type giant cells with dozens of round nuclei, showing occasional micronucleoli. A prominent feature is the presence of numerous capillary structures surrounded by tumor cells. The differential diagnosis includes a number of other neoplastic and reactive processes in which giant cells may be abundant. The cytological features of GCT appear to be characteristic enough to allow a suggestive diagnosis. However, the final diagnosis should be made only after the lesion has been studied histologically.

Evidence for a novel osteosarcoma tumor-suppressor gene in the chromosome 18 region genetically linked with Paget disease of bone

Paget disease of bone, or "osteitis deformans," is a bone disorder characterized by rapid bone remodeling resulting in abnormal bone formation. It is the second most common metabolic bone disease after osteoporosis, affecting 3%-5% of subjects aged >40 years. Recent evidence suggests that predisposition to Paget disease may have a genetic component. Genetic linkage analysis of families with multigenerational Paget disease shows linkage to a region of chromosome 18q near the polymorphic locus D18S42. Approximately 1% of Paget patients develop osteosarcoma, which represents an increase in risk that is several thousandfold over that of the general population. Osteosarcoma in Paget patients is the underlying basis for a significant fraction of osteosarcomas occurring after age 60 years. Our analysis of tumor-specific loss of constitutional heterozygosity (LOH) in 96 sporadic osteosarcomas has identified a putative tumor-suppressor locus that maps to chromosome 18q. We have localized this tumor-suppressor locus between D18S60 and D18S42, a region tightly linked to familial Paget disease. Analysis of osteosarcomas from patients with Paget disease revealed that these tumors also undergo LOH in this region. These findings suggest that the association between Paget disease and osteosarcoma is the result of a single gene or two tightly linked genes on chromosome 18.

Malignant tumors of the osteogenic matrix

This article focuses on major clinical and imaging features that are of practical interest in the diagnosis and management of osteosarcoma, a malignant tumor arising from the osteogenic matrix. The current histologic classification of this tumor is also reported. Different types of osteosarcoma are described, each of them with a definite clinical and radiographic pattern. Conventional radiography is the keystone to diagnosis because it allows analysis of the patterns relevant to the different lesions (location, site, bone destruction, periostal reaction, soft tissue masses). The most common type of osteosarcoma is defined classic or conventional high grade (75%) and it typically involves the medullary cavity. Radiographically, it may be predominantly osteosclerotic or osteolytic, but more frequently it has a mixed (osteoslerotic/osteolytic) pattern. The teleangiectatic osteosarcoma is an aggressive form (5%) characterized by marked vascularization with large blood-filled cystic cavities; its typical radiographic pattern is purely osteolytic. Juxtacortical osteosarcoma (8-10%) indicates a group of osteosarcomas apparently arising on bone surface. The most common type is parosteal osteosarcoma which affects older subjects and has a better prognosis than the classic type. Radiography shows a heavily ossified mass with a broad base attached to the underlying cortex. CT and MRI are useful in the differential diagnosis of osteosarcoma and myositis ossificans or osteocondroma. Rare types of osteosarcoma include the periosteal and high-grade surface variants, as well as secondary and multifocal osteosarcoma (osteosarcomatosis). CT and MRI are the imaging procedures of choice in locoregional staging (intraosseous and extraosseous spread, skip metastases, growth plate and articular involvement). CT of the chest is a useful tool for detecting lung metastases. Also MRI has a role in monitoring the response to chemotherapy and in detecting recurrence. It permits a more accurate study of the tumor volume than other imaging techniques and clinical examination. MRI becomes even more useful when paramagnetic contrast agents are administered because dynamic MRI with contrast enhancement help differentiate postchemotherapy changes from viable tumor--the latter enhancing rapidly and the former slowly. Thus, dynamic MRI allows a precise mapping of any residual tumor activity.

Orthopedic aspects of metabolic bone disease

Although metabolic bone disorders are common, they may be difficult to distinguish on the basis of clinical and radiologic findings. Understanding their diverse manifestations on imaging studies may allow early diagnosis. This article discusses osteoporosis, osteomalacia, rickets, hyperparathyroidism, hypothyroidism, hyperthyroidism, renal osteodystrophy, and Paget disease, with emphasis on radiologic differential diagnosis.

Primary leiomyosarcoma of bone: a clinicopathologic, immunohistochemical, and ultrastructural study of 33 patients and a literature review

Leiomyosarcoma of bone is a rare tumor in an unusual location. Previous analysis of this entity mostly involved small numbers of cases with limited follow-up. Thirty-three patients with leiomyosarcoma of bone between 1977 and 1996 were studied, and the histologic appearance and grade were correlated with subsequent treatment and clinical behavior. To be included in this study the tumor had to be intraosseous, with other primary sites of origin clinically excluded. Also, most of the sarcomatous tissue (> or =70%) had to be of intramedullary location with only limited extraosseous extension. The patient's age at diagnosis ranged from 13 to 77 years (average 44.4). The gender distribution was equal. The long bones were preferentially affected (64%), with the lower extremity, around the knee joint, predominantly involved. Five patients (15%) developed postradiation leiomyosarcomas. The histologic analysis showed that the osseous leiomyosarcomas are most commonly of the classic type, followed by the epithelioid, myxoid, and pleomorphic variants. Immunoreactivity for smooth muscle markers (smooth muscle actin, common muscle actin, desmin) was positive in all tumors, and ultrastructural confirmation was obtained in 21% of cases. All sarcomas were histologically graded, which accurately reflected the subsequent prognosis. Seventy-five percent of the lesions were high-grade and the rest low-grade. The histologic grade of the tumors correlated with both the recurrence as well as the metastatic rates and together with the clinicopathologic stage of disease represented the cornerstone on which prudent therapy should be based.

Diagnosis of malignant change in Paget's disease by Tl-201

Scintigraphy using Tc-99m MDP and Tl-201 was performed in a patient with polyostotic Paget's disease and sarcomatous degeneration in the right iliac bone. Tc-99m MDP imaging showed abnormal uptake in both types of lesions. Tl-201 imaging showed increased uptake in the sarcomatous lesion and absent uptake in pagetic lesions. This result supports the idea that Tl-201 scintigraphy may have a potential role to play in the differentiation of Paget's disease from malignancy. To the authors' knowledge, Tl-201 has never been reported for the detection of sarcomatous change of pagetic bone.

Paget sarcoma of the cervical vertebrae: an autopsy case report and review of the literature

A 69 year old Japanese woman was hospitalized for emergency treatment of sudden onset of tetraplegia and somnolence. The patient had a long history of occipital pain without definite diagnosis. After admission, the patient progressively developed generalized palsy including respiratory paralysis, and died of bronchopneumonia. Autopsy revealed osteosarcoma of the cervical vertebrae with the features of Paget's disease involving the skull and the cervical vertebrae. Paget sarcoma is rare in Japan, where Paget's disease of the bone is an uncommon condition. A review of the world literature failed to reveal any reports describing Paget sarcoma of the cervical vertebrae. The present report indicates that the development of Paget sarcoma in the upper cervical vertebrae may cause life-threatening neurologic complications.

Malignant transformation in Paget disease of bone

BACKGROUND

The previously reported incidence of malignant transformation of Paget disease up to 5.5% and its dismal prognosis have prompted the clinical investigation of a large population with Paget disease.

METHODS

A chart review of symptomatic and asymptomatic patients with a diagnosis of Paget disease between 1970 and 1985 at four large Montreal Hospitals revealed 1078 patients. Eight patients with malignant transformation were studied in detail.

RESULTS

The incidence of malignant transformation was 0.7%, and the most frequent histologic type was osteogenic sarcoma. The most prevalent site was the femur, and pathologic fracture with focal osteolysis was present in 50% of patients at the initial appearance of the tumor. Healing at the fracture site was demonstrated in one patient. Another patient died of uncontrollable hemorrhage. A case of malignant lymphoma in Paget disease is recorded.

CONCLUSIONS

Surgery or biopsy should be preceded by preoperative scintigraphic bone blood flow evaluation and, if necessary, administration of a preoperative course of mithramycin and selective embolization to minimize bleeding. The prognosis of malignant transformation in Paget disease is poor, although one patient with malignant lymphoma survived after aggressive treatment. Early biopsy and aggressive treatment should not be delayed.

The diagnosis of Paget's disease of bone

Paget's disease of the bone is a common disorder and usually presents no diagnostic difficulty. However, atypical cases may cause problems in diagnosis, particularly in younger patients, and this paper describes some of the more unusual modes of presentation mainly related to the osteolytic phase and to accentuation of normal anatomical features. The role of various imaging techniques is discussed, emphasizing that recognition of the plain radiographic changes of Paget's disease remains the key to diagnosis in most cases.

Rheumatologic manifestations of malignancy

The relationship between rheumatologic syndromes and cancer covers a very broad array of both common and distinctly rare manifestations. This discussion has outlined some of the known relationships that do exist. A high index of suspicion by both the primary care physician and subspecialist will enhance the probability of detecting cancer in the patient who may present with rheumatologic complaints.