Low-grade extraskeletal osteosarcoma of the chest wall: case report and review of literature

Extra-skeletal osteosarcoma: a review

Extra-skeletal osteosarcoma is a rare malignant soft tissue sarcoma which can cause a diagnostic challenge due to its non-specific presentation and soft tissue mineralisation, thus potentially mimicking conditions such as myositis ossificans. This review will outline the demographics, clinical presentation, key imaging features, differential diagnosis, management and outcomes of extra-skeletal osteosarcoma and serve as a reference to radiologists and other clinicians involved in the care of patients with soft tissue tumours and tumour-like lesions.

Malignant pleural mesothelioma with heterologous elements

AIMS

Malignant pleural mesothelioma with heterologous elements (such as osseous, cartilaginous or rhabdomyoblastic differentiation) is very rare. We tried to differentiate such mesothelioma cases from extraskeletal pleural osteosarcoma, which is very challenging.

METHODS

We compared 10 malignant pleural mesotheliomas (three biphasic and seven sarcomatoid types) with two pleural osteosarcomas using clinicopathological and immunohistochemical methods, and also fluorescence in situ hybridisation (FISH) to examine for homozygous deletion of p16.

RESULTS

The median age was 72 years for mesotheliomas, and 69 years for osteosarcoma. For mesothelioma, eight cases were male and two were female. Growth was diffuse in all mesothelioma cases except case 10, where it was localised, as it was for the two osteosarcomas. Among mesothelioma cases, 80% displayed osteosarcomatous and 60% chondromatous elements, while 10% exhibited rhabdomyoblastic ones. Immunohistochemical labelling for calretinin and AE1/AE3 was present in 8/10 and 7/10 mesotheliomas, respectively, but in only one osteosarcoma. Loss of methylthioadenosine phosphorylase was seen in 5/7 mesotheliomas. FISH analysis revealed homozygous deletion of p16 in 5/8 mesothelioma and 2/2 osteosarcoma. Median survival was 6.5 months after biopsy or surgical operation in mesothelioma, and 12 months after operation in osteosarcoma.

CONCLUSIONS

Although median survival was longer for osteosarcoma than for malignant mesothelioma, we could not differentiate mesothelioma from pleural osteosarcoma on the combined basis of clinicopathological and immunohistochemical data, and FISH analysis. However, diffuse growth was more frequent in mesothelioma than in osteosarcoma.

Cystic extraskeletal osteosarcoma: Three case reports and review of the literature

Extraskeletal osteosarcoma is a rare soft tissue sarcoma and typically appears as a solid mass with variable mineralization. A few cases of extraskeletal osteosarcoma have shown extensive hemorrhagic changes or bleeding due to its high-grade malignancy; however, to the best of our knowledge, no previous reports have described the pathological characteristics of tumors with non-hemorrhagic cystic change. The present report discusses three cases involving cystic lesions with a solid area at the periphery that arose in soft tissues. The large cystic spaces contained only yellowish-brown fluid and little or no blood, with no clear pathological necrotic tissue. The solid component comprised a focal area of osteoid production by highly anaplastic sarcomatous cells. All of the cases showed high-grade malignancy histologically, and the average maximum diameter was approximately 175 mm. The tumors were located at the adductor muscles in two cases and at the intermuscular region of the hamstring muscles in one case. All of the patients consulted a doctor after more than half a year had passed since the recognition of swelling or a mass on their affected extremities. Surgical treatment was performed for all patients. One patient had lymph node metastasis, and another had lymphoedema after surgery, but no histological invasion to the lymphatic ducts was observed in the excised specimen. Degenerative changes in the fluid content over a long time-course as a result of tumor bleeding or necrosis, rather than lymphorrhea by lymphatic channel invasion of the tumor, might have contributed to the formation of the cystic lesion. Only 1 patient who underwent chemotherapy remained clinically disease-free over 10 years after surgery. Chemotherapy regimens for osteosarcoma rather than those for soft tissue sarcoma are mostly effective for extraskeletal osteosarcoma, so the diagnosis by a biopsy is essential. It is important to consider extraskeletal osteosarcoma in the differential diagnosis of soft tissue tumor with cystic form and calcification and a long clinical course before consulting a doctor.

Role of radiation therapy for pediatric upper extremity extraskeletal osteosarcoma: A case series

BACKGROUND

Extraskeletal osteosarcoma is an extremely rare disease, comprising less than 0.1% of all cancers diagnosed in the United States, of which less than 5% occur in the upper extremities. The management of two cases of pediatric upper extremity extraskeletal osteosarcoma is discussed.

CASE DESCRIPTION

Two children initially noticed painless left upper extremity masses at the ages of 16 and 13, respectively. Following a period of several months, both lesions became symptomatic, necessitating operative intervention, which revealed giant cell-rich extraskeletal osteosarcoma; PET staging following gross total resection revealed no residual or metastatic disease in either patient. After extensive discussion with the patients and family, adjuvant chemotherapy was initiated for one patient, and adjuvant radiation therapy was initiated in both patients.

CONCLUSIONS

Despite the rarity of these tumors, the importance of radiation therapy has been established by current and ongoing studies such as the Children's Oncology Group study ARST0332. Radiation therapy remains an important component of the multimodality therapy comprising optimal treatment of this disease, despite the relative paucity of long-term outcome data derived from level I evidence.

Primary thoracic extraskeletal osteosarcoma: a case report and literature review

Primary extraskeletal osteosarcoma (ESOS) presenting in thoracic locations is very rare and associated with a poor prognosis. The current study presents a case involving a large anterior mediastinal mass, which was histologically confirmed as a primary osteosarcoma. The literature concerning primary thoracic ESOS is reviewed. A total of 60 cases were identified. The median age was 60 years (range, 14-93 years) and males were more prevalent among the reported cases (65%). Survival analysis revealed that the overall 5-year survival was only 22.3%. The majority of cases of thoracic ESOS presented in the lung (n=24, 40%), with others presenting in the mediastinum, pleura, or chest wall. The benefit of surgery, chemotherapy and radiotherapy was confirmed by Cox regression survival analyses.

Concurrent Nontuberculous Mycobacteria Infection and High-Grade Anterior Mediastinal Extraskeletal Osteosarcoma (ESOS): Is There a Connection?

BACKGROUND Extraskeletal osteosarcomas (ESOS) of the mediastinum are extremely rare and may present with concurrent nontuberculous mycobacteria infection. CASE REPORT We present the second documented case of high-grade anterior mediastinal extraskeletal osteosarcoma in a 59-year-old man with a history of treated, latent tuberculosis (TB). Sputum samples grew Mycoplasma avium complex and Mycobacterium fortuitum. Imaging showed a right-sided 7.6 cm mass with compression of the main bronchus. Subsequent biopsy with vimentin staining established the diagnosis of ESOS. Due to the patient's rapidly declining performance status, he was not deemed a candidate for surgery or chemotherapy. He subsequently expired within one month of presentation. CONCLUSIONS We present a unique case of high-grade anterior mediastinum ESOS and a review of the literature regarding all documented cases of ESOS to date. We suggest there is a possible link between mediastinal masses and nontuberculous mycobacteria infection.

Should High-grade Extraosseous Osteosarcoma Be Treated With Multimodality Therapy Like Other Soft Tissue Sarcomas?

BACKGROUND

Extraosseous osteosarcoma is rare, and the most appropriate therapy is unclear because there are few studies regarding its treatment. The effectiveness of radiation and chemotherapy remains uncertain owing to conflicting results in previous reports.

QUESTIONS/PURPOSES

To review our experience with contemporary multimodality treatment, we asked: (1) What is the disease-specific survival and local relapse-free survival? (2) Does American Joint Commission on Cancer (AJCC) stage, tumor size, or location relate to disease outcome? (3) Does radiation therapy improve local control or survival? (4) Do doxorubicin and ifosfamide improve local control or survival?

METHODS

Between 1990 and 2012, we treated 40 patients for localized, high-grade extraosseous osteosarcoma. In this retrospective study, we could determine the status of 36 patients (90%) either to death or for a minimum of 24 months of followup; four (10%) were lost to followup before 24 months. There were 11 patients with AJCC Stage IIA and 25 with Stage III disease. All patients underwent wide surgical excision. Of the patients with Stage IIA disease, four received radiation and none received chemotherapy. Of the patients with Stage III disease, six received radiation, seven were treated with chemotherapy, and six received radiation and chemotherapy. During the study period, high-dose doxorubicin and ifosfamide was the preferred chemotherapy regimen for patients younger than 60 years with normal cardiac and renal function. Local relapse-free survival and disease-specific survival were determined by Kaplan-Meier analysis using a prospectively maintained institutional database supplemented by information from the institutional tumor registry. The Cox proportional hazard model was used to determine the effect of various factors on local recurrence and patient survival.

RESULTS

At 5 years, local relapse-free survival was 47% (95% CI, 27%-64%), and disease-specific survival was 53% (95% CI, 35%-68%). In multivariate analysis, AJCC stage, which depends on tumor size, was the strongest predictor of local relapse-free survival (hazard ratio [HR] = 0.17, p = 0.02), while tumor depth was the best predictor of disease-specific survival (HR = 5.6, p = 0.02). Radiation improved local relapse-free survival (HR = 0.30, p = 0.03) but not disease-specific survival in multivariate analysis. A regimen of doxorubicin and ifosfamide was associated with better local relapse-free survival for patients with Stage III disease (HR = 0.16, p = 0.04) but not disease-specific survival (HR = 0.32, p = 0.08).

CONCLUSIONS

With the limited number of patients in our study, it appears that extraosseous osteosarcoma behaves differently than osteosarcoma of bone. Multimodality treatment that includes doxorubicin and ifosfamide-based chemotherapy, radiation, and surgery may be a valid therapeutic strategy for Stage III disease, but larger, prospective studies will be needed to verify our preliminary observations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Spontaneous extraskeletal osteosarcoma with various histological growth patterns in the abdominal wall of an ICR mouse

Extraskeletal osteosarcoma is extremely rare in mice. This case report demonstrates a spontaneous murine extraskeletal osteosarcoma that exhibited various histological growth patterns in an ICR mouse. At necropsy, the tumor mass was located in the abdominal wall and was 45 × 30 × 25 mm in size. Histopathologically, the tumor showed the following four growth patterns: a solid pattern of polygonal cells embedded in an osteoid eosinophilic matrix with calcification, an irregular sheet pattern of short spindle cells accompanying some eosinophilic multinucleated cells, a fascicular pattern of spindle cells and a cystic pattern lined by short spindle cells. Immunohistochemically, most of the tumor cells were positive for vimentin, proliferating cell nuclear antigen and osterix. The multinucleated cells mentioned above were desmin positive and were regarded as regenerative striated muscles but not tumor cells. Since no clear continuity with normal bone tissues was observed, the tumor was diagnosed as an “extraskeletal osteosarcoma.”

Radiation-Associated Low-Grade Extraskeletal Osteosarcoma of the Neck Following Treatment for Thyroid Cancer

Low-grade extraskeletal osteosarcoma is a rare tumor that may arise de novo or following radiation therapy. Because of the low-grade histology, it may be misdiagnosed as a benign lesion. We present a case of a 59-year-old man with a past history of radiotherapy for papillary carcinoma of the thyroid, presenting 16 years later with a low-grade extraskeletal osteosarcoma of the neck. The patient was treated with surgical excision and is disease free after 12 months of follow-up. The prognosis for patients with low-grade extraskeletal osteosarcoma is relatively good when compared with high-grade sarcomas. While there is a report of a low-grade extraskeletal osteosarcoma arising following radiotherapy for a benign condition, to the best of our knowledge this is the first reported case of a low-grade extraskeletal osteosarcoma occurring following radiotherapy for thyroid cancer, and the only case reported in the soft tissue of the head and neck region.

Low-grade extraskeletal osteosarcoma of the mediastinum: report of a case and review of literature

Extraskeletal osteosarcoma (ESOS) is a rare soft tissue sarcoma, typically characterized by a bone-producing neoplasm. Low-grade extraskeletal osteosarcoma (LGESOS) is an extremely rare soft tissue tumor, and patients with LGESOS tend to have a better prognosis. Here, we reported a case of LGESOS of the mediastinum with lung metastasis, and describe its clinical, pathological and radiological features, and compared them with those of the reported cases.

Giant osteosarcoma of chest wall requiring resection and pneumonectomy

We present the case of a 13-year-old girl who had a large swelling in her left breast with a history of weight loss, low-grade fever, and cold sweats. Computed tomography showed a large mass encroaching on the mediastinum and heart, with erosion of the adjacent ribs. Resection of the mass along with a pneumonectomy were performed. Postoperative tests showed no sign of metastases.

Large retroperitoneal low-grade extraskeletal osteosarcoma

Low-grade extraskeletal osteosarcoma is an extremely rare neoplasm with only nine cases reported in the literature, in which only one case involved the retroperitoneum. Tendency to dedifferentiate as well as recur with high-grade variant is known and management principles are not well defined, necessitating a continuous review of literature. We report management of the largest such retroperitoneal tumour (18.0 cm × 18.3 cm × 17.8 cm) in a 38-year-old man, which was treated with surgery followed by six cycles of cisplatin (90 mg/m(2) days 1 and 2) and doxorubicin (75 mg/m(2) day 3), cycled every 3 weeks (with granulocyte colony stimulating factor support as necessary). The patient is disease free after 3 years of follow-up.

Analysis of outcomes in extraskeletal osteosarcoma: a review of fifty-three cases

BACKGROUND

Extraskeletal osteosarcoma is a rare soft-tissue sarcoma about which little is known. The objectives of this study were to describe the clinical features and natural history of extraskeletal osteosarcoma and to investigate factors affecting outcomes.

METHODS

A retrospective review of a prospectively maintained database of patients diagnosed with soft-tissue sarcoma was conducted. Patients with pathologically confirmed extraskeletal osteosarcoma from 1982 to 2012 were identified and were included in the analysis. Medical records were reviewed for clinical features, treatment, and outcomes.

RESULTS

Fifty-three patients were identified from the database: forty-two presented with localized disease, two presented with metastatic disease, and nine presented with recurrent (local and/or distant) disease. The median patient age at diagnosis was sixty-four years, with a median follow-up time of thirty-four months (range, one to 290 months) for survivors. Of the fifty-three patients who were identified, forty-one had lesions in the extremities, fifty-one had high-grade lesions, forty had lesions >5 cm, and forty-two had deep lesions. For patients presenting with localized disease, the median survival was 45.8 months with a three-year cumulative incidence of death due to disease of 39%. All patients with localized disease were managed with surgical resection of the primary tumor: nineteen with surgery only, ten with adjuvant radiation, five with adjuvant chemotherapy, and eight with both radiation and chemotherapy. Eighteen patients relapsed: two patients had local recurrences, ten patients had distant metastases, and six patients had local recurrences and distant metastases. In log-rank analysis, patients with superficial tumors and negative margins at resection had a higher three-year event-free survival. No significant association of disease-specific or event-free survival was found with the addition of radiation, chemotherapy, or both to surgery.

CONCLUSIONS

For patients presenting with localized extraskeletal osteosarcoma, three-year event-free survival was higher for patients with superficial tumors and negative margins at resection. Radiation and chemotherapeutic treatment were not associated with a lower incidence of death due to disease or a longer event-free survival.

12q amplification defines a subtype of extraskeletal osteosarcoma with good prognosis that is the soft tissue homologue of parosteal osteosarcoma

Extraskeletal osteosarcomas are rare tumors with neoplastic cells synthesizing bone, usually associated with poor prognosis. We present the case of a 40-year-old man with an extraskeletal osteosarcoma that was treated by surgery and adjuvant radiotherapy. Thirteen years after the diagnosis, he remains disease-free, without any recurrences or metastases. Histopathological analysis favored the diagnosis of chondroblastic extraskeletal osteosarcoma grade II. G-banding, comparative genomic hybridization (CGH), and real-time PCR for the MDM2 and CDK4 genes were performed to describe the genetic profile of this tumor and revealed aberrations that are common findings of parosteal osteosarcomas. Ring chromosomes, giant marker chromosomes, and a telomeric association were found with G-banding. CGH revealed that 12q was amplified in the ring and giant markers identified by G-banding. Real-time PCR for MDM2 and CDK4 confirmed the amplification of these genes located in 12q. Our findings suggest that a variant of extraskeletal osteosarcoma, which is genotypically similar to parosteal osteosarcoma, exists and is associated with good prognosis.