Imaging Characteristics of Locally Recurrent Tumors of Bone
Colleen M. Costelloe1,
Rajendra Kumar1,
Alan W. Yasko1,2,
William A. Murphy, Jr.1,
R. Jason Stafford3,
Valerae O. Lewis4,
Patrick P. Lin4 and
John E. Madewell1
1 Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer
Center, 1515 Holcombe Blvd., Unit 1273, Houston, TX 77030-4009.
2 Present address: Department of Orthopaedic Surgery, Feinberg School of
Medicine, Northwestern University, Chicago, IL.
3 Division of Imaging Physics, The University of Texas M. D. Anderson Cancer
Center, Houston, TX.
4 Department of Orthopaedic Oncology, The University of Texas M. D. Anderson
Cancer Center, Houston, TX.
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Fig. 1A —51-year-old man with recurrent metastatic colon cancer.
Anteroposterior radiograph of femur obtained 2 months after curettage of
metastatic colon cancer and placement of intramedullary nail for stabilization
shows continuous arc of heterotopic bone spanning surgical defect
(arrows).
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Fig. 2A —36-year-old man with recurrent chondrosarcoma. Above-knee
amputation was performed for treatment of chondrosarcoma of distal femur.
Transfemoral resection margin is not included on initial postoperative
anteroposterior radiograph, which shows normal remaining femur.
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Fig. 2B —36-year-old man with recurrent chondrosarcoma. Radiograph
obtained 6 months after A shows development of diffuse, permeative
pattern of osteolysis with soft-tissue prominence and blurring of fascial
planes. Two main differential considerations are recurrent tumor and
osteomyelitis.
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Fig. 2C —36-year-old man with recurrent chondrosarcoma. Axial MR images
reveal large mass emanating from femur and showing T1 signal isointense to
muscle (TR/TE, 500/9) (C), high signal intensity on fat-saturated
T2-weighted image (4,000/83) (D), and heterogeneous enhancement after
administration of IV contrast material (gadopentetate dimeglumine, 0.1 mmol/kg
of body weight) on fat-saturated T1-weighted image (600/9) (E). Despite
areas of nonenhancement (necrosis), a larger degree of enhancing soft tissue
is present than would be expected with abscess. Relative lack of soft-tissue
inflammation would also be unusual for newly developed abscess in absence of
antibiotic therapy.
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Fig. 2D —36-year-old man with recurrent chondrosarcoma. Axial MR images
reveal large mass emanating from femur and showing T1 signal isointense to
muscle (TR/TE, 500/9) (C), high signal intensity on fat-saturated
T2-weighted image (4,000/83) (D), and heterogeneous enhancement after
administration of IV contrast material (gadopentetate dimeglumine, 0.1 mmol/kg
of body weight) on fat-saturated T1-weighted image (600/9) (E). Despite
areas of nonenhancement (necrosis), a larger degree of enhancing soft tissue
is present than would be expected with abscess. Relative lack of soft-tissue
inflammation would also be unusual for newly developed abscess in absence of
antibiotic therapy.
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Fig. 2E —36-year-old man with recurrent chondrosarcoma. Axial MR images
reveal large mass emanating from femur and showing T1 signal isointense to
muscle (TR/TE, 500/9) (C), high signal intensity on fat-saturated
T2-weighted image (4,000/83) (D), and heterogeneous enhancement after
administration of IV contrast material (gadopentetate dimeglumine, 0.1 mmol/kg
of body weight) on fat-saturated T1-weighted image (600/9) (E). Despite
areas of nonenhancement (necrosis), a larger degree of enhancing soft tissue
is present than would be expected with abscess. Relative lack of soft-tissue
inflammation would also be unusual for newly developed abscess in absence of
antibiotic therapy.
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Fig. 3A —22-year-old man with recurrent osteosarcoma. Frontal
radiograph of proximal right femur reveals periosteal reaction produced by
recurrent osteosarcoma near medial bone-metal interface of metallic prosthesis
(arrow).
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Fig. 3B —22-year-old man with recurrent osteosarcoma. Similar
radiograph obtained 2 months after A reveals mineralization of tumor
and maturity (thickening) of proximal aspect of periosteal reaction
(arrowhead).
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Fig. 4A —18-year-old man with recurrent giant cell tumor of bone.
Anteroposterior radiograph of left knee obtained 2 years after curettage of
giant cell tumor of proximal tibia and placement of polymethyl methacrylate
cement in osseous defect. Expansion of lateral tibial plateau indicates
recurrent tumor (arrow).
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Fig. 5A —40-year-old man with recurrent adamantinoma. Adamantinoma of
midtibial diaphysis was treated with en bloc resection and placement of
intercalary allograft 8 years before this anteroposterior radiograph of lower
leg that shows medial cortical expansion at distal bone-allograft junction
(large arrow). Proximal bone-allograft junction (small
arrow) is healed and unremarkable in appearance.
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Fig. 5C —40-year-old man with recurrent adamantinoma. Diagnosis of
recurrence is further supported by axial MR images, which reveal T1 signal
isointense to surrounding muscle (TR/TE, 500/9) (C), mildly
heterogeneous high signal intensity on fat-saturated T2-weighted image
(4,000/83) (D), and homogeneous enhancement on T1-weighted image after
administration of IV contrast material (500/9) (E). MRI reveals
complete infiltration of marrow cavity, which is greater extent of disease
than expected on basis of radiography.
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Fig. 5D —40-year-old man with recurrent adamantinoma. Diagnosis of
recurrence is further supported by axial MR images, which reveal T1 signal
isointense to surrounding muscle (TR/TE, 500/9) (C), mildly
heterogeneous high signal intensity on fat-saturated T2-weighted image
(4,000/83) (D), and homogeneous enhancement on T1-weighted image after
administration of IV contrast material (500/9) (E). MRI reveals
complete infiltration of marrow cavity, which is greater extent of disease
than expected on basis of radiography.
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Fig. 5E —40-year-old man with recurrent adamantinoma. Diagnosis of
recurrence is further supported by axial MR images, which reveal T1 signal
isointense to surrounding muscle (TR/TE, 500/9) (C), mildly
heterogeneous high signal intensity on fat-saturated T2-weighted image
(4,000/83) (D), and homogeneous enhancement on T1-weighted image after
administration of IV contrast material (500/9) (E). MRI reveals
complete infiltration of marrow cavity, which is greater extent of disease
than expected on basis of radiography.
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Fig. 6 —17-year-old boy with recurrent osteosarcoma. Lateral
radiograph obtained 3 years after resection and segmental total knee
arthroplasty for treatment of osteosarcoma of distal femur shows cloudlike
osteoid matrix (arrowheads) throughout posterior thigh and popliteal
fossa, which is consistent with tumor recurrence.
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Fig. 7 —42-year-old woman with recurrent chondrosarcoma. Follow-up
pelvic CT scan after resection of chondrosarcoma of right iliac bone shows
several nodules containing calcifications in punctate, stippled and
curvilinear, "arc-and-ring" pattern (arrows) typical of
chondroid tumors and indicative of recurrence. Attenuation of nodules is
slightly lower than that of muscle. Low attenuation and matrix mineralization
of tumor nodules differentiate them from surrounding structures.
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Fig. 8A —54-year-old woman with recurrent giant cell tumor of bone.
Lateral radiograph of left lower leg after resection of proximal fibular giant
cell tumor reveals several rimossified masses in soft tissues of calf
(arrows), which is uncommon but recognized pattern of recurrent giant
cell tumor of bone. Rim-ossified nodules can be mistaken for myositis
ossificans.
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Fig. 8B —54-year-old woman with recurrent giant cell tumor of bone.
Axial MR images through recurrent nodule reveal T1 signal isointense to muscle
(TR/TE, 519/9) (B); heterogeneous, predominately intermediate signal
intensity on fat-saturated T2-weighted image (3,600/88) (C); and ovoid
area of homogeneous high T2 signal that does not enhance on fat-saturated
T1-weighted image (450/9) (D). This appearance reflects cystic
component common to giant cell tumors. Recurrent tumor also shows areas of
nodular internal enhancement comprising approximately half of recurrent
neoplasm. Peripheral rim of low signal intensity on all pulse sequences
(arrowheads, B-D) corresponds to ossified rim seen on
radiographs. Mature myositis ossificans may not show high T1 signal intensity
and may be predominately cystic. Biopsy can distinguish between recurrent
giant cell tumor and mature myositis ossificans and should be directed to
enhancing portions of tumor (asterisk, D).
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Fig. 8C —54-year-old woman with recurrent giant cell tumor of bone.
Axial MR images through recurrent nodule reveal T1 signal isointense to muscle
(TR/TE, 519/9) (B); heterogeneous, predominately intermediate signal
intensity on fat-saturated T2-weighted image (3,600/88) (C); and ovoid
area of homogeneous high T2 signal that does not enhance on fat-saturated
T1-weighted image (450/9) (D). This appearance reflects cystic
component common to giant cell tumors. Recurrent tumor also shows areas of
nodular internal enhancement comprising approximately half of recurrent
neoplasm. Peripheral rim of low signal intensity on all pulse sequences
(arrowheads, B-D) corresponds to ossified rim seen on
radiographs. Mature myositis ossificans may not show high T1 signal intensity
and may be predominately cystic. Biopsy can distinguish between recurrent
giant cell tumor and mature myositis ossificans and should be directed to
enhancing portions of tumor (asterisk, D).
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Fig. 8D —54-year-old woman with recurrent giant cell tumor of bone.
Axial MR images through recurrent nodule reveal T1 signal isointense to muscle
(TR/TE, 519/9) (B); heterogeneous, predominately intermediate signal
intensity on fat-saturated T2-weighted image (3,600/88) (C); and ovoid
area of homogeneous high T2 signal that does not enhance on fat-saturated
T1-weighted image (450/9) (D). This appearance reflects cystic
component common to giant cell tumors. Recurrent tumor also shows areas of
nodular internal enhancement comprising approximately half of recurrent
neoplasm. Peripheral rim of low signal intensity on all pulse sequences
(arrowheads, B-D) corresponds to ossified rim seen on
radiographs. Mature myositis ossificans may not show high T1 signal intensity
and may be predominately cystic. Biopsy can distinguish between recurrent
giant cell tumor and mature myositis ossificans and should be directed to
enhancing portions of tumor (asterisk, D).
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Fig. 9A —45-year-old man with recurrent metastatic renal cell
carcinoma. Preoperative anteroposterior radiograph of right knee reveals lytic
metastasis with pathologic fracture of lateral femoral condyle. Pain from
pathologic fracture may be first indication of metastasis.
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Fig. 9B —45-year-old man with recurrent metastatic renal cell
carcinoma. Postoperative radiograph shows curettage and cementation of
resultant osseous defect. Small areas of curettage cavity (arrow)
near articular surface did not fill with cement.
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Fig. 9C —45-year-old man with recurrent metastatic renal cell
carcinoma. Follow-up radiograph obtained 3 months later reveals subtle
increase in radiolucency at articular aspect of cement bolus caused by
recurrent disease (arrow). Change is more readily apparent on
comparison with prior examination.
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Fig. 10A —43-year-old woman with bone graft in cavity formed after
curettage and ablation of giant cell tumor of bone. Lateral radiograph of left
lower leg reveals curetted cavity filled with bone graft in distal tibia.
Edges of individual pieces of graft material (arrow) are distinct.
Cavity is complicated by pathologic fracture (arrowhead).
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Fig. 10B —43-year-old woman with bone graft in cavity formed after
curettage and ablation of giant cell tumor of bone. Lateral radiograph 1 year
after A exhibits graft incorporation and blurring of previously sharp
margins (arrow).
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Fig. 11A —17-year-old girl with recurrent giant cell tumor of bone.
Postoperative radiograph of left wrist in patient with previously recurrent
giant cell tumor of bone treated with curettage, ablation, and placement of
bone graft.
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Fig. 11B —17-year-old girl with recurrent giant cell tumor of bone.
Follow-up radiograph 8 months after A reveals absence of most of graft
on medial side of ulna. Bone graft may undergo resorption rather than
incorporation, resulting in radiolucencies that can be confused with
recurrence. Cortical expansion (arrowheads) allows identification of
new medial radiolucency as recurrent tumor. Lateral radiolucency
(arrow) is indeterminate for recurrence and could represent simple
resorption. Indeterminate cases can be followed up radiographically at 3-month
intervals. Extension of radiolucency into cortex or beyond curetted cavity
indicates tumor. Inferior portion of cavity exhibits homogeneous density
(asterisk) of well-incorporated graft.
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Fig. 11C —17-year-old girl with recurrent giant cell tumor of bone.
Postoperative radiograph after repeated curettage and ablation shows cavity is
now filled with polymethyl methacrylate cement that does not undergo
resorption. Thin radiolucency and adjacent sclerotic rim (arrow) that
have formed around cement are customary findings. Lytic recurrent tumors are
often easily detected adjacent to high density of cement.
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Fig. 12A —33-year-old man with recurrent giant cell tumor of bone.
Axial fat-saturated proton density-weighted MR image (TR/TE, 3,000/31.5) of
left knee shows profound low signal intensity of cement bolus placed in
medullary cavity of lateral femoral condyle, previous location of giant cell
tumor (asterisk). Small focus of intermediate T2 signal
(arrow) is unchanged from previous examination (not shown) and
probably represents scar.
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Fig. 12B —33-year-old man with recurrent giant cell tumor of bone.
Follow-up axial fat-saturated T2-weighted image (4,000/87) obtained 11 months
after A reveals area of high T2 signal directly posterior to cement
(arrowheads), indicative of recurrent tumor, which is well visualized
adjacent to low signal intensity of cement. Asterisk indicates cement.
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Fig. 12C —33-year-old man with recurrent giant cell tumor of bone.
Lateral radiograph of knee obtained at same time as B shows posterior
cortical expansion (arrow), further verifying recurrent giant cell
tumor of bone.
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Fig. 13A —79-year-old man with recurrent metastatic fibrosarcoma.
Preoperative lateral radiograph of left femur reveals displaced pathologic
fracture complicating lytic metastasis originating from primary soft-tissue
fibrosarcoma of contralateral thigh.
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Fig. 13B —79-year-old man with recurrent metastatic fibrosarcoma.
Follow-up lateral radiograph obtained 8 months after curettage and cementation
of metastasis reveals nearly circumferential osteolysis, leaving only cement
bolus surrounding intramedullary nail.
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Fig. 13C —79-year-old man with recurrent metastatic fibrosarcoma. MR
images obtained at same time as B reveal greater extent of disease than
is evident on basis of radiography. STIR sequences were performed rather than
fat-saturated T2-weighted sequences to obtain more uniform fat suppression.
STIR coronal (TR/TE, 4,000/88; inversion time, 150 milliseconds) (C)
and axial (4,067/88; inversion time, 150 milliseconds) (D) images
reveal little metallic artifact despite large nail.
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Fig. 13D —79-year-old man with recurrent metastatic fibrosarcoma. MR
images obtained at same time as B reveal greater extent of disease than
is evident on basis of radiography. STIR sequences were performed rather than
fat-saturated T2-weighted sequences to obtain more uniform fat suppression.
STIR coronal (TR/TE, 4,000/88; inversion time, 150 milliseconds) (C)
and axial (4,067/88; inversion time, 150 milliseconds) (D) images
reveal little metallic artifact despite large nail.
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Fig. 13E —79-year-old man with recurrent metastatic fibrosarcoma. Fast
spin-echo axial T1-weighted images (450/9) before (E) and after
(F) administration of IV contrast material also reveal few artifacts.
Chemical fat saturation was not applied to contrast-enhanced sequence to
prevent distracting field inhomogeneity artifacts.
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Fig. 13F —79-year-old man with recurrent metastatic fibrosarcoma. Fast
spin-echo axial T1-weighted images (450/9) before (E) and after
(F) administration of IV contrast material also reveal few artifacts.
Chemical fat saturation was not applied to contrast-enhanced sequence to
prevent distracting field inhomogeneity artifacts.
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