DOI:10.2214/AJR.05.1132
AJR 2007; 188:855-863
© American Roentgen Ray Society
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.
Received June 30, 2005;
accepted after revision March 23, 2006.
Address correspondence to C. M. Costelloe.
CME This article is available for CME credit. See
www.arrs.org
for more information.
FOR YOUR INFORMATION
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. The purpose of this article is the identification of
recurrent tumor of bone utilizing radiography, CT, and MRI.
CONCLUSION. Radiography is frequently used to identify recurrence of
treated bone tumors through findings such as osteolysis, cortical reactions,
and characteristic matrix mineralization. CT can help evaluate the character
of osseous and calcific abnormalities. Comparison with prior radiographs can
be crucial for differentiation between postoperative alterations of bone and
subtle signs of recurrence. MRI can identify soft-tissue masses and is useful
for imaging patients with metallic hardware when it is optimized to decrease
artifacts.
Keywords: bone • cancer • MRI • musculoskeletal imaging • radiography
Introduction
Radiography is most frequently used to monitor the resection or
curettage sites of tumors arising in bone. Radiographic abnormalities include
osteolysis (focal or diffuse); cortical reactions, such as periostitis or
expansion; and formation of characteristic matrix mineralization. Although the
fluffy appearance of osteoid or an "arc-and-ring" pattern of
chondroid matrix may be detected radiographically, CT can facilitate the
evaluation of calcific abnormalities by providing detailed visualization of
their character and extent.
Surgical alteration of bone and placement of cement or hardware can
complicate the evaluation for tumor recurrence. Comparison with previous
radiographs is often necessary to distinguish recurrence from postoperative
changes. MRI can be used to evaluate the extent of disease in bone and soft
tissue. MRI is also useful in the presence of hardware when it is optimized to
decrease metallic artifacts.
Osteolysis
Osteolysis is a common radiographic indication of tumor recurrence. The
pattern of osteolysis may be focal (Fig.
1A,
1B) or diffuse. Focal
osteolysis may show well- or ill-defined margins, whereas diffuse osteolysis
often produces complete lytic destruction of the bone or a permeative
radiographic pattern (Figs. 2A
and 2B). Recurrent tumor in
bone may also give rise to masses extending into the soft tissues. Most small
masses are predominantly solid in composition; the likelihood of necrosis
increases as the tumor enlarges. Cystic or necrotic masses associated with
osteolysis can mimic osteomyelitis with abscess formation. MRI produces
excellent soft-tissue contrast and is useful for determining the extent of
recurrence and involvement of adjacent structures.
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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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Enhancement of a mass after the administration of IV gadolinium determines
that a mass is solid and can be useful in the exclusion of abscess (Figs.
2C,
2D,
2E). Recurrent tumors that are
largely cystic or necrotic typically show a greater degree of internal
enhancement than do abscesses. Uncommon exceptions include avascular masses,
such as the chondroid matrix of recurrent chondrosarcoma. Gadolinium-enhanced
MRI is also useful for directing biopsies to the diagnostically favorable
solid portions of a tumor.
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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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Cortical Abnormalities
Cortical derangements may constitute a prominent sign of recurrence,
particularly on radiography or CT. Periostitis may result from recurrent or
primary tumors. Periostitis is an aggressive feature and is not typically
caused by benign tumors unless they are complicated by a pathologic fracture,
periosteal hematoma, or superimposed infection. The periosteum is less firmly
adherent to the cortex in skeletally immature individuals than it is in
adults, making periostitis more common and more pronounced in younger age
groups. Periosteal reaction can nevertheless be seen in skeletally mature
patients (Fig. 3A,
3B).
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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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Cortical expansion is another potential manifestation of recurrent osseous
neoplasms. In addition to radiography, CT is an excellent imaging technique
for the evaluation of calcium
[1] and can display cortex in
excellent detail (Fig. 4A,
4B). The presence of
aggressive features such as cortical permeation, in addition to cortical
expansion, supports the diagnosis of recurrence (Fig.
5A,
5B,
5C,
5D,
5E).
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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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Matrix Mineralization Patterns
Characteristic matrix mineralization patterns can aid in the identification
of recurrent tumor nodules. Osteosarcoma typically produces a fluffy or
cloudlike pattern of mineralization (Fig.
6), whereas chondroid matrix often shows a stippled or
arc-and-ring appearance. CT is useful for the detection and characterization
of mineralization in recurrent tumor nodules
(Fig. 7) and can reveal
calcifications not evident on 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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Osseous tumors may recur in bone, in both bone and soft tissue, or
exclusively in soft tissue. Recurrent tumor not involving bone is difficult to
detect radiographically unless it is superficial, displaces soft-tissue
planes, or contains density other than soft tissue (such as calcification).
Giant cell tumor of bone may produce recurrent soft-tissue nodules with
ossified rims [2,
3]. Rim ossification of the
nodules is an unusual behavior considering that giant cell tumors do not
produce mineralized matrix. In addition, this rare recurrence pattern mimics
myositis ossificans on radiography. MRI of both entities can be
nonspecific.
Early myositis ossificans typically displays T1 signal isointense to
muscle, progressing to high T1 signal at maturity, recapitulating a fatty
marrow cavity. Nevertheless, myositis ossificans may never mature to the
extent of producing central fat signal
[4] and can even be cystic in
appearance [5]. The enhancement
characteristics of recurrent giant cell tumor on MRI may be cystic, solid, or
heterogeneous.
Figure 8A,
8B,
8C,
8D displays an example of a
rim-ossified recurrent giant cell tumor of bone occurring exclusively in soft
tissue. Approximately half of the nodule is cystic, revealing lack of internal
enhancement on MRI after the administration of IV contrast material. Follow-up
imaging can be expected to reveal the true nature of the lesion because
recurrent tumor nodules typically enlarge in the absence of therapy, whereas
myositis ossificans either remains stable or shows a (sometimes delayed)
decrease in size. Knowledge of the rim-ossified variant of recurrent giant
cell tumor of the bone can facilitate close radiographic follow-up at 3-month
intervals with biopsy after any increase in size of the nodule. This can help
prevent delay in diagnosis that could result in extensive surgery to gain
local control of disease.
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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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Curetted Cavities and Hardware
The altered appearance of bone after curettage or placement of metallic
hardware necessitates comparison with prior radiographs. One such example is
the evaluation of a post-operative defect containing a cement bolus. Prior
radiographs are necessary to determine whether areas of the curetted cavity
were initially unfilled. In the absence of prior radiographs, osteolysis can
be mistaken for incomplete filling of the curetted cavity (Fig.
9A,
9B,
9C,
9D).
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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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A cavity can be filled with a bone graft or polymethyl methacrylate cement.
Unlike cement, graft material typically incorporates into the bone. This
produces homogeneity across the operative site as blurring of the edges of the
individual pieces of graft material occurs (Fig.
10A,
10B). If the graft material
undergoes resorption rather than incorporation, geographic areas of
radiolucency form, simulating the osteolysis of recurrent tumor.
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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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A combination of radiographic signs, such as osteolysis and cortical
expansion (Figs. 11A and
11B), can be invaluable for
distinguishing between graft resorption and tumor recurrence. A radiolucency
that progresses beyond the margins of the curetted cavity, results in frank
cortical destruction, or produces a soft-tissue mass signifying recurrence.
Polymethyl methacrylate cement does not resorb and its high density results in
stark contrast to the lower density of the adjacent bone
(Fig. 11C) or a lytic
recurrence on radiography and CT. Cement lacks free protons, resulting in
profound low signal on all MR pulse sequences. This characteristic appearance
is also easily distinguishable from recurrent tumor (Fig.
12A,
12B,
12C).
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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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Excellent soft-tissue contrast resolution allows MRI to be used as an
adjunct to radiography to evaluate the extent of tumor. Resection sites are
often stabilized with metallic hardware that can generate marked
susceptibility artifacts and degrade the images. The following are useful
strategies for decreasing the degree of metallic artifact on MRI
[6,
7] (Fig.
13A,
13B,
13C,
13D,
13E,
13F):
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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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- Fast spin-echo sequences are less susceptible to metallic artifacts than
spin-echo or gradient-recalled echo sequences. If spin-echo or
gradient-recalled echo sequences are used, decrease the TE to minimize
artifact.
- Use inversion recovery sequences rather than chemical fat saturation for
more uniform suppression of fat signal.
- Increase receiver bandwidth.
- Decrease voxel size, which can be accomplished by decreasing slice
thickness, decreasing the field of view, or increasing the matrix size.
- Blooming artifact associated with metal is diminished in the
frequency-encoding direction, which can be optimally selected depending on the
orientation of the hardware in the area of interest.
- Orient the long axis of the hardware as parallel to the main magnetic field
(B0) as possible.
Conclusion
Radiographic patterns of tumor recurrence, such as osteolysis and cortical
reactions, are commonly manifested by recurrent tumor in bone. The development
of characteristic matrix mineralization patterns also indicates recurrence.
Primary tumors of bone can recur largely or exclusively in soft tissues.
Knowledge of these various manifestations of recurrence is helpful in making a
timely diagnosis. Late detection can increase the complexity of limb- or
joint-sparing surgery. This is particularly of concern with locally aggressive
benign tumors such as giant cell tumors of the bone. Early detection may spare
the patient significant morbidity.
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Abstract
Introduction
