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Weekly Chest CasesArchive of Old Cases

Case No : 765 Date 2012-06-27

  • Courtesy of Jeong-Gu Nam, MD., Woon-Jung Kwon, MD. / Ulsan University Hospital
  • Age/Sex 37 / M
  • Chief ComplaintVague left chest discomfortness for 1 year
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Figure 1

Diagnosis With Brief Discussion

Diagnosis
Extraskelectal osteosarcoma (pleural origin)
Radiologic Findings
Chest radiographies demonstrate rapidly growing pleural based mass with amorphous calcifications in the left lower hemithorax.
Initial chest CT images(mediastinal window setting) show bizarre shaped pleural calcifications, which are located the left diaphragmatic and lower lateral pleural space.
On follow-up CT after 7 months, the images(mediastinal window setting) demonstrate newly developed heterogenous enhancing masses arising from pleural calcifications in the left lower hemithorax. Contrast to previous CT images, pleural calcifications also slightly growing and extended.
Brief Review
The tumor was irregular shaped firm mass, measuring 8 x 6 x 4.5cm in size, which was broadly attached to left lower lobe and invaded diaphragm. The tumor extended to left 6th intercostal space and it was free from adjacent ribs. The tumor was easy to break, and included friable calcifications on the inside.
Photomicrograph of resected mass with H and E stain shows malignant spindle cell sarcoma with osteoid deposition and bone formation by pleomorphic tumor cells.
Extraskeletal osteosarcoma is a malignant mesenchymal soft-tissue neoplasm without attachment to the skeleton, which is able to produce osteoid or cartilaginous matrix. Hitologically, it is indistinguishable from osteogenic osteosarcoma, but, should be considered clinically and therapeutically separate from osteogenic osteosarcoma.
Extraskeletal osteosarcoma is a rare malignant neoplasm that accounts for approximately 1% of all soft-tissue sarcomas and 4% of osteogenic osteosarcomas. Unlike typical skeletal osteosarcomas, extraskeletal osteosarcoma affects older patients and usually presents in the sixth or the seventh decades.
Extraskeletal osteosarcoma may be asymptomatic or present with an enlarging mass or pain. The primary treatment of extraskeletal osteosarcoma is surgical resection. In addition, some patients are treated with chemotherapy or radiation therapy. Patients with extraskeletal osteosarcoma have a poor prognosis (5yrs survival rate < 40%), and more than half of the patients develop recurrences and metastases.
On radiographs, extraskeletal osteosarcoma often appears as soft-tissue opacity with variable amounts of mineralization (focal or extensive).
On CT, the tumor is separate from adjacent osseous structures and appears to have a pseudocapsule. Matrix mineralization is best appreciated on CT. On contrast-enhanced images, the tumor shows heteregeneous enhancement depending on the degree of necrosis.
On MRI, the tumor is usually a relatively well-circumscribed heterogeneous mass, which is isointense relative to skeletal muscle on T1-weighted images and isointense to mildly hyperintense on T2-weighted images. Hemorrage is not rare and may be represented by hyperintense foci on T1- and T2-weighted images.
References
1. Grainne Mc Auley, Jyothi Jagannathan, Kevin O뭃egan, Katherine M. Krajewski, Nikhil Ramaiya. Extraskeletal Osteosarcoma: Spectrum of Imaging Findings. AJR January 2012 198:W31-W37
2. Bradley Sabloff, Reginald F. Munden, Amal I. Melhem. Radiologic뻇athologic Conferences of The University of Texas M. D. Anderson Cancer Center: Extraskeletal Osteosarcoma of the Pleura. AJR April 2003 180:972
3. Gregory W. Gladish, Bradley M. Sabloff, Reginald F. Munden, Mylene T. Truong. Primary Thoracic Sarcomas. Radiographics May 2002 22:3 621-637
Keywords
pleura, malignant tumor,

No. of Applicants : 85

▶ Correct Answer : 23/85,  27.1%
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Scansworld , India Philson Mukkada
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - UWO , Canada S Lee
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Kimhae Jungang Hospital , Korea (South) Woonha Lee
  • - HIA Legouest - METZ , France Alban Gervaise
  • - China Medical University , Chia-Yi Christian Hospital ,Taiwan, R.O.C. , Taiwan Jun Jun Yeh
  • - Asan Medical Center , Korea (South) Ji Eun Kim
  • - Asan Medical Center , Korea (South) Eunyoung Kim
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - CHRU lille , France manuel toledano
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Fortis hospital , India Shaleen Rana
  • - Chungbuk univertisy hospital , Korea (South) Soohyun Lee
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Zaid Alsheriti hospital- Alsweida , Syria jehad alakabani
  • - CAC Rennes , France nicolas gautier
  • - Kohka Public Hospital , Japan Akitoshi Inoue
  • - CNUH , Korea (South) Kim Soohyun
▶ Correct Answer as Differential Diagnosis : 31/85,  36.5%
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Kurashiki Seijin-byo Center , Japan Akihiro Tada
  • - mmcri , India sangeetha srinivasan
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - XiangYa hospital , China Xia Yu
  • - HUEC , Brazil Diogo Pinheiro
  • - SMC , Korea (South) Yi Kyung Kim
  • - Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - Okayama University , Japan Takashi Tanaka
  • - radiologist, aditya imaging centre , India vivek patel
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Hanyang University Hospital , Korea (South) Yo Won Choi
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Gangnam Severance Hospital , Korea (South) Young-no Yoon
  • - Centre Hospitalier Lyon Sud , France matthieu ROUSSET
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Private sector , Greece Vasilios Tzilas
  • - Chonnam national university hospital , Korea (South) Wongi Jeong
  • - All India Institute of medical sciences , India Justin Moses
  • - Korea university anam hospital , Korea (South) Sung-Hye You
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - Chonnam university hospital , Korea (South) Park young
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Chonnam National University Hospital , Korea (South) Jung hyun Kim
  • - Chonnam national univ. hospital , Korea (South) Choi Seul-Gi
  • - Seoul St Mary Hospital , Korea (South) Chae Lim
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