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1、ImagingOsteosarcoma&SurgicalOutcomesWilliamR.Silveira,HMSIIIGillianLieberman,M.D.HarvardMedicalSchoolBethIsraelDeaconessHospitalNovember12,2007Patient1:Clinicalpresentation15yearoldboypresentswith…“Painintheupperpartofmyleftknee”Thepainbecameprogressivelyworseov
2、er3monthsHenowreports…ModeratepainatrestSeverepainwhenbearingweightFrequentwakingatnightwithkneepainHeworksout“onceinawhile”HedeniesahistoryoftraumaandinfectionHedeniespreviousproblemswithhisleftkneeNosignificantpastmedicalhistoryorfamilyhistoryNofever,chills,na
3、usea,orvomitingPatient1:Clinicalpresentation15yearoldboypresentswith…“Painintheupperpartofmyleftknee”PhysicalExamNoevidenceofinjuryMarkedtendernesstopalpationDiffuseswellingofthedistalfemurFirm,circumferential,fixedmassLimitedrangeofmotion(painful!)Intactsensati
4、on&motorfunctionStrongpulsesthroughoutextremityNolymphadenopathyPatient1:Differentialdiagnosis:AtraumatickneepaininanadolescentJuvenilerheumatoidarthritisMalignancyReactivearthritisEwing’ssarcomaInfectiousarthritisOsteosarcomaOsteomyelitisRhabdomyosarcomaOsteoch
5、ondritisdessicansLymphoidneoplasmDegenerativejointdiseaseMetastasisTendonitis,bursitisChondromalaciaReferredpainConsidertumor,inflammation&infectionM.M.ReederandBFelson,GamutsinRadiology,Springer-VerlagTelos,3rdedition,1993S.KahanandE.G.Smith,Signs&Symptoms,Blac
6、kwellpublishing,Massachusetts,2004Wheretobegin?Menuoftests:Atraumatickneepaininanadolescent1.RadiographAnteroposterior(AP)“Mandatoryworkup”ACRguidelinesLateralNotchortunnelviewAxialviewIpsolateralhipfilms(AP/frogleglateral)2.Nuclearstudy:radionuclidebonescan3.Ul
7、trasound(US)4.Computedtomography(CT)5.Magneticresonanceimaging(MRI)6.Aspiration/arthrogram7.CTpostarthrogramAmericanCollegeofRadiology,ACRAppropriatenessCriteria,dateoforigin1995,lastreviewed2005,http://www.acr.orgPatient1:Radiographoftheleftknee–APviewSofttissu
8、e1.Increasedamorphousdensity2.Diffusespiculatedmass3.ContinuouswithmetaphysisBonefromfar4.Osteoscleroticdistalfemur15.Highestdensityatthemetaphysis6.Widezoneoftransit
