British Journal of Radiology (2003) 76, 337-338
© 2003 British Institute of Radiology
doi: 10.1259/bjr/90973790
Unusual peritoneal spreading by metastatic osteosarcoma of the tibia
J-T Lin, MD1,
C-C Yen, MD1,
W-S Wang, MD1,
T-J Chiou, MD1,
J-H Liu, MD1,
H-T Wu, MD2 and
P-M Chen, MD1
1 Division of Medical Oncology and 2 Department of Radiology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
Correspondence: Chueh-Chuan Yen, MD, Division of Medical Oncology, Taipei Veterans General Hospital, 201, Sec.2, Shi-Pai Road, Shi-Pai, Taipei, Taiwan 106
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Abstract
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We report a 17-year-old boy with chondroblastic osteosarcoma initially found in left proximal tibia. He received surgical resection and chemotherapy. However, a lung metastasis was found 4 years later. Despite intensive chemotherapy, the metastatic osteosarcoma of lung continued to invade the ribs and later into retroperitoneum and liver. The metastatic pattern of chrondroblastic osteosarcoma of tibia directly to the chest and then into the abdomen is unusual.
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Introduction
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Most metastatic osteosarcoma is clinically and radiologically silent and only detected at autopsy. The sites of recurrence at autopsy are mainly lung, skeleton, pleura, heart, kidney, liver, diaphragm and lymph nodes [1]. Here we describe a case of metastatic osteosarcoma to the lung with direct invasion of the peritoneum and liver after intensive chemotherapy.
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Case report
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A 17-year-old Asian boy was admitted to the oncology ward with a mass over the left proximal tibia. Open biopsy showed chondroblastic osteosarcoma and he received chemotherapy (cisplatin and doxorubicin) and surgical excision. 4 years after the initial diagnosis, he developed severe dyspnoea and chest pain. CT of the chest showed multiple masses with internal calcification in both lungs and some of the tumours were pleurally-based, especially over right lung field. Abdominal ultrasound and whole body bone scan were normal. The patient refused biopsy, and the presumed recurrent metastatic osteosarcoma was treated by intensive chemotherapy with ifosfomide and etoposide. 2 months later, follow-up chest CT revealed the metastatic tumour extended from the right lower lung field into abdomen and along the liver surface with large ossified nodules in the liver (Figure 1
). The hepatic lesion demonstrated abnormal avidity for 99Tcm-MDP on bone scintigraphy indicating a hepatic metastasis. Due to disease progression, he received high dose chemotherapy (cyclophosphamide, cisplatin and BCNU) and autologous peripheral blood stem cell transfusion 4 months later. Although the engraftment was successful with no serious side effects, his condition deteriorated with severe liver and omental metastases and he died of pneumonia 6 months after the relapse.
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Figure 1. CT showing the presence of metastatic deposits extended from pleura into peritoneal cavity and along the surface of liver.
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Discussion
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Recurrence of osteosarcoma is observed in 40% of patients with primary bone tumour. At diagnosis, 80% of patients have localized disease, while distant metastases can be identified in only 10% [2]. The most common site of relapse in osteosarcoma has been in the lung. The pathological features of 66% of metastatic osteosarcoma of lung, however, were essentially the same as primary tumour [3]. Clinical presentation of recurrent extrapulmonary metastasis of osteosarcoma is rare. In a few cases, metastases to chest wall, epidural space, brain, skin, heart, kidney, liver, mesentery, small intestine pleura and ovary have been reported [4–10].
Lung metastases for osteosarcoma have been occasionally associated with lesions in bone, brain, chest wall, lymph node, and skin [11]. Peritoneal metastases, however, are very rare in osteosarcoma [12–14]. Recently, Westra et al [15] showed that late peritoneal spread of metastatic osteosarcoma occurred 1 year after metastatic osteosarcoma of lung was excised. It was possible that chemotherapy or radiation therapy may have changed the metastatic pattern of osteosarcoma after prolonged survival [16]. A review of English literature so far has demonstrated no report of the coexistence of metastatic osteosarcoma of lung with peritoneal spread. Direct seeding into peritoneum by metastatic osteosarcoma might be a rare, but nevertheless was responsible for the abdominal metastasis in this case, which illustrates an unusual course of metastatic osteosarcoma and the importance of frequent abdominal survey in such patients.
Received for publication May 29, 2002.
Accepted for publication October 4, 2002.
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References
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Abstract
Introduction
