1. Sports Tumors Robert M. Tamurian, MD Northern California Orthopaedic Centers Director of Orthopaedic Oncology Mercy San Juan Hospital Catholic Healthcare West

2. Disclosure Information  No financial relationships to disclose.

3. Sports Tumors  667 knee tumors were reviewed and 3.7% were treated with an intra-articular procedure due to misdiagnosis as an athletic injury  11 patients had benign tumors, while 14 patients had malignant tumors  15/25 (60%) patients had their oncologic procedure altered as a result of prior intra- articular intervention  6/14 (43%) patients with malignant tumors required amputation vs. limb salvage as a result of prior invasive procedure  Tumors About the Knee Misdiagnosed as Athletic Injuries D. Luis Muscolo, Miguel A. Ayerza, Arturo Makino, Matías Costa-Paz and Luis A. Aponte-Tinao J Bone Joint Surg Am. 2003;85:1209-1214.

4. Bone Tumors Mimicking Intra-articular pathology  Benign –Aneurysmal Bone Cyst –Giant Cell Tumor –Chondroblastoma –Osteoid Osteoma –Osteoblastoma  Malignant –Chondrosarcoma –Osteosarcoma –Ewing’s Sarcoma

5. Aneurysmal Bone Cyst ABC Natural History Natural History  Occurs primarily in adolescents, <20 yrs of age  Predilection for metaphyses of long bones or vertebral column  May be primary or secondary  Wide range of clinical behavior – pain and swelling most common

6. IOR data

7. Aneurysmal Bone Cyst Radiographic Features  Often aggressive appearing.  Mimics malignant neoplasms.  Fluid-fluid levels on CT or MRI.

8. Aneurysmal Bone Cyst Radiographic Features Central (95%)  osteolytic  some multiloculated  Radiolucent defect eccentrically enlarging or blowing out bone  Eggshell thin reactive rim often interrupted  Fine reticulated pattern Subperiosteal (5%)  radiolucent ballooning of the cortex  thin rim of reactive bone  Soft tissue mass  Mimic primary malignant bone tumor

9. Aneurysmal Bone Cyst Staging Studies  Focal increased isotope uptake, often with “doughnut” configuration.  CT - Fluid-fluid level - fine discontinuities in reactive rim - hypervascular lining with contrast.  MRI - T1 - intermediate signal T2 - intensely bright signal T2 - intensely bright signal

10. Aneurysmal Bone Cyst Example Case A 22 y/o presented with knee pain. Radio-graphs revealed a radiolucent lesion in the patella. Treated for patello-femoral syndrome. Two years later the pain increased. A 22 y/o presented with knee pain. Radio-graphs revealed a radiolucent lesion in the patella. Treated for patello-femoral syndrome. Two years later the pain increased.

11. Giant Cell Tumor (GCT)

12. Giant Cell Tumor Demographics  Age : 20 - 40  Sex : F = M except at distal radius where F 10 > M 1 F 10 > M 1  Site : Epiphyses of major long bones, vertebral body vertebral body Most around the knee (distal femur or proximal tibia)  Symptoms: Often mimics internal derangement with pain and swelling

13. Giant Cell Tumor Natural History  Stage 1 - Latent - rare  Stage 2 - Active - 60%  Stage 3 - Aggressive - 30%  Multicentric - rare  Metastases - rare

14. IOR Data

15. Giant Cell Tumor R adiographic Features  Epiphyseal-metaphyseal portion of a long bone (90%)  Rarely pelvis, sacrum, spine  Skeletally mature patient  Radiolucent  Isotope scans hot  Homogeneous on MRI

16.  Campanacci et al, Chir. Organi. Mov. Suppl. 1990. Curettage of GCT of bone. Reconstruction with subchondral grafts and cement.  Perssen. CORR 1976.

17. Chondroblastoma

18. Chondroblastoma Clinical features  Occurs in secondary ossification centers (proximal humerus common)  Rarely in apophyseal location, pelvis, talus, patella  Age: skeletally immature  Usually stage 2, some stage 3

19. Chondroblastoma Radiographic features  Secondary ossification center  Radiolucent lesion  Extensive surrounding edema on MRI  Hot on isotope scans

20. Chondroblastoma  Treatment –Open Biopsy –Intralesional extended curettage –Surgical adjuvant –Bone grafting  Recurrence –10% with intralesional treatment

21. Chondroblastoma Case Example  14 year-old with knee pain.  Followed for 8 months.  Pain did not resolve with therapy  Referred for psychiatric evaluation.  Original radiograph revealed an epiphyseal lesion.

22. Osteoid Osteoma

23. Osteoid Osteoma Demographics  Age : 8 - 18  Sex : M = F  Site : Intra-cortical, long bones Posterior elements vertebrate

24. Osteoid Osteoma Natural History  Painful active lesion, exacerbated by alcohol, virtually complete resolution of pain with aspirin or NSAIDS.  Does not enlarge, seldom exceeds 1 cm.  Spontaneously heals in 3 - 5 yrs.

25. Osteoid Osteoma Radiographic Features  Small oval or round radiolucent nidus.  Heavy mantle of reactive bone - often obscures nidus.  Reaction often enlarges diameter of the bone.

26. Osteoid Osteoma Unusual Radiographic Features  Cancellous location often has less reactive bone.  Medullary lesion often radiographically invisible.  Periarticular lesion mimics synovitis.

27. Osteoid Osteoma Imaging Studies  Intense diffuse increased uptake on bone scan  CT : Optimal for finding nidus in bone –Narrow slices identifies nidus - Speckled calcification in nidus – Nidus enhances with contrast  MRI - T-1 : Intermediate intensity nidus – T-2 : Bright intensity nidus  Optimal for finding nidus in medullary canal.

28. Osteoid Osteoma Historical Treatment Methods  Observation (NSAIDS)  Surgical resection (en bloc)  Shaving or curettage

29. Osteoid Osteoma Radiofrequency Ablation Technique  CT guided  Anesthesia  Cannulated system  Radiofrequency probe  6 minutes @ 90 degrees Celsius

30. RFA for Osteoid Osteoma  Now an outpatient procedure with minimal complications or morbidity  Typically 24-48 hour recovery and activity restrictions  Majority of patients return to full activity by 2 week follow up  Recurrent lesions amenable to repeat RFA  Image guidance with Computer Navigation helpful for difficult locations.

31. Osteoblastoma

32. Osteoblastoma Demographics  Age : 15 - 30  Sex : Male > Female  Site : Posterior elements of the spine Metaphyses of long bones

33. Osteoblastoma Natural History  Majority are slowly enlarging benign stage 2 lesions.  Occasionally “pseudomalignant” stage 3 behavior.  Rarely causes tumor associated osteomalacia.  No malignant transformation.

34. Osteoblastoma Radiographic Features  Well marginated radiolucent lesion.  Fine reticulated mineralization akin to fibrous dysplasia.  Pseudomalignant lesions resemble aggressive ABC and/or telangiectatic osteosarcoma.

35. Case Example Osteoblastoma Mimicking Internal Degrangement - Knee A 31 y/o marathon runner presented with symptoms of internal derangement of the knee. X-rays “normal.” Arthroscopic “shaving” x2 without relief. Chest X-ray and laboratory values WNL. A 31 y/o marathon runner presented with symptoms of internal derangement of the knee. X-rays “normal.” Arthroscopic “shaving” x2 without relief. Chest X-ray and laboratory values WNL.

36. Bone Tumors Mimicking Intra-articular pathology  Benign –Aneurysmal Bone Cyst –Giant Cell Tumor –Chondroblastoma –Osteoid Osteoma –Osteoblastoma  Malignant –Chondrosarcoma –Osteosarcoma –Ewing’s Sarcoma

37. Chondrosarcoma

38. Chondrosarcoma Demographics  Age : 40 - 70  Sex : M > F  Site : Pelvic Girdle Shoulder Girdle Proximal long bones

39. Chondrosarcoma Natural History  Stage I - slow growth, heavily mineralized,long interval to metastasis, often secondary, excellent DFS  Stage II - Rapid growth, lightly mineralized early metastases, usually primary, limited DFS

40. Chondrosarcoma Radiographic Features Intralesionalmatrix mineralization often described as rings and arcs, or popcorn calcification  Stage I - Heavily mineralized, usually surface, usually secondary, well marginated  Stage II - Lightly mineralized, usually central, usually primary, permeative radiolucency

41. Chondrosarcoma Imaging Studies  Plain Radiographs –Scalloping unreliable –Look for cortical thickening and / or destruction, periosteal reaction, soft tissue mass  MRI – Stage I - Low intensity heterogeneous signal – Stage II - High intensity homogenous signal  Isotope Scan –Stage I - moderate focal uptake –Stage II - intense diffuse uptake  CT –Stage I - Heavily calcified with “popcorn” pattern –Stage II - Radiolucent with punctate calcification  *Neither enhance with contrast

42. Chondrosarcoma Case Example  64 y.o. Real Estate Magnate  2 years of hip pain  Radiographs show DJD with juxtarticular cyst

43. Initial Treatement  To the OR for curretage bone, graft, and Total Hip Arthroplasty  Post-Op Film

44. Diagnosed with internal derangement Underwent arthroscopic surgery with tricompartmental debridement and a protracted post-operative course without improvement.

45. Clear Cell Chondrosarcoma  Treated with proximal tibial resection, allograft prosthetic replacement  Litigation followed.

46. Osteosarcoma

47. Osteosarcoma Demographics  Age : 15 - 30  Sex : M > F  Site : Metaphyses of large long bones

48. Osteosarcoma Radiographic Features  Permeative destructive lesion  Areas of amorphous ossification  Cortical breakthrough, interrupted Codman’s triangle, radial pattern of ossification  Occasionally purely radiolucent or entirely ossified

49. Osteosarcoma Imaging Studies  Intense extended uptake of isotope  CT - Random non-stressed pattern of ossification Enhances with contrast  MRI: T-1 - low intensity signal. Best chance of identifying “skips” – T-2 - Bright heterogeneous signal

50. Case Example 12 year old with knee pain. Avid soccer player.

51. Principles  Consider neoplasia in the differential diagnosis of pain  Imaging is indicated prior to surgical intervention  Listen to patients, therapists and family members regarding post injury and post surgical improvement  Patients that do not follow the expected clinical course should undergo further imaging –Radiographs –Bone scans –MRI

52. Presentation  If you would like to receive the full powerpoint presentation that includes pictures, please email the CME Coordinator at MSwink@McLeodHealth.org. MSwink@McLeodHealth.org