|Year : 2016 | Volume
| Issue : 1 | Page : 14-17
A typical radiographic presentation of osteosarcoma arising from skull and scapula: A rare case report
Vinay Kumar Reddy Kundoor1, Rashmi Chelimala1, Kotya Naik Maloth1, Kesidi Sunitha1, Moni Thakur2
1 Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Khammam, Telangana, India
2 Department of Oral Pathology and Microbiology, Mamata Dental College and Hospital, Khammam, Telangana, India
|Date of Web Publication||19-Feb-2016|
Kotya Naik Maloth
Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Giriprasad Nagar, Khammam - 507 002, Telangana
Source of Support: None, Conflict of Interest: None
Osteosarcoma is an aggressive malignant tumor of the bone. It can occur in any bone, but long bones are affected more such as femur (42%), tibia (19%), and humerus (10%), compared to short bones such as skull, head, and neck region (<10%). The typical radiographic appearance of sunray pattern and Codman's triangle is highly suggestive of osteosarcoma. Early diagnosis and surgical treatment is the key to high survival rate. Here, we present a case with typical radiographic appearance of osteosarcoma arising from skull and scapula in a 25-year-old male patient.
Keywords: Codman′s triangle, osteogenic sarcoma, sunray appearance
|How to cite this article:|
Reddy Kundoor VK, Chelimala R, Maloth KN, Sunitha K, Thakur M. A typical radiographic presentation of osteosarcoma arising from skull and scapula: A rare case report. J Oral Maxillofac Radiol 2016;4:14-7
|How to cite this URL:|
Reddy Kundoor VK, Chelimala R, Maloth KN, Sunitha K, Thakur M. A typical radiographic presentation of osteosarcoma arising from skull and scapula: A rare case report. J Oral Maxillofac Radiol [serial online] 2016 [cited 2022 Jan 27];4:14-7. Available from: https://www.joomr.org/text.asp?2016/4/1/14/177058
| Introduction|| |
Osteosarcoma is a most common primary malignant aggressive tumor affecting long bones, and rarely affecting the short bones (ileum, clavicle, sacrum, scapula, and clavicle), skull, head, and neck region. The incidence is about 1%-2% of all skull tumors, , and <10% in head and neck region.  The most common complications of osteosarcoma are bone pain, bone fracture, lung metastases, reduced red blood cells, increased alkaline phosphate levels, and loss of limb.  In the literature, only few cases are reported involving skull and short bones, and those of reported are frequently associated with osteosarcoma of the maxillomandibular complex.  Here, a rare case of osteosarcoma arising from skull and scapula is reported.
| Case Report|| |
A 25-year-old male patient reported to the department with a chief complaint of swelling on the right skull and left shoulder region with a 2-year history, which had rapidly enlarged within 4 months. Physical examination demonstrated a 10 cm × 14 cm firm to hard, nontender mass, fixed to bone in the right parietal-temporal area [Figure 1] and [Figure 2], and a similar mass measuring 8 cm × 6 cm on the left shoulder region with well-circumscribed macules 12 in number measuring approximately 1 cm × 1 cm [Figure 3]. Medical history was noncontributory. On laboratory investigations, alkaline phosphatase level was raised (329 IU/L). Radiographical examination with posterior-anterior skull view revealed well-defined radiopaque lesion involving right temporal and parietal bone with typical "sunray appearance" [Figure 4], a well-defined radiopaque lesion was also noted on scapula of the left shoulder and multiple radiopaque foci were seen in the lungs [Figure 5]. An axial view of skull computed tomography (CT) scan showed hyperdense lesion extending in the extra- and intra-cranial region with "sunray appearance" [Figure 6]. Lesion on the skull was surgically excised and sent for histopathology, which revealed small round cell proliferation with excessive fibrogenesis, myxoid area, and osteoid formation with occasional areas of chondroid. Neoplastic cells are scattered in groups, islands, and capillary structures. They were suggestive of small cell osteogenic sarcoma. Based on clinical, radiographical, and histopathological findings, a final diagnosis of small cell osteosarcoma was considered [Figure 7]. The patient was operated surgically and referred to higher center for chemotherapy, where high doses of intravenous (IV) methotrexate 12 g/m 2 every week for 4 weeks and cisplatin IV 60 mg/m 2 once in a 3 weeks for 3-month were administered, and the patient is under follow-up since 6-month [Figure 8].
|Figure 4: Posterior-anterior skull view showing radiopaque lesion with typical "sunray appearance"|
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|Figure 5: Shoulder radiograph showing radiopaque lesion on scapula with metastasis of lung|
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|Figure 6: Axial view of computed tomography scan showing radiopaque lesion in extra- and intra-cranial region with "sunray appearance"|
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|Figure 7: Histopathology picture showing small round cell proliferation with fibrogenesis, myxoid, osteoid, and chondroid areas|
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|Figure 8: Postoperative photograph after 1 month (a) Profile view (b) Lateral view|
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| Discussion|| |
Osteosarcoma is a common primary sarcoma of bone. It was first termed by French surgeon Alexis Boyer in 1805.  It can occur at any age, affecting mostly the younger children and about one-third occurs in older adults above 40 years of age. , "Osteosarcoma is classified as a component of Ewing's sarcoma. Generally involving are long bones such as the femur, tibia, and humerus and very rarely arising are from the short bones such as ileum, clavicle, scapula, and sacrum."  The present case was seen in a 25-year-old male involving skull and scapula.
The exact etiology and pathogenesis of osteosarcoma are unknown, but according to Hudson et al.,  the risk factors associated with osteosarcoma are rapid bone growth during the adolescence, environmental factors such as radiation, and genetic predisposition in bone dysplasias such as Paget's disease and fibrous dysplasia.
Males are affected more commonly than females with a ratio of 1.4:1. , The majority of craniofacial lesions involve the zygomatic bone.  The most common presenting signs and symptoms are swelling, pain, or both, if the patient is asymptomatic, it is diagnosed accidentally or following a traumatic event.  In the present case, the patient reported with a painless swelling.
Hayden and Hoang  classified osteosarcoma into different subtypes,
- Conventional osteoblastic (70%),
- Chondroblastic and fibroblastic (10%),
- Rare subtypes of anaplastic, telangiectatic, giant-cell rich, and small cell (<10%).
The fibroblastic subtype has good response to chemotherapy than chondroblastic subtype. The case reported here is a small cell subtype of osteosarcoma, which accounts <10%.
The plain radiography plays a major role in the initial diagnosis of bone tumors.  The typical or classic radiographic presentation of osteosarcoma is "sunray appearance" of the affected bone.  The extent of the tumor in both bone and soft tissue is best appreciated in higher imaging modalities such as CT scan and magnetic resonance imaging (MRI).  In the present case, MRI and positron emission tomography CT could not be done due to financial status of the patient, and he was more concerned about lesion on the skull due to esthetics and was not willing for any treatment for lesion on the scapula.
The treatment modalities depend on the severity and extent of the lesion manifested in the bone. Neoadjuvant chemotherapy, surgery, and postoperative chemotherapy are mainstay of the treatment. Large lesions can be treated with surgical excision, including large margins of normal bone to prevent recurrence. According to Kaste,  osteosarcoma metastasis to lungs has a recurrence rate of approximately 30%. The present case was treated surgically and referred to higher centers for chemotherapy, where combination of drugs such as methotrexate and cisplatin were administered.
| Conclusion|| |
Although osteosarcoma is a common aggressive malignant tumor of bone, its occurrence is rare in short bones and head and neck region. The clinician should be aware of the clinical and typical radiographic appearance of the lesion that may help in early diagnosis and prompt treatment to prevent the mortality, as it has a poor prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]