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Dedifferentiated chondrosarcoma is defined by the presence of a low grade malignant cartilaginous component juxtaposed to a high grade malignant non-cartilaginous sarcomatous components. Only 4 cases in which the high grade component showed epithelial differentiation have been reported in the literature; three featured a squamous and the one a glandular epithelial component. Here we describe a case of dedifferentiated chondrosarcoma exhibiting epithelial “adamantinoma-like” basaloid features. The patient underwent wide resection of the proximal tibia and post-operative chemotherapy and died 8 months after the diagnosis due to lung and bone metastases.

We report two cases of sclerosing epithelioid fibrosarcoma occurring in the deep soft tissue of the thigh, confirmed by molecular analysis and associated with bone metastases in the lumbar vertebrae and the iliac wing at the time of diagnosis. Synchronous bone metastases of sclerosing epithelioid fibrosarcoma are extremely difficult to diagnose because clinical and radiological features are not specific. In addition, the range of differential diagnoses is very wide, including metastatic carcinoma and osteosarcoma. At present, all but three published cases of sclerosing epithelioid fibrosarcoma with bone metastases showed bone metastases during follow-up. We confirm in our two cases that the distinct pattern of immunohistochemical staining for MUC4, associated with the absence of staining for both SATB2, a marker of osteoblastic differentiation, and pan-cytokeratin, allows differentiating between sclerosing epithelioid fibrosarcoma and metastatic carcinoma or osteosarcoma.

International audience; PurposeTo assess the accuracy of water-enema multidetector computed tomography (WE-MDCT) in extra-rectal colon cancer staging.Materials and methodsFifty-three patients (mean age 70years) with extra-rectal colon cancer proven by colonoscopy and biopsy were prospectively evaluated by preoperative WE-MDCT. CT scans were both intraluminal (water enema or WE) and intravenous (iodinated) contrast enhanced (CE). All patients underwent surgery. Tumors were classified with the TNM staging system. Noted CT features were: tumor size and location; tumor form and edges; spread to the pericolic fat or neighboring organs; thickening of retroperitoneal fascia; number, size, and enhancement of the peritumoral lymph nodes. Tumors were classified on CT into 3 T-stage groups: T1/T2, T3, and T4. Lymph nodes were classified by their density after injection [positive over 100 Hounsfield units (HU)].ResultsTumor localization to the specific colon segment was correct in all the cases. The agreement between WE-MDCT staging and histopathology staging was good (k=0.64). An irregular and bowl-shaped aspect of the external edges of tumor provided excellent sensitivity for T3/T4 inclusion (Se 97.7%, NPV 85.7%). Thickening of a fascia or the abdominal wall provided good specificity for T4 stage (Sp 88.1%, NPV 94.9%). Enhancement over 100HU of at least one peritumoral lymph node was the best criterion of N+ staging (Sp 67.7%, NPV 87.5%).ConclusionWE-MDCT permits good staging of colon cancer based on objective features.

Primary malignant chest wall tumors are rare. The most frequent primary malignant tumor of the chest wall is chondrosarcoma, less common are primary bone tumors belonging to the Ewing Family Bone Tumors (EFBT), or even rarer are osteosarcomas. They represent a challenging clinical entities for surgeons as the treatment of choice for these neoplasms is surgical resection, excluding EFBT which are normally treated by a multidisciplinary approach. Positive margins after surgical procedure are the principal risk factor of local recurrence, therefore to perform adequate surgery a correct preoperative staging is mandatory. Imaging techniques are used for diagnosis, to determine anatomic site and extension, to perform a guided biopsy, for local and general staging, to evaluate chemotherapy response, to detect the presence of a recurrence. This article will focus on the role of imaging in guiding this often difficult surgery and the different technical possibilities adopted in our department to restore the mechanics of the thoracic cage after wide resections.

Extraskeletal myxoid chondrosarcoma is a rare neoplasm of soft tissue. The usual location is in deep parts of the proximal extremities and limb girdles in middle-aged adults. The bone location as primary location is extremely rare and few cases are reported. We present three cases arising in bone with molecular confirmation using both RT-PCR and FISH analysis. Patients include two men and one woman with an age of 62, 69 and 73 years old. The mean size of the lesion was 13 cm (range 8–18 cm). Tumors arose in the iliac bone in two cases and in the proximal humerus in the other case. At time of diagnosis the three cases show bone cortex and soft tissue involvement. On imaging, lesions have a lobular pattern, are purely lytic, but take up contrast medium after injection. Two patients are alive with disease (local recurrence and lung metastasis) after five years and five years and six months, respectively and one patient died of disease two years after the diagnosis. The primary extraskeletal myxoid chondrosarcoma of bone seems to have a more aggressive behavior than the soft tissue counterpart. The molecular confirmation of diagnosis using RT-PCR is necessary to do the differential diagnosis with other entities, in particular with myoepithelioma that shows similar morphological features and EWSR1 and FUS genes rearrangement.

Although retroperitoneal sarcomas are rare tumours, they can be encountered by a wide variety of clinicians as they can be incidental findings on imaging or present with non specific symptoms and signs. Surgical resection can offer hope of cure and patient outcomes are improved when patients are managed in high-volume specialist centers. Failure to recognize retroperitoneal sarcomas on imaging can lead to inappropriate management in inexperienced centers. Therefore it is critical that a diagnosis of retroperitoneal sarcoma should be considered in the differential diagnosis of a retroperitoneal mass with prompt referral to a soft tissue sarcoma unit. In particular, the most common retroperitoneal sarcoma subtypes, liposarcoma and leiomyosarcoma, have characteristic imaging appearances which are discussed. This review therefore aims to set the context and guide clinicians through a diagnostic pathway for retroperitoneal masses in adults which arise extrinsic to the solid abdominal viscera.

Clear cell sarcomas are aggressive, rare soft tissue tumors and their classification among melanoma or sarcoma is still undetermined due to their clinical, pathologic, and molecular properties found in both types of tumors. This is a retrospective study of 52 patients with CCS seen between April 1979 and April 2005 in two institutions. The EWS-ATF-1 fusion transcript was studied in 31 patients and an activating mutation of theBRAForNRASgene was researched in 22 patients. 30 men and 22 women, with a mean age of 33 were studied. Forty-three tumors (82.69%) were located in the extremities, specially the foot (19 tumors). Median initial tumor size was 4.8 cm (1 to 15 cm). Necrosis involving more than 50% of the tumor cells was found in 14 cases (26.92%). High mitotic rate (>10) was found in 25 cases (48.07%). The EWS/ATF-1 translocation was found in 28 (53.84%) of 31 patients studied, and mutation ofBRAForNRASwas found in only 2 of 22 patients analyzed cases (3.84%). Among the tumor-associated parameters, only tumor size (>4 cm) emerged as a significant prognostic factor. Forty-nine patients had a localized disease at diagnosis (94.23%) and underwent surgical resection immediately (90%) or after neoadjuvant chemotherapy (CT) (10%). Various CT regimens were used in 37 patients (71.15%) with no significant efficacy. The 5- and 10-year OS rates were 59% and 41%, respectively. Tumor size was the only emerging prognosis factor in our series. Complete surgical resection remains the optimal treatment for this aggressive chemoresistant tumor.

The ‘leave me alone’ bone lesions are very classical, and, as indicated by their name, do not require any further investigation. There are very typical cases, and there are also more difficult ones, and they can be especially difficult to manage if the patient has a known cancer.

Soft tissue sarcomas are rare tumors. They may occur in any part of the body. Early step of management are essential because they directly affect functional consequences and survival of patients. It is very important to rapidly evoke the diagnostic of soft tissue sarcoma. Multidisciplinary discussion is indispensable at different step of the management: before the diagnostic to organize radiological check up and preoperative biopsy, before resection of localized tumor to decide the surgical procedure, with anatomopathological results to discuss an adjuvant treatment, at metastatic setting to decide a systemic treatment to start or inclusion in a clinical trial.

RESUME Les sarcomes des tissus mous sont definis comme les tumeurs malignes developpees aux depens du tissu conjonctif commun extra-squelettique : tissu adipeux, tissu musculaire, vaisseaux et systeme nerveux peripherique. L’entite « sarcomes des tissus mous » recouvre une cinquantaine de types et sous types histologiques differents. Leur prise en charge initiale est defectueuse dans plus de la moitie des cas ce qui a des consequences fâcheuses sur le pronostic. L’exerese chirurgicale correctement effectuee d’emblee, c’est-a-dire passant partout en tissu sain au-dela des ilots tumoraux, est de loin le facteur pronostique essentiel pour la survie de ces malades. Les rattrapages radiotherapiques et/ou chimiotherapiques ne sont pas satisfaisants ni pour la survie ni pour la fonction. Ceci entraine donc les recommandations suivantes : toute tumeur des tissus mous susceptible d’etre maligne, soit parce que survenant chez un enfant, soit parce que profonde, soit parce que de taille superieure a trois centimetres necessite un examen IRM avec injection, suivi d’une biopsie effectuee selon les criteres oncologiques reconnus, La prise en charge inclue l’envoi des lames a un laboratoire competent referent, car ces tumeurs sont frequemment d’interpretation et de classement difficiles. Ce n’est qu’apres ces examens qu’un geste chirurgical adapte pourra etre effectue en accord ou au sein d’un centre referent, comme cela se passe deja ou devrait se passer pour les tumeurs osseuses malignes dans la quasi totalite de notre pays.

At present, there is no standardised approach for the radiological evaluation of soft tissue sarcomas following radiotherapy (RT). This manuscript, produced by a European Organisation for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) and Imaging Group endorsed task force, aims to propose standardisation of magnetic resonance imaging techniques and interpretation after neoadjuvant RT for routine use and within clinical trials.

Tenosynovial giant cell tumour, diffuse type, also known under a variety of other terms including diffuse pigmented villonodular synovitis, tends to be locally aggressive and not infrequently can show multiple recurrences. The differential diagnosis with the extremely rare and somewhat controversial malignant variant of tenosynovial giant cell tumour, diffuse type, is challenging due to overlapping radiologic features of these two entities. Malignant tenosynovial giant cell tumour is defined by the presence of overtly malignant sarcomatous areas. We describe a very unusual case of a 63-year-old man affected by tenosynovial giant cell tumour, diffuse type of the knee that, despite absence of morphologic evidence of sarcomatous transformation, developed inguinal lymph node metastases following multiple surgical procedures.

To report the imaging findings of 24 periosteal chondrosarcomas diagnosed, staged, treated and followed in a single institution, to analyze and define their pattern, and discuss their practical consequences.Plain films, 16 CT examinations and four MRI examinations were reviewed, and compared with the histological evaluation.There were 20 men and four women, aged from 17 to 65 years. Twelve lesions involved the distal femoral metaphyses (8 posteriorly), five the proximal humerus, two the proximal metaphyses of the femur and two of the tibia, two the humeral shafts and one the iliac wing. Size varied from 4 to 11 cm. The cortex was always involved (thick, 15; thin, 13). Typical cartilaginous calcifications and cartilaginous lobules were very frequent. Radial thick periosteal bone formations (n = 6) indicated calcifications between the lobules of cartilage. Medullary involvement was rare (n = 2). All patients are alive and free of disease.Recognizing periosteal chondrosarcoma is of paramount importance because the prognosis is excellent after adequate local surgery alone. The patterns of other surface tumors of bone are usually different.

The appropriate diagnosis and treatment of bone tumors requires close collaboration between different medical specialists. Imaging plays a key role throughout the process. Radiographic detection of a bone tumor is usually not challenging. Accurate diagnosis is often possible from physical examination, history, and standard radiographs. The location of the lesion in the bone and the skeleton, its size and margins, the presence and type of periosteal reaction, and any mineralization all help determine diagnosis. Other imaging modalities contribute to the formation of a diagnosis but are more critical for staging, evaluation of response to treatment, surgical planning, and follow-up.When necessary, biopsy is often radioguided, and should be performed in consultation with the surgeon performing the definitive operative procedure. CT is optimal for characterization of the bone involvement and for evaluation of pulmonary metastases. MRI is highly accurate in determining the intraosseous extent of tumor and for assessing soft tissue, joint, and vascular involvement. FDG-PET imaging is becoming increasingly useful for the staging of tumors, assessing response to neoadjuvant treatment, and detecting relapses.Refinement of these and other imaging modalities and the development of new technologies such as image fusion for computer-navigated bone tumor surgery will help surgeons produce a detailed and reliable preoperative plan, especially in challenging sites such as the pelvis and spine.

Background: Patellar tumors are rare; only a few series have been described in the literature and radiographic diagnosis can be challenging. We reviewed all patellar tumors at one institution and reviewed the literature. Materials and methods: In an evaluation of the database at one institution from 1916 to 2009, 23,000 bone tumors were found. Of these, 41 involved the patella. All had imaging studies and microscopic diagnostic confirmation. All medical records, imaging studies, and pathology were reviewed. Results: There were 15 females and 26 males, ranging from 8 to 68 years old (average 30). There were 30 benign tumors; eight giant cell tumors, eight chondroblastomas, seven osteoid osteomas, two aneurysmal bone cysts, two ganglions, one each of chondroma, exostosis, and hemangioma. There were 11 malignant tumors: five hemangioendotheliomas, three metastases, one lymphoma, one plasmacytoma, and one angiosarcoma. Conclusion: Patellar tumors are rare and usually benign. As the patella is an apophysis, the most frequent lesions are giant cell tumor in the adult and chondroblastoma in children. Osteoid osteomas were frequent in our series and easily diagnosed. Metastases are the most frequent malignant diagnoses in the literature; in our series malignant vascular tumors were more common. These lesions are often easily analyzed on radiographs. CT and MR define better the cortex, soft tissue extension, and fluid levels. This study presents the imaging patterns of the more common patellar tumors in order to help the radiologist when confronted with a lesion in this location. © 2011 Elsevier Ireland Ltd. All rights reserved.

Introduction Primary bone tumors are rare and require a multidisciplinary approach. Diagnosis involves primarily the radiologist and the pathologist. Bone lesions are often heterogeneous and the microscopic diagnostic component(s) may be in the minority, especially on core needle biopsies. Reactive processes, benign, and malignant tumors may have similar microscopic aspects. For these challenging cases, the correlation of microscopic and radiologic information is critical, or diagnostic mistakes may be made with severe clinical consequences for the patient. The purpose of this article is to explain how pathologists can best use imaging studies to improve the diagnostic accuracy of bone lesions. Diagnosis Many bone lesions are microscopically and/or radiographically heterogeneous, especially those with both lytic and matrix components. Final diagnosis may require specific microscopic diagnostic features that may be present in the lesion, but not the biopsy specimen. A review of the imaging helps assess if sampling was adequate. The existence of a pre-existing bone lesion, syndrome (such as Ollier disease or multiple hereditary exostosis), or oncologic history may be of crucial importance. Finally, imaging information is very useful for the pathologist to perform accurate local and regional staging during gross examination. Conclusion Close teamwork between pathologists, radiologists, and clinicians is of utmost importance in the evaluation and management of bone tumors. These lesions can be very difficult to interpret microscopically; imaging studies therefore play a crucial role in their accurate diagnosis.

To present the results of biopsy and computed tomography (CT) guided radiofrequency ablation (RFA) for non-spinal osteoid osteomas, and compare the results before and after procedural modifications. We retrospectively studied 557 patients with non-spinal osteoid osteomas treated with biopsy and CT-guided RFA. In 68 patients we used 3-mm CT at 2-mm intervals, 19 G/5-mm active tip electrodes, and one 4-minute ablation at 90–93°C. In 489 patients we used contiguous 1-mm CT, 20 G/5-15-mm electrodes, ablation maintaining 60°C for 2 min followed by 14–15 min at 90–93°C, and multiple ablations in the same session for large and multiform lesions. 533/557 patients (96%) remained asymptomatic and 24/557 (4%) had recurrence; repeat RFA was successful in 22/24 patients (92%). Biopsy was non-diagnostic in 82%. With the modifications performed, success improved from 79% to 98%, recurrences reduced from 21% to 2% and complications from 5.9% to 0.2% (p

Introduction Parosteal osteosarcomas and well-differentiated liposarcomas (WDLPS) of soft tissue share several features: they are slowly progressive, locally aggressive tumors, tend to recur locally, and rarely or never metastasizes if not dedifferentiated. Their treatment is wide surgical resection. Microscopically, both are well differentiated tumors, very like their normal tissue counterpart. They share simple karyotypes with supernumerary ring chromosomes or giant marker chromosomes containing amplified 12q sequences including MDM2 and CDK4 genes, with subsequent overexpression of MDM2 and CDK4 proteins. We present the case of a parosteal osteoliposarcoma made of closely intermingled components of a low-grade osteosarcoma and a WDLPS. Case In a 34 year-old woman with a slowly growing mass of the arm, imaging revealed a large well-defined heterogeneous parosteal mass of the upper humerus, with two main components: bone at the base and fat at the periphery. Microscopically, these two components were consistent respectively with low grade osteosarcoma and WDLPS. Cells of the two components were labeled with anti-CDK4 antibody. No labeling with anti-MDM2 antibody and no signal detected with MDM2 FISH analysis were likely due overdecalcification. No frozen tumor tissue was available for FISH analysis nor array-CGH. Discussion Differential diagnoses of this new entity would be a well-differentiated liposarcoma with a low-grade osteosarcomatous component that originates from the soft tissues, ruled out on imaging, and an ossifying parosteal lipoma, ruled out on immunohistochemistry. Conclusion This is the first description of a low-grade parosteal sarcoma with two components that morphologically and immunophenotypically demonstrate characteristics of a parosteal osteosarcoma and of a well-differentiated liposarcoma.

Soft tissue sarcomas are rare tumors. They may occur in any part of the body. Early step of management are essential because they directly affect functional consequences and survival of patients. It is very important to rapidly evoke the diagnostic of soft tissue sarcoma. Multidisciplinary discussion is indispensable at different step of the management: before the diagnostic to organize radiological check up and preoperative biopsy, before resection of localized tumor to decide the surgical procedure, with anatomopathological results to discuss an adjuvant treatment, at metastatic setting to decide a systemic treatment to start or inclusion in a clinical trial.

Introduction Elastofibroma dorsi is a rare pseudotumor of the soft tissues. Its clinico-radiologic characteristics lead to a correct diagnosis. Material and methods We followed 43 patients with elastofibroma dorsi with a confirmed histological diagnosis or on the basis of typical imaging pattern (ultrasound, CT, MR) confirmed by evolution. Results Elastofibroma is prevalent in females, its onset occurs around 60 years of age and is most frequently localized in the deep subscapular region (93%), bilateral in 54% of cases. In 7% it was found in an atypical isolated suprascapular region, in 7% it was synchronous to that in the subscapular region. Four ultrasound patterns were detected: Type I (54%) inhomogeneous fasciculated, Type II (22%) inhomogeneous aspecific, Type III (15%) hyperechogeneous, Type IV (9%) hypoechogeneous. Three patterns were detected at CT and MR: Type A (84%) inhomogeneous fasciculated corresponding to Types I and III and partially to Type II ultrasound pattern, Type B (8%) inhomogeneous aspecific corresponding to Type II ultrasound pattern; Type C (8%) homogeneous isodense or isointense to the muscle corresponding to Type IV ultrasound pattern. Conclusion A solid, slow-growing lesion, in the deep periscapular region in females aged between 50 and 60 years, with a typical fasciculated pattern is pathognomonic of elastofibroma dorsi and bilateral location convalidates diagnosis. Ultrasound is sufficient to orientate diagnosis. CT and/or MR are reserved only for non-fasciculated ultrasound patterns, when site is atypical or in candidates for surgery. Biopsy is reserved only in cases where integrated imaging shows a non-fasciculated pattern to differentiate it from other malignant lesions.

Soft tissue benign masses and potentially malignant sarcomas are unfortunately not uncommon [1, 2, 3]. Some investigators have stated that based on the morphological features and signal intensity, as demonstrated by magnetic resonance imaging (MRI) radiologists are able to precisely characterize soft-tissue lesions in some 80% of cases. However, others have noted that most imaging appearances are nonspecific and that, at most, a correct histological result based on imaging can be reached in only 25–35% of cases [2, 3].

Introduction The differential diagnosis between benign and low-grade well-differentiated malignant lipomatous tumors might be very difficult for both the radiologist and the pathologist, although it has practical consequences. Among the criteria, muscular fibers detected inside the lesion are considered radiologically and histologically as a reliable sign of a benign intramuscular lipoma. New genetic criteria are now available. We report two cases of fat tumors containing muscular fibers both radiologically and histologically, but which are definitely malignant, considering genetic criteria. Material and methods Two cases of soft tissue fat tumors, containing muscular fibers on imaging examinations as well as histologically, had an aggressive behaviour, suggesting malignancy. Genetic criteria were therefore used to confirm the clinical impression. Results MDM2 and CDK4 confirmed the malignancy in the two cases. Conclusion Intra lesional muscular fibers detected on imaging or histological examinations should not be considered as a completely reliable sign of a benign intramuscular lipoma. In case of atypical clinical behaviour, genetic criteria should be used to prove the aggressiveness of the tumor.

In the seventies, limb-sparing surgery and radiation therapy appeared capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremities. No survival benefit could be demonstrated in the patients selected for amputation. Microscopically positive surgical margins are related to a greater risk of local recurrence, whereas overall survival is compromised by high grade and large tumor size. Presurgery multidisciplinary discussion, management in reference center and management within cancer network independently predict conformity to the clinical practice guidelines. Reoperation should be a planned part of definitive management whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. Soft tissue flap reconstruction facilitates therapy for patients with locally advanced tumors so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Vascular reconstruction is a feasible option in case of involvement of major vessels. Isolated limb perfusion (ILP) with TNF and chemotherapy is an efficient limb-sparing neoadjuvant therapy for locally advanced limb soft tissue sarcomas. Efficacy and safety of low-dose TNFalpha could greatly facilitate ILP procedures in the near future.

Retroperitoneal sarcomas comprise approximately 15% of all soft tissue sarcomas and 50% of all retroperitoneal tumours. Helical CT of the abdomen and pelvis, with selective use of MRI will establish the extent of the tumour, its retroperitoneal location, the degree of necrosis, and the evidence of metastasis. A CT guided core needle biopsy is the optimal pre operative tissue sampling. A complete surgical resection is the mainstay of the treatment with a rim of normal tissue that often requires removal of adjacent organs. The 5-year probability of local control is approximately 50%. The role of adjuvant therapy is evolving and at present should not be used outside the investigational setting.

BACKGROUND: The optimal dose of TNF-alpha delivered by isolated limb perfusion (ILP) in patients with locally advanced soft tissue sarcoma is still unknown. PATIENTS AND METHODS: Randomised phase II trial comparing hyperthermic ILP (38-40 degrees ) with melphalan and one of the four assigned doses of TNF-alpha: 0.5 mg, 1 mg, 2 mg, and 3/4 mg upper/lower limb. The main end point was objective tumour response on MRI. Secondary end points were histological response, rate of amputation and toxicity. Resection of the remnant tumour was performed 2-3 months after ILP. The sample size was calculated assuming a linear increase of 10% in the objective response rates between each dose level group. RESULTS: One hundred patients (25 per arm) were included. Thirteen per cent of patients had a systemic leakage with a cardiac toxicity in six patients correlated with high doses of TNF-alpha. Objective tumour responses were: 68%, 56%, 72% and 64% in the 0.5 mg, 1 mg, 2 mg and 3 or 4 mg arms, respectively (NS). Sixteen per cent of patients were not operated, 71% had a conservative surgery and 13% were amputated with no difference between the groups. With a median follow-up of 24 months, the 2 year overall and disease-free survival rates (95% CI) were 82% (73% to 89%) and 49% (39% to 59%), respectively. CONCLUSION: At the range of TNF-alpha doses tested, there was no dose effect detected for the objective tumour response, but systemic toxicity was significantly correlated with higher TNF-alpha doses. Efficacy and safety of low-dose TNF-alpha could greatly facilitate ILP procedures in the near future.

Generalization of breast screening programs requires efficient double reading of mammograms, which allows reduction of false negative interpretations, but it may be difficult to achieve. CAD (Computed Aided Detection) systems are dramatically improving and can now assist in the detection of suspicious mammographic lesions, either suspicious microcalcifications, masses or architectural distortion. Characterization of the lesions is improving as well. CAD mammography might complete or substitute to "human" double reading. The aim of this review is to present the main CAD systems commercially available, review the principles of CAD and discuss the results of CAD mammography. Specifically, the role of CAD within breast screening program, according to the results of recent prospective studies will be discussed.

Primary malignant bone tumors are rare. In one large series they constituted 0.2% of all neoplasms [1]. In the year 2000, the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program estimated 1,220,000 new cancer cases in the USA [2]. Of these patients, 20-85% may develop bone metastases [3, 4]. During the same period it was estimated there would be 1,400 sarcomas of bone [2]. In the UK, there were 527 new cases of primary bone cancer in 1999, with a rate of eight per million of the female population and 10 per million for the male population [5]. Despite their relative rarity, or perhaps because of it, radiologists need to be familiar with these lesions, which can mimic or be mimicked by benign and non-neo-plastic reactive lesions, so that imaging beyond the radiograph and biopsy is performed on a logical and knowledgeable basis. The spectrum and breadth of primary bone tumors is extensive, as outlined by the 2002 tables of the World Health Organization [6]. (WHO) and the American Joint Committee on Cancer (AJCC) [7]. The relative frequencies of bone sarcomas according to histological type, sex, and race are shown in Table 1 [8]. No classification system, however, is so allencompassing as to include traumatic reactive and infective lesions, all of which have to be considered by the radiologist when faced with a seemingly neoplastic lesion. Primary bone tumors as a group are bimodal, the first peak occurring during the second decade of life and the second peak in patients older than 60. Osteosarcoma, the most common non-hematological primary malignancy of bone, occurs predominantly in individuals younger than age 20, and in 80% of these patients the tumor is found in a long bone of the extremity. The predilection for the appendicular skeleton tends to decrease with age, and in patients older than 50, osteosarcoma accounts for 50% of extremity lesions [6]. Chondrosarcomas show a gradual increase in incidence rates up to the age of 50. Half of chondrosarcomas occur in the long bones; other major sites are the pelvis and ribs. Ewing’s sarcoma is similar to osteosarcoma in its age incidence and affinity for the long bones but, unlike osteosarcoma, it occurs almost exclusively in the white population (Table 1). Other selective primary tumors will be discussed under separate headings. The modality that has been introduced to the realm of orthopedic oncology since the previous edition of this volume is positron emission tomography (PET). Elevated 18-fluoro-2-deoxyglucose (18-FDG) accumulation has been demonstrated in a variety of malignant tissues, including sarcomas, and this information can be used to augment the information obtained from conventional imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI). IDKD 2005

To describe and correlate with radiation therapy the occurrence of cerebral radiation necrosis in patients irradiated for nasopharyngeal or ethmoidal tumor. Materials and Methods. From 1986 to 1998, 1 201 patients, 981 with nasopharyngeal tumors, and 220 with ethmoidal tumors were treated by radiotherapy. Twenty eight developed cerebral necrosis. MRI were performed in all patients and CT in 18 patients. Diagnosis was considered at imaging, and confirmed by follow-up.The incidence of cerebral radionecrosis was 2.33%. The time interval between treatment and necrosis ranged from 2 months to 9 years. CT showed edema and/or focal enhancement in all cases except for 4 patients with normal CT examinations. MRI showed edema and/or abnormal focal punctate or gyriform enhancement in all patients. Lesions were localized in the temporal lobe (n=18), frontal lobe (n=9), pons (n=3) and optic nerve (n=2). The doses related to the areas of necrosis ranged from 13 to 135Gy. In 2 cases necrosis was situated at the boundaries of the radiation field. Imaging follow-up showed complete (n=3) or incomplete remission (n=1), lesion progression (n=11), cerebral atrophy (n=5) and stability (n=7).MRI is useful to diagnose cerebral necrosis. New technologies may reduce the incidence of this complication.

Two patients with histologically proven port-site metastasis following laparoscopic procedures for ovarian cancer underwent a CT scan. These two patients were initially treated for a stage IA and III ovarian cancer. Port-site recurrence occurred six and 19 weeks following the laparoscopic procedure. In one patient, the abdominal wall recurrence was associated with peritoneal carcinosis. In both patients, CT scan revealed the presence of an heterogeneous nodular lesion inside the left oblique muscle. Histologic analysis confirmed the diagnosis of port-site recurrence.Port-site metastases could be observed in the treated patients with a laparoscopic approach for ovarian cancer. When this diagnosis is clinically suspected, a CT scan should be performed in order to precise the diagnosis of port-site metastasis and to evaluate potential intra-abdominal recurrent disease. However, only histologic examination can confirm a diagnosis of port-site recurrence.

Clear cell adenocarcinoma (CCA) of the vagina and the cervix is a rare tumour. Since 1971 its increased incidence has been ascribed to intrauterine exposure to diethylstilboestrol (DES) and as a consequence the US Food and Drug Administration has banned the use of all DES-type medications during pregnancy. We report a case of CCA demonstrated by magnetic resonance imaging.

To assess the value of the CT guided percutaneous biopsy of renal tumors and to promote the interest of this procedure.We report a retrospective study of 67 patients (average age, 51 years) who underwent CT guided biopsy of a single renal mass. The average size of tumors was 5 centimeters. The biopsy of tumors was carried out with needles between 16 and 21 gauge by using a conventional CT. Two to three passes per tumor were obtained.Biopsy material was sufficient for diagnosis in 48 cases (72%). A renal cell carcinoma was found in 29 (43%) samples of biopsy. The remainder included 13 metastases or lymphomas (18%). A benign lesion was found in 6 cases (9%). 59 patients had a final diagnosis. Accuracy of the biopsy for histopathologic evaluation was 81%. The average lesion size of failed biopsies was 1.5 centimeters. Morbidity occurred in 13% of cases, without immediate life threatening consequence.CT-guided renal biopsy is an effective means of obtaining tissue for the diagnosis of focal renal masses. The indications are renal lesions locally advanced, multimetastatic patients, mass in patients with a single kidney and focal lesions in patients with prior history of malignancy.

The aim of this retrospective study was to assess the advantages of free-lap reconstruction in locally advanced soft tissue sarcomas.From October 1997 to October 2000, among 256 procedures for sarcomas, 25 were associated with free-lap reconstruction. There were 16 women and nine men (mean age: 45 years). The tumor was located on inferior limbs (n = 15), superior limbs (n = 3) and trunk (n = 7), had a mean size of 12, 10 and 12 cm respectively, and was multifocal (n = 6), or recurrent (n = 10). Ten patients received a neoadjuvant chemotherapy. Tumoral excision was associated with a complementary procedure in 10 patients. Reconstruction was performed with free-laps of the latissimus dorsi (n = 21) and transverse rectus abdominis myocutaneous (TRAM) (n = 4). Early postoperative radiotherapy was associated in 15 patients.Median duration of the procedure was 6.5 hours. There were no postoperative deaths. Two free-laps necrotized and another free-lap was constructed. Tumoral excision was Ro (n = 20), R1 (n = 4) and R2 (n = 1). With a median follow-up of 20 months, there were no local recurrences in patients Ro. Ten patients developed pulmonary metastases and five of them died.With free-lap reconstruction, tumoral excision was larger, amputation of the limb was avoided in 14 patients, and early postoperative radiotherapy was possible in 15 patients. Multidisciplinary management and collaboration of the oncologist and plastic surgeon are associated with a better prognosis of locally advanced soft tissue sarcomas.

A 58 year old woman suffering from lumbalgia over 3 years is admitted for bilateral cruralgia. Ten years before, she was treated for cervix carcinoma by hysterectomy, pelvic and lumbo-aortic radiotherapy and chemotherapy. On admission, physical examination reveals L2 level hypoesthesia and abolition of deep tendon reflexes. Plain films and CT scan show a lysis of L3, L4 and L5 vertebral bodies and a cuneiform appearance of vertebral body of L2 due to a large abdominal aortic aneurysm.

Ollier's disease is a rate affliction (not more than approximately 100 cases have been reported over a 30-year period) characterized by bone dysplasia in which evolution to degenerative neoplasia has been described. Diagnosis of chondrosarcoma is delicate in these cases. It is a kind of slowly evolving low grade malignant tumor. Surgery is the primary treatment course, and can lead to remission. Prognosis, depending on the number and dimension of the lesions, their localization and metastasis prevention, is usually good, but relapses are relatively frequent: 25 to 50%. In case of relapse, radiotherapy and chemotherapy were tested but their efficacy is limited. We report here two clinical cases and discuss literature data.

The prognosis for a patient with a musculoskeletal sarcoma has improved considerably over the past two decades largely due to the use of adjuvant chemotherapy. Surgical techniques have become more sophisticated with limb salvage, the preferred management in the majority of cases. Imaging plays an important role in the assessment of suspected local recurrence of tumor. This pictorial essay reviews the different imaging options and highlights various pitfalls in the detection and diagnosis of recurrence. The role of magnetic resonance imaging in this respect is stressed.