1990, The British Journal of Radiology, 63, 304-305
Case reports
The mechanism whereby the calcification has cleared in our patient is uncertain. Theoretically, spontaneous reduction in the amount of observed calcification could occur if a fistula developed, and intestinal perforation by a tuberculous psoas abscess has been reported (Blumenthal et al, 1981). However, no evidence for this was seen in our patient. At no time did either abscess contain air, and there has been no disturbance of bowel function. Similarly, surgical or percutaneous drainage of an abscess could also cause a reduction in the amount of calcification, but no such intervention was undertaken. Furthermore, colleagues who have had considerable experience in the field of spinal tuberculosis cannot recall seeing such an event (Griffiths, 1988; Murray, 1988). References BLUMENTHAL, D. H., MORIN, M. E., TAN A. & Li, Y. P.,
Figure 2. A radiograph taken in 1989 showing bilateral psoas abscesses but the calcification, particularly on the right side, is considerably less.
Calcification commonly occurs, and without intervention remains static.
1981.
Intestinal penetration by tuberculous psoas abscess. American Journal of Roentgenology, 136, 995-997. GRIFFITHS, D. LL., 1988. Personal communication. MURRAY, R. O., 1988. Personal communication. SEDDON, H. ET AL, 1973. Medical Research Council Working Party on Tuberculosis of the Spine, Second Report. Tubercle, 54, 261-282.
Osteosarcoma: an unusual thoracic metastasis By M. J. Charig, BSc, MRCP, FRCR, *S. J. Golding, FRCR and D. R. M. Lindsell, FRCR Department of Radiology, John Radcliffe Hospital, Oxford and *Regional CT Unit, Churchill Hospital, Oxford (Received July 1989)
Metastases from osteosarcoma often occur in the lungs, usually as multiple nodules but sometimes as a solitary mass. Lymph node involvement is unusual. We present a case of metastatic recurrence as a solitary, stellate, ossified, pulmonary mass extending across the pleura associated with ossified hilar lymphadenopathy. Case report A 15-year-old male, whose only previous medical history was resection of a right ventricular infundibular stenosis 18 months earlier, presented in November, 1987 with pain and swelling in the distal right femur. This proved on biopsy to be caused by an osteosarcoma, and after staging with chest radiograph, computed tomography (CT) and bone scintigraphy, no spread was evident. After three courses of cisplatinum and adriamycin, the distal femur containing the primary tumour was resected and a knee prosthesis inserted. Following three further courses of chemotherapy he. remained well for nearly a year, until March, 1989. A follow-up chest radiograph at this time revealed right paratracheal lymphadenopathy and an upper lobe mass (Fig. 1). A chest radiograph 2 months earlier had been normal. Computed tomography demonstrated an irregular, stellate mass with central ossification in the right upper
304
lobe, extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus (Fig. 2). The latter was connected to the mass by strands of ossified material. Scintigraphy with "Tcm-hydroxy methylene diphosphonate ("TcmHMDP) revealed intense uptake in the mass and nodes but no skeletal metastases (Fig. 3). At thoracotomy ossified tumour was found to be invading through the pleura into the superior sulcus and was resected together with the involved nodes. Histology showed an osteoblastic osteosarcoma consistent with spread from the femoral primary. Discussion
The lungs are the most frequent site for metastases from osteosarcomas (Jeffree et al, 1975; Weiss & Gilbert, 1978). Pulmonary nodules are seen in 10% of patients at presentation and more than 70% at death (McKenna et al, 1966). The nodules are usually multiple and bilateral but in 35% of patients may be unilateral, as in this case. The usual appearance of pulmonary metastases from any primary is of well-circumscribed, spherical nodules (Crow et al, 1981) and those from osteosarcomas may contain calcification or ossification. The British Journal of Radiology, April 1990
Case reports
Figure 3. Posterior and anterior views shown on "Tc m -HMDP scintigrams.
Figure 1. Chest radiograph showing right paratracheal lymphadenopathy and an upper lobe mass.
Fifty-one per cent are subpleural and may cause spontaneous pneumothorax in 5% of patients (McKenna et al, 1966), while 49% are parenchymatous (Vanel et al, 1984). The best technique for demonstrating pulmonary deposits is CT; scintigraphy can detect only 5% of these
(Vanel et al, 1984). However, scintigraphy can demonstrate metastases at many sites, usually from osteoblastic primaries. Lymph node involvement is a bad prognostic sign in osteosarcoma (McKenna et al, 1966) and is uncommon, being seen in only 3% of patients, in life (Jeffree et al, 1975). However, in the same study, 26% of cases at post-mortem had spread to local, hilar, mediastinal, mesenteric or abdominal nodes. Lymph node deposits appear more common from an osteoblastic primary (Tobias et al, 1985; Madsen, 1979) than from other histological types and can be demonstrated by scintigraphy (Heyman, 1980). In our case the mass is unusual in that while lymph node deposits and metastatic uptake of "TCm-HMDP are more likely with an osteoblastic osteosarcoma, a solitary, invasive, stellate metastasis has not been previously described. Acknowledgments We wish to thank Dr M. Moncrieff and Mr S. Westaby for permission to report on their patient. The prints were prepared by Medical Illustration at the John Radcliffe Hospital.
References CROW,
J.,
SLAVIN,
G.
&
KREEL,
L.,
1981.
Pulmonary
metastasis: a pathologic and radiologic study. Cancer, 47, 2595-2602. HEYMAN, S., 1980. The lymphatic spread of osteosarcoma shown by Tc-99m-MDP scintigraphy. Clinical Nuclear Medicine, 5, 543-545. JEFFREE, G. M., PRICE, C. H. G. & SISSONS, H. A.,
1975.
The
metastatic patterns of osteosarcoma. British Journal of Cancer, 32, 87-107. MADSEN, E. H., 1979. Lymph node metastases from osteoblastic osteogenic sarcoma visible on plain films. Skeletal Radiology, 4, 216-218. MCKENNA,
R.
J.,
SCHWINN,
C.
P.,
SOONG,
K.
Y.
&
HIGINBOTHAM, N. L., 1966. Sarcomata of the osteogenic series (osteosarcoma, fibrosarcoma, chondrosarcoma, parosteal osteogenic sarcoma, and sarcomata arising in abnormal bone). Journal of Bone and Joint Surgery, 48A, 1-25. TOBIAS, J. D., PRATT, C. B., PARHAM, D. B., GREEN, A. A. &
Figure 2. Computed tomographic scans demonstrating an irregular, stellate mass with central ossification in the right upper lobe extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus. Vol. 63, No. 748
RAO, B., 1985. The significance of calcified regional lymph nodes at the time of diagnosis of osteosarcoma. Orthopedics, 8, 49-52. VANEL, D.,
HENRY-AMAR, M.,
LUMBROSO, J.,
LEMALET,
E.,
305
Case reports
1990, The British Journal of Radiology, 63, 306-308 COUANET, D . , PlEKARSKI, J. D . , MASSELOT, J., BODDAERT, A . , KALIFA, C , LE CHEVALIER, T. & LEMOINE, G., 1984.
tomoscintigraphy. American Journal of Roentgenology, 143, 519-523.
Pulmonary evaluation of patients with osteosarcoma: roles of standard radiography, tomography, CT, scintigraphy, and
WEISS, L. & GILBERT, H. A., 1978. In Pulmonary Metastasis (G.
K. Hall & Co, Boston, USA), pp. 100-103.
Pneumonia, diagnosed on the abdominal radiograph, as a cause for acute abdomen in children By P. A. S. Spencer, BSc, MRCP, FRCR Department of Radiology, Royal Hallamshire Hospital, Sheffield
{Received July 1989 and in revised form August 1989)
Three cases of acute abdomen in children are described where a diagnosis of pneumonia was recorded as the cause of the abdominal pain. In each case, pulmonary consolidation was identified on the plain abdominal radiograph. The diagnostic value of plain abdominal radiographs in children is increased by deliberately including the lung bases. Acute abdominal pain is a common cause of paediatric emergency referral and admission to hospital. Acute appendicitis is the most common identifiable organic cause (Drake, 1980). Extensive lists can be made of other possible causes (Table I), arid investigations are directed to reaching a working diagnosis within a few hours of admission. I report three recent cases of acute abdominal pain in children in which pneumonia was diagnosed as the
cause of the pain. In each case, the diagnosis was suggested by identifying pulmonary consolidation on the plain abdominal radiograph. Case reports Case 1 A 10-year-old girl was admitted with a 4 day history beginning with a sore throat which had settled after 24 hours.
Table I. Important causes of acute abdominal pain in children Non-specific abdominal pain Gastrointestinal: Appendicitis Constipation Mesenteric adenitis Intestinal obstruction Gastroenteritis Hepatitis Henoch-Schonlein purpura Inflammatory bowel disease Inflamed Meckel's diverticulum Pancreatitis Genito-urinary:
Infection Calculus Reflex Hydronephrosis Torsion of testis
Diabetic ketoacidosis Gynaecological Pneumonia Porphyria Trauma
306
Figure 1. Case 1. Plain abdominal radiograph including the lung bases and revealing changes consistent with consolidation.
The British Journal of Radiology, April 1990
Case reports
The mechanism whereby the calcification has cleared in our patient is uncertain. Theoretically, spontaneous reduction in the amount of observed calcification could occur if a fistula developed, and intestinal perforation by a tuberculous psoas abscess has been reported (Blumenthal et al, 1981). However, no evidence for this was seen in our patient. At no time did either abscess contain air, and there has been no disturbance of bowel function. Similarly, surgical or percutaneous drainage of an abscess could also cause a reduction in the amount of calcification, but no such intervention was undertaken. Furthermore, colleagues who have had considerable experience in the field of spinal tuberculosis cannot recall seeing such an event (Griffiths, 1988; Murray, 1988). References BLUMENTHAL, D. H., MORIN, M. E., TAN A. & Li, Y. P.,
Figure 2. A radiograph taken in 1989 showing bilateral psoas abscesses but the calcification, particularly on the right side, is considerably less.
Calcification commonly occurs, and without intervention remains static.
1981.
Intestinal penetration by tuberculous psoas abscess. American Journal of Roentgenology, 136, 995-997. GRIFFITHS, D. LL., 1988. Personal communication. MURRAY, R. O., 1988. Personal communication. SEDDON, H. ET AL, 1973. Medical Research Council Working Party on Tuberculosis of the Spine, Second Report. Tubercle, 54, 261-282.
Osteosarcoma: an unusual thoracic metastasis By M. J. Charig, BSc, MRCP, FRCR, *S. J. Golding, FRCR and D. R. M. Lindsell, FRCR Department of Radiology, John Radcliffe Hospital, Oxford and *Regional CT Unit, Churchill Hospital, Oxford (Received July 1989)
Metastases from osteosarcoma often occur in the lungs, usually as multiple nodules but sometimes as a solitary mass. Lymph node involvement is unusual. We present a case of metastatic recurrence as a solitary, stellate, ossified, pulmonary mass extending across the pleura associated with ossified hilar lymphadenopathy. Case report A 15-year-old male, whose only previous medical history was resection of a right ventricular infundibular stenosis 18 months earlier, presented in November, 1987 with pain and swelling in the distal right femur. This proved on biopsy to be caused by an osteosarcoma, and after staging with chest radiograph, computed tomography (CT) and bone scintigraphy, no spread was evident. After three courses of cisplatinum and adriamycin, the distal femur containing the primary tumour was resected and a knee prosthesis inserted. Following three further courses of chemotherapy he. remained well for nearly a year, until March, 1989. A follow-up chest radiograph at this time revealed right paratracheal lymphadenopathy and an upper lobe mass (Fig. 1). A chest radiograph 2 months earlier had been normal. Computed tomography demonstrated an irregular, stellate mass with central ossification in the right upper
304
lobe, extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus (Fig. 2). The latter was connected to the mass by strands of ossified material. Scintigraphy with "Tcm-hydroxy methylene diphosphonate ("TcmHMDP) revealed intense uptake in the mass and nodes but no skeletal metastases (Fig. 3). At thoracotomy ossified tumour was found to be invading through the pleura into the superior sulcus and was resected together with the involved nodes. Histology showed an osteoblastic osteosarcoma consistent with spread from the femoral primary. Discussion
The lungs are the most frequent site for metastases from osteosarcomas (Jeffree et al, 1975; Weiss & Gilbert, 1978). Pulmonary nodules are seen in 10% of patients at presentation and more than 70% at death (McKenna et al, 1966). The nodules are usually multiple and bilateral but in 35% of patients may be unilateral, as in this case. The usual appearance of pulmonary metastases from any primary is of well-circumscribed, spherical nodules (Crow et al, 1981) and those from osteosarcomas may contain calcification or ossification. The British Journal of Radiology, April 1990
Case reports
Figure 3. Posterior and anterior views shown on "Tc m -HMDP scintigrams.
Figure 1. Chest radiograph showing right paratracheal lymphadenopathy and an upper lobe mass.
Fifty-one per cent are subpleural and may cause spontaneous pneumothorax in 5% of patients (McKenna et al, 1966), while 49% are parenchymatous (Vanel et al, 1984). The best technique for demonstrating pulmonary deposits is CT; scintigraphy can detect only 5% of these
(Vanel et al, 1984). However, scintigraphy can demonstrate metastases at many sites, usually from osteoblastic primaries. Lymph node involvement is a bad prognostic sign in osteosarcoma (McKenna et al, 1966) and is uncommon, being seen in only 3% of patients, in life (Jeffree et al, 1975). However, in the same study, 26% of cases at post-mortem had spread to local, hilar, mediastinal, mesenteric or abdominal nodes. Lymph node deposits appear more common from an osteoblastic primary (Tobias et al, 1985; Madsen, 1979) than from other histological types and can be demonstrated by scintigraphy (Heyman, 1980). In our case the mass is unusual in that while lymph node deposits and metastatic uptake of "TCm-HMDP are more likely with an osteoblastic osteosarcoma, a solitary, invasive, stellate metastasis has not been previously described. Acknowledgments We wish to thank Dr M. Moncrieff and Mr S. Westaby for permission to report on their patient. The prints were prepared by Medical Illustration at the John Radcliffe Hospital.
References CROW,
J.,
SLAVIN,
G.
&
KREEL,
L.,
1981.
Pulmonary
metastasis: a pathologic and radiologic study. Cancer, 47, 2595-2602. HEYMAN, S., 1980. The lymphatic spread of osteosarcoma shown by Tc-99m-MDP scintigraphy. Clinical Nuclear Medicine, 5, 543-545. JEFFREE, G. M., PRICE, C. H. G. & SISSONS, H. A.,
1975.
The
metastatic patterns of osteosarcoma. British Journal of Cancer, 32, 87-107. MADSEN, E. H., 1979. Lymph node metastases from osteoblastic osteogenic sarcoma visible on plain films. Skeletal Radiology, 4, 216-218. MCKENNA,
R.
J.,
SCHWINN,
C.
P.,
SOONG,
K.
Y.
&
HIGINBOTHAM, N. L., 1966. Sarcomata of the osteogenic series (osteosarcoma, fibrosarcoma, chondrosarcoma, parosteal osteogenic sarcoma, and sarcomata arising in abnormal bone). Journal of Bone and Joint Surgery, 48A, 1-25. TOBIAS, J. D., PRATT, C. B., PARHAM, D. B., GREEN, A. A. &
Figure 2. Computed tomographic scans demonstrating an irregular, stellate mass with central ossification in the right upper lobe extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus. Vol. 63, No. 748
RAO, B., 1985. The significance of calcified regional lymph nodes at the time of diagnosis of osteosarcoma. Orthopedics, 8, 49-52. VANEL, D.,
HENRY-AMAR, M.,
LUMBROSO, J.,
LEMALET,
E.,
305
Case reports
1990, The British Journal of Radiology, 63, 306-308 COUANET, D . , PlEKARSKI, J. D . , MASSELOT, J., BODDAERT, A . , KALIFA, C , LE CHEVALIER, T. & LEMOINE, G., 1984.
tomoscintigraphy. American Journal of Roentgenology, 143, 519-523.
Pulmonary evaluation of patients with osteosarcoma: roles of standard radiography, tomography, CT, scintigraphy, and
WEISS, L. & GILBERT, H. A., 1978. In Pulmonary Metastasis (G.
K. Hall & Co, Boston, USA), pp. 100-103.
Pneumonia, diagnosed on the abdominal radiograph, as a cause for acute abdomen in children By P. A. S. Spencer, BSc, MRCP, FRCR Department of Radiology, Royal Hallamshire Hospital, Sheffield
{Received July 1989 and in revised form August 1989)
Three cases of acute abdomen in children are described where a diagnosis of pneumonia was recorded as the cause of the abdominal pain. In each case, pulmonary consolidation was identified on the plain abdominal radiograph. The diagnostic value of plain abdominal radiographs in children is increased by deliberately including the lung bases. Acute abdominal pain is a common cause of paediatric emergency referral and admission to hospital. Acute appendicitis is the most common identifiable organic cause (Drake, 1980). Extensive lists can be made of other possible causes (Table I), arid investigations are directed to reaching a working diagnosis within a few hours of admission. I report three recent cases of acute abdominal pain in children in which pneumonia was diagnosed as the
cause of the pain. In each case, the diagnosis was suggested by identifying pulmonary consolidation on the plain abdominal radiograph. Case reports Case 1 A 10-year-old girl was admitted with a 4 day history beginning with a sore throat which had settled after 24 hours.
Table I. Important causes of acute abdominal pain in children Non-specific abdominal pain Gastrointestinal: Appendicitis Constipation Mesenteric adenitis Intestinal obstruction Gastroenteritis Hepatitis Henoch-Schonlein purpura Inflammatory bowel disease Inflamed Meckel's diverticulum Pancreatitis Genito-urinary:
Infection Calculus Reflex Hydronephrosis Torsion of testis
Diabetic ketoacidosis Gynaecological Pneumonia Porphyria Trauma
306
Figure 1. Case 1. Plain abdominal radiograph including the lung bases and revealing changes consistent with consolidation.
The British Journal of Radiology, April 1990
