Radiological quiz-musculoskeletal

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Radiological Quiz – Musculoskeletal R BALAJI, K RAMACHANDRAN, AS KRISHNAKUMAR, M VENUGOPAL Ind J Radiol Imag 2006 16:4:931-932

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17 year old male was referred to our centre with complaints of progressive swelling and pain in both forearms. He was diagnosed in June 2002 with osteosarcoma of the right proximal femur. He underwent limb conservation surgery with wide excision of the tumor and then a custom-made stainless steel prosthesis implant was carried out. Thereafter he received chemotherapy with Ifosfamide, Adriamycin, and CDDP. The patient developed an infection of the prosthesis and subsequently a disarticulation had to be performed. Physical examination of the patient revealed clubbing of fingers, thickening and swelling in the wrists and large

distal joints of both upper limbs. No other positive signs or symptoms were elicited. Radiographs of both the forearms revealed periosteal bone deposition involving the distal diaphyses and the metaphyses of tibia, fibula, radius and ulna sparing the epiphyseal ends. The periosteal reaction had a laminated appearance with smooth layers of new bone formation and cortical thickening (Figs .1 and 2).Chest radiograph revealed soft tissue opacities in the right lower zone. (Fig.3) CT scans showed a bulky mass with ossific density in the right lower lobe and ossific nodules in both lungs (Fig .4).

Fig .3 Chest radiograph shows soft tissue mass in right lower zone

Fig.1 and Fig.2 Radiographs of distal metaphyses of ulna and radius reveal laminated periosteal reaction.

Fig 4 Computerized Tomography image of the lungs shows right lower lobe mass with ossification within.

From the Imageology Division, Regional Cancer Centre, Trivandrum 695011, Kerala Request for Reprints: Dr R Balaji, Imageology Division, Regional Cancer Centre, Trivandrum 695011, Kerala Received on 6 June 2005; Accepted 10 October 2006

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IJRI, 16:4, November 2006

Radiological Diagnosis HYPERTROPHIC PULMONARY OSTEOARTHROPATHY

Discussion HPOA is a rare condition of uncertain etiology that is caused by an underlying lung disease. Of all the potential intra thoracic malignancies bronchogenic carcinoma and pleural tumors are the most common underlying lesions for the cause of HPOA (5-10%). Lung metastases rarely cause HPOA. Other thoracic causes of secondary HPOA are abscess, bronchiectasis and emphysema, The association of HPOA with pulmonary metastases of an osteosarcoma is a rare occurrence with only two reported cases in literature [2, 3]. Staalman and Umans reported nasopharyngeal carcinoma metastases as the underlying cause for the development HPOA in children [4]. The classic picture of HPOA is digital clubbing, polyarthralgia and periostosis. Articular symptoms and signs are the presenting manifestations of HPOA. Pain and tenderness appear first with subcutaneous skin thickening. The wrists, elbows, knees, ankles and metacarpophalangeal joints are most commonly involved. The stimulating factor in HPOA etiology is platelet derived growth factor (PGDF). PGDF induces tissue damage and excessive fibroblast production. In malignancy cytokines, transforming growth factor and interleukin - 1 are liberated which in turn enhance production of PGDF. Periostitis is the hallmark of HPOA and occurs usually in the metadiaphyseal regions of the ulnae, radii, fibulae and tibiae [1]. Less commonly, the femora, humerii, metacarpals and metatarsals may be involved. The typical feature is that periostitis does not extend to the epiphysis. Usually smooth multi layered laminated new bone formation is seen. Rarely simple elevation of the periosteum or periosteal cloaking may be seen. On radionuclide bone scans, a diffuse symmetric uptake occurs in the diaphyses and metaphyses of tubular bones creating the typical "double stripe sign". Periostitis occurs in a wide spectrum of diseases. Of this primary HPOA pachy dermoperiostitis and thyroid

acropachy are most common. Periostitis in pachydermoperiostitis can be differentiated in that it is more florid, irregular and extends to the epiphyses while in thyroid acropachy there is a particular predilection for small bones of the hands and feet. Other causes include hypervitaminosis A, chronic venous insufficiency and diffuse idiopathic skeletal hyperostosis [1]. References 1. Resnick D .Diagnosis of Joint and Bone Disorders. Vol. 5. 4th edition. pp. 4877-4485. Saunders Co, 2002 2. Flueckiger F, Fotter R, Hausegger K, Urban C .Hypertrophic osteoarthropathy caused by lung metastases of an osteosarcoma .Peditr Radiol 1989:20:128-130 3. Tarasova GV ,Shafranskii LL ,Suleimanov BN .Systemic ossifying periostoses in a patient with osteogenic sarcoma metastases to lungs .Ortop Travmatol Protez 1972:33:81-82 4. Staalman CR, Umans U .Hyprttrophic osteoarthropathy in childhood malignancy. Medical and Pediatric Oncology .1993:21:676-679 5. Daly BD. Thoracic Metastases from Nasopharyngeal Carcinoma presenting as Hypertrophic Pulmonary Osteoarthropathy: Scintigraphic and CT Findings. Clinical Radiology 1995:50:545-547