CASE 5107 Published on 13.02.2008
0

Osteofied lung metastases due to tibioperoneal osteosarcoma

Section

Chest imaging

Case Type

Clinical Cases

Authors

Anastasia Oikonomou, Nicolaos Pantazis, Maria Poppidou, Panos Prassopoulos

Connected authors
Patient

33 years, male

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Clinical History
Patient with dyspnea, weakness and swelling of right tibia (history of myositis ossificans). Chest roentgenogram and computed tomography were performed.
Imaging Findings
A 33 year-old farmer was admitted to hospital with dyspnea and weakness, after he had sprayed with weed killer. He had a smoking history of 30 pack/yrs. Physical examination revealed reduction of respiratory murmur of left lung and swelling of his right tibia. The patient had a previous history of myositis ossificans proved with biopsy at the age of 29 yrs. Laboratory investigations revealed mild anemia (Ht 32,5%) with haemoglobin of 11.1g/dl, WBC 20.000, ALP 1179, ESR 105 and 96% oxygen saturation. The chest roentgenogram showed complete opacification of the left hemithorax and multiple nodules of different density and size in the right lung. The chest CT scan disclosed bilateral pleural collections. The left one was significantly larger and was accompanied by complete atelectasis of the left lung. CT revealed a large number of ossified nodules both in the atelectatic left lung and in the expanded right lung (figure 1, 2). In the right lung a significant number of nonossified nodules was demonstrated. The radiologic findings were combatible with ossified and nonossified hematogenous lung metastases most probably secondary to osteosarcoma. A roentgenogram and a CT scan of the right tibia (figure 3) were performed and showed osteoblastic bone destruction-reaction with invasion of the medullary cavity accompanied by a large soft tissue mass (31cm x 19cm x14cm) with coarse calcifications consistent with tibioperoneal osteosarcoma.
Discussion
Multiple different size lung nodules are compatible with metastases. A large variety of neoplasms can produce calcified or ossified lung metastases. Calcification refers to the deposition of calcium salts in tissues, in contrast to ossification, which indicates bone tissue formation (calcification in a collagen matrix), with or without marrow elements (1). Pulmonary metastases of osteogenic sarcoma are considered to result from bone formation (1). Calcification / ossification in metastases arises through a variety of mechanisms: bone formation in tumor osteoid, calcification and ossification of tumor cartilage, dystrophic calcification and ossification of tumor cartilage, dystrophic calcification and mucoid calcification. The sarcomas that are most commonly reported in the literature to develop calcified or ossified lung metastases are osteogenic sarcoma, chondrosarcoma, synovial sarcoma and giant cell tumor (2). Among carcinomas, the papillary and mucinus adenocarcinomas are the histological types most likely to develop calcified lung metastases (2,3). Extremely unsual neoplasms that have also been reported to produce calcified lung metastases are malignant mesenchymoma, fibrosarcoma of the breast and medullary carcinoma of the thyroid (2). Sarcoma is the prototype tumor for pulmonary metastasectomy, as more than 70% of patients with sarcoma metastatic to the lung have the lung as the sole site of metastasis. Calcification can also develop at the site of pulmonary metastases that have vanished after successful chemotherapy. This chemptherapeutic effect can be manifested as persistent nodules that, on histologic examination show only necrosis and fibrosis without residual viable neoplastic tissue. Metastatic testicular neoplasms are particularly prone to this outcome (4). A number of benign causes can also produce multiple calcified pulmonary nodules: histoplasmosis, amyloidosis, alveolar microlithiasis, mitral valve stenosis, tuberculosis, varicella and silicosis (1). Central, laminated, popcorn or diffuse calcifications are characteristic of benign solitary lung nodules. Since calcified/ossified lung metastases can strongly resemble granulomas or hamartomas, a reasonable suspicion of malignancy is necessary when evaluating calcified/ossified pulmonary nodules (2).
Differential Diagnosis List
Ossified lung metastases due to tibioperoneal osteosarcoma
Final Diagnosis
Ossified lung metastases due to tibioperoneal osteosarcoma
Case information
URL: https://www.eurorad.org/case/5107
DOI: 10.1594/EURORAD/CASE.5107
ISSN: 1563-4086
Figure 1

Figure 1

Figure 1
Figure 1 a: CT scan on lung window (a) and mediastinal window without contrast (b) at the level of the upper lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Bilateral pleural effusions are seen.
Figure 1
Figure 1 b: CT scan on lung window (a) and mediastinal window without contrast (b) at the level of the upper lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Bilateral pleural effusions are seen.
Figure 2

Figure 2

Figure 2
Figure 2 a: CT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted.
Figure 2
Figure 2 b: CT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted.
Figure 2
Figure 2 c: CT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted.
Figure 3

Figure 3

Figure 3
Figure 3 a: Two sequential axial CT scans of the right tibia and fibula showing extensive coarsely calcified – osteofied amorphous soft tissue mass surrounding the diaphyses of the two bones (a) and infiltration of the bone marrow of both bones (b).
Figure 3
Figure 3 b: Two sequential axial CT scans of the right tibia and fibula showing extensive coarsely calcified – osteofied amorphous soft tissue mass surrounding the diaphyses of the two bones (a) and infiltration of the bone marrow of both bones (b).