Indian Journal of Pathology and Microbiology

: 2012  |  Volume : 55  |  Issue : 4  |  Page : 595--597

Calcaneal osteosarcoma

Mahima Sharma, Vandana Sharma, Anuja Sharma, Arvind Khajuria 
 Department of Pathology, ASCOMS and Hospital, Sidhra, Jammu and Kasmir, India

Correspondence Address:
Vandana Sharma
Senior Resident, Department of Pathology, ASCOMS, Sidhra, Janipur, Jammu

How to cite this article:
Sharma M, Sharma V, Sharma A, Khajuria A. Calcaneal osteosarcoma.Indian J Pathol Microbiol 2012;55:595-597

How to cite this URL:
Sharma M, Sharma V, Sharma A, Khajuria A. Calcaneal osteosarcoma. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Oct 24 ];55:595-597
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Osteosarcoma is the most common primary malignancy of the bone excluding multiple myeloma and frequently involves the knee. [1],[2],[3] It is commonly seen in the second and third decades of life. [2],[3],[4] Osteosarcoma of the foot is very rare. [1],[2] The reported incidence is 0.8% of all osteosarcomas and calcaneum is the most favored site in the foot. [1],[4] It affects the older age group. Owing to the rarity of the location, it is often misdiagnosed or there is a delay in the diagnosis. The literature shows that the time delay for the diagnosis of osteosarcoma of calcaneum ranges between 15 weeks and 28 months. [1],[4] Many factors such as histological grading, patient's age, and the time to definitive diagnosis of the tumor may play a role in the clinical outcome and should be carefully considered. [2]

A 38-year-old male presented with 8-month-old history of pain and swelling on the left ankle in April, 2010. Fine needle aspiration cytology (FNAC) of the patient was done twice before coming to our institute. First FNAC was reported as tubercular granuloma with cold abscess and the patient was put on antitubercular treatment (ATT). The patient did not improve and underwent the second FNAC which revealed blood, scattered giant cells, and a few suspicious large cells with abundant blue cytoplasm and round to oval nuclei. On this report, curettage was done which showed fragments of dead bone, abundant osteoid, and slight anaplasia and he was diagnosed as a case of chronic osteomyelitis. The patient did not respond to treatment. The X-ray foot showed ill-defined heterogeneous sclerotic lesion involving calcaneum with associated pathological fracture and large soft tissue component. [Figure 1]. Correlating the clinico-radiological details, below-knee amputation was done. On gross examination, a diffuse, bulky lesion involving the left ankle was seen. The cut section of the lesion showed gritty, grey white tumor with areas of hemorrhagic and cystic degeneration, involving the calcaneum. The tumor was infiltrating the cortex. Microscopic examination showed abundant eosinophilic osteoid forming lacelike network and thin trabeculae. [Figure 2] In between the osteoid there were pleomorphic, bizarre tumor cells having large, hyperchromatic nuclei. [Figure 3] The mitotic rate was high. Dilated vessels and multinucleated giant cells were also seen. Based on these findings, the patient was diagnosed as having osteosarcoma calcaneum.{Figure 1}{Figure 2}{Figure 3}

Osteogenic sarcoma is the most common non-hematopoietic primary malignant neoplasm of the bone. [2],[4] Although it is the second most common malignant bone tumor, affecting especially children and adolescents, osteosarcoma of the foot is infrequent. [2] It may represent a distinct subgroup that differentiate it from conventional osteosarcoma as it is a low-grade tumor and affects the older age group in contrast to its counterparts at other sites. Osteosarcoma of the foot has been associated with Werner's syndrome, hereditary retinoblastoma, Paget's disease and Li-Fraumeni syndrome. [2],[4],[5]

These tumors produce symptoms early because of the confined structure of the foot, but their rarity may lead to delay in diagnosis. The patients are frequently misdiagnosed with more common musculoskeletal problems that initially improve with conservative measures. [4]

Histologically, osteosarcoma has been classified as osteoblastic, chondroblastic, and fibroblastic, according to the most predominant matrix. Most of the cases show a mixed pattern. There is no clear correlation between these variants of osteosarcoma and prognosis. But a certain degree of correlation has been reported between some histological variants and their response to radiotherapy. [3] In a series conducted at the Mayo clinic on osteosarcoma foot, the incidence of chondroblastic tumors was high as compared to osteoblastic and most of the tumors were of high grade. [1],[5]

Radiographically, osteosarcomas are commonly sclerotic in 45% of cases, purely lytic in 30%, and mixed in the remaining 25%. [2],[4],[5] Plain radiographs are diagnostic of osteosarcomas. Further radiographic evaluation for ascertaining disease may be necessary with modalities like computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, and radionuclide bone scan. In addition, MRI helps in the accurate estimation of tumor boundaries in relation to the surrounding structures and also detects skip lesions. [2],[5]

Due to the superficial location of the calcaneus and because calcaneus supports the whole body weight, traumatic lesions are common as compared to neoplastic lesions. The differential diagnosis includes all slightly mineralized and ill-defined lesions extending into soft tissues. Osteoid osteoma, desmoplastic fibroma, chondrosarcoma, enchondroma, eosinophilic granuloma, Ewing's sarcoma, and metastatic carcinoma are the most frequent entities in the calcaneum. [3] However, osteosarcoma should also be considered in the differential diagnosis, particularly in the event of a sclerotic bony lesion. [3],[4] And for the confirmation of diagnosis, open biopsy is required to avoid any delay in the management of the patient.


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