Osteosarcoma x ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2]

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On X-ray, osteosarcoma is characterized by medullary and cortical bone destruction, periosteal reaction, tumor matrix calcification, and soft tissue mass.

X Ray

Conventional radiography continues to play an important role in diagnosis of osteosarcoma. Typical appearances of conventional high grade osteosarcoma include:[1][2][3][4][5][6][7]

  • Sunburst appearance
  • Codman triangle
  • Lamellated (onion skin) reaction: less frequently seen
  • Variable: reflects a combination of the amount of tumor bone production, calcified matrix, and osteoid.
  • Ill-defined fluffy or cloud-like cf. to the rings and arcs of chondroid lesions.
  • The following table illustrates the findings on x-ray for the subtypes of osteosarcoma:[1]
Subtype X-Ray findings
Intracortical osteosarcoma
  • Presents as an oval intracortical geographic osteolytic lesion in the diaphysis with surrounding sclerosis.
  • Measures approximately 4 cm in length.
  • Multiple calcific foci can be seen within the lytic region, suggesting osteoid matrix.
Parosteal osteosarcoma
  • Large lobulated exophytic, 'cauliflower-like' mass with central dense ossification adjacent to the bone.
  • String sign: Thin radiolucent line separating the tumor from cortex, observed in 30% of cases.
  • Tumor stalk: Grows within tumor in late stages and obliterates the radiolucent cleavage plane.
  • +/- soft tissue mass.
  • Cortical thickening without aggressive periosteal reaction is often seen.
  • Tumor extension into medullary cavity is frequently observed.
Periosteal osteosarcoma
  • Typically seen as a broad-based surface soft-tissue mass causing extrinsic erosion of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into the soft-tissue component.
Telangiectatic osteosarcoma
  • Typically seen as an expansile lytic metaphyseal bony lesion.
  • Geographic bony destruction with wide zone of transition tends to be more common than permeative bony destruction.
  • Less osteoid matrix compared to conventional type.
Low grade osteosarcoma
  • Because the fibrous dysplasia and central low-grade osteosarcoma are so similar histologically, the radiographic features are an extremely important part of the diagnosis.
  • Radiographic features of low-grade osteosarcomas are variable.
  • Most common pattern is as a large intracompartmental expansile lytic fibro-osseous lesion with coarsely thick or thin incomplete trabeculations. Another less common pattern is as a sclerotic lesion.
  • Cortical erosion and soft tissue extension is also a common feature.
Extra skeletal osteosarcoma
  • Soft tissue density with a variable amount of calcification which represents osteoid matrix formation, and is seen in approximately 50% of cases.


  1. 1.0 1.1 Osteosarcoma. Dr Amir Rezaee ◉ and Dr Frank Gaillard ◉ et al. Radiopaedia.org 2015. http://radiopaedia.org/articles/osteosarcoma
  2. Gürtler KF, Riebel T, Beron G, Heller M, Euler A (April 1984). "[Comparison of x-ray plain films, x-ray tomograms and computed tomograms in lung nodules in children and adolescents]". Rofo (in German). 140 (4): 416–20. doi:10.1055/s-2008-1052998. PMID 6425164.
  3. Riebel T, Knop J, Winkler K, Delling G (October 1986). "[Comparative x-ray and nuclear medical studies of osteosarcomas to evaluate the effectiveness of preoperative chemotherapy]". Rofo (in German). 145 (4): 365–72. doi:10.1055/s-2008-1048952. PMID 3022331.
  4. Dinkel E, Uhl H, Roeren T (April 1985). "[Lung metastases--limitations and possibilities of radiologic diagnosis]". Radiologe (in German). 25 (4): 158–65. PMID 3889998.
  5. Kesselring FO, Penn W (1982). "Radiological aspects of 'classic' primary osteosarcoma: value of some radiological investigations: A review". Diagn Imaging. 51 (2): 78–92. PMID 7042255.
  6. Kubo T, Furuta T, Johan MP, Adachi N, Ochi M (September 2016). "Percent slope analysis of dynamic magnetic resonance imaging for assessment of chemotherapy response of osteosarcoma or Ewing sarcoma: systematic review and meta-analysis". Skeletal Radiol. 45 (9): 1235–42. doi:10.1007/s00256-016-2410-y. PMID 27229874.
  7. Rothermundt C, Seddon BM, Dileo P, Strauss SJ, Coleman J, Briggs TW, Haile SR, Whelan JS (May 2016). "Follow-up practices for high-grade extremity Osteosarcoma". BMC Cancer. 16: 301. doi:10.1186/s12885-016-2333-y. PMC 4859955. PMID 27154292.

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