Radiology Osteosarcoma Radiology Journal - Literature Review Assessment Answers

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Task Students have a choice of assessment task. During your career and ongoing CPD requirements, you will be required to document clinical case studies as teaching cases or review of the literature. You have some of those skills already but this is an opportunity to refine those skills prior to internship / graduation and to integrate those skills with both academic and clinical learning. You are adult learners and are responsible enough to choose your assessment not based on convenience or perception of being easy, but on your education needs. So choose one of the following tasks, plan early and do it well: Note: not all students will find an interesting teaching case suitable. Don't assume you will or that the department will let you use it. You would be wise to have a review topic in mind as a fall back if the case does not materialise. A case study might seem an easier option but it may also be harder to get great marks. Done well (as a teachign case not just as an interesting case) it will be able to get 100%. The literature review is not a simple summary of literature, it needs to be systematic in nature, have defined methodological approaches and represent the full breadth of literature. Both tasks are focussed on image guided therapy. On your cover page, indicate which specialisation you are enrolled in (medical imaging, nuclear medicine or radiation therapy). This taks will be primarily examined by an academic within your discipline. 10% of each cohort will be then remarked by each of the other 2 specialisations to provide moderation and benchmarking so students receive equitable marks. Option 1: Write a literature review suitable as a CPD article for a journal suitable for your profession (eg. JMIRS, JMRS, JNMT, radiography). You MUST indicate on your cover page which journal you have written for. Use the journal guidelines for authors including the referencing method.Do not mark it up as a published journal article though (columns, wrapped text etc). That is, read the actual instructions for authors every journal provides, do not just look at an article in the journal and try to format that way. The end product should be of publishable quality or it will attract less than 50% and require re-submission. Convolve a topic that links learning across this subject (and to your profession). Choose wisely so that you can best satisfy the objectives of this assessment. Do not choose a topic that is closely related to your group task. Students will not be asked to resubmit, they will be given zero. Examine a key pathology related to your specialisation (radiography, nuclear medicine or radiation therapy). Provide an insight into the clinical importance of image guided therapy for the pathology. Your review MUST be evidenced based and to that end, extensive research is expected. Be specific. For example do not choose heart disease but rather heart failure or CAD. Do not choose cancer but rather breast cancer or NET etc The review should be fully referenced and progress logically and coherently and, apart from the body of text, include an abstract, introduction, discussion, conclusion and references. Write for the audience. That is, journal readers. Make sure you write atthe appropriatelevel; thisincludes professional language and writing style butbe mindfulnot to waste time and word counton basic information that is assumed knowledge. You will need to exercise professional judgment with regard to what is assumed knowledge. Research, synthesis, communication and professional writing are essential competencies. You would be wise to refer to the guidelines Geoff has developed for guiding writing a review. Option 2: Write a case review / teaching case suitable as a CPD article for a journal suitable for your profession (eg. JMIRS, JMRS, JNMT, radiography). You MUST indicate on your cover page which journal you have written for. Use the journal guidelines for authors including the referencing method. Do not mark it up as a published journal article though (columns, wrapped text etc). That is, read the actual instructions for authors every journal provides, do not just look at an article in the journal and try to format that way. The end product should be of publishable quality or it will attract less than 50% and require re-submission. Be mindful that a case report is not a simple case study that shows a set of images and a disease. It needs to be structured to provide in depth details of the case, correlative imaging, extensive discussion and research of similar cases and well defined and articulated teaching points. The focus needs to be on image guided therapy. On clinical (undergraduates) or in your workplace (DE), find a case study that links learning across this subject. You should choose based on IGT; choose wisely so that you can best satisfy the objectives of this assessment. ENSURE you have permission from the department to use the case for your report. Do not choose a topic that is closely related to your group task. Students will not be asked to resubmit, they will be given zero. Examine a key pathology related to your specialisation (radiography, nuclear medicine or radiation therapy). Provide an insight into the clinical importance of image guided therapy for the pathology. Your case report MUST be evidenced based and to that end, extensive research is expected. Be specific. Do not simply restate the patients clinical notes, request and report. The report should be fully referenced and progress logically and coherently and, apart from the body of text, include an abstract, introduction, case history, discussion, teaching points, conclusion and references. Write for the audience. That is, journal readers. Make sure you write at the appropriate level; this includes professional language and writing style but be mindful not to waste time and word count on basic information that is assumed knowledge. You will need to exercise professional judgment with regard to what is assumed knowledge. Research, synthesis, communication and professional writing are essential competencies. The case needs to be original and interesting. Just because it is the first time you have seen it does not make it interesting. So when you find a case, you will need to do some research to see why it is interesting if in fact it is. YOU ARE NOT to simply find a case online. YOU MUST do a case you are integrally involved in. Provide an insight into pathogenesis, patient history, their journey, impact of diagnosis and therapy (role of IGT). Yourdiscussion MUST be evidenced based and to that end, extensive research is expected that includes detailed teaching points. Thecaseshould be fully referenced and progress logically and coherently and, apart from the body of text, include an abstract, introduction, discussion, conclusion and references. Rationale This assignment is designed to assess your understanding of key concepts. This assignment is designed to utilise your analysis,review, research and writing skills combined with cognitive skills in judgment and decision making. Youareare expected to show developing skills from year 1 and through year 2 to the point where you are ready for professional transition. Your ability to conduct appropriate research and synthesise that knowledge into a integrated and well communicated piece is being examined. Keep in mind that this task parallels skills expected throughout your professional life with mandatory CPD to maintain registration. This task specifically aligns with the following learning outcomes of this subject:

be able to describe the physical characteristics and imaging appearance of major common pathologies and demonstrate an insight through synthesis for a variety of medical radiation science modalities;
be able to explain the aetiology and pathogenesis of commonly imaged pathologies;
be able to analyse the various imaging modality options and their efficacy in the diagnosis of commonly imaged pathologies;
be able to describe and justify the therapeutic approaches for commonly imaged pathologies.

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Introduction Osteosarcoma is the disease, which is characterized by bone forming tumors. This kind of tumor is second most common after multiple myeloma. These tumors are found in primary and secondary form, and every tumor is found with different distribution and epidemiology. Osteosarcoma can occur in any individual, and in any age. Significantly long bones are affected by this tumor, but in some cases it can occur in short bones as well. Children are highly affected with this disease due to their rapid growth, but it also occurs in adults. Osteosarcoma can be treated with chemotherapy, amputation, surgery, prosthetics and rotationplasty. Monitoring patient’s condition is always very necessary. Literature Review Importance of Different Imaging Techniques in Osteosarcoma Osteosarcoma (OS) is a malignant bone tumor; it is detected through disorganized woven bone formed by mesenchymal tumor cells. This kind of tumor account around 15%-35% of all primary tumors, and it is the most common primary malignant bone tumor. His is mainly found in children and adolescents, between the age of 15 and 25 years. . It is the sarcoma of the bone, which mainly occurs during period of rapid bone development or puberty. According to the study of Findik et al. (2012), “Osteosarcoma is classified as a component of Ewing’s sarcoma…generally [has] long bone involvement such as the femur, tibia and humerus…very rarely [it] arises from the short bones such as [the] ileum, clavicle, scapula and sacrum” (p.173). The occurance of this tumor in short bones is very rare, although it can also occur in neck and head. However, the chances of being found in neck and head “account for less than 10 percent of all osteosarcomas in general” (Yamamoto et al. 2011, p. 201). The study of Gebhardt, Dempsey, and Neff (2008) states that osteosarcoma can also occur in the flat bones of skull, hips, ribs, spine and scapula. The second peak of the lesions is observed in adults, who are above the age of 50 years. In adults the development of this tumor is mainly detected in flat bones (vertebrae and pelvic bone) and axial skeleton. It is very rare that osteosarcoma may arise in soft tissues of thighs and upper extremity. The development of OS is more common in men than in women. This kind of tumor is found in two forms; mandible and maxillary. Occurance of mandibular tumors is more frequent and is found in horizontal ramus. However, maxillary tumors are commony found in sunus, palate, floor and ridge. Since osteosarcoma can be found in different body parts, there are different ways to detect the disease and treat it. For the diagnosis of the disease it is important to recognize the signs and symptoms of OS. According to Guillon et al (2011) and Babazade, Mortazavi, and Jalalian (2011), the common symptom related to the disease is pain. If the patient do not complain about pain, then detection of the disease is done through traumatic events. By traumatic events osteosarcoma is detected by chance. Thus, primary bone tumors are multidisciplinary and rare. The main diagnosis of the lesions is done by the involvement of radiologists and pathologists. According to Larousserie et al (2013), “Bone lesions are often heterogeneous and the microscopic diagnostic component(s) may be in the minority, especially on core needle biopsies. Reactive processes, begin, and malignant tumors may have similar microscopic aspects” (p. 2111). There are the major challenges that informs that radiologic information is very critical, or mistakes in the diagnosis could be made that could lead to serious clinical consequences for the patient. The diagnosis accuracy of the bone tumors in osteosarcoma can be improved by imaging. The bone lesions in OS can be radigraphicallt heterogeneous, for which specific microscopic diagnosis is very important. Proper imaging review helps significantly in access to disease sampling. Larousserie et al (2013), states that “imaging information is very useful for the pathologist to perform accurate local and regional staging during gross examination” (p. 2112). For management of OS, it is important that radiologists, pathologists and clinicians work together in an effective manner. For understanding and recognizing the problem, the next step is to determine that how OS appers in radiography. According to Gebhardt et al. (2008), “The plain radiograph is the best diagnostic tool. Osteosarcomas may either completely destroy the bone (radiolucent lesion) or replace the bone with a blastic response (radiodense), but they most often do both” (p. 1951). Once the disease is discovered, it becomes easy to find the options about treatment. This is because radiographic imaging helps to evaluate the severity of the disease, and how much bone have been affected.

(Image 1) (Kundu, 2014) The above image displays the radiographic image of the femur of a patient suffering from Osteosarcoma.

(Image 2) (Kundu, 2014) The above image displays the lateral radiography of the distal femur in a patient suffering with Osteosarcoma. This image includes metaphysics and metadiphysics. The white arrow explains that presence of abnormal texture, aggressive periosteal changes, moth-eaten appearance, mild sclerosis of the distal femoral shaft, while black arrow shows large mass of soft tissues. In Osteosarcoma, lesions occur to be aggressive, and with ill defined edges. They can also present in small cortical holes. The plain radiography main show mixture of lytic and sclerotic areas (illdefined), or only display well defined lytic. Thus, conventional radiography plays an important role in diagnosis of Osteosarcoma (bone tumor). Thus, it is clear that value of radiographic approach is undeniably and greatly contributed in enhanced diagnosis of OS. This approach has also lead to overemphasis and oversimplification of the diagnosis. The significance of radiology is also universally accepted in diagnosis of bone tumors. The contribution of the radiologists in the management of OS and other tumors are however, underestimated and remains unrecognized in most of the cases. When bone tumors like OS are treated with teamwork, the importance and significance of radiology is quite apparent. The close cooperation of the clinicians, surgeons, pathologists, radiologists, oncologists and radiation therapists is required in the treatment and management of Osteosarcoma. On the initial stage of the diagnosis, the radiographic images with proper clinical context play a specific role. The decision making about securing the tissue and per-cutaneous needle biopsy are also made with the help of radiologists. They may also be very helpful in suggesting the proper location for biopsy in order to save the tissues. After the diagnosis of the disease, radiology becomes the most significant part of the disease management, as it involves simple radiography, CT, MRI, Nuclear imaging and ultra sonography. All these approaches help in understanding the stage of the disease and making a choice about the treatment. Chemotherapy is the first treatment of Osteosarcoma. Chemotherapy can also be used as neoadjuvant chemotherapy and post operative chemotherapy. The first kind of chemotherapy is important, when the clinicians and surgeons make the decision about operating the affected area. The level of chemotherapy can be determined by radiological images. The main aim of this kind of therapy is to reduce the size of tumor, and it is not a very drastic surgery. This approach is also beneficial in understanding the needs of the treatment and communication helps the physician to make the best possible decision for patient. This involves patient’s autonomy, dignity and concern. It has been noted that management of Ostosarcoma is improved after chemotherapy. After the chemotherapy also, the role of radiologists remain significant, as he helps to evaluate the records and identify the chances of reoccurrence of the disease. The radiographic images help the physicians to determine the possible complications after chemotherapy. CT (Computed Tomography) scan is important, when the plain radiographic appearances are not clear and seems to be confusing. Axial anatomy is demonstrated through CT scans. This scan is mainly useful in the areas, where complex anatomy is found. The clear bone destruction could be detected through CT scan. It also clearly explains the soft tissue mass in clearer way than plain radiography. Thus, the role of radiologists remains significant at different level of disease diagnosis and, treatment and management. CT scans can also be helpful in detecting mineralized osseous matrix, which may not be possible in radiographs. The clinical history and the availability of the lab data are important, where patients have history of trauma, blood dyscrasia and high serum calcium. The presence of single or multiple tumors must be detected on the initial stage of the diagnosis, and this is possible only through radiography. Once the lesion is detected, it becomes easy to address the disease with proper treatment. The age of the patient is also important, to determine, while carrying out radiology, as it helps the radiologists to understand the severity of the tumor and bone damage. Radiographs are the main screening technique used for the Osteosarcoma (Stalley etal, 2010). On every step of treatment, radiography and radiologists play a significant role. Imaging is also beneficial in prognosis and aids in separation from the focal bone pathology. Once the patient has been diagnosed with OS, MRI (Magnetic Resonance Imaging) becomes the most important step, as it helps in evaluating the involvement of the soft tissues. MRI is considered as the modality of choice for evaluating the extent and level of the disease. MRI is significant as it is excellent in soft tissue contrast, bone marrow and multiplanar capabilities. The below images display the MRI characteristics in Osteosarcoma (Stalley etal, 2010).

(Image 3) (Guillon et al, 2011) This is a sagittal T1 weighted MRI. The above image displays the MRI of the leg, where intensity of the bone marrow seems to be normal in the distal femoral epiphysis. But, it is also noted that abnormal single intensity is visible in shaft. The extension of tumor is limited in the growth plate. Arrow displays the cortical destruction and soft tissue mass. The MRI also shows the heterogeneous signal intensity in the quadriceps tendon.

(Image 4) (Guillon et al, 2011) Image 4 displays Coronal T1-weighted MRI. The black arrow shows the soft tissue mass and abnormal signal intensity in the metaphyseal marrow. White arrow displays the extension of the tumor in early stage beyond the growth plate into the epiphysis. MRI is considered as the most important imaging technique for local staging and diagnosis of Osteosarcoma. It also helps in applying the most accurate surgical management. For staging of the disease, understanding the relation of tumor to the anatomic compartment and other compartments is important. “MRI fulfills this job exceptionally well and defines individual bones, joints, and surrounding fascia and neurovascular bundles elegantly” (Irion, Hamdan, & Krishna, n.d.)Compartment encompasses joints individual bones, and clearly defined spaces of soft tissues. When the disease or the tumor remain confined to its original compartment, it shows that prognosis of the disease is correct. The MRI of longitudinal sequence, which covers the entire bone, must be significantly performed to detect lesions. T1 weighted images are useful in this context. MRI is also important in pre and post chemotherapy interventions, as it helps to inform about the size parameters of the tumor. According to Kundu, (2014), “MRI is also being coupled with Positron Emission Tomography for detection of the systemic involvement by the tumor, local recurrence, and metastasis after treatment” (p. 238). Nuclear imaging is another radiological approach that displays the increased uptake of the radioisotope, when bone scans are done. This imaging is done with the help of technetium-99m (99mTc) methylene diphosphonate (MDP) (Stalley etal, 2010). Such scans are very significant in detecting multifocal diseases. This kind of imaging excludes pulmonary metastases by taking up radioisotope. However, it is recorded that skip lesions are effectively excluded by MRI. The only limitation is that “osteosarcomas typically show increased uptake, bone scans are sensitive but are not specific” (Stalley etal, 2010). Ultrasonography technique is not normally used in the staging of classic osteosarcoma lesions. But this modality can be very significant in guiding percutaneous biopsy. Sonography can be the only significant imaging modality in the patients, who are treated with prosthetic implants. Sonography is important in detecting early local recurrence; it is basically based on the imaging of CT scans or MRIs. Role of Radiologists Radiologists have the duty of using the medical resources efficiently and appropriately. The primary care physicians are the first contact for the patients, but the role of radiologists is also important in the initial diagnosis of the disease. In Osteosarcoma, the role of radiologists is evaluated to be very significant. This is because the results produced from the radiological examination, helps in detecting the disease and its stage. It further helps in additional diagnosis, tests and disease management. The role of radiologists also becomes more vital, as it “can use to facilitate the appropriate allocation of resources is clinician education” (Knechtges & Carlos, 2007, p. 228). The appropriate evaluation of the disease saves the patients from ionizing radiation and spending extra money on the unnecessary exams. Considering the fact that there is a rapid technological advancement in radiology, regular lectures and professionals meeting/communication, enhances the skills and knowledge of physicians (Knechtges & Carlos, 2007, p. 229). In addition, regular communication and collaboration of the healthcare professionals results in identifying more suitable investigations for the patients. Radiologists can help in developing better and enhanced investigation that may result into collaborative selection of suitable treatment and disease management strategies. According to Knechtges & Carlos (2007), “This type of collaboration between radiologists and clinicians can be taken a step further by jointly developing clinical decision rules or guidelines for imaging” (p. 229) Radiologists are the clinical specialists, who have specialization in imaging technology. They have expertise in image capturing technology and applying the most recent information technology of healthcare, which is the main reason to drive radiology. Radiology has emerged the key diagnostic tool for many chronic and severe diseases, such as cancer, heart failure and bone diseases. Radiology specifically plays significant role in monitoring patient’s condition and prediction patient outcomes. This technological approach involves varied physical principles related to different complexities. According to European Society of Radiology (2009), “the anatomical detail and sensitivity of these techniques is now of a high order and the use of imaging for ultrastructural diagnostics, nanotechnology, functional and quantitative diagnostics and molecular medicine is steadily increasing.” Clinical effectiveness has been improved with the help of radiographic approach. Radiologists have the duty of practicing and implementing technological developments in their clinical setting and ensure the best possible use of the healthcare resources (European Society of Radiology, 2009). Occurrence of the bone tumors includes multimodality approach. The extraordinary improvements have been done by the cross-sectional imaging to characterize tumors, diagnosis of primary osseous related to “lesion location, margin, matrix mineralization, cortical involvement and adjacent periosteal reaction”. MRI is considered as the best practice for local staging and focal extent. “The excellent contrast resolution and multiplanar capabilities of MRI lead to improved evaluation of both intracompartmental and extra compartmental extent of bone.” The therapy mainly related to Osteosarcoma is Neoadjuvant chemotherapy. This therapy involves limb salvage surgery, which decreases micrometastasis, and also reduces the size of the tumor (Min, Kang, & Ro, 2009). This therapeutic approach plays a significant role in radiographic imaging. Radiology is one of the least acknowledged medical technologies, but it is a very important medical specialization. In terms of important values, radiologists are able to add quality to patient care and health outcomes. They play a pivotal role in patient’s care by utilizing their special radiological knowledge and skills. The responsibilities of the radiologists must include best way to use the technology to investigate the disease (Min, Kang, & Ro, 2009). Particular treatment must be selected with reference to patient’s condition, in order to save time and cost. The quality of the images must be ensured by the radiologists, this reflects quality of their practice as professionals. Critical thinking skills are required to be used, while apply radiological examination. Communication also plays a pivotal role in this profession. Healthy communication and collaboration includes providing findings to the physicians in a time appropriate manner and making a regular follow-up. Appropriate and sufficient imaging must be performed by the radiologists in order to detect the primary malignant tumor of the bone. Conclusion Osteosarcoma is the primary malignant bone tumor. This kind of disease can occur in any age, but significantly found in the early growth period. Research studies have stated that there are different kinds of Osteosarcoma, where some are more prevalent in others. The significant patients of Osteosarcoma are children and adults between ages of 15-25 years. This is the age, when there is significant and rapid growth of bones takes place. This disease is an ancient disease and exact reasons behind the occurrence of this disease are still unknown. This disease starts growing by primitive mesenchymal bone-forming cells. The main characteristic of this disease is associated with histological hallmark related to the production of malignant osteoid. Within this disease other kind of cell formation is also noted, but main diagnosis of the disease is done through presence of malignant bone in the lesion. Most of the cases of Osteosarcoma, it is found that it is solitary lesions, which are found in the long bones of young children. Though any bone can be affected by this disease, but most significant areas are distal femur, proximal humerus and the proximal tibia. The literature review presented the importance of radiological therapy in Osteosarcoma. It is found that this disease, which mainly occurs in the long bones, is diagnosed through radiography. Thus, radiography plays a significant role in prognosis of the disease and its management. The incidence of this disease is higher in males then in females.

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