SUBCUTANEOUS NODULES AS INITIAL METASTATIC SITES IN OSTEOSARCOMA

A 54-year-old woman presented with two nonsymptomatic subcutaneous nod ules. Approximately 3 months previously, after sustaining a fall, her X-rays revealed a pathologic fracture and a highly destructive appeari ng lesion. She underwent amputation of the right leg up to the middle of the femoral bone. Her history was negative for any preexisting bone condition and her family history was negative for malignant diseases. The pathology report macroscopically showed a neoplastic tumor with a maximal diameter of 12 cm which literally occupied almost all of the knee arthrosis and extended into the femoral condylus. Microscopic exa mination of the specimen showed a high grade malignant sarcoma compris ing mainly spindle cells with a large percentage of necrosis. The exac t histologic typing was uncertain, but was probably fibroblastic-type osteosarcoma (Fig. 1). On admission, her physical examination was sign ificant for the presence of two subcutaneous nodules. One nodule was l ocated on the abdominal wall in the lower left area (approximately 1x1 cm) and the other on the apex area of the scalp (approximately 1.5x1. 5 cm). These lesions were not ulcerated and there was no change in ski n pigmentation. The patient mentioned that they appeared a couple of m onths ago. She also complained of recent dim vision in the left eye. L aboratory findings included a positive fine needle aspiration (FNA) of both nodules showing metastatic infiltration of the skin and subcutan eous tissue by osteosarcoma (Fig. 2), as well as a positive computed t omography (CT) scan of the orbita showing a metastatic tumor retro-ocu larly to the left which pressed against the optic nerve and was in con tact with the lateral rectus. It is noteworthy to point out that, in t his patient, both chest roentgenogram and CT of the chest were negativ e. Bone scan, liver ultrasound, and CT of the upper and lower abdomen were also negative. All other laboratory findings were within normal l imits. The decision was made that the patient was to undergo chemother apy consisting of two cycles of Adriamycin (ADR) and Platamine (CDDP), 21 days apart, followed by one cycle of BCD (Bleomycin, Cyclophospham ide, and Dactinomycin) after 21 days. This regimen was to be repeated once for a total of six cycles, each 21 days apart. One day prior to t he commencement of chemotherapy, a third subcutaneous nodule presented on the right side of the back in the scapular area. This also had a p ositive FNA showing metastatic osteosarcoma. On admission of the patie nt for the second cycle of chemotherapy (ADR and CDDP), a fourth nodul e was discovered on the upper third of the left thigh, and on admissio n for the third cycle (BCD), a fifth nodule was found on the left arm (brachium area). The patient's chest roentgenogram continued to be neg ative. A little over 21/2 months after initiating chemotherapy, on ent ering the fourth cycle (ADR and CDDP), it was observed that two of the five nodules (on the left arm and in the left lower abdominal area) h ad disappeared. There was also a decrease in the size of the remaining three. Furthermore, the patient mentioned improvement with regard to her vision. At the time of admission for the fifth cycle of chemothera py (ADR and CDDP), all nodules, except that on the apex area of the sc alp, had disappeared. The remaining nodule was stable in size and, on admission for the sixth cycle (BCD), had decreased in size. One month following the sixth cycle of chemotherapy, the patient was admitted fo r follow-up. All five subcutaneous nodules (Fig. 3) had clinically com pletely disappeared. Furthermore, the patient mentioned complete resto ration of her vision. The laboratory tests (bone scan, liver ultrasoun d, orbital CT, CT of the upper and lower abdomen, and thoracic CT) wer e all negative. At present the patient is in remission with regard to her disease and in general good health.