Paget's Disease of the Spine and Secondary Osteosarcoma
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- Sofka, C.M., Ciavarra, G., Saboeiro, G. et al. HSS Jrnl (2006) 2: 188. doi:10.1007/s11420-006-9007-2
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Paget's disease of bone is not uncommon with spine involvement seen in over half of cases . Paget's disease is seen radiographically as areas of enlargement of the bone with thickened, coarsened trabeculae. Usually, a mixed picture of sclerotic and lytic Paget's is encountered; however, there are dominantly lytic forms of Paget's that can confuse the radiographic picture. Increased radiotracer uptake is seen in Paget's with nuclear scintigraphy and does not necessarily indicate malignant transformation.
Malignant transformation of Paget's disease remains uncommon with a wide range of reported incidences, depending on the population sampled, ranging from 0.9 to 20% . Sarcomatous degeneration of Paget's disease into osteosarcoma has been reported rarely with resultant neurologic compromise when occurring in the spine [3–5]. A familial incidence of osteosarcoma in the setting of Paget's disease has also been reported, suggesting a potential environmental or genetic association .
The most reliable imaging indication of potential malignant transformation of Paget's is noting a change over time. On conventional radiographs as well as CT, lytic areas of bone destruction, which are new compared to previous serial imaging examinations, can be seen, often in association with a soft tissue mass.
The use of imaging guidance to solve potential cases of malignant degeneration of Paget's can provide a reliable diagnosis with less morbidity than open biopsy . Percutaneous transpedicular biopsy of spinal lesions with imaging guidance has been demonstrated to be safe, efficacious, and cost effective [8, 9]. Direct visualization of the needle within the area of interest provides the most reliable means of ensuring that accurate biopsy samples are taken. The procedure can be performed as an outpatient with a minimum of potential complications .
A variety of pathologies can be diagnosed with percutaneous biopsy including both primary and secondary neoplastic lesions as well as infectious spondylodiscitis . The most commonly encountered complications include localized bleeding, usually self-limited, and with procedures involving the thoracic or upper lumbar spine, potentially pneumothorax. Meticulous trajectory planning prior to inserting the needle, however, can lessen the incidence of pneumothorax [11, 12]. A large prospective study of 128 cases evaluated not only diagnostic accuracy but also patient discomfort levels, surgeon satisfaction with the core samples, and total procedure time of percutaneous image-guided biopsy vs. open surgical biopsy. The results demonstrated that with image-guided biopsy, the average procedure time was only 30 min, with overall high patient satisfaction and less patient discomfort .
In conclusion, image-guided biopsy of the spine is an accurate and safe method for providing rapid diagnosis of a variety of pathologies and is a reliable problem-solving tool.