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1 Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved T he scapula is a small bone in which many neoplasms can develop. Few radiology articles report the types and appearances of these tumors. The Musculoskeletal Tumor Society has developed a classification system for shoulder girdle tumors that divides the scapula into two zones [1]: the acromial glenoid complex comprises the S2 region and the blade spine portion comprises the S1 region (Fig. 1). The system helps provide a functional classification for resections and reconstructions and a logical division of the abnormalties that develop in the scapula. Neoplasms of the S1 region include those that commonly develop in the flat bones (i.e., Ewing s sarcoma, multiple myeloma, and lymphoma). Neoplasms of the S2 region include those that commonly develop at the ends of the bone (i.e., giant cell tumors and aneurysmal bone cysts) [2]. We describe bone neoplasms that develop in the scapula and present examples of these tumors on radiographs, T scans, and MR images. Osteochondroma Osteochondroma (Fig. 2) is the most common primary benign neoplasm of the scapula with an incidence of 4.6% [3]. Usually, it is a single lesion located on the anterior surface of the scapular body. Patients with osteochondroma complain of a snapping sensation when internally rotating and abducting their arm. Surgical resection is the treatment of choice for osteochondroma. Osteoid Osteoma Osteoid osteoma is a rare tumor of the scapula with only 15 cases reported in the literature [4]. The location of this neoplasm remains unclear, though it has developed in the coracoid process and the subglenoid region [2, 4]. Most patients with osteoid osteoma complain of night pain that can be relieved with salicylates. Radiographic findings include sclerosis, but a nidus may be difficult to see on radiography. T may facilitate finding the nidus (Fig. 3). Treatment includes surgical excision of the nidus [2]. Fig. 1. Drawing shows system for classification of skeletal resection, developed by ommittee of Musculoskeletal Tumor Society [1]. S1 corresponds to scapular blade and S2 to glenoid acromial complex. Pictorial Essay Neoplasms of the Scapula Marcia F. lacksin 1 and Joseph enevenia 2 neurysmal one yst neurysmal bone cysts are lytic expansile lesions. They have been reported in the coracoid (Fig. 4), a region that embryologically corresponds with the end of a long bone [2, 5]. Fluid fluid levels can be seen on T scans and MR images [6]. These lesions usually develop in patients that are between 11 and 30 years old. Surgical therapy includes excision with cementation, bone grafting, or both [2]. hondrosarcoma hondrosarcoma is the most common malignant neoplasm of the scapula, found in both the S1 and S2 regions. These tumors have been seen in preexisting osteochondromas [2, 7] (Fig. 5). Radiographs may show cortical destruction by a lesion containing a calcified cartilaginous matrix, but the lesion can also appear lytic and expansile (Fig. 6). This neoplasm can Received ugust 30, 1999; accepted after revision November 16, Department of Radiology, University of Medicine and Dentistry of New Jersey, University Hospital, -320, 150 ergen St., Newark, NJ ddress correspondence to M. F. lacksin. 2 Department of Orthopedic Surgery, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ JR 2000;174: X/00/ merican Roentgen Ray Society JR:174, June

2 lacksin and enevenia Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old man with osteochondroma of scapula., Scapular Y radiograph shows lesion (arrow) on anterior surface of body., xial T scan shows bony protuberance, in which cortex and medullary canal are contiguous with parent bone (arrowhead). Fig year-old man with asymptomatic osteoid osteoma., 99Tc-methyldiphosphonate bone scan obtained for prostatic cancer metastasis screening shows focus of increased tracer uptake (arrowhead ) in lateral scapular body., Frontal radiograph of scapula shows sclerotic lesion (arrowhead)., xial T scan reveals sclerotic lesion without well-defined nidus (arrowhead). D, Specimen radiograph reveals lesion (arrow). Histology was consistent with osteoid osteoma and healed nidus. D 1730 JR:174, June 2000

3 Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved Neoplasms of the Scapula Fig year-old girl with aneurysmal bone cyst after pathologic fracture., Frontal radiograph shows large expansile lesion (arrows) in acromion., Sagittal oblique fat-suppressed T2-weighted MR image shows well-defined lesion (arrowhead) with large cystic component., xial spin-echo T1-weighted MR image shows homogeneous high signal intensity in cystic portion of lesion (arrowheads), consistent with degraded blood products. Fig year-old boy with chondrosarcoma in preexisting osteochondroma., Frontal radiograph shows osteochondroma (arrowheads) inferior to glenoid rim., xial T scan obtained at same time as shows osteochondroma and suspicious irregular cartilage cap (arrowheads)., Frontal radiograph obtained 1 year after resection shows lesion recurrence in glenoid. D, xial T scan shows large cartilage component surrounding bony glenoid (arrowheads) with cortical destruction. E, xial fat-saturated T2-weighted MR image shows high-signal-intensity cartilage component (arrowheads). D JR:174, June 2000 E 1731

4 Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved lacksin and enevenia Fig year-old man with chondrosarcoma., Scapular Y radiograph shows lytic expansile lesion (arrowheads) in scapular body., Sagittal oblique fat-saturated T2-weighted MR image shows large high-signal-intensity cartilage component and infiltration of bone marrow (arrows). Ewing s Sarcoma Ewing s sarcoma frequently develops in the pelvis and lower extremities but it is also seen in the scapular body. This disease can have a permeative or lytic pattern (Fig. 8). Similar to the appearance of this tumor in other bones, a soft-tissue mass and periosteal reaction are frequent findings [9] (Figs. 8 and 8). Treatment is similar to that of osteosarcoma with neoadjuvant chemotherapy and limb salvage [7] (Fig. 8D). Malignant Fibrous Histiocytoma cause diagnostic difficulty on radiographs because the lesion can resemble an aneurysmal bone cyst or a giant cell tumor. hondrosarcoma is usually seen in older patients and has not been reported to contain fluid fluid levels. T may be helpful in revealing matrix calcification and the absence of fluid levels. MR imaging can depict the typical appearance of cartilage with a lobulated high-signal-intensity mass on T2-weighted images. Therapy includes limb salvage procedures [7]. Osteosarcoma Osteosarcoma is a frequent malignant neoplasm of the scapula [2]. oth chondroblastic and osteoblastic types have been reported (Fig. 7); however, we discuss the telangiectatic type. Similar to the chondrosarcoma, the telangiectatic type of osteosarcoma may be lytic and expansile (Figs. 7 7D) and can mimic benign scapular neoplasms. We have seen the telangiectatic type in the coracoid, but osteoblastic or central osteosarcomas are also seen in the S1 region. one formation in scapular osteosarcomas is frequent, and many tumors are associated with bulky soft-tissue masses [8]. Patients with osteosarcoma are usually between 11 and 30 years old [5, 7, 8]. Neoadjuvant chemotherapy followed by wide excision and limb salvage is commonly performed [7]. Malignant fibrous histiocytoma was recognized as a distinct abnormality in the 1960s. s a primary bone tumor of the appendicular skeleton, this neoplasm can occur at any age [10]. Fibrosarcoma has been reported in the scapula in older literature, but more recently, only one case of primary scapular malignant fibrous histiocytoma has been reported [8]. Our case is also primary to the scapula with a lytic lesion (Fig. 9). Though regions containing fibrous tissue can be seen on MR imaging of malignant fibrous histiocytoma, images often show only heterogeneously increased signal intensity on T2-weighted sequences [11] (Figs. 9 and 9). Treatment options are similar to those used for osteosarcoma [7]. Multiple Myeloma Multiple myeloma can appear with a honeycomb pattern or manifest as a lytic expansile Fig. 7. Osteosarcoma of scapula., Frontal radiograph of 25-year-old man with steosarcoma in scapular body producing neoplastic new bone (arrowheads)., Frontal radiograph of 7-year-old girl with telangiectatic type of osteosarcoma expanding coracoid (arrows). (Fig. 7 continues on next page) 1732 JR:174, June 2000

5 Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved Neoplasms of the Scapula D Fig. 7. (continued) Osteosarcoma of scapula., xial fat-saturated T2-weighted MR image of patient in shows heterogeneous expansile lesion (solid arrows) with rim of high-signal-intensity edema (open arrows) surrounding scapula. D, Sagittal oblique fat-saturated T2-weighted MR image of patient in shows marked expansion of coracoid (arrowheads). E, Frontal radiograph of unconstrained total scapular prosthesis with cemented humeral component used for limb salvage of patient in. E Fig. 8. Ewing s sarcoma of scapula., Frontal radiograph of 17-year-old boy with palpable mass shows lytic lesion (arrows) in superior rim of scapular body., xial T scan of patient in shows destructive lesion with large soft-tissue mass (arrowheads)., xial T scan of 19-year-old woman shows rim of periosteal reaction (arrows). JR:174, June

6 Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved lacksin and enevenia Fig year-old man with primary malignant fibrous histiocytoma of scapula., Frontal radiograph shows lytic lesion (arrowhead) in body of scapula., Sagittal oblique spin-echo T1-weighted MR image shows lesion (arrowheads) that is isointense to muscle with cortical destruction., Sagittal oblique fat-saturated T2-weighted MR image shows heterogeneous high signal intensity with soft-tissue extension (arrows). Fig. 10. Multiple myeloma., Scapular radiograph of 64-year-old man during arthrography shows lytic bubbly plasmacytoma (arrows) in body of scapula., Frontal radiograph of 80-year-old man with honeycomb appearance of multiple myeloma in humerus, acromion, and ribs shows discrete punched-out lesion in lateral cortex (arrowhead). plasmacytoma [12] (Fig. 10). Multiple myeloma and lymphoma are tumors of adulthood that originate in the marrow and occur in the scapula [5]. In our patient, the plasmacytoma occurred in the scapular body or the 1734 flat bone equivalent of the scapula. The appearance of multiple myeloma can resemble that of a giant cell tumor or an aneurysmal bone cyst. Treatment includes radiation therapy and chemotherapy [7]. In summary, the scapula may contain a wide range of benign and malignant tumors, many of which have similar lytic expansile radiographic appearances. enign lesions such as aneurysmal bone cysts or giant cell tumors JR:174, June 2000

7 Neoplasms of the Scapula Downloaded from by on 11/21/17 from IP address opyright RRS. For personal use only; all rights reserved occur in the S2 region. ommon malignancies such as chondrosarcomas and osteosarcomas occur throughout the scapula. Ewing s sarcoma, lymphoma, and multiple myeloma frequently occur in the S1 region. With the advancement of limb salvage procedures, it becomes incumbent on the radiologist to accurately identify tumor extent because it dictates the type of surgery required [1]. References 1. Enneking W, Dunham W, Gebhardt M, Malawar M, Pritchard D. system for the classification of skeletal resections. hir Organi Mov 1990;75[suppl 1]: Ogose, Sim FH, O onnor MI, Unni KK. one tumors of the coracoid process of the scapula. lin Orthop 1999;358: Galate JF, lue JM, Gaines RW. Osteochondroma of the scapula. Mo Med 1995;92: Moshieff R, Leibergall M, Ziv I, mir G, Segal D. Osteoid osteoma of the scapula. lin Orthop 1991;262: Samilson RL, Morris JM, Thompson RW. Tumors of the scapula. lin Orthop 1968;58: ory D, Fritsch S, ohen MD, et al. neurysmal bone cysts: imaging findings and embolotherapy. JR 1989;153: Gibbons LMH, ell RS, Wunder JS, et al. Function Notice to uthors after subtotal scapulectomy for neoplasm of bone and soft tissue. J one Joint Surg r 1998;80-: Kellie SJ, Pratt, Parham DM, Fleming ID, Meyer WH, Rao N. Sarcomas (other than Ewing s) of the flat bones in children and adolescents. ancer 1990;65: Reinus WR, Gilula L, Intergroup Ewing s Sarcoma Study ommittee. Radiology of Ewing s sarcoma: intergroup Ewing s sarcoma study. RadioGraphics 1984;4: oland PJ, Huvos G. Malignant fibrous histiocytoma of bone. lin Orthop 1986;204: Kransdorf MJ, Murphey MD. Imaging of soft tissue tumors, 1st ed. Philadelphia: Saunders, 1997: Meszaros WT. The many facets of multiple myeloma. Semin Roentgenol 1974;9: uthors of accepted manuscripts can now receive galley proofs via . The author s system must be able to read in- Hex files and have version 3.0 of dobe crobat Reader. The RRS Web site ( has a link to the dobe Web site, where authors can download free copies of the most recent version of the reader. JR:174, June