Doppler Sonography for Children with Osteosarcoma and Ewing's Sarcoma

I. Begun; Minsk Region/BY: "Doppler Sonography for Children with Osteosarcoma and Ewing's Sarcoma"

DOI: 10.1594/ecr2011/C-0518

Copyright ©: 2001–2006 European Congress of Radiology, 2007 European Society of Radiology. All rights reserved

Taking into account features of the pathogenesis of malignant neoplasm at the
stage of primary diagnosis in addition to combination of methods of medical
visualization require the presence of major pathophysiological clinical indicators
characterizing of the livelihood of a native tumor and, above all, its blood supply.
Systemic approaches in studying blood supply of bone sarcomas had not yet
been demonstrated [1,2,3]. The task of the present study is to study some aspects
of the pathogenesis disorders of macrohemodynamics at the systemic, organ,
and intratumoral levels in malignant tumors of the lower extremities to improve
of ultrasonic method in the diagnosis of osteosarcoma and Ewing sarcoma in


Methods and Materials
Ultrasound examinations were done of 21 children and adolescents of both sexes,
8-17 years, with OS (median of age 13 (12-15 years) and 14 - with ES (median of
age 12 (10-16) years). All of the tumors were localized at the lower extremities.
These were morphologically-confirmed sarcomas of the tubular bones (in the 2-4
stages of disease). In the control group of comparison were 26 patients (median
age 13.5 (10-16) years) with benign tumors of similar localization. The vascular
patterns of the soft tissue component of the tumor were evaluated in the modes of
color Doppler mapping and pulsed wave Doppler, indices - of resistance, pulsative
(RI, PI) and volume blood flow (Q) on common femoral artery (CFA) for affected
and healthy limbs were calculated. The cardiac output (CO) was determined by
echocardiography assay


In most cases, the ultrasound study demonstrated an extraosseous component
of the tumor, which was adjacent to the affected bone (Fig. 1). The volume
median of malignancies was 239 ml (lower quartile 112 ml, upper quartile 365
ml). Tumor vascularization by color Doppler was determined in most cases
(Fig. 2). There were no differences in the degree of vascularization of Ewing's
sarcoma in comparison with osteosarcoma in these studies. Through the aid
of three-dimensional reconstruction, vascular channel tumors were found to
have the chaotic spatial arrangement of vessels of small-medium caliber (Fig 3).
Vascularization of the tumor was presented in the form of randomly arranged

polymorphous vascular structures of 0,5 - 2 mm caliber. The resistance index for
the intratumorally vessels have been varied (0,70±0,26). The curves Doppler of
blood flow for CFA of the affected limbs (in contrast to the non affected limb) in
most cases have been with high amplitude and above zero line during the pulse
cycle (Fig 4,5). This coincides with data of Bramer J.A. et al (2004) [3]. Blood flow in
the CFA differed on quantitative characteristics in the affected and healthy limbs
in patients with OS and ES too. At the same time, between these groups (OS and
SE) there were no statistically significant differences in age, CO and in all the other
studied regional indicators. For sarcomas unequivocally, directions of affected
limbs change characterized by an increase in Q and by a decrease in RI, PI for CFA
blood flow compared with contralateral side and compared with the affected limb
of patients with benign tumors (Fig. 6). For example, the volume blood flow of the
CFA to the affected limb was 885 ± 324 ml / min, and for a healthy limb - 424±138
ml / min (p<0001). For pulsative index respectively there was falling on the side
of lesion - 2,60±0,90 compared with healthy limbs - 5,17±0.90 (p <0001). Smaller
values of Q in the CFA of the non affected limbs in the group of the sarcomas
patients in comparison with group of benign tumors (p<0,001) can indicate the
nature of the regional hemodynamics disorders (redistribution) in the patients with
sarcomas. In the sarcomas groups there was a correlation between the volume of
tumor and major parameters of hemodynamic of the affected limb (Q, % decrease
in RI) r=0,37-0,43 (p<0,05) #nd to central hemodynamics (CO) r=0,56 (p<0,05). For
the non affected limbs in both the sarcomas and benign tumors group, significant
differences in the RI were not detected. When studying the parameters of the
central hemodynamics in this work identified elevated (p<0,05) relative to group
comparison values CO in patients with sarcomas.


Fig. 1: Transverse scan at the lower third of the tibia on the left in comparison with
healthy limb in patient with Ewing's sarcoma. There are Irregular shaped, fuzzy contours,
heterogeneity of echostructure of the tumor, the violation of the integrity of the affected


Fig. 2: Duplex scanning in the affected area (lower third of the femur on the right) patient
with osteogenic sarcoma. Tumor vascularization in the form of randomly distributed
polymorphic vascular structures


Fig. 3: Reconstruction of vascular bed (osteogenic sarcoma)


Fig. 4: Blood flow in CFA to the non affected limb in mode color and pulsed wave Doppler
in a patient's with localized sarcomas at the bottom 1 / 3 of the femur on the left side


Fig. 5: Blood flow in CFA to the affected limb in mode color and pulsed wave Doppler in
a patient's with localized sarcomas at the bottom 1 / 3 of the femur on the left side


Fig. 6: A comparison of the relative changes in volume blood flow (Q) and index of
resistance (RI) in affected limbs for the CFA of malignant (mal) and benign (ben) tumors


From the data obtained by using Doppler technique describing marked: circulatory
bed of the tumor itself (features of vascular patterns, the value of resistive
index); functional restructuring of the state of the vascular bed throughout the
affected extremity (the value changes pulsative index, volume blood flow for
CFA); and, systemic effects of the tumor on the body (changes in CO). Such
systematic deviations can help diagnose the restructuring of central and regional
hemodynamics of the patient in time when the clinical manifestations of malignant
tumor growth are non specific, and there is no unambiguous interpretation of
radiological findings. These data at the initial stage of diagnosis together with by
X-ray methods will permit better identification of patients with signs of malignant
lesions of the lower limbs.


1. Bodner G., Schocke M.F., Rachbauer F. et al. Differentiation of Malignant
and Benign Musculoskeletal Tumors: Combined Color and Power Doppler
US and Spectral Wave Analysis // Radiology. 2002. V. 223, N 2. P. 410-
2. S. Kaushik, T. Miller, L. Nazarian, W. Foster. Spectral Doppler Sonography
of Musculoskeletal Soft Tissue Masses // J Ultrasound Med., Vol. 22. 2003.
P. 1333- 1336.
3. Bramer J.A., Gubler F. M., Maas M. E. et al. Colour Doppler ultrasound
predicts chemotherapy response, but not survival in paediatric
osteosarcoma // Pediatr Radiol. 2004. Vol. 34. P. 614-619.

Personal Information
Igor Begun, MD
Head of Department Functional&Ultrasonic diagnostics
State Onco-Haematology Child Centre
Minsk Region
223040 Belarus

Fax/tel: : +375 17 265-42-22 / +375 17 265-25-19