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Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas

Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone... Hindawi Sarcoma Volume 2019, Article ID 7385470, 5 pages https://doi.org/10.1155/2019/7385470 Research Article Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas 1 1 2 1 3 Ashish Gulia , Ajay Puri , T. S. Subi, Srinath M. Gupta , S. L. Juvekar, and Bharat Rekhi Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai 400012, India Department of Surgical Oncology, Rajagiri Hospital, Aluva, Kerala 683112, India Department of Radiology, National Cancer Institute, Nagpur 441108, India Department of Surgical Pathology, Tata Memorial Hospital, HBNI, Mumbai 400012, India Correspondence should be addressed to Ajay Puri; docpuri@gmail.com Received 23 August 2019; Revised 24 October 2019; Accepted 6 November 2019; Published 29 November 2019 Academic Editor: Valerae O. Lewis Copyright © 2019 Ashish Gulia et al. ,is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In today’s era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. ,e present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing’s sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. ,e maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. ,e arithmetic mean difference, Wilcoxon signed-rank test, and Spearman’s correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1± 4.85 cm (mean± standard deviation), while it was 10.77± 4.6 cm (mean± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing’s sarcoma (1)), MRI measurement was equal to histopathology. ,e Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R � 0.948, P< 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection. considered as the best imaging modality to detect the extent of 1. Introduction tumor involvement [7, 8]. Accurate estimation of tumor extent Complete tumor removal is critical to achieve adequate disease on MRI is the key to plan optimal resection margins [9–13]. control and provide optimum oncological outcomes in bone Currently, there are limited studies comparing MRI with sarcomas. In today’s era, limb salvage surgery has become the postresection histopathological measurements. procedure of choice and the current standard of care in ap- ,e present study compares measurements in bone propriately selected patients [1, 2]. For adequate oncologic sarcomas (osteosarcoma, Ewing’s sarcoma, and chon- clearance, preoperative evaluation of the extent of tumor is drosarcoma) as determined by the MRI with the histo- mandatory [3, 4]. Inadequate excision of tumor-bearing bone pathological extent seen on resected specimens. can result in tumor recurrence and contribute to poor onco- logical outcomes, and hence limb salvage should only be performed after detailed preoperative planning that ensures 2. Materials and Methods complete tumor removal [5]. Unnecessary resections can lead to compromised function and a higher incidence of reconstruction We prospectively evaluated 100 consecutive patients with failure [6]. Presently, magnetic resonance imaging (MRI) is a diagnosis of bone sarcoma who underwent limb salvage 2 Sarcoma surgery between May 2014 and December 2014. Institutional (mean± standard deviation) on histopathology. ,e mean ethics committee approval was obtained for the study. ,e difference and standard deviation of subgroups are given in study included patients with a confirmed histopathological Table 1. In 8 cases (osteosarcoma (7), Ewing’s sarcoma (1)), diagnosis of osteosarcoma/Ewing’s sarcoma/chon- MRI measurement was equal to histopathology. drosarcoma who underwent limb salvage surgery at our ,e Spearman correlation analysis showed a high cor- centre. We excluded patients who underwent reimplantation relation of tumor length on histopathology with the MRI for of bone after extracorporeal radiation therapy where mar- all patients (R � 0.948, P< 0.0001). gins and tumor extent could not be assessed on post-re- section histopathology (HP) [14]. 4. Discussion At presentation, all patients underwent local disease evaluation with a plain radiograph in two perpendicular With improved surgical techniques and effective neoadjuvant planes and MRI of the local site imaging the entire length of therapy, the current rate of limb salvage in bone sarcomas is the involved bone. After confirmation of histopathological 85% to 90% [16, 17]. An adequate surgical resection provides diagnosis and staging, the patients were treated as per the best chance for local disease control, which contributes to standard hospital protocol (neoadjuvant chemotherapy for better disease-related survival in bone sarcomas [10, 11, 18]. osteosarcoma and Ewing’s sarcoma) and upfront surgery for Balancing the desire to retain best possible function neces- chondrosarcoma. After completion of neoadjuvant therapy sitates that the surgical excision must have adequate oncologic which lasted for approximately 3 months, a repeat MRI was clearance while avoiding unnecessary excessive resection. done for all patients. ,e last MRI was performed within 6 Prior to the era of current advanced imaging modalities, weeks of index surgery. Both pre- and postchemotherapy intraoperative evaluation of the bone marrow by frozen MRI images were reviewed by a radiologist specialising in section was the norm in surgical treatment of bone sarcomas musculoskeletal oncology, and details of the tumor site, size, [19]. ,is is time consuming, needs the availability of and maximum disease extent (intramedullary extent/peri- a dedicated pathologist for assessing the sample during osteal reaction/soft tissue mass) were noted. For the purpose surgery, and adds an additional financial cost to treatment of this study, the maximum extent of disease as measured on [20]. Advances in imaging have improved our ability to ac- noncontrast T1-weighted images was noted [15]. ,e curately assess the extent of tumor on MRI. ,is can help maximum longitudinal (cranio-caudal) dimension of tumor reduce or obviate intraoperative frozen section sampling [20]. on MRI (irrespective of whether it was a prechemotherapy or Anderson et al. in a study of 142 patients concluded that postchemotherapy MRI) was considered as this is the extent frozen section can be omitted to determine the disease status which determines the level for tumor resection [15]. ,e at the osteotomy site [20] though they did suggest exami- imaging was performed on 1.5T system (Signa, GE). T1-WI nation of the split gross specimen as an adjunct to clinical and coronal sequences were performed using a body coil with radiological findings to ensure negative margins. a repetition time range/echo time range of 300–600 ms/4– While there are a few published studies comparing the 6 ms and 4 mm section thickness and 1 mm spacing. accuracy of imaging in determining the extent of disease in After surgical resection, the excised specimens were grossed osteosarcoma, studies comparing the same for Ewing’s sar- by a pathologist specialising in musculoskeletal oncology. After coma and chondrosarcoma are scarce [8, 19, 21–28]. Gillepsy bisecting the specimen longitudinally, the gross dimensions of et al. [22] compared CT and MRI in 17 cases of osteosarcoma the tumor were recorded. ,e extent of disease involvement as and determined that MRI is extremely accurate in assessing seen on the specimen was measured using a millimetre scale the intraosseous extent with a difference of 4.9± 4.3 mm. In and was confirmed by histopathology sections that evaluated a subgroup of five specimens with an identical plane of maximum disease extent. ,e radiological and histopatho- section, the average difference reduced to 1.8 mm± 1.6. logical dimensions were correlated. All the radiological and O’Flanagan’s study [26] comparing CT, MRI, and bone scans histopathological assessments were done by the same radiol- to estimate the extent of tumor in resected specimens de- ogist and pathologist who specialised in musculoskeletal on- termined that an MRI gave the most accurate results. Onikul cology and were aware of the ongoing study. Examples of et al. documented a mean difference in MRI and post- measurements are shown in Figures 1 and 2. operative gross specimen measurements within 2 cm [8]. ,e arithmetic mean difference, Wilcoxon signed-rank In Han et al.’s series, restricted to only osteosarcoma test, and Spearman’s correlation analysis were used to test cases, the maximum underestimation was 0.9 cm and the the differences and correlation between groups. maximum over estimation was 3.4 cm [23]. Tao’s study [25] excluded tumors involving thin bones like the radius, ulna and fibula, whereas we have included all tumors in 100 3. Results consecutive cases. In their study, estimation of tumor length A total of 100 cases were included in the study; 73 osteosar- was done on gross specimens whereas we had histopa- comas, 20 Ewing’s sarcomas, and 7 chondrosarcomas. Prox- thology confirmation confirming the pathologic extent of imal tibia (30) and distal femur (29) were the most common disease as well. Tao et al. showed a median difference of sites involved (Figure 3). 89 patients received chemotherapy. 2 mm (range: 0.1 cm to 1.5 cm) where the radiological dis- Mean tumor size on MRI based on the largest extent on ease extent was overestimated and a median difference of 5 mm (range: 0.1 cm to 1.8 cm) when the radiological disease either pre/postchemotherapy MRI was 12.1± 4.85 cm (mean± standard deviation), while it was 10.77± 4.6 cm extent was underestimated [25]. In our study when MRI Sarcoma 3 (a) (b) Figure 1: Tumor length measurements in the case of distal femur osteosarcoma on the gross specimen (a) 16.5 cm and noncontrast T1- weighted coronal MRI (b) 15.2 cm. Note that the white arrow indicates the periosteal reaction and soft tissue component exceed the intramedullary tumor extent. (a) (b) Figure 2: Tumor length measurements in the case of distal femur osteosarcoma on the gross specimen (a) 14 cm and noncontrast T1- weighted coronal MRI (b) 16 cm. Note that the white arrow indicates the periosteal reaction exceeds the intramedullary tumor extent. 4 Sarcoma Figure 3: Distribution as per site. Table 1: Subgroup analysis. Mean difference± SD (cm) Minimum (cm) Maximum (cm) MRI length> HP (79) 1.79± 1.56 0.10 4.00 Mean difference in tumor length in cases where dimension in MRI is more than HP Osteosarcoma (54) 1.8± 1.2 0.10 4.00 Ewing’s sarcoma (19) 1.98± 1.10 0.30 4.00 Chondrosarcoma (6) 1.12± 0.79 0.50 2.50 HP size> MRI (13) 0.58± 0.43 0.10 1.50 Mean difference in tumor length in cases where dimension in HP is more than MRI Osteosarcoma (12) 0.58± 0.45 0.10 1.50 Chondrosacoma (1) 0.6± 0.6 0.60 0.60 overestimated the extent of disease, the mean was 1.79 cm disease extent with intraoperative frozen section sampling or with a standard deviation of 1.56 cm. When the disease examination of split gross specimens in these cases. extent was underestimated on MRI, the mean was 0.58 cm with a standard deviation of 0.43 cm. 5. Conclusions While in Tao’s series, the maximum underestimation was 1.8 cm, and it was 1.5 cm in our series. ,us, a margin of ,e findings of the present study reiterate the fact that MRI 2 cm from the maximum tumor extent can be considered an is accurate in delineating the extent of bone sarcomas. A adequate safety margin to avoid intralesional resections. margin of 2 cm from the maximum tumor extent is adequate While a 2 cm margin is ideal, occasionally there will be and can avoid unnecessary lengthy resections. In the current instances when a surgeon may choose to have a lesser margin era of imaging, frozen section sampling after resection in in order to preserve a growth plate or an articular joint. It bone sarcomas may be omitted without compromising may be advisable to augment radiologic estimations of oncologic clearance in cases where a 2 cm margin is possible. Sarcoma 5 [14] A. Puri, S. Byregowda, A. Gulia, V. Patil, S. Crasto, and Data Availability S. Laskar, “Reconstructing diaphyseal tumors using radiated (50 Gy) autogenous tumor bone graft,” Journal of Surgical, ,e datasets of the current study are available from the vol. 118, no. 1, pp. 138–143, 2018. corresponding author upon request. [15] C. , evenin-Lemoine, ´ L. Destombes, J. Vial et al., “Planning for bone excision in ewing sarcoma: post-chemotherapy MRI Conflicts of Interest more accurate than pre-chemotherapy MRI assessment,” 3e Journal of Bone and Joint Surgery, vol. 100, no. 1, pp. 13–20, ,e authors declare that there are no conflicts of interest regarding the publication of this paper. [16] E. Halperin, L. Constine, N. Tarbell, and L. Kun, “Pediatric radiation oncology,” 2012, https://books.google.com/books? hl�en&lr�&id�UMKN7qerq3wC&oi�fnd&pg�PA184&ots� References SdlLVkDq9g&sig�yFonYACVRZPvqoT-CQMjZwQaMH0. [17] A. Gulia, “Osteosarcoma—a clandestine enigma,” Journal of [1] J. S. Meyer and W. Mackenzie, “Malignant bone tumors and Bone & Soft Tissue Tumors, vol. 2, no. 1, pp. 6-7, 2016. limb-salvage surgery in children,” Pediatric Radiology, vol. 34, [18] A. J. Chou, P. R. Merola, L. H. Wexler et al., “Treatment of no. 8, pp. 606–613, 2004. osteosarcoma at first recurrence after contemporary therapy,” [2] S. T. Wallack, E. R. Wisner, J. A. Werner et al., “Accuracy of Cancer, vol. 104, no. 10, pp. 2214–2221, 2005. magnetic resonance imaging for estimating intramedullary [19] M. S. Meyer, S. S. Spanier, M. Moser, and M. T. Scarborough, osteosarcoma extent in pre-operative planning of canine “Evaluating marrow margins for resection of osteosarcoma. A limb-salvage procedures,” Veterinary Radiology Ultrasound, modern approach,” Clinical Orthopaedics and Related Re- vol. 43, no. 5, pp. 432–441, 2002. search, vol. 363, pp. 170–175, 1999. [3] K. I. A. Reddy, H. Wafa, C. L. Gaston et al., “Does amputation [20] M. E. Anderson, P. E. 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Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas

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Copyright © 2019 Ashish Gulia et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Sarcoma Volume 2019, Article ID 7385470, 5 pages https://doi.org/10.1155/2019/7385470 Research Article Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas 1 1 2 1 3 Ashish Gulia , Ajay Puri , T. S. Subi, Srinath M. Gupta , S. L. Juvekar, and Bharat Rekhi Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai 400012, India Department of Surgical Oncology, Rajagiri Hospital, Aluva, Kerala 683112, India Department of Radiology, National Cancer Institute, Nagpur 441108, India Department of Surgical Pathology, Tata Memorial Hospital, HBNI, Mumbai 400012, India Correspondence should be addressed to Ajay Puri; docpuri@gmail.com Received 23 August 2019; Revised 24 October 2019; Accepted 6 November 2019; Published 29 November 2019 Academic Editor: Valerae O. Lewis Copyright © 2019 Ashish Gulia et al. ,is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In today’s era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. ,e present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing’s sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. ,e maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. ,e arithmetic mean difference, Wilcoxon signed-rank test, and Spearman’s correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1± 4.85 cm (mean± standard deviation), while it was 10.77± 4.6 cm (mean± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing’s sarcoma (1)), MRI measurement was equal to histopathology. ,e Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R � 0.948, P< 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection. considered as the best imaging modality to detect the extent of 1. Introduction tumor involvement [7, 8]. Accurate estimation of tumor extent Complete tumor removal is critical to achieve adequate disease on MRI is the key to plan optimal resection margins [9–13]. control and provide optimum oncological outcomes in bone Currently, there are limited studies comparing MRI with sarcomas. In today’s era, limb salvage surgery has become the postresection histopathological measurements. procedure of choice and the current standard of care in ap- ,e present study compares measurements in bone propriately selected patients [1, 2]. For adequate oncologic sarcomas (osteosarcoma, Ewing’s sarcoma, and chon- clearance, preoperative evaluation of the extent of tumor is drosarcoma) as determined by the MRI with the histo- mandatory [3, 4]. Inadequate excision of tumor-bearing bone pathological extent seen on resected specimens. can result in tumor recurrence and contribute to poor onco- logical outcomes, and hence limb salvage should only be performed after detailed preoperative planning that ensures 2. Materials and Methods complete tumor removal [5]. Unnecessary resections can lead to compromised function and a higher incidence of reconstruction We prospectively evaluated 100 consecutive patients with failure [6]. Presently, magnetic resonance imaging (MRI) is a diagnosis of bone sarcoma who underwent limb salvage 2 Sarcoma surgery between May 2014 and December 2014. Institutional (mean± standard deviation) on histopathology. ,e mean ethics committee approval was obtained for the study. ,e difference and standard deviation of subgroups are given in study included patients with a confirmed histopathological Table 1. In 8 cases (osteosarcoma (7), Ewing’s sarcoma (1)), diagnosis of osteosarcoma/Ewing’s sarcoma/chon- MRI measurement was equal to histopathology. drosarcoma who underwent limb salvage surgery at our ,e Spearman correlation analysis showed a high cor- centre. We excluded patients who underwent reimplantation relation of tumor length on histopathology with the MRI for of bone after extracorporeal radiation therapy where mar- all patients (R � 0.948, P< 0.0001). gins and tumor extent could not be assessed on post-re- section histopathology (HP) [14]. 4. Discussion At presentation, all patients underwent local disease evaluation with a plain radiograph in two perpendicular With improved surgical techniques and effective neoadjuvant planes and MRI of the local site imaging the entire length of therapy, the current rate of limb salvage in bone sarcomas is the involved bone. After confirmation of histopathological 85% to 90% [16, 17]. An adequate surgical resection provides diagnosis and staging, the patients were treated as per the best chance for local disease control, which contributes to standard hospital protocol (neoadjuvant chemotherapy for better disease-related survival in bone sarcomas [10, 11, 18]. osteosarcoma and Ewing’s sarcoma) and upfront surgery for Balancing the desire to retain best possible function neces- chondrosarcoma. After completion of neoadjuvant therapy sitates that the surgical excision must have adequate oncologic which lasted for approximately 3 months, a repeat MRI was clearance while avoiding unnecessary excessive resection. done for all patients. ,e last MRI was performed within 6 Prior to the era of current advanced imaging modalities, weeks of index surgery. Both pre- and postchemotherapy intraoperative evaluation of the bone marrow by frozen MRI images were reviewed by a radiologist specialising in section was the norm in surgical treatment of bone sarcomas musculoskeletal oncology, and details of the tumor site, size, [19]. ,is is time consuming, needs the availability of and maximum disease extent (intramedullary extent/peri- a dedicated pathologist for assessing the sample during osteal reaction/soft tissue mass) were noted. For the purpose surgery, and adds an additional financial cost to treatment of this study, the maximum extent of disease as measured on [20]. Advances in imaging have improved our ability to ac- noncontrast T1-weighted images was noted [15]. ,e curately assess the extent of tumor on MRI. ,is can help maximum longitudinal (cranio-caudal) dimension of tumor reduce or obviate intraoperative frozen section sampling [20]. on MRI (irrespective of whether it was a prechemotherapy or Anderson et al. in a study of 142 patients concluded that postchemotherapy MRI) was considered as this is the extent frozen section can be omitted to determine the disease status which determines the level for tumor resection [15]. ,e at the osteotomy site [20] though they did suggest exami- imaging was performed on 1.5T system (Signa, GE). T1-WI nation of the split gross specimen as an adjunct to clinical and coronal sequences were performed using a body coil with radiological findings to ensure negative margins. a repetition time range/echo time range of 300–600 ms/4– While there are a few published studies comparing the 6 ms and 4 mm section thickness and 1 mm spacing. accuracy of imaging in determining the extent of disease in After surgical resection, the excised specimens were grossed osteosarcoma, studies comparing the same for Ewing’s sar- by a pathologist specialising in musculoskeletal oncology. After coma and chondrosarcoma are scarce [8, 19, 21–28]. Gillepsy bisecting the specimen longitudinally, the gross dimensions of et al. [22] compared CT and MRI in 17 cases of osteosarcoma the tumor were recorded. ,e extent of disease involvement as and determined that MRI is extremely accurate in assessing seen on the specimen was measured using a millimetre scale the intraosseous extent with a difference of 4.9± 4.3 mm. In and was confirmed by histopathology sections that evaluated a subgroup of five specimens with an identical plane of maximum disease extent. ,e radiological and histopatho- section, the average difference reduced to 1.8 mm± 1.6. logical dimensions were correlated. All the radiological and O’Flanagan’s study [26] comparing CT, MRI, and bone scans histopathological assessments were done by the same radiol- to estimate the extent of tumor in resected specimens de- ogist and pathologist who specialised in musculoskeletal on- termined that an MRI gave the most accurate results. Onikul cology and were aware of the ongoing study. Examples of et al. documented a mean difference in MRI and post- measurements are shown in Figures 1 and 2. operative gross specimen measurements within 2 cm [8]. ,e arithmetic mean difference, Wilcoxon signed-rank In Han et al.’s series, restricted to only osteosarcoma test, and Spearman’s correlation analysis were used to test cases, the maximum underestimation was 0.9 cm and the the differences and correlation between groups. maximum over estimation was 3.4 cm [23]. Tao’s study [25] excluded tumors involving thin bones like the radius, ulna and fibula, whereas we have included all tumors in 100 3. Results consecutive cases. In their study, estimation of tumor length A total of 100 cases were included in the study; 73 osteosar- was done on gross specimens whereas we had histopa- comas, 20 Ewing’s sarcomas, and 7 chondrosarcomas. Prox- thology confirmation confirming the pathologic extent of imal tibia (30) and distal femur (29) were the most common disease as well. Tao et al. showed a median difference of sites involved (Figure 3). 89 patients received chemotherapy. 2 mm (range: 0.1 cm to 1.5 cm) where the radiological dis- Mean tumor size on MRI based on the largest extent on ease extent was overestimated and a median difference of 5 mm (range: 0.1 cm to 1.8 cm) when the radiological disease either pre/postchemotherapy MRI was 12.1± 4.85 cm (mean± standard deviation), while it was 10.77± 4.6 cm extent was underestimated [25]. In our study when MRI Sarcoma 3 (a) (b) Figure 1: Tumor length measurements in the case of distal femur osteosarcoma on the gross specimen (a) 16.5 cm and noncontrast T1- weighted coronal MRI (b) 15.2 cm. Note that the white arrow indicates the periosteal reaction and soft tissue component exceed the intramedullary tumor extent. (a) (b) Figure 2: Tumor length measurements in the case of distal femur osteosarcoma on the gross specimen (a) 14 cm and noncontrast T1- weighted coronal MRI (b) 16 cm. Note that the white arrow indicates the periosteal reaction exceeds the intramedullary tumor extent. 4 Sarcoma Figure 3: Distribution as per site. Table 1: Subgroup analysis. Mean difference± SD (cm) Minimum (cm) Maximum (cm) MRI length> HP (79) 1.79± 1.56 0.10 4.00 Mean difference in tumor length in cases where dimension in MRI is more than HP Osteosarcoma (54) 1.8± 1.2 0.10 4.00 Ewing’s sarcoma (19) 1.98± 1.10 0.30 4.00 Chondrosarcoma (6) 1.12± 0.79 0.50 2.50 HP size> MRI (13) 0.58± 0.43 0.10 1.50 Mean difference in tumor length in cases where dimension in HP is more than MRI Osteosarcoma (12) 0.58± 0.45 0.10 1.50 Chondrosacoma (1) 0.6± 0.6 0.60 0.60 overestimated the extent of disease, the mean was 1.79 cm disease extent with intraoperative frozen section sampling or with a standard deviation of 1.56 cm. When the disease examination of split gross specimens in these cases. extent was underestimated on MRI, the mean was 0.58 cm with a standard deviation of 0.43 cm. 5. 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