Management of Squamous Cell Carcinoma in Chronic Osteomyelitis: Role of Magnetic Resonance Imaging in Differential Diagnosis

Purpose or Learning Objective: Chronic osteomyelitis can rarely cause squamous cell carcinoma (SCC), so an early diagnosis and appropriate treatment is fundamental for correct patient management. Magnetic resonance imaging (MRI) represents the gold standard for identifying features, an adequate differential diagnosis, and a well-planned follow-up.

Methods or Background: We retrospectively reviewed 73 cases of patients with chronic osteomyelitis treated between 1995 and 2019. Six of these patients (8.2%) had a malignant degeneration into SCC. The average age of patients at tumoral diagnosis was 63.5 years (range: 47–84 years); all of them were men.

All the patients with malignant degeneration were evaluated with preoperative radiography, computed tomography, and gadolinium-enhanced MRI. MR examinations were performed with a 1.5-T scanner (AERA, Siemens Medical Solutions, Erlangen, Germany). Unenhanced examination included a coronal and sagittal T1-weighted turbo spin-echo sequence (TSE), a coronal fat-suppressed intermediate-weighted spin-echo sequence, a transverse T1-weighted TSE sequence, and a transverse T2-weighted TSE sequence. Dynamic contrast-enhanced MRI was performed after the intravenous administration of a gadolinium chelate (0.2 mmol/kg body weight) using an automated power injector at a flow rate of 1.5 mL/s, followed by 20 to 30 mL saline at the same flow rate.

A time-resolved angiography with interleaved stochastic trajectories sequence was used for dynamic images. For each sequence, 31 dynamic-phase scanning images with a temporal resolution of 10 seconds were obtained for covering arterial and venous phases. The total scanning time for dynamic gadolinium enhancement was 3 minutes. Static coronal T1-weighted TSE and transverse T1-weighted with fat saturation sequences were then performed.

Conclusion: The onset of SCC on the osteomyelitis site is an uncommon occurrence and makes a differential diagnosis from the osteomyelitis itself more difficult. The change in the clinical scenario is an alert that can lead to a diagnosis of tumoral transformation. The role of MRI during the follow-up of chronic osteomyelitis is crucial making the differential diagnosis between infected and tumoral tissue.

Publication History

Article published online:
26 May 2023