title: Surface osteosarcoma: Clinical features and therapeutic implications.
abstract: BACKGROUND
  Surface osteosarcoma are rare variant of osteosarcoma that include parosteal osteosarcoma, periosteal osteosarcoma and high grade surface osteosarcoma. These lesions have different clinical presentation and biological behavior compared to conventional osteosarcoma, and hence need to be managed differently.
  
  
  OBJECTIVE
  The aim of this study is to analyze the clinico-pathological features and outcome of a series of surface osteosarcoma in an attempt to define the adequate treatment of this rare entity.
  
  
  METHODS
  It is a retrospective and bicentric study of 18 surface osteosarcoma that were seen at the KASSAB's Institute and SAHLOUL Hospital from 2006 to 2013. The authors reviewed the clinical and radiologic features, histologic sections, treatments, and outcomes in this group of patients.
  
  
  RESULTS
  Seven patients were male (38.9%) and 11 were female (61.1%) with mean age of 25 years (range from 16 to 55 years). Eleven lesions were in the femur and 7 in the tibia. We identified 11 parosteal osteosarcoma (six of them were dedifferentiated), 3 periosteal osteosarcoma and 4 high grade surface osteosarcoma. Six patients had neoadjuvant chemotherapy and all lesions had surgical resection. Margins were wide in 15 cases and intra lesional in 3 cases. Histological response to chemotherapy was poor in all cases. The mean follow up was 34.5 months. Six patients (33.3%) presented local recurrence and 8 patients (44.4%) presented lung metastases. Six patients (33.3%) died from the disease after a mean follow up of 12 months (6-30 months); all of them had high grade lesions.
  
  
  CONCLUSIONS
  Histological grade of malignancy is the main point to assess in surface osteosarcoma since it determines treatment and prognosis. Low grade lesions should be treated by wide resection, while high grade lesions need more aggressive surgical approach associated to post operative chemotherapy.
authors.affiliation: Department of Adult Surgery, KASSAB's Orthopedic Institute, University El Manar II, Tunisia.
authors.forename: H
authors.initials: H
authors.lastname: Nouri
authors.affiliation: Department of Orthopedic Surgery, SAHLOUL's Hospital, University of SOUSSE, Tunisia.
authors.forename: M
authors.initials: M
authors.lastname: Ben Maitigue
authors.affiliation: Department of Pathology, KASSAB's Orthopedic Institute, University El Manar II, Tunisia.
authors.forename: L
authors.initials: L
authors.lastname: Abid
authors.affiliation: Department of Radiology, KASSAB's Orthopedic Institute, University El Manar II, Tunisia.
authors.forename: N
authors.initials: N
authors.lastname: Nouri
authors.affiliation: Department of Pathology, SAHLOUL's Hospital, University of SOUSSE, Tunisia.
authors.forename: A
authors.initials: A
authors.lastname: Abdelkader
authors.affiliation: Department of Radiology, KASSAB's Orthopedic Institute, University El Manar II, Tunisia.
authors.forename: M
authors.initials: M
authors.lastname: Bouaziz
authors.affiliation: Department of Adult Surgery, KASSAB's Orthopedic Institute, University El Manar II, Tunisia.
authors.forename: M
authors.initials: M
authors.lastname: Mestiri
keywords: Chemotherapy-surgery; High grade surface osteosarcoma; Parosteal osteosarcoma; Periosteal osteosarcoma