Multimodal Imaging of Osteosarcoma: From First Diagnosis to Radiomics

Osteosarcoma is a primary malignant bone tumor characterized by the production of an osteoid matrix. Although histology remains the definitive diagnostic standard, imaging plays a crucial role in diagnosis, therapeutic planning, and follow-up. Conventional radiography serves as the initial checkpoint for detecting this pathology, which often presents diagnostic challenges due to vague and nonspecific symptoms, especially in its early stages. Today, the integration of different imaging techniques enables an increasingly personalized diagnosis and management, with each contributing unique and complementary information. Conventional radiography typically initiates the imaging assessment, and the Bone Reporting and Data System (Bone-RADS) of the Society of Skeletal Radiology (SSR) is a valuable tool for stratifying the risk of suspicious bone lesions. CT is the preferred modality for evaluating the bone matrix, while bone scans and PET/CT are effective for detecting distant metastases. MRI reveals the extent of the lesion in adjacent soft tissues, the medullary canal, and joints, as well as its relationship to neurovascular structures and the presence of skip lesions. Advanced techniques such as dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), diffusion-weighted imaging (DWI), and perfusion MRI help characterize the tumor environment and assess treatment response. Osteosarcoma comprises a range of subtypes with differing clinical and imaging characteristics, some of which are particularly distinctive, such as in the case of telangiectatic osteosarcoma. Knowledge of these variants can guide radiologists in the differential diagnosis, which includes both central and surface forms, ranging from highly aggressive to more indolent types. In this review, we present a wide range of representative cases from our hospital case series to illustrate both typical and atypical imaging presentations. Finally, we discuss recent advancements and challenges in applying artificial intelligence approaches to the imaging of osteosarcoma.