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Background Primary osteosarcoma of craniovertebral junction is extremely rare and reports in paediatric patients are limited. The symptoms are subtle and mostly underestimated. Case presentation. We present an unusual case of a 11-years old girl affected by an extensive and metastatic osteosarcoma of the atlas presented with cervicalgia and right torticollis refractory to medical treatment. The patient underwent open biopsy confirming the malignant histology. Conclusions Cervicalgia with or without a torticollis refractory to medical treatment, in absence of history of fell or trauma, is highly suspicious and should be considered as a warning sign for a severe pathology and it should not be neglected.

Highlights • The overall survival of osteosarcoma patients in the last 15 years has improved. • The proportion of patients with metastases at the time of diagnosis unchanged. • Consultation with specialists within 4 weeks can contribute to a better prognosis., Aims Examine: (1) If length of symptoms (LS) of children with osteosarcoma has improved in the last 15 years (2) Is delay in diagnosis related to the presence of metastases at presentation? (3) The impact of delay in diagnosis on prognosis. Methods 250 consecutive patients with a diagnosis of osteosarcoma of bone treated at a national bone tumor treatment center between 2004 and 2018 were studied retrospectively. Three groups comprising those diagnosed over a five-year period (Group 1: 2004–2008, Group 2: 2009–2013; Group 3: 2014–2018) were studied. Results There were 126 males and 124 females with a mean age 12.2 years. The median LS for all patients was eight weeks. The median LS for Group 3 was significantly shorter than that for other groups. Development of metastasis during follow-up period was significantly less in Group 3 compared to the other groups. Overall survival gradually improved over the whole study period. There was no difference in the proportion presenting with metastases at diagnosis between the three groups. The survival rates in patients with LS shorter than 4 weeks was better than those with LS longer than 4 weeks, irrespective of the study time period. Conclusions There has been an improvement in the LS in patients diagnosed with osteosarcoma over the last 15 years. The development of metastasis during follow-up has reduced and the overall survival in the last 15 years has improved. LS longer than 4 weeks is associated with a poorer prognosis.

Primary breast osteosarcoma is a rare malignancy, with mostly case reports in the literature. The appearance of breast osteosarcoma on digital breast tomosynthesis imaging has not yet been described. A 69-year-old woman presents for routine screening mammography and is found to have a calcified mass in her right breast. Pattern of calcification appeared “sunburst” on digital breast tomosynthesis images. This mass was larger than on the previous year's mammogram, at which time it had been interpreted as a benign calcified fibroadenoma. The subsequent workup demonstrated the mass to reflect primary breast osteosarcoma. The patient's workup and treatment are detailed in this case. Primary breast osteosarcoma, although rare, should be included as a diagnostic consideration for breast masses with a sunburst pattern of calcifications, particularly when the mammographic appearance has changed.