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A lesion in the talus of an 88 year old woman with 2 previous tumors

Case Identification
Case ID Number: 
20110208LT
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 88 year old woman has dementia, left ankle pain, and a lesion in the left talus. There was treatment for two different tumors approximately 10 years ago, but further details are not available. The local exam shows swelling and tenderness, but no redness, no old incisions or scars,and moderate tenderness generalized around the ankle. The patient is afebrile.

Radiological findings:: 
A destructive, permeative lesion is seen in the body, neck and head of the talus, with no matrix mineralization, no periosteal reaction, and a slightly displaced fracture of the talar neck. The lesion also appears to involve the calcaneus near the sinus tarsi. The articular spaces and cortical surfaces are largely preserved. There is generalized osteopenia. A CT scan shows how permeative the lesion is. No MRI or other imaging was deemed necessary prior to biopsy. An ultrasound was performed to rule out blood clots, which notes an enlarged node in the ipsilateral groin.
Laboratory results:: 
WBC normal, no left shift. CRP 0.6
Differential Diagnosis: 
Primary bone tumor Metastatic bone tumor from previous tumors? Atypical infection
Further Work Up Needed:: 
Treatment plan needed.
Pathology results:: 
See the images shown. 1- 100x © 2011 bonetumor.org courtesy M. Misialek 2- 200x © 2011 bonetumor.org courtesy M. Misialek 3- 400x © 2011 bonetumor.org courtesy M. Misialek 4- 200x, immunohistochemical stain for CD20 © 2011 bonetumor.org courtesy M. Misialek
Treatment Options:: 
As an additional challenge, given the diagnosis, what orthopedic treatment is required?

A lytic lesion in the distal humerus

Case Identification
Case ID Number: 
20100728DH
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

This 60-year-old right handed woman has had gradual onset of pain in the right elbow. X-rays show a destructive bone lesion in the distal humerus. Further radiographic evaluation has shown that there is a 6.9 cm mass in the lower pole of the left kidney. It has a heterogeneous appearance consistent with renal cell carcinoma. The bone scan shows multiple areas of abnormality, including two lesions in the skull.

Radiological findings:: 
The plain radiographs of the right distal humerus show an aggressive destructive process centered just above the olecranon fossa. The lesion is purely lytic and the surrounding bone shows a permeative pattern of destruction. The lesion measures approximately 40 by 30 mm, and the medial cortex of the humerus has been damaged and appeared to be slightly fractured. There is no periosteal reaction and no visible ossification within the substance of the lesion. The MRI shows a mass occupying the upper portion of the olecranon fossa and projecting anteriorly into the soft tissues.
Treatment Options:: 
The right distal humerus lesion is large and there is clearly a high risk of fracture. Hopefully this can be stabilized rapidly before the patient has a fracture. This area cannot be stabilized with a rod, since it is too distal. Rodding of renal cell carcinoma lesions may lead to recurrence since they are not sensitive to radiotherapy. Options for the right distal humerus lesion include complete resection with reconstruction with an elbow prosthesis, or curettage of the lesion and packing with cement, combined with plating of the distal humerus. Both options should give the patient a durable reconstruction.

A machinist with pain at work

Case Identification
Case ID Number: 
20090721AM
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a 44-year-old machinist who has had pain in the right hip for approximately one year. It is exacerbated by standing, walking and heavy activity, and somewhat relieved by rest.

Radiological findings:: 
There is no significant night pain but there may be a dull ache. Motrin does not relieve the pain. There is no significant past history or family history. On examination of the right hip there is an excellent full range of motion without apparent pain. There is some anterior irritability to deep palpation but no mass can be appreciated. There is no skin abnormality, no ecchymosis, no warmth. No other pertinent findings are noted on the exam. Plain radiographs, CT scan, bone scan are available for review. There is a mixed lytic and sclerotic lesion in the proximal femur, centrally located in the intramedullary space, just above the lesser trochanter. The cortex does not appear to be violated. The area in the center of the lesion is lucent without matrix. Surrounding this is a very dense area of sclerosis which is somewhat irregular. The CT scan shows essentially similar findings but shows that the lesion is larger when seen on CT that when seen on radiographs. The central area is actually two lobulated central lucent defects in the bone. The lesion is very slightly increased uptake on bone scan. No other areas of abnormality on the bone scan are appreciated.
Differential Diagnosis: 
The differential diagnosis of this lesion should include fibrous dysplasia, fibroxanthoma (non-ossifying fibroma), polymorphic fibro-osseous tumor of bone, liposclerosing myxofibrous tumor of bone, myxofibroma, lipoma, cyst, bone infarct, Paget's disease, and, chondroma. The lesion is too large for an osteoid osteoma but might be an osteoblastoma. The lesion does not have aggressive features so osteosarcoma is unlikely. No orthopedic surgeon considering a bone-forming lesion in the femur should fail to at least consider osteosarcoma, regardless of the age of the patient.
Special Features of this Case:: 
The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. On pathology, the lesion is composed of crudely woven bone that may have a pagetoid appearance. surrounded by fibrous tissue. Fat and myxoid change may also be present. The lesion may mimic fibrous dysplasia. This tumor is usually in the proximal femur.. A diagnosis must be based on the combination of the location and appearance with the predominant histological pattern. These lesions are usually incidental findings. The age range is broad, usually adults, The tumors probably arise in childhood. Their appearance may evolve slowly over time. The tumor may not have features that allow diagnosis without careful biopsy, thus observation only is not appropriate management of this tumor. After biosy, this tumor does not require aggressive resection. Treatment by curettage is sufficient. The patient should be followed to check for progression. In parallel with some enchondromas and bone infarcts, a minority of lesions undergo malignant transformation. References: Hum Pathol. 1993 May; 24(5): 505-12. Polymorphic fibro-osseous lesions of bone: an almost site-specific diagnostic problem of the proximal femur. Ragsdale BD. This lesion was biopsied by minimally invasive means, with an approach calculated to minimize the risk of biopsy-induced pathologic fracture as well as to minimize the risk of contamination of uninvolved structures which might complicate limb salvage if it became necessary. The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. This tumor does not require aggressive resection. Treatment by curettage is sufficient. In in this case the patient will be followed to check for progression.
Image Reference: 

A massively swollen arm with tumors

Case Identification
Case ID Number: 
20090722MS
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

The patient is 53 and at around age 30, he developed a mass in his left neck. Since then he has had development of innumerable masses in the left arm, the left chest wall, and the left shoulder.

Radiological findings:: 
Prior to the developed mass at age 30, he did not have any arm or shoulder problems. He has had by his estimation, 23 surgeries. The lesions would become larger and larger and he would call the doctor who would arrange to remove the most symptomatic ones. His last surgery was about 13 years ago. The patient is generally healthy. He does not have hypertension, diabetes, heart disease, and he has never been a smoker. He has had chemotherapy, which he describes as given in pill form, type unknown, as well as 4,500 cGy radiation therapy to the left chest, shoulder, and arm. Recently, he has had onset of lymphedema. This seems to have developed in the last three to six months. He has had development of large tortuous veins on the chest wall and the proximal portion of the arm. Recently his symptoms have been worsening rapidly. The pain in the arm is unrelenting. The arm has become a useless, painful burden to him. He would like to have the arm amputated. On the chest wall, there are dilated veins and erythema. However, there are no individual cutaneous tumors or hairy dark patches of skin. Clinical photos are shown. The patient carries his arm in a makeshift sling. He has no useful motion of the arm. It is grossly swollen. There are multiple scars, as well as a thoracotomy scar. There are multiple palpable firm masses within the arm. The arm is exquisitely tender to the touch, and the dilated veins and areas of the chest wall adjacent to the arm are also quite tender. There is an MRI available. There are multiple nodular masses within the left upper extremity. Xrays show pathologic fracture of the humerus and extreme lytic destruction of the bone.
Treatment Options:: 
Given what you know, what treatment options are appropriate for this patient?
Image Reference: 
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