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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.