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pelvis - entire

52 year old man with left hip pain

Case Identification
Case ID Number: 
20120907BT
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

A 52 year old gentleman presents with a 6 month history of pain in his left lower side and left groin. He was admitted to hospital with pain and malaise.

Radiological findings:: 
Plain radiographs reveal a large osteolytic lesion in the left ilium directly superior to the left acetabulum. It measures approximately 5.4cm in its largest dimension. The lesion is ovoid in shape and relatively well-circumscribed. There is no surrounding sclerosis or periosteal reaction. The lesion is not expansile. CT of the pelvis show multiple smaller osteolytic lesions throughout the pelvis bilaterally. The left-sided lesion has not completely eroded the cortex. There are no fractures or protrusio femoris. There is a smaller osteolytic lesion in the right ilium but not in contact with the acetabulum on that side.
Laboratory results:: 
Blood tests: Hypercalcaemia, hyperuricaemia and reduced eGFR.
Differential Diagnosis: 
Multiple myeloma
Pathology results:: 
Pending
Treatment Options:: 
Chemotherapy. Fracture prophylaxis for the large left ileal osteoyltic lesion.

A 22 year old woman with pain in the left ischium for about two year

Case Identification
Case ID Number: 
20091117AK
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a very pleasant 22-year-old woman who is generally healthy, she recently graduated college and was previously a ballet dancer. She has no serious medical problems and there is no history of injury to the area in question.

Radiological findings:: 
The patient has had pain in the left ischium for about two years which has not been getting worse, but not been getting better. She has no problems except for when sitting, and has difficulty because the left hip is sore when sitting Examination of the area which is the left initial tuberosity reveals no tenderness and no mass. Comparison with the opposite side reveals no side-to-side differences.

A nurse with hip pain

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

The patient is a generally healthy 38-year-old licensed practice nurse who has had pain in the left hip which began one year ago. The pain is somewhat lessened by wearing compression tights over the area.

Radiological findings:: 
The patient is a cigarette smoker and is taking Percocet for the pain. There is no abdominal mass or tenderness. On the left side of the pelvis, there is a palpable mass just inside the anterior superior iliac spine that is mildly tender. There is a fullness in the hip musculature above the trochanter. There is a full range of motion of the hip but there is pain with motion. Distally, the neurovascular status is normal. Sensation is normal in the foot. Circulation is normal. Plain radiographs a vague, lytic, permeative process in the left ilium, with a vague but non-mineralized mass in the soft tissues surrouning the anterior superior iliac spine. n MRI is available for review. There is an abnormality in the left hemipelvis with a intraosseous and extra osseous mass arising from the ileum, with abnormal signal in the ileum from the anterior superior iliac spine all the way down to the supra-acetabular area at the top of the hip joint. There is a soft tissue mass both on the inside and on the outside of the pelvis, it measures at least eight or 10 cm in maximum dimension. There is diffuse abnormality in the hip abductor musculature. The hip joint does not appear to be grossly involved, but the coronal images of the acetabulum show that the lesion reaches down to the subchondral bone of the acetabulum were possibly to be cartilage of the acetabulum on the left side. No definite abnormality is seen within the femoral head or inside the joint itself. A CT scan of the pelvis shows a partially lytic and destructive mass inside and outside the pelvis with no distinctive mineralization within the soft tissue mass. The tumor appears to arise from the left ileum, just posterior and distal to the anterior superior iliac spine. On the bone scan, there is abnormality in the left hemipelvis. There is also slightly increased uptake in the left proximal femur. A CT scan of the chest shows no nodules, no lymphadenopathy, and no evidence of metastasis.
Pathology results:: 
The patient underwent incisional biopsy. On medium power, the is an irregular pattern of cells. Some of the matrix is blue stained, characteristic of proteoglycans, which make up chondroid matrix, but other areas of dense pink matrix show osteoid production. A higher power view shows the lacy pink osteoid and highlights the variability of the nuclei, which is termed "nuclear atypia" and "nuclear pleomorphism".
Special Features of this Case:: 
Questions for self-study: Construct a differential diagnosis for this lesion. If this lesion is a sarcoma, what surgical option would you recommend for this patient? What choice for reconstruction would you choose? What is the significance of the bone scan uptake in the left proximal femur, and what would you do about it?
Image Reference: 

A woman from Kenya with a bizarre looking right ilium

Case Identification
Case ID Number: 
20120314BI
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This is a consult from an ortho clinic in Kenya, a 62 y/o F presents with a transverse, midshaft femur fracture from a low-energy trauma (mechanical fall) about one week ago. She has a history of chronic hip pain for several years. She had been ambulatory prior to the fall. Additionally, she has a very bizarre-appearing hemipelvis and hip joint ipsilaterally.

Radiological findings:: 
The hemipelvis is almost entirely involved, diffusely enlarged, with the cortex thinned, scalloped, and there appears to be old fractures of the pubic rami. The hemipelvis is normally aligned with the normal left side, and the overall size of the right pelvis is similar to the left, suggesting a process that started after skeletal maturity, or did not interfere with the initial growth development of the hip/pelvis and proximal femur. The Acetabulum is enlarged and thinned, but can still be seen, and is approximately spherical. The acetabulum is proximally located in the pelvis, as if a gradual process of erosion, expansion, protrusion and migration of the center of rotation occurred over a period of years. The process reaches fully to the symphysis pubis, but does not cross it, instead leaving the nearby left pubic symphysis entirely normal. The tumor is best seen in the area of the pubic symphysis on the right, with cortical thinning, expansion, areas of condensation of bone or mineral, and other areas where there is lucency. No periosteal reaction or extraosseous mass is seen, and neither is there any area where the bone is completely destroyed. On the femoral side, the joint is gone, and an old fracture of the proximal femur/neck is seen, which has resulted in fragmentation and extrusion of the superior portion of the neck and most of the head. However, the proximal femur, up to the level of the greater troch/base of the neck, looks pretty normal in shape and development except for the osteopenia.
Laboratory results:: 
Her Hct is 39 and chemistries are normal (calcium hasn’t been done). Her INR is 1.5, which is a little surprising since she isn’t on coumadin. CXR was clean with no mets. She has no palpable soft tissue mass in the area.
Differential Diagnosis: 
Please submit a three-item ddx. Explain your reasoning for each listed diagnosis. See below for email address.
Further Work Up Needed:: 
Biopsy of the pelvic lesion, at some superficial location. A retrograde rod is an excellent choice for the femur.
Pathology results:: 
Pending an update from Kenya.
Treatment Options:: 
Given a primary bone lesion, the bone fragility would eventually lead to protrusio of the head, (think shepards crook) then eventually a fracture, say 10 or more years ago, and with many years of walking on a non-united femoral neck fracture, this appearance could be the late result. Most likely, there nothing of interest in the femur at the site of the fracture, a biopsy there is not recommended.
Special Features of this Case:: 
We invite your input on this case. Send 3-item ddx to - questions (at :P) bonetumor (dot :P) org. Leave out the smileys!
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