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Tumors of Bone

A 95 year old lady with increasing pain and swelling in her thigh

Case Identification
Case ID Number: 
20120918SF
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

This 95 year old woman presents with increasing pain and an enlarging mass in her right thigh. She recalls a fall onto the right leg the previous year and has been having ongoing pain since then.

Radiological findings:: 
X-rays of the right femur show a large permeative poorly defined lesion in the mid to distal diaphysis measuring 8 - 10 cm in total length. No periosteal reaction is appreciated. No soft tissue mass is visible on plain film. There is no calcification within the known soft tissue mass. There is a transverse sclerotic line over the distal femur. Vascular calcification is also noted on plain radiograph of the femur. Full skeletal survey has not revealed any other sinister bony lesions but there is substantial osteoarthritis in the spine. MRI shows a large enhancing lesion which appears to have started in the medullary space of the mid to distal diaphysis of the femur which now occupies the entire marrow space. It has extended into the soft tissue circumferentially around the femur. The lobular soft tissue mass is extensive in size measuring 13 x 8 cm in maximum dimension. The soft tissue mass extends to but does not involve the sciatic nerve. The neurovascular bundle does not appear to be involved. There is substantial permeation of the cortex of the femur. Bone scan shows scattered uptake consistent with osteoarthritis and substantial uptake in the right distal femur for the entire length of the lesion. CT of the chest, abdomen and pelvis were significant for two small 3mm sub-pleural nodules in the chest. These were not deemed to be indicative of metastasis. There is also sacral Paget's disease which is unchanged when compared to a previous scan 3 years prior to presentation.
Differential Diagnosis: 
Ewing's sarcoma, lymphoma of bone
Pathology results:: 
Diffuse large B cell lymphoma
Treatment Options:: 
Definitive treatment is dependent on the pending biopsy results

A bone tumor in the finger

Case Identification
Case ID Number: 
20120426TF
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The 34-year-old man has a 2 year history gradual growth of a slightly tender mass on the index finger. There is no other significant medical history or exam finding.

Radiological findings:: 
There is a mass on the dorso-radial surface of the middle phalanx, with a slight abnormality in the cortex.
Laboratory results:: 
no laboratory analysis was made.
Differential Diagnosis: 
The differential diagnosis will include surface lesions.
Special Features of this Case:: 
Surface lesions are a special group of tumors, and since there are only a few tumors in this group, the list of possibilities is short. A surface lesion on the phalanx of a finger or toe, especially with the xray features this one has, is a "classic" presentation of one tumor in particular. Which one is it? For exam purposes, students should memorize the names of all surface lesions along with their features.
Image Reference: 

A pathological fracture in a 10 year old boy

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

This 10 year old boy sustained a pathological fracture in his right arm whilst catching a football in his arms. On further questioning, this occurred on a background of vague intermittent pain in that arm.

Radiological findings:: 
There is a pathological spiral displaced fracture through the mid-shaft of the right humerus. The fracture is through a large, ovoid, well-circumscribed osteolytic lesion in the middle third of the right humerus with scalloping of the inner cortex. On MRI, it is mostly hyperintense on T2 weighted imaging, but complex superiorly where there is mixed isointense and hypointense signal. There is mild surrounding edema, however there is no soft tissue component.
Laboratory results:: 
None needed.
Differential Diagnosis: 
Unicameral bone cyst, fibrous dyplasia, Langerhans cell histocytosis and nonossifying fibroma
Treatment Options:: 
The patient was treated conservatively with a long arm splint and followed up with repeat x-rays.

Aneurysmal Bone Cyst

Aneurysmal bone cyst (ABC) is a solitary, expansile and erosive lesion of bone. The cause of this non-neoplastic lesion is unknown.
Most patients are under 20, but the tumor can occur at any age.
The tumor presents with pain for several weeks with local swelling. Any bone may be involved, but the most common sites include the long bones and the posterior parts of the spinal vertebra.On xrays, the lesion has a destructive, lytic, and expansile appearance.
Most ABC's are sucessfully treated with curettage and packing with bone chips or bone cement.

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