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unknown tumor - small round blue cells

An aggressive tumor in the distal femur

Submitted by henry on Tue, 07/28/2009 - 15:17
Case Identification
Case ID Number: 
20090728AT
Periosteal Reaction: 
present
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 27 year old man has 14 month history of knee pain that was minor at first and accompanied by low grade fevers. After several months, warmth and swelling in the knee developed and an xray was taken.

Radiological findings:: 
See images
Image Reference: 
An aggressive tumor in the distal femur
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Bones, but no moans or stones

Submitted by henry on Tue, 07/28/2009 - 16:00
Case Identification
Case ID Number: 
20090728BB
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 58 year old woman has multiple lesions in multiple bones. She complains of "achy bones". She is weak, and has been confused and forgetful recently.

Laboratory results:: 
A CBC shows anemia.
Special Features of this Case:: 
What is the diagnosis? Why is the patient confused? What is the cause of the renal failure?
Image Reference: 
Bones, but no moans or stones
»

Intense pain in the knee and a permeative lesion

Submitted by henry on Thu, 05/06/2010 - 10:13
Case Identification
Case ID Number: 
20100506IP
Periosteal Reaction: 
present
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is 63. She has pain in the right knee which has been increasing gradually for the past 4 or 5 months. It is now very intense. Initial x-rays (shown) were unimpressive. Later a lesion in the right distal femur was discovered. Because of the patient's medical history a large number of diagnostic possibilities exist.

Radiological findings:: 
Radiological findings include a large somewhat permeative mass in the right distal femur. Review of the x-rays from February and from March revealed that they were basically normal. The MRI shows a large lesion that extends into the soft tissues in the posterior portion of the distal right femoral metaphysis. There is a modest periosteal reaction. A CT scan of the chest does not show any definite abnormality. The patient sustained a pathological fracture through the lesion and was admitted to the hospital on an emergent basis. A biopsy has been performed and results are pending
Laboratory results:: 
No significant abnormality.
Differential Diagnosis: 
The patient's medical history reveals several significant conditions. She is a long-term smoker, she has a history of a pituitary mass, which was treated with radiation and completely resolved. The prompt resolution after radiation lead her doctors to presume that the lesion was a lymphoma but this was not confirmed pathologically. Following the radiation for the pituitary mass she had panhypopituitarism requiring replacement hormones. She has a history of a meningioma. She has a history of high-dose steroids and this led to multi-site avascular necrosis of bone, including left proximal humerus and both femoral heads, which required bilateral total hip replacements. Finally, she has a history of a mass in the right neck which after biopsy was found to be a low grade follicular lymphoma. Her oncologist has stated that no treatment was necessary for this particular lesion
Further Work Up Needed:: 
After the biopsy, the challenge will be to reconstruct this badly damaged bone segment in a way that is durable, with rapid return to function and the fewest possible complications. can the bone be saved and repaired or should it be replaced?
Pathology results:: 
The sections reveal a monotonous infiltrate of mixed small and large lymphocytes with associated crush artifact and area of extensive necrosis. Immunohistochemical stains reveal: Positive staining for: LCA (CD45) CD20 CD10 Bcl-2 CD15, scattered positivity (hampered by necrosis and associated acute inflammation) Ki-67, approximately 50% Negative staining for: cytokeratin AE1/3, CD3, CD5, cyclin D1, CD30. There are at least 10 large cells/high power field.
Treatment Options:: 
After the biopsy, the challenge will be to reconstruct this badly damaged bone segment in a way that is durable, with rapid return to function and the fewest possible complications. can the bone be saved and repaired or should it be replaced?
Special Features of this Case:: 
An unusually complicated number of neoplastic and metabolic conditions and cancer risk factors are found in this patient, and the clinician is challenged to make a differential that includes a broad range of entities.
Image Reference: 
Intense pain in the knee and a permeative lesion - third xray series
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Right thigh pain in a 37 year old man

Submitted by henry on Mon, 07/27/2009 - 08:51
Case Identification
Case ID Number: 
20090727TP
Periosteal Reaction: 
present
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 37 year old IT manager has 6 months of mild thigh pain, which gradually has gotten worse and is now bothering him at night.

Radiological findings:: 
There is a permeative lesion in the meta-diaphysis of the right femur. Bone scan shows increased uptake, and MRI shows a mass in the surrounding soft tissues. The imaging studies show an aggressive lesion. Complete work up showed multiple nodules in the lungs. Aggressive lesions include malignant bone tumors and some benign lesions.
Differential Diagnosis: 
The differential should include osteosarcoma, Ewing's sarcoma, primary lymphoma, osteoblastoma, infection, and eosinophilic granuloma.
Special Features of this Case:: 
What is the most likely diagnosis?
Image Reference: 
Right thigh pain in a 37 year old man
»
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