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knee, thigh, distal femur, proximal tibia

A woman with right knee pain

Submitted by henry on Fri, 10/01/2010 - 08:10
Case Identification
Case ID Number: 
20101001KP
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A very pleasant 70 year old woman who has Padget's disease, a history of liver failure, and right knee pain with a worrisome mass in the distal femur.

Radiological findings:: 
The plain radiographs are notable for the absence of any visible padgetoid changes in the affected area of the right distal femur. The initial radiographs were in fact read as normal. The most significant findings are on the MRI of the knee. There is a permeative lytic destructive process in the distal femur, involving most of the lateral femoral condyles and the distal portion of the femoral shaft, sparing a portion of the medial femoral condyle. The mass has expanded into the soft tissues slightly proximal and posterior to the patella, in the process transgressing the cortex of the anterior femur just proximal to the patella. There is a circumferential mass surrounding the distal femur. In the proximal tibia there is a round lesion, roughly the size of a quarter, in the marrow of the tibial plateau, which has signal abnormalities similar to the lesion in the proximal femur, and to my eye appears to be related to the lesion in the distal femur. I think this tibial focus represent a so-called skip metastasis or regional metastasis, or a separate marrow focus of disease if this turns out to be a marrow tumor. The x-rays are not very impressive in fact were read as normal. In retrospect, the radiologist added to comment that there was a slightly sclerotic abnormality in the distal femur, but this is pretty difficult to discern. The CT scan of the chest, abdomen, and pelvis are notable for multiple nodules in the left lung fields, and a few on the right as well. A lesion is seen in the manubrium which has bony destruction and a soft tissue extension. No mass is seen in the liver, and the rest of the abdominal CT is not remarkable.
Laboratory results:: 
No labs are requested.
Differential Diagnosis: 
The unimpressive plain radiograph results plus the permeative nature of the tumor, combined with the potential multiple sites of marrow involvement by this disease, favors the possibility of a tumor such as lymphoma or myeloma. However, with the patient's history, a Padget sarcoma must be considered. Other possibilities include an adenocarcinoma metastatic to the distal femur.
Further Work Up Needed:: 
A biopsy is clearly necessary. I think in order to establish without doubt the stage of disease, both the distal right femur lesion needs to be biopsied and the right proximal tibial lesion needs to be biopsied and these can be accomplished easily through a minimally invasive techniques.
Pathology results:: 
See the images.
Special Features of this Case:: 
The history of Padget's disease, liver failure, the patients age, and the appearance of the lesion point in different diagnostic directions. Will the orthopaedic treatment this patient needs vary according to the diagnosis or not?
Image Reference: 
A woman with right knee pain

A young adult with a massive femoral tumor

Submitted by henry on Wed, 05/25/2011 - 10:30
Case Identification
Case ID Number: 
20110525MF
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This young adult has a massive femoral tumor. No further information is available. However, the appearance is very distinctive and may be diagnostic.

Radiological findings:: 
A very large, lytic mass occupies the distal 23 centimeters of the left femur in a skeletally mature individual. The lesion appears to have started in the metaphysis. A honeycomb pattern of complex lucent areas and trabeculation is present, along with expansion of the bone, a minimal periosteal reaction, and chronic deformity from progressive small fractures.
Differential Diagnosis: 
What is the differential?
Image Reference: 
A young adult with a massive femoral tumor
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A young man with a very painful lesion of the knee

Submitted by henryd on Tue, 12/11/2012 - 15:54
Case Identification
Case ID Number: 
20121211VP
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 15 year old boy has a painful tumor in his tibia, near the knee. A biopsy showed "giant cells" in the lesion. It continued to grow, and he has pain, a mass, and substantial leg atrophy.

Radiological findings:: 
A sclerotic and granular appearing lesion in the posterior and lateral tibial plateau, just under the joint surface, with some enlargement of the bone. There is a healed incision, without any sign of infection, but the area is very tender to the touch.
Laboratory results:: 
None available
Differential Diagnosis: 
Infection, chondroblastoma, osteosarcoma
Pathology results:: 
pending
Treatment Options:: 
Based on a presumptive diagnosis, a thorough curettage of the lesion was performed.
Special Features of this Case:: 
The patient was treated at the HEODRA hospital in Leon, Nicaragua
Image Reference: 
A young man with a very painful lesion of the knee
»

A young man with a worrisome tibial lesion

Submitted by henry on Wed, 01/26/2011 - 14:18
Case Identification
Case ID Number: 
20110126YM
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 18 year old male has pain in the shin for 4 months. The pain is exacerbated by his ongoing training for the "iron man" competition. Examination of the tibia shows there slight point tenderness, but no mass or swelling. No regional lymphadenopathy. Knee exam is normal.

Radiological findings:: 
Plain radiographs show a well-circumscribed proximal tibial lesion, with a sclerotic rim. The lesion has slightly expanded the anterior cortex of the tibia. It extends through the anterior cortex into the medullary cavity. It is radiolucent, there is no matrix mineralization. It appears that there is diffuse mineralization or increased density of the bone surrounding the lesion for several centimeters proximal and distal which has a very even non-flocculent appearance. Technetium 99 bone scan shows that there is intense abnormal uptake in the area of the lesion and no other skeletal lesions are seen. An MRI shows that the lesion has a well-circumscribed sclerotic rim, it measures approximately 4 cm from proximal to distal, and about 3 cm from anterior to posterior.It has slightly expanded the cortex and reaches from outside the tibia on the anterior medial surface across the full width of the cortex into the central medullary canal, at which point it is well bounded by a relatively dense sclerotic rim. On one sagittal view, there is a faintly seen dense horizontal line at the level of the lesion and in the center of the reactive zone around the lesion, which would be characteristic of a stress fracture. Within the lesion itself, there are multiple lobular areas that have variable signal intensity, with some very bright, some intermediate, and there are what appear to be internal septations. Surrounding the lesion, and extending proximally 6 to 8 cm all the way across the location of the proximal tibial physis, and extending distal from the lesion for 4 to 6 cm is a diffuse increase in bone marrow signal intensity, suggesting reactive change. There is no definite periosteal reaction.
Laboratory results:: 
No lab exams needed for this case.
Differential Diagnosis: 
The differential diagnosis includes both benign and malignant tumors, as well as nontumorous conditions. The bone scan uptake and MRI bone marrow abnormality appear to be related to the tumor.
Further Work Up Needed:: 
This lesion might be an eosinophilic granuloma, it could be a fibrous dysplasia with cystic change, it might be a non-ossified fibroma, an osteoblastoma, a chondromyxoid fibroma, an intra-cortical lesion such as intracortical osteosarcoma. The large abnormal area of the tibia is of concern. Open biopsy has been performed and the results are shown. An accurate diagnosis is needed prior to planning treatment.
Pathology results:: 
See images shown.
Special Features of this Case:: 
There is a lesion that appears relatively small and well circumscribed, yet it has some features that are concerning, such as the apparent transgression of the anterior cortex. The large area of abnormal bone scan uptake (which is the same as the large area of abnormal signal on the MRI) must be accounted for. How is this finding related to the tumor?
Image Reference: 
A young man with a worrisome tibial lesion
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