Case presentation: Pain in Left Hip for One Year

The patient is a 38-year-old woman who works as a licensed practice nurse in a nursing home, who has had pain and difficulty in her left hip which began one year ago. She is seen at the request of her primary care physician and her orthopedic surgeon.

The patient is generally healthy. The patient smokes. The patient is taking Percocet for pain. and vitamin B12. She finds that the pain is somewhat lessened by wearing compression tights over the area. She has been unable to work recently because of 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.

An 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 metastasi.s

The patient underwent incisional biopsy.

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?

Metastatic Tumors Case of the Month Bone Tumor Basics Tumor Jeopardy Fracture Risk Adamantinoma Aneurysmal bone cyst Angiosarcoma - High gd. Bizarre parosteal ost. pro. Brown tumor Chondroblastoma Chondromyxoid fibroma Chondrosarcoma Chordoma Desmoplastic fibroma Enchondroma Eosinophilic granuloma Epithelioid hemangioma Epithelioid hemangioend. Ewing's sarcoma Fibrosarcoma Fibrous dysplasia Florid reactive periostitis Giant cell tumor Glomus tumor Granulocytic sarcoma Hardcastle's syndrome Hemangioma Hemangiopericytoma Juxtacortical chondroma Langerhan's histiocytosis Malignant fibrous histio. Melorheostosis Metastatic cancer menu Multiple myeloma Myositis ossificans Neurofibroma of bone Nora's lesion Osteoblastoma Osteochondroma Osteofibrous dysplasia Osteoid osteoma Osteoma Osteomyelitis Osteopathia striata Osteopoikilosis Osteosarcoma Intro Paget's sarcoma Parosteal osteosarcoma Periosteal osteosarcoma Pigmented villonodular... Schwannoma of bone Solitary bone cyst Synovial chondromatosis Unicameral bone cyst

Click on an image to enlarge