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hip and proximal femur

A 73-year-old man with right hip pain and prostate cancer

Case Identification
Case ID Number: 
20090708NB
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is a generally active 73-year-old gentleman who is retired. He has prostate cancer that has been well controlled. Now, he has right hip pain and lesions in the acetabulum and proximal femur.

Radiological findings:: 
On both sides of the right hip, along with joint space narrowing and bone-on-bone contact, there are well defined cystic lesions, with sclerotic rims, which abut the joint on both sides. MRI scan the scan shows extensive abnormality in the right hip and acetabulum and supraacetabular region as well as the right femoral head. There was a cystic focus, joint space narrowing, and perilesional edema. The cystic lesions have a well defined dark rim.
Laboratory results:: 
The patient's prostate cancer is currently staged T3, N0, with suspicion of metastatic disease. PSA 19 at the time of treatment. Current PSA is 1.3.
Differential Diagnosis: 
Subchondral cyst versus metastasis or new primary malignancy.
Treatment Options:: 
Please see our page on subchondral cyst.
Special Features of this Case:: 
To differentiate between subchondral cyst and a true bone tumor or a metastatic cancer deposit in bone, look for the following features: 1) The lesion is right next to the joint. Careful examination of the radiographs may reveal an actual communication between the joint space and the cyst cavity. If doubt about the nature of the lesion exists, a fine cut CT scan on the area may allow this communicating opening to be seen and help establish the true diagnosis. 2) There are radiographically visible signs of osteoarthritis, usually moderate but sometimes mild, seen in the adjacent joint. If these are entirely absent, the diagnosis should be reconsidered. In the hip, these lesions occur the acetabulum in women with "shallow hips" which can be determined by calculating the center-edge angle. The shallow hip is prone to early degenerative changes and cysts are common in these patients. 3)There is usually a sclerotic rim around some areas of the lesion. The zone of transition is narrow, whereas in a metastatic lesion a sclerotic rim is absent and the zone of transition may be poorly defined. 4) The lesion should be fluid filled, and this may be seen best on MRI images. 5) These lesions are rarely progressive, and pathological fractures are rare.
Image Reference: 

A machinist with pain at work

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

The patient is a 44-year-old machinist who has had pain in the right hip for approximately one year. It is exacerbated by standing, walking and heavy activity, and somewhat relieved by rest.

Radiological findings:: 
There is no significant night pain but there may be a dull ache. Motrin does not relieve the pain. There is no significant past history or family history. On examination of the right hip there is an excellent full range of motion without apparent pain. There is some anterior irritability to deep palpation but no mass can be appreciated. There is no skin abnormality, no ecchymosis, no warmth. No other pertinent findings are noted on the exam. Plain radiographs, CT scan, bone scan are available for review. There is a mixed lytic and sclerotic lesion in the proximal femur, centrally located in the intramedullary space, just above the lesser trochanter. The cortex does not appear to be violated. The area in the center of the lesion is lucent without matrix. Surrounding this is a very dense area of sclerosis which is somewhat irregular. The CT scan shows essentially similar findings but shows that the lesion is larger when seen on CT that when seen on radiographs. The central area is actually two lobulated central lucent defects in the bone. The lesion is very slightly increased uptake on bone scan. No other areas of abnormality on the bone scan are appreciated.
Differential Diagnosis: 
The differential diagnosis of this lesion should include fibrous dysplasia, fibroxanthoma (non-ossifying fibroma), polymorphic fibro-osseous tumor of bone, liposclerosing myxofibrous tumor of bone, myxofibroma, lipoma, cyst, bone infarct, Paget's disease, and, chondroma. The lesion is too large for an osteoid osteoma but might be an osteoblastoma. The lesion does not have aggressive features so osteosarcoma is unlikely. No orthopedic surgeon considering a bone-forming lesion in the femur should fail to at least consider osteosarcoma, regardless of the age of the patient.
Special Features of this Case:: 
The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. On pathology, the lesion is composed of crudely woven bone that may have a pagetoid appearance. surrounded by fibrous tissue. Fat and myxoid change may also be present. The lesion may mimic fibrous dysplasia. This tumor is usually in the proximal femur.. A diagnosis must be based on the combination of the location and appearance with the predominant histological pattern. These lesions are usually incidental findings. The age range is broad, usually adults, The tumors probably arise in childhood. Their appearance may evolve slowly over time. The tumor may not have features that allow diagnosis without careful biopsy, thus observation only is not appropriate management of this tumor. After biosy, this tumor does not require aggressive resection. Treatment by curettage is sufficient. The patient should be followed to check for progression. In parallel with some enchondromas and bone infarcts, a minority of lesions undergo malignant transformation. References: Hum Pathol. 1993 May; 24(5): 505-12. Polymorphic fibro-osseous lesions of bone: an almost site-specific diagnostic problem of the proximal femur. Ragsdale BD. This lesion was biopsied by minimally invasive means, with an approach calculated to minimize the risk of biopsy-induced pathologic fracture as well as to minimize the risk of contamination of uninvolved structures which might complicate limb salvage if it became necessary. The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. This tumor does not require aggressive resection. Treatment by curettage is sufficient. In in this case the patient will be followed to check for progression.
Image Reference: 

A painless density in the femoral head.

Case Identification
Case ID Number: 
20090728PD
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A woman who had a bone scan for back pain was found to have an abnormality in the right femoral hear. The exam is normal, and there is no pain.

Radiological findings:: 
An isolated density within the cancellous area of the femoral head. MRI, CT, and plain films are shown.
Special Features of this Case:: 
What is the diagnosis? What should be done?

A ski instructor who tripped on a "snow snake"

Case Identification
Case ID Number: 
10212009SS
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 42 year old man who works as a ski instructor at a ski area near Boston presents to the emergency room after suffering an injury to the right hip. He states that he was skiing through a thin layer of new snow on top of the base snow pack when his right ski caught on something, twisting his leg, at which point he felt something very painful happen to his right hip. He fell down and was unable to stand. He said he though he might have caught a "snow snake."

Radiological findings:: 
A fracture is seen through the neck of the right femur, where a lesion can be noted in the femoral head. No other bone lesions are present.
Differential Diagnosis: 
What is the differential here?
Further Work Up Needed:: 
Should this patient have surgery for the fracture combined with biopsy, or some other treatment plan?
Pathology results:: 
Biopsy material is shown. What is the diagnosis?
Image Reference: 
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