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Metastatic Tumors

A 57-year-old woman who has a lesion in the talus bone

Case Identification
Case ID Number: 
20091105MK
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a very pleasant 57-year-old woman who has pain and a lesion in the talus bone. She was initially seen by a variety of practitioners, including one who gave her an injection for gout or for arthritis. The patient is generally healthy.

Radiological findings:: 
The patient has had tonsillectomy, and a benign tumor removed from the right breast. She does not smoke. In the family there is high blood pressure in the brother and diabetes and a brother. There is no other contributory history. Examination of the left ankle shows diffuse swelling. The range of motion is preserved. There is diffuse tenderness, but no definite mass is palpable. There is a faint mild lesion in the neck of the talus, that was visible on the original xrays taken months ago. MRI films show a mass in the neck of the talus which appears to have arisen in bone or adjacent to bone. A bone scan shows there are two areas of increased uptake, one in the talus and one in the hip. A CT scan of the abdomen is shown.
Differential Diagnosis: 
Possibilities include pigmented villonodular synovitis, giant cell tumor of bone, and malignancy, among others.
Further Work Up Needed:: 
Clearly biopsy is going to be necessary in order to decide on the appropriate course of treatment. I do not believe that biopsy and removal in one stage is an appropriate choice.
Pathology results:: 
See images.
Special Features of this Case:: 
Lesions in the foot may arise from pathology elsewhere. The clinician needs to maintain a broad perspective.
Image Reference: 

A 90 year old woman with 3 weeks of foot pain

Case Identification
Case ID Number: 
20110512FP
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

This delightful 90-year-old woman has pain in the right foot, in the midfoot at the base of the second and third metatarsals. There is a lesion on the x-rays and on the MRI in that area. The patient has a history of nephrectomy for renal cell carcinoma 6 years ago.

Radiological findings:: 
On the plain radiographs, there is a lytic, destructive, completely lucent lesion in the base of the second metatarsal, that seems to extend in into the base of the third metatarsal. There may be very faint mineralization of the lesion. Deletion has a relatively aggressive appearance. There is no periosteal reaction present. There is diffuse demineralization of the nearby bones. An MRI shows a T1 dark, T2 intermediate lesion extending across the second and third metatarsal base, into the base of the cuneiforms. It has a slightly lobular outline that extends outside the contour of the bones themselves.
Laboratory results:: 
no laboratory examinations are requested
Differential Diagnosis: 
The working diagnosis would be metastasis from renal cell carcinoma. Other metastasis such as from lung and breast carcinoma is possible. Although metastatic deposits in the bones of the foot are rare, they definitely can occur, and should be at the top of the differential in a patient with a prior history of cancer with propensity to metastasize to bone and the new onset of foot pain with a bone lesion.
Further Work Up Needed:: 
The patient needs a complete assessment of the skeleton, including a whole body bone scan, and a CT scan of the chest, abdomen, and pelvis with oral and intravenous contrast. This workup combined with the x-rays and MRI of the foot, will complete the radiological examinations necessary to stage the patient. The biopsy will provide the histological information necessary to confirm the local lesion, and the slides and blocks from the original nephrectomy should be reexamined to compare these with the cells from the foot. Together, this series of procedures will confirm the diagnosis, the stage of the disease, and these two pieces of information lead directly to the preferred treatment.
Pathology results:: 
See the images from the frozen section that are shown. Findings include abundant foamy and in some areas clear cytoplasm, round nuclei with prominent nucleoli, and prominent small blood vessels in the tumor. Final analysis is pending.
Treatment Options:: 
Patients with metastatic lesions in the foot require surgical treatment for biopsy only. It is uncommon that reconstructive surgical intervention is necessary. Radiation treatment is mandatory, and bisphosphonate medication such as Zometa should be given as soon as the patient can receive them to prevent further bone damage as much as possible. In most of these cases, the patient is immobilized in a removable walking boot and allow to be partially weightbearing.
Special Features of this Case:: 
Although uncommon, a presentation of metastatic carcinoma with deposits in the skeleton of the foot can occur. A number of case reports of presentation of renal cell carcinoma with metastasis to the foot have been published. Foot Ankle Spec. 2008 Dec;1(6):338-43. Epub 2008 Oct 21. Metastases to bones of the foot: a case series, review of the literature, and a systematic approach to diagnosis. El Ghazaly SA, DeGroot H 3rd.

A lytic lesion in the distal humerus

Case Identification
Case ID Number: 
20100728DH
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

This 60-year-old right handed woman has had gradual onset of pain in the right elbow. X-rays show a destructive bone lesion in the distal humerus. Further radiographic evaluation has shown that there is a 6.9 cm mass in the lower pole of the left kidney. It has a heterogeneous appearance consistent with renal cell carcinoma. The bone scan shows multiple areas of abnormality, including two lesions in the skull.

Radiological findings:: 
The plain radiographs of the right distal humerus show an aggressive destructive process centered just above the olecranon fossa. The lesion is purely lytic and the surrounding bone shows a permeative pattern of destruction. The lesion measures approximately 40 by 30 mm, and the medial cortex of the humerus has been damaged and appeared to be slightly fractured. There is no periosteal reaction and no visible ossification within the substance of the lesion. The MRI shows a mass occupying the upper portion of the olecranon fossa and projecting anteriorly into the soft tissues.
Treatment Options:: 
The right distal humerus lesion is large and there is clearly a high risk of fracture. Hopefully this can be stabilized rapidly before the patient has a fracture. This area cannot be stabilized with a rod, since it is too distal. Rodding of renal cell carcinoma lesions may lead to recurrence since they are not sensitive to radiotherapy. Options for the right distal humerus lesion include complete resection with reconstruction with an elbow prosthesis, or curettage of the lesion and packing with cement, combined with plating of the distal humerus. Both options should give the patient a durable reconstruction.

A smoker with a painful kidney and a shoulder tumor

Case Identification
Case ID Number: 
20100802SM
Periosteal Reaction: 
absent
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

The patient is 59, and she has a 40 pack years smoking history. Seven years ago, she had a painful kidney removed, and a tumor was found in the kidney.

On examination, the left upper extremity is in a sling. The patient cannot really move the arm outside of the sling. No mass is felt around the shoulder at all, and there is no swelling of the affected bone.

Radiological findings:: 
Plain radiographs show an aggressive destructive mass occupying the proximal humerus with pathological fracture. There is a somewhat permeated appearance of the shaft of the humerus below the lesion.
Differential Diagnosis: 
The patient has a bone lesion in the left proximal humerus which will require biopsy and stabilization of pathological fracture. Possibilities include renal cell carcinoma, lung carcinoma, myeloma or lymphoma, and other.
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