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A 22 year old woman with a large tibial mass

Case Identification
Case ID Number: 
03252009a
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

A case sent for consulation. A 22 year old woman presents with a 1-year history of leg pain. No other clinical data are available.

Radiological findings:: 
A large surface based lesion projects from the posterior and proximal tibia. There is a gradual and mature looking expansion of the posterior cortex of the tibia, which appears to be of long standing. From this cortex projects the mass, very heavily calcified, with a somewhat varigated pattern of calcification, with some ring or round shaped lucent areas.
Laboratory results:: 
None available
Differential Diagnosis: 
Exostosis, exostosis with associated low-grade chondrosarcoma, periosteal osteosarcoma, parosteal osteosarcoma.
Further Work Up Needed:: 
I would recommend a CT scan, and if possible an MRI. The CT scan will show the relationship of the lesion to the bone, and as you may know, the specific appearance of the junction between the lesion and the bone will allow the diagnosis to be made with a high degree of certainty.
Pathology results:: 
None available
Treatment Options:: 
Clearly, removal is needed. This is a very difficult place to operate, and a very large tumor, I recommend this patient be operated by a very experienced surgeon or team of surgeons, if that is possible.
Special Features of this Case:: 
A lesion of exceptionally large size.

A mass on the big toe for more than 10 years

Case Identification
Case ID Number: 
20110901TY
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This 69 year old male has a mass on the lateral aspect of the great toe for at least 10 years. The mass has now gotten large enough to be troublesome. The lesion is not painful. It is fleshly, and moderately soft.

Radiological findings:: 
The lesion is completely radiolucent. There is no calcification. The density appears to be higher than that of lipid. MRI findings show a well circumscribed mass, T1 dark, T2 intermediate signal intensity. There appears to have a normal tissue plane between the Mass and the adjacent first distal phalanx.
Laboratory results:: 
none ordered
Differential Diagnosis: 
There are a large number of benign soft tissue lesions. Lipoma and variants of lipoma, fibrous lesions, tumors that arise from nerve cells or nerve sheath cells, and tumors of vascular origin are among the possibilities.
Further Work Up Needed:: 
The concerns here are the potential for cancer, which exist despite the very slow growth, and the skin loss that will result from excision. Although local coverage may be possible, a split thickness skin graft should be considered. It does not appear that a local flap or rotational flap will be necessary.
Treatment Options:: 
Excision with local or split thickness skin graft coverage is planned.

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: 

A smoker with elbow pain

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

This 67 year old male has pain and a mass in the right dominant elbow. He had a history of smoking for many years. Work-up revealed a lytic lesion in the distal humerus.

Radiological findings:: 
An aggressive lytic destructive lesion has destruyed most of the humerus just above the elbow. No matrix is seen and no periosteal reaction is evident. A bone scan shows the lesion, but no other abnormal areas. An MRI shows the lesion has expanded aggressively into the soft tissues.
Treatment Options:: 
This lesion could be a primary sarcoma, if so what type is most likely? What would you do? This lesions might also be a metastatic tumor - if so what is the most likely source? What should be done in that case?
Image Reference: 
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