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Tumors - unknown type

A 32 year old auto mechanic with multiple femur lesions

Case Identification
Case ID Number: 
20091117AM
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 35 year old auto mechanic whose wife had just had their first baby presented with severe pain in the distal femur. Subsequent work up showed multiple ipsilateral lesions. Pathology images from a similar lesion are shown.

Radiological findings:: 
The initial work-up revealed multiple lesions in both lower extremities, including a lesion in the mid-diaphysis of the ipsilateral tibia and two lesions in the contralateral femur. A CT scan of the chest showed pulmonary nodules.
Differential Diagnosis: 
metastatic adenocarcinoma, metastatic sarcoma, multiple myeloma (very rare in this age group)
Pathology results:: 
Images are from a similar tumor

A mysterious lesion in the tibia

Case Identification
Case ID Number: 
20110307ML
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This healthy and active 56 year old woman has a painless lesion in the distal tibia. The lesion was discovered on an MRI that was performed for unrelated foot pain. The lesion is totally invisible on the xray, but easily seen on the MRI.

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 woman from Kenya with a bizarre looking right ilium

Case Identification
Case ID Number: 
20120314BI
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

This is a consult from an ortho clinic in Kenya, a 62 y/o F presents with a transverse, midshaft femur fracture from a low-energy trauma (mechanical fall) about one week ago. She has a history of chronic hip pain for several years. She had been ambulatory prior to the fall. Additionally, she has a very bizarre-appearing hemipelvis and hip joint ipsilaterally.

Radiological findings:: 
The hemipelvis is almost entirely involved, diffusely enlarged, with the cortex thinned, scalloped, and there appears to be old fractures of the pubic rami. The hemipelvis is normally aligned with the normal left side, and the overall size of the right pelvis is similar to the left, suggesting a process that started after skeletal maturity, or did not interfere with the initial growth development of the hip/pelvis and proximal femur. The Acetabulum is enlarged and thinned, but can still be seen, and is approximately spherical. The acetabulum is proximally located in the pelvis, as if a gradual process of erosion, expansion, protrusion and migration of the center of rotation occurred over a period of years. The process reaches fully to the symphysis pubis, but does not cross it, instead leaving the nearby left pubic symphysis entirely normal. The tumor is best seen in the area of the pubic symphysis on the right, with cortical thinning, expansion, areas of condensation of bone or mineral, and other areas where there is lucency. No periosteal reaction or extraosseous mass is seen, and neither is there any area where the bone is completely destroyed. On the femoral side, the joint is gone, and an old fracture of the proximal femur/neck is seen, which has resulted in fragmentation and extrusion of the superior portion of the neck and most of the head. However, the proximal femur, up to the level of the greater troch/base of the neck, looks pretty normal in shape and development except for the osteopenia.
Laboratory results:: 
Her Hct is 39 and chemistries are normal (calcium hasn’t been done). Her INR is 1.5, which is a little surprising since she isn’t on coumadin. CXR was clean with no mets. She has no palpable soft tissue mass in the area.
Differential Diagnosis: 
Please submit a three-item ddx. Explain your reasoning for each listed diagnosis. See below for email address.
Further Work Up Needed:: 
Biopsy of the pelvic lesion, at some superficial location. A retrograde rod is an excellent choice for the femur.
Pathology results:: 
Pending an update from Kenya.
Treatment Options:: 
Given a primary bone lesion, the bone fragility would eventually lead to protrusio of the head, (think shepards crook) then eventually a fracture, say 10 or more years ago, and with many years of walking on a non-united femoral neck fracture, this appearance could be the late result. Most likely, there nothing of interest in the femur at the site of the fracture, a biopsy there is not recommended.
Special Features of this Case:: 
We invite your input on this case. Send 3-item ddx to - questions (at :P) bonetumor (dot :P) org. Leave out the smileys!
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