J Orthop Sci. 2011 Sep;16(5):665-9. Epub 2011 May 10.
You are seeing a 16-year-old female with shoulder pain. She is otherwise healthy and denies trauma. Based on the radiograph, MRI, and histology shown in Figures A-C, what is your diagnosis?
Simple bone cyst
Aneurysmal bone cyst
Unicameral bone cyst
There are reported cases of ABC crossing the physis. The attached article is one of them. I think in the question you do not have GCT or telangectatic osteosarcoma in the options. So, your answer has to be ABC. Telangectatic Osteosarcoma can be very similar to ABC in radiology and very difficult to differentiate. I would do frozen section in all cases of ABC before proceeding with final management. I have experience with cases where the radiology suggest GCT or ABC and the final pathology deviate from the radiology diagnosis and malignant osteosarcoma was diagnosed.Primary aneurysmal bone cyst of the proximal tibia crossing the open physis.Arora S, Sabat D, Arora SK, Kumar V, Saran RKJ Orthop Sci. 2011 Sep. doi: 10.1007/s00776-011-0070-2. pii: S0949-2658(15)30741-7. 16. (5). :665-9PMID: 21556894 (Link to Abstract)Primary aneurysmal bone cyst of the proximal tibia crossing the open physis.Arora S, Sabat D, Arora SK, Kumar V, Saran RKJ Orthop Sci. 2011 Sep. doi: 10.1007/s00776-011-0070-2. pii: S0949-2658(15)30741-7. 16. (5). :665-9PMID: 21556894 (Link to Abstract)
Without a high power histology slide, the presence of osteoid in the current path image, and radiographic findings, it would be a challenge to exclude telangiectatic osteosarcoma from the differential. The lack of a soft issue mass component on MRI may steer you towards ABC.Maybe a high power image would address potential confusion when choosing the "best answer".
J Am Acad Orthop Surg. 2013 Apr;21(4):225-33.
A 65-year-old male patient presents with pain and swelling in his thigh 1 year. Radiographs and biopsy findings are seen in Figures A through C. What is the most appropriate treatment?
Surgery and chemotherapy
Surgery, chemotherapy and radiotherapy
the 2 cases I have participated in with this location resulted in a proximal femoral replacement following wide resection of the proximal femur
A 21-year-old male presents with increasing shoulder pain for the past 6 months. Radiograph, CT scan, bone scan, MRI, and histology slide are shown in Figures A through E. What is the most appropriate diagnosis?
Radiographically, how do you rule out melorheostosis?
Agree with previous posts...path slide indicates a high grade lesion, and I would have chosen intramedullary osteosarcoma if it were not for the radiograph provided. Good idea to change path slide or eliminate altogether to avoid confusion for the examinee.
A 8-year-old boy presents with knee pain and an effusion. Biopsy and staging studies show a distal femoral osteosarcoma with contamination of the knee joint. Which of the following treatment options will provide this child with the best chance of local control and the highest level of function?
Through knee amputation
Above knee amputation
Extra-articular resection, endoprosthetic reconstruction, and free flap coverage
Extra-articular resection, allograft prosthetic composite, and free flap coverage
where's evidence that rotationplasty gives better function?
The UK sarcoma group have published the guidelines for the management of bone sarcomas. I think they are great guidelines with well documented evidence. They are uploaded in Oncology group.http://www.orthobullets.com/group/home?id=911&defaultPage=true
Hand Clin. 2013 Nov;29(4):579-84. Epub 2013 Oct 15.
Management of Low Grade Chondrosarcoma
I think curettage and bone graft or cement for low grade chondrosarcoma is reasonable unless associated with soft tissue mass. In case of soft tissue mass, then biopsy should be done to rule out dedifferentiated chondrosarcoma (high grade) which need wide margin resection.Wide margin resection in Low Grade Chondrosarcoma is associated with less function and almost similar recurrence rate.[PMLINK][PMTITLE]Long-term results of intralesional curettage and cryosurgery for treatment of low-grade chondrosarcoma.[/PMTITLE] [PMAUTH]Meftah M, Schult P, Henshaw RM[/PMAUTH] [PMSRC]J Bone Joint Surg Am. 2013 Aug 7. pii: 1723321. doi: 10.2106/JBJS.L.00442. 95. (15). :1358-64[/PMSRC] [PMID]23925739[/PMID][/PMLINK][PMLINK][PMTITLE]A systematic review and meta-analysis of intralesional versus wide resection for intramedullary grade I chondrosarcoma of the extremities.[/PMTITLE] [PMAUTH]Hickey M, Farrokhyar F, Deheshi B, Turcotte R, Ghert M[/PMAUTH] [PMSRC]Ann Surg Oncol. 2011 Jun. doi: 10.1245/s10434-010-1532-z. 18. (6). :1705-9[/PMSRC] [PMID]21258968[/PMID][/PMLINK]
Recurrent Lytic Lesion of the Proximal Femur (C2779)
36 / F - 36 year old female previously presented with a history of left hip pain 3 years ago with a lytic lesion in the left intertrochantric area. She was operated on with a fixed angle plate, bone graft and biopsy.
8 months ago removal of implant was done and attached is X-Ray post removal and result of histopathology.
1 month ago, patient presented with progressive left hip pain and X-Ray is shown with a recurrent lytic lesion with extension to the femoral neck.
What is the best option of treatment?
too old for reconstruction, end the patient suffering from repeated frustrating attempts of healing of this big hole and give her total hip
- too young for arthroplasty (keep it for later in case of new recurrence or head necrosis)- no effraction of the medullary canal=> wide lateral window. aggressive curettage, high speed drill, local adjuvant ttt, cementation, prophylactic fixation with "DHS" type implant +/- trochanter cerclage- tell the patient about local recurrence, fracture and plate/cerclage-related pain
Lytic lesion of the right ischium in a 42M (C2673)
42 / M - The patient is a 42 year old male who gives a history of injury to his right buttock after sustaining a fall while playing volleyball approximately 6 months ago.
He recovered well from the initial injury and was able to run and continue training.
He subsequently developed activity-related mild right buttock pain that began about ~1 month after the initial injury.
The patient feels his current pain may be related to his previous injury.
No fever / night pain / weight loss / rest pain / systemic symptoms.
What is the likely diagnosis?
Plain x-ray?? MetsCT chest abdomen and pelvis?Bone scan?
En bloc resection of primary sacral tumors: classification of surgical approaches and outcome
an excellent article with good classification of different types of sacral resections. The classification is according to level of nerve root resected with the tumor in addition to unilateral resections. higher level of resection end with more bowel, bladder and lower limb dysfunctions.[PMLINK][PMTITLE]En bloc resection of primary sacral tumors: classification of surgical approaches and outcome.[/PMTITLE] [PMAUTH]Fourney DR, Rhines LD, Hentschel SJ, Skibber JM, Wolinsky JP, Weber KL, Suki D, Gallia GL, Garonzik I, Gokaslan ZL[/PMAUTH] [PMSRC]J Neurosurg Spine. 2005 Aug. doi: 10.3171/spi.2005.3.2.0111. 3. (2). :111-22[/PMSRC] [PMID]16370300[/PMID][/PMLINK]
A 70-year-old female has unrelenting lower back pain and severe left anterior thigh pain. She has hip flexion weakness on the left that is limiting her ambulation. A representative image from her abdominal CT is shown below as well as a sagittal MRI of her spine. Nonoperative management has failed. What is the next appropriate step before performing an anterior corpectomy and stabilization of the spine?
CT-guided biopsy of spinal lesion
External beam radiation
Arteriography and embolization of the spinal lesion
Excellent discussion. I totally agree with confirmation of the disease before doing final surgical treatment. I have uploaded a video for steps of en bloc resection of spine metastasis in the oncology grouphttp://www.orthobullets.com/video/view?id=1645
J Surg Oncol. 2016 Apr;113(5):587-92. Epub 2016 Feb 5.
In general speaking, I would biopsy every case before definitive surgery. But remember there are different types of biopsy, it does not necessarily mean a separate procedures. For pathological fractures highly suspected to be caused by metastatic carcinomas, I will do INTRA-OPERATIVE biopsy. I will prepare everything for the planned definitive surgery (IM nail or joint replacement).When start the surgery, I will first use a needle or micro-pituitary rongeur to biopsy the lesion through a stab incision, send it for frozen section. If frozen section confirms a carcinoma, proceed with the planned surgery. If any doubt on frozen section, supsend the surgery. When it comes to orthopaedic oncology, there are a lot things can happen unexpected.Regarding this case, I would order a CT guided needle biopsy first, and I will also order a whole boday PET-CT or bone survey. If this is a SOLITARY bone met from RCC, wide resection does show better prognosis than intralesional resection (curettage), even in spinal cases. For this purpose, a pathological diagnosis and full staging are required. This is a L2 lesion, the pt has radicular symptoms, but appears to have no caudal symtoms. Thus even though the spinal surgery is urgent, but not emergent. Also talk to the urologist, see if they want to do the nephrectomy simultaneously since you are making an anterior approach for the T/L spine juction anyway.Spinal metastasectomy of renal cell carcinoma: A 16-year single center experience with a minimum 3-year follow-up.Kato S, Murakami H, Demura S, Nambu K, Fujimaki Y, Yoshioka K, Kawahara N, Tomita K, Tsuchiya HJ Surg Oncol. 2016 Apr. doi: 10.1002/jso.24186. 113. (5). :587-92PMID: 26846902 (Link to Abstract)