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A 42-year-old male presents to clinic with 1 year of atraumatic left knee pain. He also reports subjective fever and chills. His physical examination is remarkable for diffuse knee pain but there is no overlying erythema or induration. His current laboratory values reveal a white blood cell count of 9200/µL (reference range [rr], 5000-12000/µL), absolute neutrophil count of 1800/µL (rr, 2000-7000/µL) with 53.7% lymphocytes (rr, 20-40%), an erythrocyte sedimentation rate (ESR) of 21 mm/h (rr, 0-20 mm/h), and a C-reactive protein (CRP) level of 2.2 mg/dL (rr, < 2 mg/dL). He has attempted a trial of physical therapy as well as a trial of oral antibiotics with no improvement of symptoms. Imaging is shown in Figures A-C. A biopsy is performed and is shown in Figure D. Which of the following is the best next step in management?
Observation, NSAIDs, continued physical therapy
Chemotherapy + limb salvage resection ± adjuvant radiation
Multi-agent chemotherapy ± local irradiation
Select Answer to see Preferred Response
A 45-year-old woman presents with severe thigh pain and constitutional symptoms for the past 4 months. A radiograph of the femur is shown in Figure A. Figure B displays a coronal T2 MRI and Figure C shows a sagittal T1 MRI with an arrow pointing to an adjacent soft tissue mass. Histology of a biopsy specimen is shown in Figure D. Immunohistochemistry stains are positive for CD20 and CD45. What is the most appropriate treatment for this tumor?
Above knee amputation
Intramedullary nail placement with adjuvant multiagent chemotherapy and possible irradiation
Limb salvage with wide resection and tumor prosthesis placement
Neoadjuvant chemotherapy followed by surgical resection followed by adjuvant chemotherapy
A 75-year-old man presents with a displaced femoral neck fracture. During your surgical exposure for a hemiarthroplasty, the femoral neck has fractured through a pathologic lesion which is diagnosed as a lymphoma on frozen section. The lesion is located in the center of the femoral neck and the calcar femorale is not involved. Your treatment should include:
Closure of the wound and chemotherapy
Radical resection of the proximal femur and megaprothesis hemiarthroplasty
Hemiarthroplasty with postoperative staging and chemo-radiotherapy as indicated
Bone marrow transplantation