BONE TUMOR CASE STUDY

Dan Preece DPM PGY-2

HPI: 9 yo healthy male with dorsal right foot pain. Duration of pain x 3 months. Hx of multiple episodes of blunt trauma to right foot. Mass noted with swelling dorsal right foot, pain 7/10, some night pain, CAM boot failed to resolve pain, dorsal mass appears to enlarging.

PE: painful palpable mass over Right 1st met base.  L and R feet asymmetric. No erythema, ulceration, rash. Remainder of exam is consistent with healthy 9 yo male.

WHAT WOULD YOU DO NOW?

IMAGING:

IMAGING:

WHAT NEXT? What other imaging? Differential? Treatment options?

1ST MRI, JAN 2011: Findings: diffuse edema within the

proximal 1st metatarsal with diffuse periostitis.  There are periosteal or subcortical cystic lesions which are felt to represent superiosteal hematoma or seroma given the pt’s hx of repeated injury to this location.  Short interval f/u is recommended as there are additional lesions which could have this appearance.  Repeat imaging recommended in 3-6 months, with and w/o contrast.

PROGRESS NOTE: Pain worsening, Right foot mass

enlarging clinically. CAM walker failed to relieve pain.

No other changes to health status.

What are you going to do now?

2nd MRI 3 months later (April 2011):

2ND MRI READ: T2 hyperintense expansile proximal met eccentric

lesion abutting the dorsal growth plate of the 1st met. Regional periosteal thickening present. Prominent marrow edema and enhancement. Lesion measures 2 x 1.2 cm, increased from 1.6 x 1.7 cm.

Diff: chronic intraosseous abscess or unusual unicameral bone cyst w/ inflammatory changes (less likely). The expansion and peripheral location could be seen w/ aneurysmal bone cyst but single internal cavity is not typical of that Dx.

Surgical evaluation should be considered.

NEXT STEP?

TX: Debridement, curettage. Care taken to

preserve growth plate.

Packed deficit with: Osteosponge (Bacterin)

Osteosponge:• 100% bone• Osteoconductive• Osteoinductive• Elastic, sponge-like properties• Radiolucent• Complements orthopedic applications

SURGICAL FINDINGS: Op report: appearance of intraosseous

ganglion cyst, gelatinous fluid aspirated, dorsal cortex discovered fractured with aspects absent, growth plate not penetrated or affected by mass.

Path: sent to Mayo Clinic and UoU by pathology for consultation: Dx: benign chondromyxoid fibroma. 

Fluid Cytology: No malignant cells. 

POST OP: 30 days s/p surgery, walking in boot, no

pain.

X-rays show incorporation of graft, no pathologic fx or recurrence of lesion.

CHRONDOMYXOID FIBROMA: Rare, benign, cartilage-forming tumor of the tubular long bones.

Clinical Features — usually presents in the teens or 20s. Approximately one-quarter of cases occur in the proximal tibia, distal femur and calcaneus next most common sites. Males affected 1.5 times as often as females. Symptoms include pain and swelling.

Radiographic Findings — eccentric, intramedullary, lobulated or bubbly lesion in the metaphysis; it has a sclerotic border. It typically is lucent, with a rare chondral matrix.

Differential Diagnosis — Nonossifying fibroma , aneurysmal bone cyst, chondroblastoma, osteomyelitis, fibrous dysplasia.

Treatment — curettage and bone grafting.

Prognosis — generally is good. There is a 20 percent risk of recurrence, which may require en bloc resection.

Source: Up To Date