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Case presentation

Case presentation. MUSCULOSKELETAL MODULE Jacques le Roux 20/07/2012. Clinical picture. 10 year old girl with 3 week history of progressive left knee pain and soft tissue swelling left lower leg. Clinical information.

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Case presentation

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  1. Case presentation MUSCULOSKELETAL MODULE Jacques le Roux 20/07/2012

  2. Clinical picture • 10 year old girl with • 3 week history of progressive left knee pain and soft tissue swelling left lower leg

  3. Clinical information • Renal function normal • CRP elevated 50. ESR not available • WCC normal • HB normal, Platelets normal. • RVD negative

  4. Lower limb X-rays

  5. Lateral view Right Left

  6. Musculo sonar

  7. CXR

  8. Differential diagnosis 1 ) Soft tissue infection / inflamm mass – pain, raised CRP 2 ) Hematoma - ? trauma history, no # seen 3 ) Hemangioma – no phleboliths seen, no skin lesion, more infants 4) ALERT! Then Exclude malignant stuff always - Ewing sarcoma – not classical bone findings - Superficial osteosarcoma - no osteiod matrix, older patient - Rhabdomyosarcoma – more neck region

  9. Nuclear medicine findings • Bloodflow and bloodpool images showed increased uptake in the lateral aspect of the left knee • Static late phase : much less than the uptake in the soft tissue around the left knee, not convincing • No bony metastases seen - ? Soft tissue pathology

  10. MRI T1

  11. Ax Sag STIR Sag

  12. Cor Sag T1 post contrast

  13. Ax T1 + C

  14. Histology / biopsy • PNET tumour – Ewing sarcoma

  15. CT chest and abdomen

  16. APPROACH TO BONE LESION ( quick recap)1. Location (central, eccentric) - Diaphysis - Metaphysis - Epiphysis 2. Benign Well defined borders (narrow zone of transition and with sclerosis) Intact cortex Periosteal reaction absent / smooth No soft tissue mass 3. Age Aggressive Poorly defined (wide zone) Cortical destruction Moth-eaten /permeative – small holes Present e.g. - Multilaminated (onion skin) - Spiculated perpendicular hair on end - Divergent Sunburst - Elevated Codman Present

  17. DIFF ΔΔ OF AGGRESSIVE BONE LESIONS (CHILD)1. Ewing vs Osteosarcoma – can be difficult Ewing Osteosarcoma Conventional Parosteal Periosteal Telangiectatic (osteolysis) older child/young adult Metaphysis Slerotic to lung + = bone matrix Most common bone Ca (child) Boys > girls Family : PNET (peripheral) Askin (rib/chest wall) Age: children Location: diaphysis Appearance: lucent Mets: to bone Soft tissue mass+ (no new bone form)

  18. 2.Lymphoma/Leukemia • lympadenopathy • absence of soft tissue mass 3.Mets to BM • neuroblastoma (< 5 years) / [rhabdomyosarcoma (common head, neck and orbit) 5 – 10 years] • renal cell Ca and thyroid Ca - lytic 4.OM • may look identical (aggressive) • Clinical 5. LCH (EG) • lytic (punch-out) - skull, long bones - vertebra plana • some central sequestrum ΔΔ OM 6. Hemangioma • most common infants • bone destruction • flow voids (T₂) • phleboliths

  19. EWING SARCOMA – LEFT FIBULA (DIAPHYSIS) A. Cortex- moth-eaten + soft tissue mass B. Soft tissue mass+ BM T₂↑ (edema) C. MassCE + D. Askin tumor- arising from rib E. Back mass- no bone destruction - biopsy : extraosseous Ewing

  20. OSTEOSARCOMA – X-RAYS A. Osteoblastic– sunburst periost. reaction B. Osteoblastic– Codman C. Telangiectatic– osteolysis D. Parosteal - soft tissue mass with new bone - classic lucent zone E. Periosteal– cortical thickening + soft tissue mass

  21. OSTEOSARCOMA – CT/MRI A. Pelvis (ilium) – diffuse sclerotic + cortical destruction + soft tissue mass +areas new bone formation B. BMinvolvement with intra- and extra pelvic soft tissue mass Left: T₂↑ (fat-saturated) Right: T₁fatsats with contrast areas with CE + and CE – (necrosis) C. Lung - Ca ⁺⁺ Mets D. Telangiectatic Left: T₂ fatsats ↑ (fluid) Right: T₁ fatsats + contrast CE + E. Periosteal - sessile soft tissue mass along ant. cortex - no BM involvement

  22. NEUROBLASTOMA

  23. LEUKEMIA

  24. RHABDOMYOSARCOMA

  25. LANGERHANS CELL HISTIOCYTOSIS A, B. Punch-out lytic lesion - small, large lesion C. In bone defect soft tissue lesion - CE + D. Pituitary stalk lesion - CE +: diabetes insipidus ( Hand-Schuller-Christian disease) E. Focal osteolysis - small F. Large bony lesion with aggressive cortical destruction G. Vertebra Plana - T₂ ↑

  26. EG - Lytic lesion with bony sequestrum ΔΔ OM

  27. OSTEOMYELITIS OM cellulitis

  28. HEMANGIOMA

  29. COMMON BENIGN BONE LESIONS IN CHILDREN (classics) – C,D AND E can become malignant A. Fibrous cortical defect(most common, benign bone lesion in child) small <2cm lytic cortex (femur-metaphysis) B.NOFgrape-like lytic lesion > 2cm – no pain or periostitis C. Enchondroma lytic + sclerotic rim + popcorn Ca⁺⁺ (diff –medullary bone infarct) D.Enchondroma lytic (phalanges) – no Ca⁺⁺ in the phalanges E.Osteochondroma– cartilage-capped bone exostosis , can become malignant

  30. SUMMARY In a child with a soft tissue mass think deeper (bone)

  31. REFERENCES 1. Gooding CA, Essentials Of Paediatric Radiology. Cambridge 2010 2. Johnson K, Paediatric Radiology Oxford 2009.

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