04.01.05 - Bone & Soft Tissue Scenarios - Dr
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Bone and Soft tissue lumps and bumps – Clinical scenarios
Happy Spring
Suzanne Graham MD 1 April 2005
Cherry red papule on cheek of a 6 year old boy
More similar lesions
• Cavernous hemangioma • Deep cavernous hemangiomas with thrombosis = phleboliths that are dense or calcify
A 57 year old woman develops rapidly ascending spongy red lesions of her left arm, having had a radical mastectomy 25 years previously for breast cancer.
• Angiosarcoma – Stewart Treves Syndrome, angiosarcoma status post long term lymphedema
Rapidly spreading (from 1 to 3 cms in diameter in 2 months) red irregular slightly raised plaque on the scalp of a 75 year old man. Irregular anastamosing blood vessels are found on biopsy.
• Angiosarcoma, high grade
4 cm painless spongy subcutaneous mass on back of 45 year old woman. She noticed it 2 months ago
• Lipoma – benign fatty lesion • Looks like normal fat with a capsule
4 cm painless spongy subcutaneous mass on the shoulder of 75 year old man. He noticed it 2 months ago
• Fatty lesion • More cellular and atypical on microscopic – surprise! • Well differentiated liposarcoma or atypical lipoma – resect and cured.
Three 1-2 cm painful yellow subcutaneous masses that appeared one after another over 7 months on the upper arm of a 34 year old woman • Fatty lesion again • Tiny clotted vessels at edge of capsule – an angiolipoma • Notable for multiple and painful lesions.
Two cm very painful subcutaneous mass that “popped up over 2 weeks on the forearm of a 24 year old man
Infection Epidermal inclusion cyst Nodular fasciitis TOO fast for most malignancies, epithelial or mesenchymal • TOO young for most sarcomas • • • •
An 0.5 cm subungual (under the fingernail) mass in a 45 year old man that is exquisitely painful on compression, with pain radiating up the arm
• Glomus tumor • Epidermal cyst • Malignant melanoma • Trapped blood (hammer hit!)
An 0.3 cm dark brown to black painless subungual mass that a 43 year old man noticed a weak ago
• Glomus tumor • Epidermal cyst • Malignant melanoma • Trapped blood (hammer hit!)
An irregular lumpy firm mass in the palm of a 43 year old man, also involving the little finger; removed surgically
• Superficial fibromatosis (Dupuytren contracture)
34 year old woman with forearm mass which has recurred twice
• Deep fibromatosis (trichrome stain)
A 55 year old man with an enormous firm well circumscribed mass replacing most of the soft tissue of the lateral leg.
A 55 year old man with an enormous firm well circumscribed mass replacing most of the soft tissue of the lateral leg. Malignant lipoblast
• Liposarcoma • Malignant fibrous histiocytoma • Other less common sarcomas
Similar lesion in lateral hip CT scan
55 year old man wit a 15 cm well circumscribed mass deep in the anterior soft tissue of the thigh that has slowly increased in size over the past year
55 year old man with a 15 cm well circumscribed mass deep in the anterior soft tissue of the thigh that has slowly increased in size over the past year
• Liposarcoma • Malignant fibrous histiocytoma (big uglies with no evidence other lineage differentiation • Other less common sarcomas
A 36 year old man develops a well circumscribed mass near his knee about 3 months after a rugby accident
Other examples same lesion
A 36 year old man develops a well circumscribed mass near his knee about 3 months after a rugby accident
Central soft tissue
Woods lamp – white is bone Peripheral bone
• Myositis ossificans • Calcifying neoplasm
A 35 year old man presents with a plantar mass which proves to be much larger than expected, with erosion of the foot bones
A 35 year old man presents with a plantar mass
• Monophasic pattern
• Biphasic pattern
A 35 year old man presents with a plantar mass • Synovial sarcoma • Clear cell sarcoma • Squamous cell carcinoma • Plantar fibromatoses • Infections
Cytokeratin stain
21 year old man with a 1 cm subcutaneous mass is said to have a neurofibroma. How do you differentiate it from a schwannoma??? How are they the same?? But about their associations with neurofibromatosis?
Schwannoma
Palisading nuclei
Lesion Nerve Capsule
Nerve
Plexiform neurofibroma
Lesion
Nerve
14 year old girl develops left proptosis and cheek prominence over the last 4 years
14 year old girl with proptosis • Fibrous dysplasia • Infection
A 2 year old boy develops left proptosis over a period of three months
A 2 year old boy develops left proptosis over a period of three months • • • • •
Rhabdomyosarcoma Retinoblastoma Osteosarcoma Infections Etc
A 14 year old boy develops a 7 cm mass over his lateral chest wall over 7 months. A biopsy reveals sheets of small blue cells with little cytoplasm. What is the differential and what would you do (tests, etc) to clarify the situation?
• • • • • •
PNET Ewing sarcoma of soft tissue Rhabdomyosarcoma Wilms tumor Neuroblastoma Retinoblastoma
A 50 year old man complains of vague back pain and is found to have a 25 cm right retroperitoneal mass on CT scan
• Retroperitoneal mass differential – anything and everything; remember local visceral structures as well as soft tissue lesions
A 35 year old man is in an accident and fractures a rib. An incidental anterior/superior/posterior/middle mediastinal mass is found incidentally
• The mediastinal mass differential
A 10 cm hard mass over the scapular area in a 65 year woman that has been growing slowly over 3 years. It involves her scapula
• Chondrosarcoma.
A 14 year old young man complains of pain for the last 3 months in his leg just above the knee. He is afebrile with a normal WBC.
A 14 year old with knee pain – Choice 1
A 14 year old with knee pain – Choice 2
A 14 year old with knee pain – Choice 3
Compare (different levels of magnification
A 14 year old with knee pain • • • •
Acute osteomyelitis Ewing Sarcoma of bone Osteosarcoma Giant cell tumor of bone
An 11 year old young man complains of right upper arm pain when he pitches softball. He has a low grade fever. There is ‘onion skinning’ reaction in the diaphyseal periosteum.
An 11 year old young man complains of right upper arm pain when he pitches softball. He has a low grade fever. There is ‘onion skinning’ reaction in the diaphyseal periosteum.
• Ewing sarcoma of bone • Osteomyelitis • Eosinophilic granuloma (Langerhans histiocytosis)
A 9 year old boy complains of terrible pain about 6 inches below his hip joint on the right. He points to the spot. It persists at night. A focal area of marked bony sclerosis is seen around a 1 cm lucent lesion. You prescribe aspirin and it works like a charm – the pain is relieved.
• Osteoid osteoma • Focal infection
Happy Spring
Suzanne Graham MD 1 April 2005
Cherry red papule on cheek of a 6 year old boy
More similar lesions
• Cavernous hemangioma • Deep cavernous hemangiomas with thrombosis = phleboliths that are dense or calcify
A 57 year old woman develops rapidly ascending spongy red lesions of her left arm, having had a radical mastectomy 25 years previously for breast cancer.
• Angiosarcoma – Stewart Treves Syndrome, angiosarcoma status post long term lymphedema
Rapidly spreading (from 1 to 3 cms in diameter in 2 months) red irregular slightly raised plaque on the scalp of a 75 year old man. Irregular anastamosing blood vessels are found on biopsy.
• Angiosarcoma, high grade
4 cm painless spongy subcutaneous mass on back of 45 year old woman. She noticed it 2 months ago
• Lipoma – benign fatty lesion • Looks like normal fat with a capsule
4 cm painless spongy subcutaneous mass on the shoulder of 75 year old man. He noticed it 2 months ago
• Fatty lesion • More cellular and atypical on microscopic – surprise! • Well differentiated liposarcoma or atypical lipoma – resect and cured.
Three 1-2 cm painful yellow subcutaneous masses that appeared one after another over 7 months on the upper arm of a 34 year old woman • Fatty lesion again • Tiny clotted vessels at edge of capsule – an angiolipoma • Notable for multiple and painful lesions.
Two cm very painful subcutaneous mass that “popped up over 2 weeks on the forearm of a 24 year old man
Infection Epidermal inclusion cyst Nodular fasciitis TOO fast for most malignancies, epithelial or mesenchymal • TOO young for most sarcomas • • • •
An 0.5 cm subungual (under the fingernail) mass in a 45 year old man that is exquisitely painful on compression, with pain radiating up the arm
• Glomus tumor • Epidermal cyst • Malignant melanoma • Trapped blood (hammer hit!)
An 0.3 cm dark brown to black painless subungual mass that a 43 year old man noticed a weak ago
• Glomus tumor • Epidermal cyst • Malignant melanoma • Trapped blood (hammer hit!)
An irregular lumpy firm mass in the palm of a 43 year old man, also involving the little finger; removed surgically
• Superficial fibromatosis (Dupuytren contracture)
34 year old woman with forearm mass which has recurred twice
• Deep fibromatosis (trichrome stain)
A 55 year old man with an enormous firm well circumscribed mass replacing most of the soft tissue of the lateral leg.
A 55 year old man with an enormous firm well circumscribed mass replacing most of the soft tissue of the lateral leg. Malignant lipoblast
• Liposarcoma • Malignant fibrous histiocytoma • Other less common sarcomas
Similar lesion in lateral hip CT scan
55 year old man wit a 15 cm well circumscribed mass deep in the anterior soft tissue of the thigh that has slowly increased in size over the past year
55 year old man with a 15 cm well circumscribed mass deep in the anterior soft tissue of the thigh that has slowly increased in size over the past year
• Liposarcoma • Malignant fibrous histiocytoma (big uglies with no evidence other lineage differentiation • Other less common sarcomas
A 36 year old man develops a well circumscribed mass near his knee about 3 months after a rugby accident
Other examples same lesion
A 36 year old man develops a well circumscribed mass near his knee about 3 months after a rugby accident
Central soft tissue
Woods lamp – white is bone Peripheral bone
• Myositis ossificans • Calcifying neoplasm
A 35 year old man presents with a plantar mass which proves to be much larger than expected, with erosion of the foot bones
A 35 year old man presents with a plantar mass
• Monophasic pattern
• Biphasic pattern
A 35 year old man presents with a plantar mass • Synovial sarcoma • Clear cell sarcoma • Squamous cell carcinoma • Plantar fibromatoses • Infections
Cytokeratin stain
21 year old man with a 1 cm subcutaneous mass is said to have a neurofibroma. How do you differentiate it from a schwannoma??? How are they the same?? But about their associations with neurofibromatosis?
Schwannoma
Palisading nuclei
Lesion Nerve Capsule
Nerve
Plexiform neurofibroma
Lesion
Nerve
14 year old girl develops left proptosis and cheek prominence over the last 4 years
14 year old girl with proptosis • Fibrous dysplasia • Infection
A 2 year old boy develops left proptosis over a period of three months
A 2 year old boy develops left proptosis over a period of three months • • • • •
Rhabdomyosarcoma Retinoblastoma Osteosarcoma Infections Etc
A 14 year old boy develops a 7 cm mass over his lateral chest wall over 7 months. A biopsy reveals sheets of small blue cells with little cytoplasm. What is the differential and what would you do (tests, etc) to clarify the situation?
• • • • • •
PNET Ewing sarcoma of soft tissue Rhabdomyosarcoma Wilms tumor Neuroblastoma Retinoblastoma
A 50 year old man complains of vague back pain and is found to have a 25 cm right retroperitoneal mass on CT scan
• Retroperitoneal mass differential – anything and everything; remember local visceral structures as well as soft tissue lesions
A 35 year old man is in an accident and fractures a rib. An incidental anterior/superior/posterior/middle mediastinal mass is found incidentally
• The mediastinal mass differential
A 10 cm hard mass over the scapular area in a 65 year woman that has been growing slowly over 3 years. It involves her scapula
• Chondrosarcoma.
A 14 year old young man complains of pain for the last 3 months in his leg just above the knee. He is afebrile with a normal WBC.
A 14 year old with knee pain – Choice 1
A 14 year old with knee pain – Choice 2
A 14 year old with knee pain – Choice 3
Compare (different levels of magnification
A 14 year old with knee pain • • • •
Acute osteomyelitis Ewing Sarcoma of bone Osteosarcoma Giant cell tumor of bone
An 11 year old young man complains of right upper arm pain when he pitches softball. He has a low grade fever. There is ‘onion skinning’ reaction in the diaphyseal periosteum.
An 11 year old young man complains of right upper arm pain when he pitches softball. He has a low grade fever. There is ‘onion skinning’ reaction in the diaphyseal periosteum.
• Ewing sarcoma of bone • Osteomyelitis • Eosinophilic granuloma (Langerhans histiocytosis)
A 9 year old boy complains of terrible pain about 6 inches below his hip joint on the right. He points to the spot. It persists at night. A focal area of marked bony sclerosis is seen around a 1 cm lucent lesion. You prescribe aspirin and it works like a charm – the pain is relieved.
• Osteoid osteoma • Focal infection
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