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Large osteosarcoma not apparent on conventional radiography
The Journal of Emergency Medicine, Vol. 26, No. 3, pp. 351⫺352, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/04 $–see front matter
doi:10.1016/j.jemermed.2003.11.018
Visual Diagnosis in Emergency Medicine
LARGE OSTEOSARCOMA NOT APPARENT ON CONVENTIONAL RADIOGRAPHY Michael K. Doney,
MD, MS
and Gary M. Vilke,
MD
Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California Reprint Address: Gary M. Vilke, MD, Department of Emergency Medicine, UCSD Medical Center, 200 West Arbor Drive, Mailcode 8676, San Diego, CA 92103
A conventional radiograph of the pelvis was obtained. The Emergency Physician interpretation of this radiograph was that it was a normal study. The radiologist confirmed this general impression, noting only a questionable osteolytic lesion involving S1 (Figure 1). Given the patient’s history and abnormal physical examination, a non-contrast computed tomography (CT) scan of the lumbar spine and pelvis was ordered in the ED and revealed an extensive osteolytic lesion of the right sacrum and ileum with extension into the right iliac wing. An associated ill-defined soft tissue mass was noted with infiltration into the ipsilateral gluteus and iliopsoas muscle. The radiologist noted this appearance to be most consistent with a primary bone neoplasm such as Ewing sarcoma (Figure 2a and b). The patient was admitted for pain control and diagnostic testing that included tissue biopsy with immunohistochemical staining that was diagnostic of Ewing sarcoma. Despite the presence of a large locally invasive osteolytic neoplasm, conventional radiography was deceptively unremarkable. A history of persistent pain and an examination significant for tissue swelling and pain out of proportion to findings was suggestive of the underlying neoplasm that was clearly demonstrated on CT imaging.
The patient is a 27-year-old man who presented to the Emergency Department (ED) with a 1-year history of lower back and right hip pain with swelling and a mass sensation in the right pelvis. Magnetic resonance imaging of the lumbar spine at the time of onset failed to demonstrate any pathology. Six months later, he developed frequent episodes of right buttock pain and pain radiating from the lower back to the right hip. Plain radiographs of the right hip at that time were unremarkable. The patient then reported worsening low back pain over the prior 5– 6 weeks with radiation to the right knee, and the sensation of a mass in the right pelvis with pain and swelling over the right posterior iliac crest for the prior 1–2 weeks. Physical examination was notable for a young man in severe pain. He was afebrile and the vital signs were normal. The most significant finding was an approximate 3 ⫻ 4 centimeter rounded area of soft tissue asymmetry in the right posterior suprailiac region. Palpation of the area revealed lack of a distinct border and absence of warmth, erythema, fluctuance, or induration. There existed only mild tenderness with palpation despite complaints of severe pain. Examination of the spine revealed only minimal tenderness at the sacrum. The physical examination was otherwise unremarkable.
RECEIVED: 11 April 2003; FINAL ACCEPTED: 5 November 2003
SUBMISSION RECEIVED:
24 September 2003;
351
352
M. K. Doney and G. M. Vilke
Figure 1. Plain radiograph, essentially unremarkable except for a questionable osteolytic lesion involving S1.
Figure 2. A and B) Non-contrast CT scan showing an extensive osteolytic lesion of the right sacrum and ileum with extension into the right iliac wing (arrows), with an ill-defined soft tissue mass infiltrating into the ipsilateral gluteus and iliopsoas.
doi:10.1016/j.jemermed.2003.11.018
Visual Diagnosis in Emergency Medicine
LARGE OSTEOSARCOMA NOT APPARENT ON CONVENTIONAL RADIOGRAPHY Michael K. Doney,
MD, MS
and Gary M. Vilke,
MD
Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California Reprint Address: Gary M. Vilke, MD, Department of Emergency Medicine, UCSD Medical Center, 200 West Arbor Drive, Mailcode 8676, San Diego, CA 92103
A conventional radiograph of the pelvis was obtained. The Emergency Physician interpretation of this radiograph was that it was a normal study. The radiologist confirmed this general impression, noting only a questionable osteolytic lesion involving S1 (Figure 1). Given the patient’s history and abnormal physical examination, a non-contrast computed tomography (CT) scan of the lumbar spine and pelvis was ordered in the ED and revealed an extensive osteolytic lesion of the right sacrum and ileum with extension into the right iliac wing. An associated ill-defined soft tissue mass was noted with infiltration into the ipsilateral gluteus and iliopsoas muscle. The radiologist noted this appearance to be most consistent with a primary bone neoplasm such as Ewing sarcoma (Figure 2a and b). The patient was admitted for pain control and diagnostic testing that included tissue biopsy with immunohistochemical staining that was diagnostic of Ewing sarcoma. Despite the presence of a large locally invasive osteolytic neoplasm, conventional radiography was deceptively unremarkable. A history of persistent pain and an examination significant for tissue swelling and pain out of proportion to findings was suggestive of the underlying neoplasm that was clearly demonstrated on CT imaging.
The patient is a 27-year-old man who presented to the Emergency Department (ED) with a 1-year history of lower back and right hip pain with swelling and a mass sensation in the right pelvis. Magnetic resonance imaging of the lumbar spine at the time of onset failed to demonstrate any pathology. Six months later, he developed frequent episodes of right buttock pain and pain radiating from the lower back to the right hip. Plain radiographs of the right hip at that time were unremarkable. The patient then reported worsening low back pain over the prior 5– 6 weeks with radiation to the right knee, and the sensation of a mass in the right pelvis with pain and swelling over the right posterior iliac crest for the prior 1–2 weeks. Physical examination was notable for a young man in severe pain. He was afebrile and the vital signs were normal. The most significant finding was an approximate 3 ⫻ 4 centimeter rounded area of soft tissue asymmetry in the right posterior suprailiac region. Palpation of the area revealed lack of a distinct border and absence of warmth, erythema, fluctuance, or induration. There existed only mild tenderness with palpation despite complaints of severe pain. Examination of the spine revealed only minimal tenderness at the sacrum. The physical examination was otherwise unremarkable.
RECEIVED: 11 April 2003; FINAL ACCEPTED: 5 November 2003
SUBMISSION RECEIVED:
24 September 2003;
351
352
M. K. Doney and G. M. Vilke
Figure 1. Plain radiograph, essentially unremarkable except for a questionable osteolytic lesion involving S1.
Figure 2. A and B) Non-contrast CT scan showing an extensive osteolytic lesion of the right sacrum and ileum with extension into the right iliac wing (arrows), with an ill-defined soft tissue mass infiltrating into the ipsilateral gluteus and iliopsoas.