1/109. Delay in the diagnosis and treatment of primary bone sarcoma of the pelvis.BACKGROUND: Symptoms arising from primary bone sarcoma of the pelvic girdle are often insidious in onset and nonspecific in nature. To make the subtle initial signs and symptoms of these tumors more apparent to clinicians, we studied a cohort of patients who had a primary bone sarcoma of the pelvic girdle. Our purpose was to describe the initial clinical findings and to evaluate the duration, frequency, and implications of delays in the treatment of these tumors. methods: We retrospectively analyzed the data on sixty-eight patients who had a primary bone sarcoma of the pelvic girdle. The data that we reviewed included demographic characteristics; histological diagnosis; anatomical location, size, and stage of the tumor; characteristics of the biopsy specimen; duration and description of symptoms before an accurate diagnosis was made; delay before recognition of the tumor on radiographs; results of diagnostic imaging; inaccurate diagnoses; type of intervention based on these inaccurate diagnoses; and outcome with regard to survival. There were forty high-grade sarcomas and twenty-eight low-grade sarcomas. RESULTS: Excluding two asymptomatic patients in whom the sarcoma was noted incidentally, the average duration of symptoms before an accurate diagnosis was made was ten months (median, six months; range, one month to four years). Common symptoms and findings on physical examination included pain in the buttock (twenty-three patients; 35 percent), a mass (twenty patients; 30 percent), sciatica (nineteen patients; 29 percent), pain in the hip (seventeen patients; 26 percent), pain in the groin (thirteen patients; 20 percent), and low-back pain (fourteen patients; 21 percent). In thirty (44 percent) of the sixty-eight patients, the pelvic sarcoma was not recognized initially and an inaccurate diagnosis was made. The misdiagnoses included a herniated lumbar disc, spinal stenosis, spondylolisthesis, tendinitis, bursitis, an inguinal hernia, a stress fracture, a pilonidal cyst, a recurrent urinary-tract infection, and degenerative arthritis of the spine, hip, and knee. Inappropriate treatment for these misdiagnoses included seven operative procedures (two laminectomies, two debridements, one hip arthrotomy, one total knee replacement, and one inguinal herniorrhaphy), six courses of nonsteroidal anti-inflammatory medications, five chiropractic adjustments, four trials of physical therapy, and three local injections of steroids. It took an average of seven months for the clinicians to arrive at the diagnosis of primary pelvic sarcoma. With the numbers available, no significant association between the duration of symptoms before an accurate diagnosis was made and the grade or the stage of the tumor could be detected. In addition, no association between the duration of symptoms and the survival of the patient (p = 0.54) could be determined, with univariate analysis. The grade and the stage of the tumor were strongly associated with the outcome, with a low tumor grade proving to be a favorable prognostic indicator for survival (p = 0.006). CONCLUSIONS: patients who have a primary bone sarcoma of the pelvis often have had symptoms for a long duration that mimic those of more commonly encountered non-neoplastic musculoskeletal conditions. When a patient has symptoms that appear to be out of the ordinary, particularly refractory pain or pain at rest, physicians should include the pelvic girdle in the evaluation and should carefully examine a high-quality radiograph of the entire pelvis.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
2/109. Bilateral elastofibroma dorsi. Two case reports.Elastofibroma dorsi is a benign fibroproliferative lesion of unknown pathogenesis. It is most commonly found in the periscapular region in elderly women. The majority of patients are asymptomatic. The lesions have a characteristic location and a specific magnetic resonance imaging (MRI) appearance allowing accurate prospective diagnosis. The importance of recognizing the benign nature of this lesion to avoid an unnecessary operation is apparent. We describe two cases of bilateral elastofibroma dorsi with characteristic findings on MRI and typical histological appearances.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
3/109. Retreat from death?The case of Terry Jenkins, a 15-year-old boy, who was found to have a sarcoma of bone, was discussed on television under the title of 'Inside medicine'. The discussion revolved, not so much on the clinical details of the case or even of cancer of bone in a young person, as on the emotional disturbance that followed when the boy's mother refused to allow her son to be told about the nature of his illness or the proposed treatment. With hindsight, as is made clear in the discussion, the case should have been handled quite differently, with the general practitioner acting as the lynch pin and a psychiatrist and a social worker being brought into the emotional 'treatment' of the boy and his mother. As it was the boy was so disturbed about what he had guessed about his condition that he attempted suicide: fortunately he was rescued in time, and Terry is now stable, working, and mobile on his artificial leg.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
4/109. Solitary skeletal hemangioma of the extremities.OBJECTIVE: To report the clinicopathologic features of solitary skeletal hemangioma of the extremities and to review previous cases in the English language medical literature. patients: In addition to five of our own cases, 34 literature cases with substantial and 75 with partial clinicopathologic information were found. RESULTS: Our patients, three men and two women, ranged in age from 37 to 83 years (mean 65.6 years). The lesion was an incidental radiologic finding in two patients, while three were symptomatic. In no case was a correct preoperative radiologic diagnosis made, a malignant process being considered as a possibility in all. The hemangiomas were medullary; two involved a metacarpal, two the fibula, and one the humerus. In contrast, previously reported patients were younger (mean age 32 years), predominantly female (60%), and symptomatic in over 90% of cases. The lesion is rare in those younger than age 10 years or older than age 60 years. As in our patients, the long bones are most frequently involved (75%), with the diaphysis or metadiaphysis, as in four of our patients, the most common locations. Although 20% of cases occur in the hands or feet, metacarpal involvement is rare. Medullary origin, as in all of our cases, is most frequent, but 45% of cases are either periosteal (33%) or intracortical (12%). In the literature, cavernous hemangioma is the most frequent type. Three of our hemangiomas were cavernous, one capillary, and one venous, the latter being rarely reported in extremity bones. CONCLUSIONS: Due to the diversity of radiologic patterns produced by skeletal hemangioma, a correct preoperative diagnosis is rarely made. Almost all patients do well, even those with less than complete removal of the lesion; local recurrence is rare. All of our patients were well following either therapeutic or simple diagnostic procedures. Due to the destructive nature of some biopsy procedures, the histologic diagnosis of hemangioma may at times also be problematic.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
5/109. pain management in palliative care. Reviewing the issues.BACKGROUND: Cancer pain remains significantly undertreated despite being one of the most prevalent and feared symptoms associated with cancer. Approximately 90% of patients can have their cancer pain controlled through relatively simple measures. OBJECTIVE: The aim of this review is to facilitate the current optimal approach to the assessment and management of cancer pain within the context of the multidimensional nature of the pain experience. DISCUSSION: Each component of the pain experience is addressed using a four point approach to pain and involves pharmacological and nonpharmacological measures. The general practitioner's role is pivotal in optimal cancer pain management. This is the first of two articles by Kiran Virik and Paul Clare on pain management in palliative care. The second, outlining treatment options, will appear in the December issue of Australian family Physician.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
6/109. thoracic outlet syndrome caused by first rib hemangioma.We report a case of first rib hemangioma that caused thoracic outlet syndrome. A 50-year-ole woman who was admitted to our hospital with a clinical diagnosis of thoracic outlet syndrome presented with fullness and easy fatigue of her right arm. Her right arm discomfort was associated with intermittent engorgement of superficial veins over the shoulder girdle. A chest radiograph revealed an enlargement of the anterior aspect of the first rib with fine bony trabeculations. Computed tomography scan showed contrast enhancement over the enlarged rib. Our tentative preoperative diagnosis was a benign first rib hypertrophic change, such as an old fracture with exuberant callus formation. A right-arm venogram revealed a patent subclavian vein with an extrinsic compression, which occluded on arm abduction. The findings of neural conduction studies of both upper extremities were symmetric and normal. The patient agreed to surgery because of the occlusive condition of the subclavian vein on arm abduction and progressive arm weakness in recent months. Segmental transection of the offending portion of the enlarged first rib was complicated by difficulty in isolating the whole length of the compressed but normal-appearing subclavian vein by our initial transaxillary and infraclavicular approaches because the medial aspect of the subclavian vein was obstructed by the enlarged first rib, which extended medially to the junction of the right jugular and subclavian veins. Successful segmental transection of the enlarged first rib was finally accomplished by combined transaxillary, infraclavicular, and supraclavicular approaches. A moderate amount of rib bleeding from resection ends was noted during segmental resection of the enlarged first rib, resulting in local hematoma formation. A 470-mL bloody discharge was collected from the vacuum ball inserted via the transaxillary route during her 12-day hospitalization. Pathologic examination revealed an intraosseous hemangioma. The patient had a prolonged course to partial recovery of her arm numbness, but signs of venous compression were much improved at 6 months' follow-up. Although hemangioma is benign, its hypervascular nature may cause catastrophic intraoperative bleeding.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
7/109. carcinoma breast metastatic to the hand and the foot.Metastases to the peripheral bones of the extremities are rare. Such lesions are often diagnosed as inflammatory or infective in nature. We present a report of a case of simultaneous involvement of the peripheral bones of the extremities--the talus and the thumb of the left hand--with a brief review of pathophysiology and management.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
8/109. Penile metastasis from rectal carcinoma.We are presenting a 65-year old patient with metastatic carcinoma of the penis which was discovered 19 months after abdomino-perineal resection for rectal cancer (Duke A). There was also metastasis in the perineum and one rib. Penile biopsy and cavernosography were carried out and established the metastatic nature. The patient declined further therapy and died 5 months after diagnosis.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
9/109. Chest wall metastasis from recurrent meningioma.Meningiomas are generally considered benign lesions. A minority, however, are capable of metastasis. The ones most likely to do so are commonly recurrent or frankly malignant in nature. The optimal management of such metastases is unclear. This is the first reported case of meningioma presenting as an isolated metastasis to the chest wall. This case involves a 64-year-old woman without significant medical or family history who underwent resection of a meningioma of the right cerebral hemisphere. She was treated 10 years later for recurrence by stereotactic radiosurgery. Three years after that, the patient's family noticed a mass on the left chest wall. A CT scan revealed destruction of the ninth rib laterally and subpleural extension. The patient subsequently underwent resection of full-thickness chest wall for a presumed soft-tissue sarcoma. Further pathologic evaluation including electron microscopy and immunohistochemistry revealed metastatic meningioma. The patient received adjuvant radiation to the chest wall and is currently free of disease at the chest wall one year after surgery. This case illustrates the difficulty in establishing an accurate diagnosis of metastatic meningioma. Consequently in selected patients with a history of the disease the diagnosis of metastatic meningioma must at least be considered. Resection of an isolated metastasis in this setting appears warranted.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
10/109. hemangiosarcoma of the bone. Problems arising from the heterogeneity of malignant vascular tumors of the bone.BACKGROUND: hemangioendothelioma of the bone is a rare vasoformative tumor of the bone with an intermediately aggressive nature. The tumor is said to have a long clinical course depending on the sites involved. diagnosis is particularly difficult since vascular tumors of the bone often present heterogeneous differentiation. CASE REPORT: We report on a 65-year-old female patient who had been diagnosed with an epitheloid hemangioendothelioma of the iliac bone and who underwent wide local excision. Although the initial biopsy specimens had clearly shown an epitheloid hemangioendothelioma, the final pathological analysis revealed a heterogeneous tumor, partially with some characteristics of an epitheloid hemangiosarcoma. The patient subsequently developed pulmonary metastasis, received a multimodality treatment, but died 14 months after the initial diagnosis from pulmonary insufficiency due to pleural sarcomatosis. CONCLUSION: hemangioendothelioma of the bone needs to be discussed as a differential diagnosis of osteolytic lesions. Our case stresses the importance of multimodality treatment in centers for cancer treatment. Histopathologic evaluation is essential in the diagnosis of epitheloid hemangioendothelioma. It is particularly difficult due to the heterogeneous differentiation of vasoformative tumors of the bone.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
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