0:00

So let's look at case two.

0:02

Here, we have a 32 year old man with a history of

0:05

hypertension now represented with two years of hip and

0:08

groin pain. So the pain is unrelieved by ibuprofen and

0:11

say it and on steroidal anti-inflammatory drug, and it's

0:14

worse when he gets up in the morning.

0:16

So physical examination actually demonstrates some point

0:19

tenderness over the entry aspect of that left hip

0:22

and groin with an obvious firm sort

0:25

of protuberance. The extremity neurov. Ask

0:28

examination is grossly normal and the range of motion and that hip

0:31

it's also normal but limited

0:34

So a low extremity x-ray is ordered and it's demonstrated to

0:37

show what we see here, which is

0:40

to the right. We have a plane radiograph and

0:43

exostartic mass arising from

0:46

that intraocrinetic region.

0:50

So what we see in the impression is a pedunculated exostosis

0:53

along the medial margin of the proximal femur measuring

0:56

about 8.5 by 5.4 centimeters

0:59

fairly large. So the differential offered by

1:02

the radiologist is that this could be an stochondroma or a chondrosarcoma?

1:06

So the MRI of the left hip is then recommended for

1:09

future evaluation.

1:12

The MRI of the lower extremities is performed.

1:16

So what do we see in the reading room?

1:21

So what we see is this.

1:24

Heterogeneously enhancing bony Expressions

1:27

originally from the anterior legal margin of

1:30

the subtraocantric left femur.

1:33

It's thought to be regular and shape and thickened

1:36

and and has a cartilaginous cap. And

1:39

what's its thought to be consistent with is an excess static

1:42

osteochondroma or low grade chondro

1:45

sarcoma, the patients also found of a trace

1:48

greater trochanteric bursitis.

1:51

So what are our next steps in this particular case the patient

1:54

follows up with its outpatient provider reviews Imaging

1:57

report?

1:58

So based on the presence of this large femoral Mass the

2:01

provider requested the patient on the global biopsy if this lesion

2:05

so what significant risk, is there

2:08

a performing a percutaneous biopsy of a malignant

2:11

bone lesion is there risk of hemorrhage from

2:14

friable tumor vessels?

2:17

Is there risk of an intractable post-apsy pain?

2:20

Is a risk of malignant seating of the biopsy tract or

2:23

is the risk of a high false positive rate relative

2:26

to the open surgical biopsy.

2:29

well

2:30

It's important to know that there's risk of malignancying of

2:33

the biopsy track in the invent of an

2:36

unconfirmed neoplasm. We should not risk upstaging.

2:40

So the question now for you should you perform a biopsy of

2:43

this patient's Mass? Why or why not?

2:46

Yes, this is absolutely likely to be

2:49

rapidly destructive malignancy or no, you must wait for

2:52

orthopedic surgery input.

2:54

The answer is no you must wait for

2:57

orthopedic surgery input.

2:59

So the choice to biopsy really should be made in tandem

3:02

in consultation in communication with the

3:05

our orthopedic surgery Partners. So the percutaneous

3:08

routes that we choose to perform the biopsy

3:11

and must be planned relative to the

3:14

operative routes. So that a biopsy track with potential malignant

3:17

seeding can be excised. The reason

3:20

being is this is particularly critical for limbs bearing

3:23

therapy. So imagine if you went and

3:26

we went to perform a biopsy

3:29

and that biopsy in choosing a safe route the

3:32

way we would choose a safe route.

3:34

Actually went through another compartment inadvertently.

3:38

And that was not the compartment that the orthopedic surgeon

3:41

was going to be using to excavate or remove that

3:44

particular mass in question. Now we can actually end

3:47

up extending the surgery and

3:50

thus the morbidity from this procedure when in

3:53

fact if we had communicated with the orthopedic surgeon

3:56

preemptively prospectively this would

3:59

not have happened.

4:00

So always consult your orthopedic surgeons

4:03

whenever a biopsy of such masses are

4:06

requested so that the biopsy

4:09

route is discussed and agreed upon.

4:13

So the patient is referred to an orthopedic oncologist at

4:16

a separate Institution.

4:18

the orthopedist selects for Imaging surveillance

4:20

and their justification is that this quote

4:23

unquote acts of static chondrosarcoma with

4:26

thick cartilaginous cap.

4:29

It's thought to be a slow growing entity low grade and with

4:32

low metastatic potential.

4:36

So next step for this particular patient is

4:39

the patient returns two years later for surveillance MRI

4:42

of its low extremity.

4:47

So what do we see?

4:50

Well patient has a persistent large heterogeneous bony

4:53

exostosis along the left proximal femoral

4:56

metaphysis a regular chondral cap.

5:00

Now significant interval change compared to the prior.

5:03

Stability is reassuring in this particular setting.

5:06

So the thought is that this most likely in the

5:09

differential diagnosis is likely a

5:12

benign large osteochondroma.

5:15

next steps

5:16

the patient scheduled for routine radiographic follow-up

5:19

at 6 to 12 months. No biopsies performed

5:22

given the suspicion for this to

5:25

be a benign lesion.