CASE STUDY NO. 1

Brief History:

Pain and swelling right knee since March 1997 (for six months duration when he attended the clinic).

Patient is limping.

No history of trauma or fever.

Investigations:

(done 29/Sep/1997)

·          Active bony lesion involving proximal part of the right tibia and left hip joint (head of femur).

·          No other lesion is detected.

(done on 7th and 12/Oct/1997)

·          Both studies showed significant uptake in the right tibia lesion but not in the left femoral lesion.

·          The MIBI showed significant washout at the 3 hours delayed image.

CONCLUSION:
Most probably the lesion seen in the right tibia is malignant and lesion in the left femur is not. The ^99mTc-SestaMIBI washout may indicate that this tumour is chemoresistant in nature because MIBI may represent multidrug resistent system.

(done on 4/Oct/1997)

There is no focal parenchymal lung lesion detected.

Minimal pleural thickening can be seen along the latero-posterior chest wall on the right side.There is no pleural effusion seen.

No hilar or mediastinal lymphoadenopathy detected.
 

(done on 8/Oct/1997)
A large destructive bony lesion is observed at lateral aspect of the right tibia extending from metaphysis to the upper diaphysis. Apparent cortical bony destruction of affected tibial bone as well as erosion and extension of the lesion to the right upper fibula soft tissue enhancing mass is observed along lateral aspect of the right upper tibia and fibula with distortion of the muscular facial planes.
 

Extension of the lesion is observed to the medullary cavity of right tibia down to its upper 1/3.

There is no extension to the knee joint.

Comment:
Picture is suggestive of an aggressive destructive bony malignant growth of the upper right tibia likely paraosteal sarcoma. Biopsy is recommended.

(done on 18/Oct/1997)

Sections reveal multiple bony trabeculae and foci of lesion shows spindle cells with mild nuclear enlargement, hyperchromasia and occasional mitotic figures, separated by fibrous tissue.

No marked pleomorphism or osteoid bone formation are seen.

Diagnosis:

Bone piece from upper tibia:

Consistent with spindle cell tumour.

Specimen from Right tibia done on 31/Oct/1997:

The specimen was sent to Imperial Cancer fund - London for second opinion. The panel agree with our osteoarticular expert that the lesion is not paraosteal, but it is a predominantly osteolytic lesion involving the proximal tibia. The biopsy shows a malignant spindle-celled tumour, without any evidence of bone formation. There are some mildly chondroid areas, but my diagnosis on the present material is fibrosarcoma. If, as I expect, the lesion is treated by resection or amputation, it would be interesting to see any further tissue, which may help to clarify the diagnosis.

(done on 24/Jan/1998)

There is active bony lesion seen in the proximal part of the right tibia as was reported 4 months ago.

There are another bony lesions seen which may represent secondaries:

·          in the left femur - trochanteric area.

·          in the left sacro-iliac joint region.

·          in the right iliac bone.

·          in the left scapula (or rib?).

(done on 24/May/1998)

The images were taken at 30 mins, 4 hrs and 24 hrs post injection.

There is significant increased tracer uptake noted in the region of upper part (proximal part) of right tibia in 30 minutes images which shows slow wahsout in 4 hours images.

There is also another area of increased tracer uptake in the region of head of left femur but less markedly than the lesion in the right tibia. It shows also mild washout in 4 hours images.

Remark:
24 hours images show very low uptake due to low count rate in the whole body, activity is noted only in the kidneys.

(done on 1/June/1998)

In comparison with study done 4 months ago (21/01/98):

·          The lesion in the right tibis, the left femur, the pelvis and ribs are unchanged.

·          There is a new lesion seen in the sacrum (approx. S1).

Treatment:

Patient received 3 cycles of chemotherapy consisting of Doxorubicine 30 mg/day and Infosfamide with Mesna 3 grams Taken on:

1. 12/2/1998 to 14/2/98

2. 16/3/1998 to 18/3/98

3. 13/4/1998 to 15/4/98