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Presented by Edward McCarthy, M.D. and prepared by Natasha Rekhtman, M.D., Ph.D.
Case 3: A 40 year old man had pain in his elbow for one year.
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Week 204: Case 3
A 40 year old man had pain in his elbow for one year. A radiograph demonstrated a well defined lytic lesion in the distal humerus. In addition there were lytic lesions in the proximal ulna and radius.images/EMC 11 19 04 case 3 Image3.jpg
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images/EMC 11 19 04 case 3 Image5.jpg
images/Pb022133.jpgCorrect
Answer: Pigmented villonodular synovitis
Histology: Pigmented villonodular synovitis is a proliferative lesion of the synovial membrane characterized by a population of rounded macrophage-like-stromal cells admixed with multi-nucleated giant cells, foam-cells, and hemosiderin laden cells macrophages. Approximately 20 per cent of cases of pigmented villonodular synovitis cause bone erosion. If the bone erosion is extensive, as in this case, the stromal cells admixed with giant cells may masquerade as a giant cell tumor. The abundant hemosiderin pigment in this case should raise the suspicion that this is a pigmented villonodular synovitis. In addition, the presence of another lesion on the other side of the joint raises the possibility that an intra articular process is responsible for both lesions.
Discussion: The lesion is not a giant cell tumor because the process is synovial based and is eroding both bones on either side of the joint. The abundant hemosiderin is a clue that this is not a giant cell tumor. The radiologic pattern of an epiphyseal lesion (as in this case) is a typical x-ray pattern of giant cell tumor. However, an MRI would show that the process is a synovial disease with bone erosion on either side of the joint.
The lesion is not a malignant fibrous histiocytoma because there is no atypia and mitotic figures are rare. Moreover, the radiographic pattern is one of a slow going benign process rather than the aggressive permeative pattern of a malignant bone tumor.
Incorrect
Answer: Pigmented villonodular synovitis
Histology: Pigmented villonodular synovitis is a proliferative lesion of the synovial membrane characterized by a population of rounded macrophage-like-stromal cells admixed with multi-nucleated giant cells, foam-cells, and hemosiderin laden cells macrophages. Approximately 20 per cent of cases of pigmented villonodular synovitis cause bone erosion. If the bone erosion is extensive, as in this case, the stromal cells admixed with giant cells may masquerade as a giant cell tumor. The abundant hemosiderin pigment in this case should raise the suspicion that this is a pigmented villonodular synovitis. In addition, the presence of another lesion on the other side of the joint raises the possibility that an intra articular process is responsible for both lesions.
Discussion: The lesion is not a giant cell tumor because the process is synovial based and is eroding both bones on either side of the joint. The abundant hemosiderin is a clue that this is not a giant cell tumor. The radiologic pattern of an epiphyseal lesion (as in this case) is a typical x-ray pattern of giant cell tumor. However, an MRI would show that the process is a synovial disease with bone erosion on either side of the joint.
The lesion is not a malignant fibrous histiocytoma because there is no atypia and mitotic figures are rare. Moreover, the radiographic pattern is one of a slow going benign process rather than the aggressive permeative pattern of a malignant bone tumor.
