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Presented by Edward McCarthy, M.D. and prepared by Jon Davison, M.D.
Case 2: A 65-year-old man had pain in his lower leg for several years.
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Question 1 of 1
1. Question
Week 208: Case 2
A 65-year-old man had pain in his lower leg for several years. A plain radiograph demonstrated a long lesion with a lytic area and coarsened trabeculae.images/JMD_1-17-05_SPWC/Case_2/1.jpg
images/JMD_1-17-05_SPWC/Case_2/2.jpg
images/JMD_1-17-05_SPWC/Case_2/3.jpgCorrect
Answer: Paget’s disease
Histology: none provided
Discussion: This is an example of late phase Paget’s disease with sclerotic bone. The principle histologic finding is an increase in remodeling lines that form a mosaic pattern. There is increased osteoclastic activity. This increase is due to the exaggerated and chaotic bone-remodeling characteristic of Paget’s disease. In addition, osteoclastic activity is very prominent. Many osteoclasts are gigantic. Although metastatic carcinoma is an important consideration in any bone lesion in this age group, the absence of epithelial cells rules out this diagnosis. Often, keratin stains must be performed to exclude the presence of hidden epithelial cells. Prostate cancer causes a similar increase in bone density. However, the mosaic pattern of remodeling lines is not present in metastatic prostate cancer. In addition, almost all patients with metastatic prostate cancer will have an elevated PSA. By contrast, patients with Paget’s disease almost always have an elevated alkaline phosphatase. The diagnosis is not osteomyelitis. Although osteomyelitis may produce marrow fibrosis and increased bone density similar to Paget’s disease, the mosaic pattern of remodeling is not present in osteomyelitis. In addition, osteomyelitis does not show giant osteoclasts.
Incorrect
Answer: Paget’s disease
Histology: none provided
Discussion: This is an example of late phase Paget’s disease with sclerotic bone. The principle histologic finding is an increase in remodeling lines that form a mosaic pattern. There is increased osteoclastic activity. This increase is due to the exaggerated and chaotic bone-remodeling characteristic of Paget’s disease. In addition, osteoclastic activity is very prominent. Many osteoclasts are gigantic. Although metastatic carcinoma is an important consideration in any bone lesion in this age group, the absence of epithelial cells rules out this diagnosis. Often, keratin stains must be performed to exclude the presence of hidden epithelial cells. Prostate cancer causes a similar increase in bone density. However, the mosaic pattern of remodeling lines is not present in metastatic prostate cancer. In addition, almost all patients with metastatic prostate cancer will have an elevated PSA. By contrast, patients with Paget’s disease almost always have an elevated alkaline phosphatase. The diagnosis is not osteomyelitis. Although osteomyelitis may produce marrow fibrosis and increased bone density similar to Paget’s disease, the mosaic pattern of remodeling is not present in osteomyelitis. In addition, osteomyelitis does not show giant osteoclasts.
