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Presented by Edward McCarthy, M.D. and prepared by Natasha Rekhtman, M.D., Ph.D.
Case 3: A 65-year-old man with a history of prostate cancer was found to have a radiodense lesion.
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1. Question
Week 229: Case 3
A 65-year-old man with a history of prostate cancer was found to have a radiodense lesion in his proximal humerus on routine skeletal survey. His PSA was not elevated. He had minimal discomfort in this area, probably related to bursitis of the shoulder./images/EMC 06 2005 case 3 1.jpg
/images/EMC 06 2005 case 3 2.jpg
/images/EMC 06 2005 case 3 3.jpgCorrect
Answer: Bone island
Histology: Bone islands are developmental abnormalities that result in the medullary location of dense compact bone. Most bone islands are small, and these are very common. However, occasionally bone islands may be very large and masquerade as other bone forming lesions. This bone island, like others, is extremely well demarcated. Characteristically, bone islands are asymptomatic. Histologically, the biopsy shows very dense compact bone without a cellular infiltrate.
Discussion: The lesion is not metastatic carcinoma. The normal PSA in this gentleman strongly points to this not being a focus of metastatic prostate cancer. In addition, the extremely sharp demarcation of this lesion would be atypical for metastatic cancer. The absence of cytokeratin-positive cells eliminates the possibility of metastatic carcinoma.
The lesion is not an osteoid osteoma. Osteoid osteomas are extremely painful. The radiodensity associated with osteoid osteoma is generally in a zonal pattern unlike the present case. In addition, the nidus characteristic of osteoid osteoma is not present in this case.
Incorrect
Answer: Bone island
Histology: Bone islands are developmental abnormalities that result in the medullary location of dense compact bone. Most bone islands are small, and these are very common. However, occasionally bone islands may be very large and masquerade as other bone forming lesions. This bone island, like others, is extremely well demarcated. Characteristically, bone islands are asymptomatic. Histologically, the biopsy shows very dense compact bone without a cellular infiltrate.
Discussion: The lesion is not metastatic carcinoma. The normal PSA in this gentleman strongly points to this not being a focus of metastatic prostate cancer. In addition, the extremely sharp demarcation of this lesion would be atypical for metastatic cancer. The absence of cytokeratin-positive cells eliminates the possibility of metastatic carcinoma.
The lesion is not an osteoid osteoma. Osteoid osteomas are extremely painful. The radiodensity associated with osteoid osteoma is generally in a zonal pattern unlike the present case. In addition, the nidus characteristic of osteoid osteoma is not present in this case.
