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Presented by Edward McCarthy, M.D. and prepared by Jeffrey Seibel, M.D. Ph.D.
Case 4: A 60 year-old man had pain in his knee for two years.
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1. Question
Week 48: Case 4
A 60 year-old man had pain in his knee for two years. Radiographs demonstrated a large lytic lesion in the proximal tibia involving the epiphysis and the metaphysis. There was also joint space narrowing with bony sclerosis and osteophyte formation typical of osteoarthritis./images/JS0709case4a.jpg
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/images/JS0709case4d.jpgCorrect
Answer: Giant osteoarthritic cyst
Histology: The lesion shows fibrous tissue with focal mucoid change. The mucoid areas coalesce to form a cavity with a fibrous lining.
Discussion: This patient shows radiographic changes consistent with osteoarthritis. The large subchondral defect in the proximal tibia should be considered radiographically to be a very osteoarthritic cyst. A giant cell tumor may show an identical radiographic appearance. The giant cell tumor characteristically involves the epiphysis and metaphysis of long bones in skeletally mature patients. The presence of osteoarthritis in this case should highly raise the suspicion that this may be an osteoarthritic cyst. The histology shows no giant cells. This differential is primarily a radiologic one. Metastatic carcinoma should be top on the list for any older adult with a lytic bone lesion. However, there is no histologic evidence of epithileal cells in this tissue. In the event of any suspicion, keratin stains should be performed.
Incorrect
Answer: Giant osteoarthritic cyst
Histology: The lesion shows fibrous tissue with focal mucoid change. The mucoid areas coalesce to form a cavity with a fibrous lining.
Discussion: This patient shows radiographic changes consistent with osteoarthritis. The large subchondral defect in the proximal tibia should be considered radiographically to be a very osteoarthritic cyst. A giant cell tumor may show an identical radiographic appearance. The giant cell tumor characteristically involves the epiphysis and metaphysis of long bones in skeletally mature patients. The presence of osteoarthritis in this case should highly raise the suspicion that this may be an osteoarthritic cyst. The histology shows no giant cells. This differential is primarily a radiologic one. Metastatic carcinoma should be top on the list for any older adult with a lytic bone lesion. However, there is no histologic evidence of epithileal cells in this tissue. In the event of any suspicion, keratin stains should be performed.
