Florid reactive periostitis of the thumb: a case report and review of the literature

Florid reactive periostitis is a rare benign bone lesion that occurs most often in the phalanges of hands and feet. Histologic evaluation is commonly required to distinguish this benign lesion from clinically indistinguishable malignant and infectious disorders. The lesion is typically self-limiting or cured by local excision; however, in very aggressive cases ray amputation may be indicated. The authors report a case of florid reactive periostitis affecting the thumb with satisfactory outcome and without recurrence at 2-year follow-up.     

Florid reactive periostitis of the middle phalanx: a case report and review of the literature.

Florid reactive periostitis is an uncommon bone lesion that occurs most often in the phalanges of the hands and feet. Histologic evaluation is commonly required to distinguish this benign lesion from clinically indistinguishable malignant and infectious etiologies. While the lesion is typically self-limiting or cured by simple excision, we report a case of aggressive recurrence following an excisional biopsy that ultimately led to ray amputation.     

Proximal bile duct stricture disguised as malignant neoplasm.

BACKGROUND: Discrimination of malignant proximal bile duct (PBD) stricture from a benign lesion is difficult with nonsurgical methods; indeed, 8% to 13% of PBD strictures prove to be benign after histologic examination of the surgically resected specimen. METHODS: In a 7-year period 178 patients with PBD stricture were admitted, and 99 of them underwent radical resection for presumably malignant lesions. In 14 of these patients the stenotic lesions were proved to be benign by postoperative histologic assessment. We reviewed these patients retrospectively by collecting data from their charts. RESULTS: Preoperative radiologic findings including cholangiography and angiography were compatible with malignancy in all 14 patients. Preoperative histologic studies suggested malignancy in 2 of 8 examined. Findings at laparotomy could not allow differentiation between malignant and benign lesions in any of the patients and strongly suggested malignancy in 3. Histologic examination of the resected specimens revealed extensive fibrosis with inflammatory cellular infiltration in all patients. There was 1 episode of significant morbidity postoperatively (transient cholangitis) but no mortality. CONCLUSION: Benign PBD strictures, although rare, are usually indistinguishable from malignant PBD strictures by preoperative or perioperative investigation. Given the minimal morbidity, all PBD strictures should be presumed malignant and managed accordingly, even at the risk of overtreating some benign cases.     

Florid reactive periostitis ossificans of the humerus: Case report and differential diagnosis of periosteal lesions of long bones

A case of florid reactive periostitis ossificans (RPO) arising in a long bone is presented. This is a rare bone proliferation with a pronounced periosteal reaction. Less than 100 cases have been described in the literature with far fewer outside the bones of the hand, feet, fingers, and toes. Although the etiology is unknown, a relationship to preceding trauma is suggested. The imaging and histologic features show an overlap with other bone lesions including bizarre parosteal osteochondromatous proliferation, subungual exostosis, and malignant surface tumors of bone and cartilage which include, periosteal and parosteal osteosarcoma. It is important to recognize the clinical presentation and diagnostic features of RPO as a benign entity so that it is not mistaken for a more aggressive neoplasm. We present a case of a right distal humeral lesion that on histopathological review revealed florid RPO. This diagnosis was not suspected on imaging studies, but was made on open biopsy of the mass. The patient remains disease free, years postoperatively. In addition to presenting this unique case report, we review the pertinent literature, and offer a differential diagnosis and treatment strategy for its management.     

Periostitis secondary to prolonged voriconazole therapy in a lung transplant recipient

This article reports a case of perostitis deformans in a lung transplantation patient taking the fluoride-containing medication voriconazole, a relatively new and potent anti-fungal. The patient had a normal range of motion in all joints and a normal gait. On radiographs at presentation, multifocal areas of periostitis were visualized involving the left-hand first, second, and third proximal phalanx shafts. Similar periostitis was present on the left-hand third, fourth, and fifth middle phalanx shafts. Plain radiographs of the right hand also demonstrated multifocal periostitis of the third and fourth proximal and middle phalanges. Aggressive periostitis at the level of the right fourth proximal and middle phalanges was also present. Given her long-term treatment with voriconazole and a presentation consistent with periostitis deformans, voriconazole was presumed to be the offending agent and was replaced with itraconazole. The patient's symptoms resolved shortly after withdrawal of voriconazole.Voriconazole-associated periostitis has only recently been reported in the literature. Food and Drug Administration-approved in 2002, voriconazole is efficacious in treating serious, invasive fungal infections that are generally seen in immunocompromised patients. Due to the novel nature of voriconazole and the uncommon indications for its long-term use, the periostitis deformans described in this article may be unfamiliar to the orthopedic surgeon. Consequently, a patient presenting with bone pain and periosteal involvement on plain radiographs may provoke a broad, expensive, and ultimately unnecessary diagnostic evaluation. The clinical case and imaging findings presented here can help to promote understanding of this benign condition and its simple cure: voriconazole discontinuation.     

Diagnostic challenges in clinical,radiological and histopathological tests regarding papillomatous lesions of the breast

Papillomas of the female breast is a relatively frequent lesion, and the majority are benign when excised. However, some may host malignant or premalignant areas. Consequently, it is a worldwide accepted principle to excise the lesion whenever diagnosed. However, this leads to a large number of patients having an unnecessary operation. The present study was designed to investigate whether we could find clinical, radiological and pathological factors in the preoperative, diagnostic setting that could identify patients hosting a benign papilloma in order to avoid operation.The patient material consisted of 260 patients, all with a preoperative diagnosis of a papillomatous process in core biopsy. The lesion was excised, and 71% had a benign lesion. The rest had lesions ranging from premalignant to malignant. In the clinical, radiological and histopathological investigations conducted, we were not able to identify factors that statistically significant could predict whether the lesion was benign or malignant. However, our data showed a higher prevalence of malignant and premalignant lesions for older patient, larger lesions, and lesions found at a longer distance from the papilla.We conclude that, since almost 30% of the patients in our study ended up with a premalignant or malignant diagnosis, where no statistically significant preoperative factors could indicate a benign outcome, operation is warranted in all patients with a preoperative diagnosis of a papillomatous lesion.     

Florid reactive periostitis of the hand

Florid reactive periostitis is a relatively rare lesion that most often develops in the tubular bones of the hands and feet. This lesion can easily be confused with malignant or infectious processes. Correlation of physical examination and radiographic findings with histologic findings usually is diagnostic. Excisional biopsy with careful removal of all diseased tissue is most often curative. However, recurrent cases have been described as sometimes requiring ablative procedures.     

Cystosarcoma phylloides in adolescent female patients

Nine cases of cystosarcoma phylloides in adolescent female patients are reported along with an additional 35 cases collected from the literature. Analysis of these 44 cases revealed 37 (84.1 percent) benign lesions, 6 (13.6 percent) malignant tumors, and 1 borderline lesion. Excision was the most common operative procedure and was performed in 35 patients. Nine patients underwent mastectomy. There were three recurrent lesions (one benign and two malignant) for a recurrence rate of 6.8 percent. Wide excision was successful in the treatment of recurrent lesions. On the basis of these data, excision is the preferred initial therapy of cystosarcoma phylloides in the adolescent patient regardless of the histologic classification of the lesion. Malignant cystosarcoma is more likely to recur than a benign lesion but a recurrence can be managed with reexcision. Sacrifice of the adolescent breast at the initial procedure is strongly discouraged.     

Prediction of malignancy in the solitary thyroid nodule by physical examination, thyroid scan, fine-needle biopsy and serum thyroglobulin. A prospective study of 100 surgically treated patients

A prospective study was made of 100 consecutive patients selected for surgical treatment of a clinically solitary thyroid nodule. Anamnestic data and findings at physical examination, thyroid scan, fine-needle aspiration biopsy and measurement of serum thyroglobulin were correlated with the postoperative histologic diagnoses. The histologic findings were malignant in 18 cases and benign in 82. Familial occurrence of benign goiter was reported more frequently by patients with benign than by those with malignant histology (46 and 11%). Of the 11 nodules that were hard at palpation, 7 were malignant. All 12 scintigraphically "hot" nodules were benign, but 13 of 59 "solitary, cold" nodules were malignant. The cytologic specimens were reviewed and reclassified. The needle aspirate was insufficient for cytologic diagnosis in 11 cases. Papillary carcinoma was cytologically recognized in four cases. Of 36 lesions cytologically reported to be neoplasm of unspecified type, 12 were histologically shown to be malignant, 20 were follicular adenomas and 4 were colloid goiter. Benign lesion was the cytologic diagnosis in 47 cases. One diagnosis was false negative, but the cancer lay beneath the index nodule. The thyroglobulin level was significantly higher in patients with thyroid cancer than in those with benign disorders, but the test's predictive value was low. Thyroglobulin levels more than tenfold the upper limit of normal were found only in three patients with thyroid cancer and two with thyrotoxicosis. Although all of the mentioned investigative data were helpful in the management of solitary thyroid nodule, fine-needle biopsy was the best single method. When cytologic examination shows malignancy or unspecified neoplasm, surgery is indicated. For most patients with cytologically benign lesions, careful follow-up will suffice.     

Multiple palisading granulomas in the scalp of an infant: a case report.

BACKGROUND: We describe an unusual lesion that represents an uncommon but important element in the differential diagnosis of subcutaneous scalp nodules in a child. CASE DESCRIPTION: A 1-year-old boy presented with two clusters of subcutaneous scalp nodules. The lesions increased in size and number. Computed tomography showed no changes in underlying bone. Findings on magnetic resonance imaging were nonspecific. Serologic and clinical evaluation showed no evidence of rheumatic disease. Complete excision of the nodules, together with adjacent fascia and galea, was performed. Histopathologic examination showed the lesions to be palisading granulomas; given the absence of rheumatic disease, these represented deep granuloma annulare, a benign condition. No recurrence has been observed in our patient. CONCLUSION: While we chose total excision because of preoperative concerns about a possible malignant tumor, some other authors have suggested that surgery be limited to confirmatory biopsy when a benign lesion such as palisading granuloma is strongly suspected.     

Malignant fibrous histiocytoma of bone

Malignant fibrous histiocytoma of bone is a highly malignant neoplasm similar to that found in soft tissues. It accounts for at least 5% of all primary malignant bone tumors. The majority of lesions are primary, but some arise in preexisting benign lesions. Definitive diagnosis is made on histologic examination, a storiform arrangement of spindly tumor cells being the classic finding. Radical resection combined with preoperative and postoperative chemotherapy is the treatment of choice.     

Myositis ossificans: A rare location in the foot. Report of a case and review of literature

BackgroundMyositis ossificans is a benign, tumor-like lesion characterized by heterotopic ossification of soft tissue that usually affects the elbow and thigh. At different stages of maturity, it show similar histologic appearances with sarcomatous lesions or maturing bone. Misdiagnosis can result in unnecessary radical treatment.Case reportA 50-year-old woman with dorsal forefoot soft tissue mass was diagnosed as myositis ossificans after surgical excision and confirmed by a histopathological examination.DiscussionTo our knowledge, myositis ossificans occurrence in the foot is rare and only a few cases have been reported in the literature.SummaryIncreasing awareness on the unusual sites for myositis ossificans occurrence is necessary for differentiating this lesion from a malignant soft- tissue tumors and avoiding diagnostic pitfalls and unnecessary investigations, which can have major consequences and complications for patients.     

Desmoplastic fibroma of the first metatarsal. A case report

Desmoplastic fibroma is a benign but frequently aggressive tumor of bone. A 27-year-old man was treated for this lesion in the first metatarsal. The lesion recurred, extending into the medial cuneiform necessitating ray resection. The similar clinical and histologic findings of this tumor and other tumors, both benign and malignant, makes familiarity with the character of desmoplastic fibroma essential for proper treatment.     

Chondromyxoid Fibroma of the Calcaneus: Two Case Reports and Literature Review

Chondromyxoid fibroma occurs primarily in the long tubular bones of the lower extremity, with the foot representing the second most frequent location after the knee. This benign cartilaginous tumor of bone is currently the rarest reported neoplasm of cartilaginous origin. This mass can mimic other benign and malignant bone tumors owing to its variable histologic features. We report 2 cases of chondromyxoid fibroma of the calcaneus with varying presentations. Initially, advanced imaging studies pointed to a diagnosis of a unicameral bone cyst. Pathologic examination is difficult but can be used to differentiate this lesion from more serious conditions. A quick and accurate diagnosis of chondromyxoid fibroma can prevent unnecessary treatment that could be harmful to the patient.     

Diagnosis and Treatment of the Adrenal Cyst

Adrenal cysts, first described in 1670, typically presented with abdominal pain or palpable mass. In the modern era, incidentally identified adrenal cysts are commonplace, as imaging studies have become a mainstay in patient evaluation. The rubric of adrenal cysts comprises a broad differential diagnosis, rendering definitive diagnosis and subsequent management difficult. These cysts are categorized into four subtypes: endothelial, pseudocyst, epithelial, and parasitic. Endocrine workup should rule out functional status. Radiologic differentiation is helpful; however, imaging characteristics, such as hemorrhage in a pseudocyst, can confound identification of benign versus malignant lesions. Any functional lesion, potentially malignant lesion, or benign lesion more than 5 cm in diameter deserves surgical treatment. For small, benign lesions, conservative management is a viable option, although no surveillance protocols have been described.     

Ultrasound imaging as a screening study for malignant soft-tissue tumors

Fifty patients who had a palpable soft-tissue mass and an apparently normal radiograph were studied with ultrasound imaging before excision or biopsy of the lesion was done. As shown by the sonograms, thirty-five lesions had a discrete echo pattern (usually reduced echoes and a clearly defined lesional margin) and fifteen had an ill defined pattern (similar to the pattern of the surrounding normal tissues with no definable lesional margin). Fourteen lesions were malignant and thirty-six, benign. The sonograms of all fourteen malignant lesions showed a discrete pattern, while the sonograms of the benign ones showed twenty-one discrete and fifteen ill defined patterns. Therefore, the malignant lesions produced a discrete pattern in every instance, and every lesion that produced an ill defined pattern was benign. Fourteen of the fifty lesions were cystic; of these, thirteen were benign and one was malignant. The sonograms correctly identified the cyst in seven of the thirteen benign lesions and in the one malignant cystic lesion. Based on these findings, we concluded that all palpable soft-tissue masses that appear to be discrete on a sonogram should be diagnosed without delay by examination of a specimen taken at biopsy, whereas lesions that have an ill defined appearance on a sonogram may be assumed to be benign and may safely be observed in selected patients.     

The treatment dilemma caused by lumps in surfers' chins

This is an account of 2 male surfing enthusiasts who recently sought care at our hospital after developing tumorous masses on their chins. Although the lesions appeared grossly benign, establishing a definitive treatment plan was perplexing because of the insidious nature of the protuberances. The lesion in the first patient was managed surgically. The approach was modified for the second patient because of information learned from the first.While the technical aspects of care management were simple, once the histologic structure of the tumor was defined, establishing an accurate clinical diagnosis before surgery was troublesome. The histologic findings for the lesion removed from the first patient consisted of primarily parenchymal fibrosis without concomitant structural abnormalities in overlying epidermis, suggesting that repetitive blunt trauma to the chin area while paddling the surfboard was probably the factor responsible for the pathogenesis of tumor formation. These findings and our experience in managing the 2 patients have formed the basis of this report.     

Intra-abdominal bronchogenic cyst with gastric attachment: Report of a case

We report a rare case of an intra-abdominal bronchogenic cyst. An abnormal lesion was detected on an ultrasonogram, done as part of a physical checkup, in an 81-year-old woman. Computed tomography and magnetic resonance imaging showed a cystic mass attached to the lesser curvature of the stomach. Initially, we suspected a congenital cyst without malignant components; however, as the patient wished to have the lesion removed, we performed a minilaparotomy. The cystic lesion was firmly attached to the lesser curvature by fibrous tissue. Microscopic examination subsequently revealed the 26-mm mass to be a benign bronchogenic cyst with a bronchial element. We compared our findings with those of 50 previously reported cases of intraabdominal bronchogenic cysts. None of these patients was older than ours, and lesions attached to the esophagus or stomach were extremely unusual. Bronchogenic cysts are difficult to diagnose preoperatively based on imaging findings, but surgery may be indicated if malignant components are suspected, or if the lesion is enlarging or causing symptoms.     

Long bone florid reactive periostitis ossificans: a case in the distal femur mimicking osteosarcoma

Florid reactive periostitis ossificans is a well-known benign lesion classically described in hands and feet which histopathological features can lead to a misdiagnosis of osteosarcoma. To the best of our knowledge, there is only one previous report of this lesion in a long bone. In this study we report a case of florid reactive periostitis ossificans located in the distal metaphysis of the left femur that histologically mimicked an osteosarcoma and discuss the differential diagnosis between these two entities to warn about a diagnostic pitfall.