Pelvic bone tumor Quiz 3

Female 32 C/C: vague pelvic pain P/I: about 6-7 months ago

H/: ◦Pain: vague not related to activity or nocturnal ◦Mild limping ◦No constitutional symptoms (fever, weigth loss, etc.) ◦Hip ROM was normal ◦Laseque was negative ◦FABER test was positive

Paraclinic ◦Lab exam = N ◦ ( CBC, ESR, CRP, Ca, P, Alk Ph, BUN, Creat, FBS, RF, ELISA ) ◦Plain X ray (as follow) ◦Bone scan ◦ Increase uptake in pelvic close to SI Joint ◦CT Scan (as follow)

Pelvic plain Radiography

CT Scan

What is D/D? What is diagnostic app? What is surgical app?

Answer Our App.

Our DD: Benign lesion ◦Enchondroma ◦UBC ◦ABC ◦GCT Infection Malignancy ◦Chondrosarcoma ◦Metastasis

Diagnostic app. Options; ◦Biopsy  Needle biopsy  Incisional biopsy  Curettage and biopsy ◦Definitive treatment  Curettage + BG, Bone cement, etc. Our app; ◦Curettage biopsy without adjuvant therapy

Surgical app. ◦Ant app. ◦Post app. Our app. ◦Localization ot tumor under VT guide Under local anesthesia ◦Dorsal app. With minimal incision

Localization of the lesion

Minimal incision

Post operative Xray

Two weeks post operative

Pathology report ◦GCT

Follow-up ◦Two weeks ◦ Pain relief ◦ No limping ◦Three months ◦ Pelvic vague pain ◦ Pelvic CT no changes ◦Six months ◦ No improve of the pain ◦ Pelvic MRI revealed the same tumor ◦ Consultation with three expertist ◦Nine months ◦ Candidate for operation

Follow-up ◦Two weeks ◦ Pain relief ◦ No limping ◦Three months ◦ Pelvic vague pain ◦ New pelvic CT no changes ◦Six months ◦ No improve of the pain ◦ Pelvic MRI revealed the same tumor ◦ Consultation with three expertist ◦Nine months ◦ Candidate for operation

Follow-up ◦Two weeks ◦ Pain relief ◦ No limping ◦Three months ◦ Pelvic vague pain ◦ Pelvic CT no changes ◦Six months ◦ No improve of the pain ◦ Pelvic MRI revealed the same tumor residue without recurence ◦ Consultation with three expertist, continue of physiotherapy ◦Nine months ◦ Candidate for operation

Follow-up ◦Two weeks ◦ Pain relief ◦ No limping ◦Three months ◦ Pelvic vague pain ◦ Pelvic CT no changes ◦Six months ◦ No improve of the pain ◦ Pelvic MRI revealed the same tumor ◦ Consultation with three expertist ◦Nine months ◦ Candidate for operation

The patient underwent 3.5 parathyroidectomy She improved post operative, pain relief thenafter.

Discusion Nowadays hyperparathyroidism revealed in lab examination in about 50% of cases. Brown tumor as the presenting finding is so rare. Ca and P occasionally is normal in the hyperpara specially in the beginning of the disease.

In retrospective evaluation in our patient, we found an increase of 24 h urine calcium in the preoperative lab examination. We had to repeat laboratory examination when the symptoms had been continued. Hyperparathyroidism must be in our differential diagnosis as our radiologist offered.

Responsible surgeon, and prepare of the quiz