PMC9872517_01
Preoperative imaging. (A,B) A radiograph of the left hip joint shows the extension of the tumor from the proximal femur to the subtrochanter of the femur; osteolytic lesions invading the bone cortex and proximal bone marrow cavity, as well as local osteosclerosis, can be observed. (C) Three-dimensional computed tomography (CT) reconstruction shows that the tumor is mainly located in the trochanteric area of the femur, with obvious bone erosion and insect erosion appearance. (D,E) A CT scan of the left hip shows that the tumor's lower and upper boundaries are clear and unclear, respectively, and osteolytic bone destruction can be observed. (F) A whole-body bone scan shows no other obvious positive areas. (G) A sagittal view of a T2-weighted image shows that the tumor is well-bounded and multilocular, with lytic destruction and the tumor extending outside the bone. (H) A sagittal view of a T1-weighted image illustrates that the tumor has a low signal shadow, similar to the muscle signal, and the area is larger than the plain film area. (I) A transverse view of a T2-weighted image shows uneven hypersignal shadows in the left trochanteric area with soft tissue infiltration on the posterolateral side of the trochanter. (J) A transverse view of a T1-weighted image shows that low signal shadows dominate the entire trochanteric area.
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F1
On November 26, 2017, a plain radiograph showed an osteolytic lesion with cystic destruction in the left femur's intertrochanteric region, and the lesion's boundary was clear without periosteal reaction (Figures 1A,B). Computed tomography (CT) showed that the tumor broke through the bone cortex and formed a significant soft tissue mass (Figures 1C-E). T1 and long T2 signals (Figures 1G-J). T1-weighted images showed that the tumor signal was similar to that of the muscle tissue, and the lesion included some parts of the femoral neck, trochanter, and subtrochanter. A whole-body bone scan showed that the intertrochanteric nuclides of the left femur were enriched and that bone salt metabolism had increased significantly; however, the bone salt metabolism of other parts of the body had not significantly increased (Figure 1F). The patient's whole treatment and follow-up process is summarized in the timeline (Supplementary Figure S1).
Intraoperative imaging and postoperative gross specimen. (A,B) The proximal femur is completely resected, and the tumor prosthesis is successfully implanted. (C) The gross specimen shows an uneven mass in the trochanter of the femur, with a size of approximately 6.0 cm x 6.0 cm x 4.0 cm. (D) The section of the specimen shows that the center of the mass is gray-white, with bleeding and necrotic areas invading the bone cortex.
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F2
We customized the prosthesis and performed extensive resection of the femoral intertrochanteric leiomyosarcoma and tumor prosthesis replacement under general anesthesia (Figure 2).
Results of postoperative pathological examination of the bone tumor. (A) Hematoxylin and eosin staining 40x: fusiform cell diffuse hyperplasia and tumor cells infiltrate adjacent bone trabeculae, as indicated by the arrow. Inflammation is observed around the bone trabeculae. (B) Hematoxylin and eosin staining 400x: fusiform cell diffuse hyperplasia with a myxohyaline matrix pervading the intercellular space, as indicated by the arrow. (C) Smooth muscle actin 200x: cytoplasmic staining is diffuse and strongly positive, as indicated by the arrow. (D) Smooth muscle actin 400x: cytoplasmic staining is diffuse and strongly positive, as indicated by the arrow. (E) Desmin 200x: some cytoplasmic staining is positive, as indicated by the arrow. (F) Desmin 400x: some cytoplasmic staining is positive, as indicated by the arrow.
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F3
The postoperative resected specimens were then sent for pathological examination (Figure 3).
Postoperative imaging. (A,B) A radiograph of the left hip joint shows that the joint prosthesis is in place 1 week after the operation. (C) Coronal view of a computed tomography (CT) scan performed 1 week postoperatively. (D-G) Chest, abdominal, and pelvic CT examinations at 42 months postoperatively show no obvious metastasis in the lungs. Meanwhile, the joint prosthesis is in place, and there is no obvious recurrence in the local area. (H-J) After 13, 24, and 32 months postoperatively, whole-body bone scan findings show no obvious recurrence.
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F4
Currently, 4 years postoperatively, the patient is in good physical condition and remains active, with no obvious pain in the hip joint or evident signs of tumor recurrence or metastasis (Figure 4).