PMC5936765_01
Frontal radiograph of the left femur demonstrates a large lytic lesion of the distal diaphysis with wide zone of transition and aggressive-appearing periosteal reaction at the medial margin.
fonc-08-00137-g001.jpg
PMC5936765_01_fonc-08-00137-g001.jpg
F1
Radiographs demonstrated a large lytic lesion of the distal femur with cortical destruction (Figure 1).
(A) Coronal T1 magnetic resonance imaging (MRI) image of the left femur demonstrates T1 hypointense lesions (starts) with normal intervening bone marrow (arrow), (B) sagittal T2 fat-saturated MRI image of the dominant distal femur lesion demonstrated intermediate T2 hyperintensity with areas of marked low signal intensity centrally (arrows), suggestive of areas of sclerosis not appreciated radiographically.
fonc-08-00137-g002.jpg
PMC5936765_01_fonc-08-00137-g002.jpg
F2
Urgent evaluation with magnetic resonance imaging (MRI) confirmed a 10 cm destructive distal metadiaphyseal lesion in the left femoral diaphysis as well as coexistent central areas of T2 hypointensity suggestive of metaphyseal sclerosis which were not appreciated radiographically (Figure 2). Review of the axial CT images of the femur obtained to localize the lesion for biopsy demonstrated a predominantly lytic lesion and also small areas of sclerosis (Figure 3A) corresponding to the areas of T2 hypointensity on MRI (Figure 2B).
(A) Axial computed tomography (CT) image of the femur obtained to localize the lesion for CT-guided biopsy demonstrates a destructive lytic lesion with cortical breakthrough anteriorly (arrow) and areas of bone sclerosis (arrowheads), (B) sagittal image of a CT of the chest, abdomen, and pelvis demonstrates multiple sclerotic lesions in the spine, including within T6, T8, T10, L2, and L3 vertebrae (arrows).
fonc-08-00137-g003.jpg
PMC5936765_01_fonc-08-00137-g003.jpg
F3
Review of the axial CT images of the femur obtained to localize the lesion for biopsy demonstrated a predominantly lytic lesion and also small areas of sclerosis (Figure 3A) corresponding to the areas of T2 hypointensity on MRI (Figure 2B). Given the atypical MRI findings of sclerotic appearance on T2, a CT of the chest, abdomen, and pelvis was performed and demonstrated diffuse osteoblastic metastatic lesions, including multiple sclerotic lesions throughout the spine (Figure 3B).
(A) Excised left femur with hemorrhagic tumor involving the diaphysis (gross specimen), (B) prostatic specific membrane antigen expression in prostate adenocarcinoma (left) and negative in multiple myeloma (right), and (C) coexisting metastatic prostate adenocarcinoma and multiple myeloma in same histologic section; note the gland forming adenocarcinoma (left) and sheets of plasma cell infiltration (right).
fonc-08-00137-g004.jpg
PMC5936765_01_fonc-08-00137-g004.jpg
F4
Pathology examination of the distal femur identified both plasma cell neoplasm and metastatic adenocarcinoma of prostate origin within the same metastatic lesion (Figure 4).