PMC6159157_01
An 18-year-old male presents with proximal arm pain. Anteroposterior radiograph of the proximal left humerus at initial presentation demonstrating cortical saucerization of the proximal metaphysis (arrow).
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Plain radiograph demonstrated saucerization of the humerus cortex at the proximal metaphysis (Figure 1).
MR scans performed at initial presentation. (a) Axial T1 fat-saturated post-contrast image demonstrating periosteal lesion rim with low-grade enhancement (arrow). (b) Axial T2 fat-saturated image demonstrating a hyperintense periosteal lesion (arrow) of the left humerus cortex with saucerization. (c) Coronal T2 fast spin echo image demonstrating hyperintense periosteal lesion of the left humerus (arrow). Absence of bone marrow invasion is observed.
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There was low-grade peripheral contrast enhancement (Figure 2a). T2 weighted sequences showed central hyperintensity, compatible with cartilage (Figure 2b,c).
CT-guided core needle biopsy at initial presentation. (a) Axial CT scan, bone algorithm, of the left humerus during first pass biopsy showing location of Bard Truguide 17 G x 7 cm coaxial needle (Bard Biopsy Systems, Tempe, AZ) (arrow). Absence of cortical breech is observed (arrowhead). (b) Axial CT scan, bone algorithm, of the left humerus during second pass biopsy showing AprioMed Bonopty 15 G x 16 cm biopsy needle (Apriomed AB, Uppsala, Sweden) breaching the cortex with needle tip (arrow) located just within the medulla.
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AZ) (Figure 3a). The tissue sample was non-diagnostic, yielding skeletal muscle only. After discussion with the referring Sarcoma Multidisciplinary team, a second pass biopsy was performed using AprioMed Bonopty 14  G x 9.5 cm penetration set and AprioMed Bonopty 15 G x 16 cm biopsy set (Apriomed AB, Uppsala, Sweden). The biopsy needle was bored through the humeral cortex to obtain an adequate tissue sample and ensure there was no subcortical involvement of the lesion (Figure 3b).
MR images obtained 10 months after those seen in Figure 2, to investigate the complaint of worsened pain. (a) Coronal T2 fat-saturated image demonstrating the presence of hyperintense intramedullary lobulated mass (arrows) deep to the low signal, linear needle biopsy tract (arrowhead). (b) Axial T1 fat-saturated post-contrast image demonstrating the original juxtacortical lesion (arrow) as well as cartilage enhancement in the medullary cavity (arrowhead).
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MRI showed the original lesion had developed a cartilaginous, multilobulated component, invading through the cortical biopsy tract into the medulla (Figure 4a,b).