PMC8592600_01
(a,b) Pre-operative Imaging Right Tibia. AP view (1a) of the right leg demonstrates an expansile, multilocular, lytic lesion with 'soap bubble' appearance and narrow zone of transition within the diaphysis of the tibia affecting the cortex and medullary canal. There is associated cortical remodeling and endosteal thinning. No cortical breakthrough is present and only a slight benign-appearing periosteal reaction is present (Arrow I). Lateral view (1b) of the right leg corroborates the findings on the frontal projection.
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AP/lateral X-rays of the right tibia, MRI of the right tibia with and without contrast (Figures 1(a,b) and (a-c)) were performed. A biopsy was subsequently performed. Figure 1(a,b) demonstrates a pre-operative plain radiograph of the right tibia and fibula.
(a-c) Coronal T1 weighted image (2a) demonstrates hypodensity of a tibial lesion. Sagittal fat-saturated T2 weighted image (2b) of the left tibia demonstrates marked hyperintensity of the lesion, which extends from the anterior to posterior cortex. Axial contrast-enhanced, fat-saturated T1 image (2c) through the mid diaphysis demonstrates marked enhancement of the soft tissue mass, which completely obliterates the marrow. The cortex is thinned, but there is no extension of mass beyond the periosteum. No edema is present within the musculature.
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On T-2 fat-saturated MR images, the lesion is hyperintense to muscle and fat (Figure 2(a-c)).
(a-d) Gross image and pathology of tibial lesion. A longitudinal section shows a 9.2 x 3.6 x 2.7 cm intramedullary tumor that involves the cortex (3a). Low power (3b) and high power (3c) views demonstrate a lesion with a biphasic pattern characterized by epithelial islands (Arrow I) surrounded by an abundant fibrous stroma (Arrow II). Figure 3(d) shows the epithelial component demonstrating positivity for pan keratin.
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An open biopsy of the patient's right tibial shaft was analyzed (Figure 3(a-d)). Grossly, a longitudinal section revealed an intramedullary tumor that involved the cortex (Figure 3(a)).