PMC9091406_01
(a and b) Plain radiographs (antero-posterior and lateral view) showing eccentric osteolytic lesion in distal femur with soft tissue involvement. (c and d) Immediate post-operative plain radiograph of the reconstructed intercalary defect, (e and f) 2 years follow-up post-operative plain radiograph.
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F1
The pre-operative radiograph showed an eccentric lytic lesion in the distal femur with moth-eaten appearance and involvement of surrounding soft tissue (Fig. 1). Post-operative plain radiograph was done (Fig. 1).
(a and b) MRI images showing a well marginated distal femoral lesion.
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F2
It was located 25 cm from the tip of the greater trochanter and 5 cm proximal to articular surface laterally and 3 cm medially (Fig. 2).
(a and b) Preoperative PET scan showing evidence of left nephrectomy with meta-static osteolytic lesion involving posteromedial femoral cortex of right side with associated FDG avid soft tissue component.
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F3
PET scan showed no other lesions in the body (Fig. 3).
Diagrammatic representation of pre-operative plan of margins for wide local resection.
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F4
Pazopanib before orthopedic consultation was sought, but the tumor showed no regression in its size. Pre-operative planning for resection of the tumor with the reconstruction of the intercalary defect with bone cement was done and exact margins of resection were decided (Fig. 4).
(a) Plane of resection with a cuff of surrounding muscles. (b and c) Skeletal defect after resection reconstruction with cement and plate. (c) The resected tumor mass (dimensions 16.5 x 7 x 5 cm).
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F5
Wide local excision of the tumor with its intact capsule, along with the cuff of surrounding vastus intermedius muscle was carried out (Fig. 5).
(a) 40x image of clear cell carcinoma showing pleomorphic cells with clear cyto-plasm and round nuclei. (b) Oil immersion view showing atypical mitotic figures and areas of angiogenesis.
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F6
Post-operatively, the histopathology report confirmed the diagnosis to be metastatic clear cell tumor of the right distal femur, consistent with metastatic RCC (Fig. 6).
Postoperative clinical picture showing satisfactory knee range of motion.
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F7
At 2 years follow-up the patient walks without support, with knee flexion up to 120 degrees without any complaints or complications (Fig. 7).
(a and b) Postoperative PET scan showing no metabolically active soft tissue mass lesion anywhere in the body except for mild soft tissue enhancement near surgical site probably due to post-operative soft tissue inflammation.
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F8
A follow-up PET scan did not show any active lesion in the body (Fig. 8).