Multifocal primary bone sarcoma in the elderly: a rare case and review of the literature.

To our knowledge there are no reports of a primary multifocal spindle cell sarcoma affecting both long bones of the lower limb in an elderly patient. An 83-year-old man presented with a progressively painful right ankle, without a history of trauma. Radiographs demonstrated a pathological fracture through a mixed lytic and sclerotic lesion in the distal tibia. Staging investigations, including bone scintigraphy and magnetic resonance imaging, revealed a second lytic lesion in the right distal femur. A provisional diagnosis of metastatic disease was favoured and intramedullary nailing was considered. However, computed tomography of the chest, abdomen and pelvis, and relevant blood tests revealed no evidence of a primary malignancy. Open biopsy of the tibial lesion showed high-grade pleomorphic spindle cells consistent with a primary bone sarcoma. The patient was treated successfully with a right trans-femoral amputation. In conclusion, we recommend early bone biopsy to allow accurate diagnosis and appropriate skeletal management in elderly patients.

Malignant peripheral nerve sheath tumour in the ischio-rectal fossa.

Primary sarcomas in the ischiorectal fossa are occasionally reported and represent a significant challenge due to the proximity of rectum, levator muscles and pudendal neurovascular structures. We report a case in which the diagnosis changed between biopsy (desmoid tumour) and resection (malignant peripheral nerve sheath tumour), requiring a multidisciplinary surgical approach involving different sub-specialties. It also illustrates the importance of undertaking sarcoma surgery in a recognized sarcoma centre with sarcoma expertise available across a range of disciplines.

Disorders of the sternoclavicular joint.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.

Repeat radiographs in GP referrals to an orthopaedic clinic.

Repeat radiographs are expensive, both financially and in terms of cancer risks. This study looks at new referrals to an orthopaedic clinic, and examines the extent and some of the causes of the problem.

Posterior vertebral rim fractures.

Fracture of the posterior vertebral endplate is a cause of low back pain in adolescents and young adults. Clinically it resembles an acute disc prolapse with low back pain and radiculopathy, but may present with neurogenic claudication due to spinal stenosis in older patients. The lesions may be incidental findings. Plain radiographs are diagnostic in about 40% of cases. CT shows the fracture fragment and vertebral defect in most cases but the fracture fragment may be overlooked on MRI. Accurate diagnosis is essential as the surgical technique for disc herniation is inadequate for endplate fractures. In this pictorial essay we review the imaging findings.

Synovial presentation of non-Hodgkin's lymphoma.

The MRI appearances of synovial involvement from non-Hodgkin's lymphoma are described in a 61-year-old man. These appearances have not previously been described and the differential diagnosis is discussed.

Mucocele of the appendix presenting as a sigmoid mass.

Mural tumours of the colon are rare and may be difficult to distinguish from extrinsic lesions. We report a case of an apparent intramural sigmoid tumour due to a mucocele of the appendix and discuss the radiological diagnosis of mural tumours of the large bowel.

A case of hereditary pancreatitis and pancreas divisum.

Hereditary pancreatitis is a rare form of chronic pancreatitis inherited as an autosomal dominant. Pancreas divisum results from a developmental failure of fusion of the dorsal and ventral parts of the pancreas and is associated with an increased incidence of pancreatitis. Co-existence of the two conditions in one patient is very rare. We report a case.

Idiopathic hyperphosphatasia with dermal pigmentation. A twenty-year follow-up.

Hyperphosphatasia, or hereditary bone dysplasia with hyperphosphatasaemia, is a rare genetic disorder which is characterised by failure to transform woven into lamellar bone. Clinical, radiological and histological features establish the diagnosis, fractures, deformities, diffuse sclerosis on radiographs and high serum alkaline phosphatase being characteristic. We report the case of a 27-year-old man with follow-up at the same hospital for 20 years. Attempts at treatment with calcitonin and disocium etidronate (EHDP) failed, but stapling of the growth plates at the knee was successfully performed. Transverse "brittle" fractures of the humerus, lower leg and ribs healed normally, but internal fixation and late bone grafting were required for a subtrochanteric stress fracture of the femur at the age of 24 years. At present the patient has no clinical problems and leads a normal life.

Primary extra-cranial meningioma following total hip replacement.

A 61-year-old man presented with pain at the left hip and decreased mobility 10 years after total hip replacement. Imaging demonstrated a large destructive expansile mass adjacent to the prosthesis. Histological analysis confirmed the presence of an extra-cranial meningioma. Primary tumours after total hip replacement are rare and include soft tissue sarcomas, bone sarcomas and lymphomas. To our knowledge, no previous cases of primary extracranial meningioma have been identified. The imaging features, histology, pathogenesis and differential diagnosis are discussed.

MRI surveillance after resection for primary musculoskeletal sarcoma.

This study reports the experience of one treatment centre with routine surveillance MRI following excision of musculoskeletal sarcoma. The case notes, MRI and histology reports for 57 patients were reviewed. The primary outcome was local tumour recurrence detected on either surveillance MRI in asymptomatic patients, or interval MRI in patients with clinical concern. A total of 47 patients had a diagnosis of soft-tissue sarcoma and ten of a primary bone tumour. A total of 13 patients (22%) had local recurrence. Nine were identified on a surveillance scan, and four by interval scans. The cost of surveillance is estimated to be pound4414 per recurrence detected if low-grade tumours with clear resection margins are excluded. Surveillance scanning has a role in the early detection of local recurrence of bone and soft-tissue sarcoma.