CASE 1

Clinical History:

An 18-year-old man had a six-month history of progressive pain in his left distal thigh. He had some moderate swelling about his knee for the past month. He noted that the pain was worse at night. He did not have pain with ambulation. On physical examination he was afebrile. He had slightly decreased range of motion of his left knee due to swelling in the lower left thigh. There was no erythema, warmth, or tenderness. No external signs of trauma were noted. There were no other abnormal findings. Laboratory studies showed Hgb 14.8 g/dL, Hct 44.5%, serum calcium 9.1 mg/dL, phosphorus 3.5 mg/dL, alkaline phosphatase 222 U/L, total protein 7.1 g/dL, and albumin 5.3 g/dL. Radiographs demonstrated a lesion of the distal femur.

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Questions:

1. What is the diagnosis?
2. In whom and at what sites is this lesion most common?
3. Can you name possible environmental causes for such a lesion?

CASE 2

Clinical History:

An 11-year-old previously healthy boy has complained of pain in his right leg for the past 3 months. The pain is worse at night and there is no mechanical pain. On physical examination he has decreased motion of the knee, secondary to pain. There is focal tenderness over the right anterior lateral calf region. He is at the 55th percentile for height and weight for age. Laboratory studies show Hgb 13.9 g/dL, Hct 42.1%, platelet count 264,000/microliter, serum calcium 9.0 mg/dL, phosphorus 3.5 mg/dL, alkaline phosphatase 189 U/L, albumin 5.2 g/dL, and total protein 6.9 g/dL. Radiographs are taken of the right lower leg.

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Questions:

1. What is the diagnosis?
2. In whom and at what sites is this lesion most common?
3. What are some other small round cell tumors of childhood?
4. Who decides what kind therapy he gets?

CASE 3

Clinical History:

A 56-year-old man had a history of smoking 2 packs of cigarettes per day for the past 35 years. He has experienced back pain for the past 4 months. On physical examination there are no abnormal findings. Laboratory studies show Hgb 12.7 g/dL, Hct 38.0%, serum calcium 10.9 mg/dL, phosphorus 3.1 mg/dL, alkaline phosphatase 213 U/L, albumin 4.9 g/dL, and total protein 6.8 g/dL. A bone scan is performed. Three months later he experiences marked pelvic pain, and a radiograph (image 3.2) and a CT scan (image 3.3) reveal additional lesions, even though there was no history of trauma. A bone marrow biopsy is performed (image 3.4).

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Questions:

1. What is the diagnosis?
2. From the history, what might have you suspected?
3. What descriptive name is given to the fracture in this case?
4. How would you describe the lesion seen on CT scan?

Clinical Histories:

A 52-year-old woman experienced a 6 kg weight loss over the last 6 months of life. She had a left mastectomy with lymph node sampling performed 5 years before for infiltrating ductal carcinoma that was estrogen receptor positive. She had back pain and shoulder pain that was dull but constant. At autopsy, the gross (image 3.5) and microscopic (image 3.6) appearances of one of her lesions are seen. Compare this with the lesion seen at autopsy in a 45-year-old man (image 3.7). A different pattern is seen in the CT scan of a 70-year-old man (image 3.8).

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Questions:

1. What is the diagnosis for the 52-year-old woman?
2. What is the diagnosis for the 45-year-old man?
3. How would you describe the lesions seen on CT in the 70-year-old man?

CASE 4

Clinical History:

A 65-year-old caucasian man has noted increasing low back pain, and left proximal leg pain, particularly after sitting for extended periods of time, worsening over the past 5 years. Laboratory studies show Hgb 13.7 g/dL, Hct 42.2%, serum calcium 8.7 mg/dL, phosphorus 3.4 mg/dL, alkaline phosphatase 177 U/L, albumin 4.4 g/dL, and total protein 6.4 g/dL. A CT scan of the pelvis is performed. A bone biopsy is performed.

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Questions:

1. What is the diagnosis?
2. In whom and at what sites is this lesion most common?
3. What is the clinical course of this disease?

CASE 5

Clinical History:

A 15-year-old adolescent has occasionally felt discomfort in the area of his knee for the past 3 years. On physical examination a painless mass is palpable over the lateral and postero-lateral aspects of his tibia. Laboratory studies show serum calcium 9.0 mg/dL, phosphorus 3.8 mg/dL, alkaline phosphatase 151 U/L, albumin 5.4 g/dL, and total protein 7.5 g/dL. Radiographs demonstrate a bony exostosis growing from the lateral portion of the tibia, but there is no destruction of the tibia.

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Questions:

1. What does the clinical history tell you about the biologic behavior of this lesion?
2. What is the diagnosis?
3. In whom and at what sites is this lesion most common?
4. What hereditary disease could be associated with multiple lesions of this type?

CASE 6

Clinical History:

An 18-year-old woman has noted pain and swelling of her right distal thigh for the past 2 months. The pain is associated with activity. She is a cheerleader and notices tenderness after performing acrobatics. She has no history of any trauma. Laboratory studies show serum calcium 8.9 mg/dL, phosphorus 3.3 mg/dL, alkaline phosphatase 133 U/L, albumin 4.9 g/dL, and total protein 6.8 g/dL. Radiographs are taken of the right knee region. A lesion is curretted.

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Questions:

1. What is the diagnosis?
2. What is the major differential diagnosis?
3. In whom and at what sites is this lesion most common?
4. Why should these lesions not be treated with radiation?

CASE 7

Clinical History:

A 65-year-old woman died as a result of severe occlusive coronary atherosclerosis. She had evidenced increasing kyphosis over the past 10 years of her life. She also had developed progressive dementia and was bedridden for most of the past year.

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Questions:

1. What is the diagnosis?
2. Why did this disease occur in this woman?
3. What is the usual setting for this disease?
4. How does this disease differ from those caused by vitamin D deficiency or by scurvy?
5. What therapy is available for this disease?
6. What is a prevention strategy for this disease?

CASE 8

Clinical History:

A 46-year-old man comes to her physician because of progressive pain and swelling of his right hip region for the past 6 months. The swelling is worse than the pain. On physical examination, he is mildly obese and it is difficult to assess the right hip region. Laboratory studies show serum calcium 9.3 mg/dL, phosphorus 3.5 mg/dL, alkaline phosphatase 148 U/L, albumin 4.2 g/dL, and total protein 6.3 g/dL. A radiograph of the pelvis is performed and reveals a lesion. A pelvic CT scan demonstrates similar findings. A bone scan is performed. A resection of the lesion is performed.

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Questions:

1. What is the lesion?
2. In whom and at what sites is this type of lesion most common?
3. Name a condition in which multiple cartilagenous tumors are found.

CASE 9

Clinical History:

A 58-year-old woman has suffered from chronic arthritis for the past 9 years. She has pain and swelling of her hands and feet that is aggravated by movement. Over the past 5 years she has noted increasing deformity of her hands and feet, making it difficult to walk and to perform simple daily activities such as buttoning a blouse or even combing her hair. She has no history of any trauma. Physical examination reveals firm, non-tender, less than 1 cm nodules over the elbows. Radiographs are taken.

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Questions:

1. What is the diagnosis?
2. What is the major differential diagnosis for this arthritis and what further testing is helpful?
3. In whom and at what sites is this disease most common?
4. What is the pathogenesis of the lesions?