Case 5
A 71-year-old male presented with a 6 week history of increasing pain in the proximal thigh.. Forty-one years earlier he had sustained a compound fracture of the proximal femur which had been managed by debridement, internal fixation, and 6-months in a hip spica
A: AP radiograph of the thigh at presentation.
A presumptive diagnosis of osteomyelitis lead to removal of the plate and screws. Cultures of the wound produced no growth. Symptoms were not relieved.
B: Follow-up radiographs were done 6 weeks later.
C: An angiogram was done to exclude an aneurysm. A large mass adjacent to the defect in the femur displacing the superficial and deep femoral arteries was seen on this early phase of the arteriogram. The mass was highly vascular.
A biopsy of the mass in the medial aspect of the thigh was done.
D: A panoramic field from the periphery of the mass. At low magnification the field is composed of cellular tissue with little or no intervening matrix. The cells are of varying size and shape. Coursing throughout the tissue are many branching small vessels.
E: A field from the interior of the mass. At greater magnification many capillaries, some with and some without lumina are evident. The characteristics of the stromal cells and those forming the walls of the capillaries are the same indicating a lesion of vascular histogenesis is highly probable.
F: An electron micrograph of cells in the center of the previous field. In the center of the field are two non-nucleated RBC. The cell to the right contains many electron-dense (dark bars) particles that represent rudimentary particles of basement membrane, marking this as a lesion of vascualr histogenesis.
A diagnosis of stage II-A hemangioendothelioma was made. Because of the intimate relationship between the mass and the femoral neurovascular bundle as well as the sciatic nerve, a modified hemipelvectomy to obtain a radical margin was done
G: A photograph of the dissected surgical specimen shows the mass bound to the femur. The lower hemostat points to the femoral neurovascular bundle, while the upper forceps displays the sciatic nerve. The central vascular area indicates the biopsy site.
H: The axial cut surface shows the mass eroding the adjacent medial cortex of the femur. Within the mass at 2 o'clock the open lumen shows the superficial femoral artery, at 6 o'clock is seen the open lumen of the deep femoral artery, and just inside and below the superficial femoral artery the wall of the femoral vein encircles a thrombus of tumor - most likely the site of the lesions origin!
I: Of interest is this specimen radiograph of the adjacent femoral cortex. The arrow points to the screwhole left by removal of the screws, now filled by tumor in the ensuing weeks.
The patient died of pulmonary and cerebral metastases 7 months post-operatively.
A 71-year-old male presented with a 6 week history of increasing pain in the proximal thigh.. Forty-one years earlier he had sustained a compound fracture of the proximal femur which had been managed by debridement, internal fixation, and 6-months in a hip spica