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• W2016140516 abstract "A 69-year-old woman presented with a 5-month history of pain and discomfort in the lateral aspect of her right knee. Her medical history was remarkable for resection of a gastric carcinoma 6 months ago, which was complicated by a wound infection and a liver abscess. She had undergone three and one-half cycles of chemotherapy with methotrexate and 5-fluorouracil. The pain began 5 months ago, was variable in severity, and was temporally related to beginning physical rehabilitation. She received numerous cortisone shots without any relief. Her medical history was also significant for diabetes mellitus, and the review of symptoms was significant for weight loss and decreased appetite (presumably secondary to the chemotherapy). Physical examination was notable for tenderness and mild fullness over the lateral femoral condyle. Range of motion was normal and no skin changes were present. Plain radiographs (Fig 1) and magnetic resonance (MR) images (Fig 2) were obtained.Fig 1A: B. (A) Frontal and (B) lateral radiographs of the right knee.Fig 2: Coronal T1 weighted image (echo time = 500; repetition time = 30) of the right knee.Based on the history physical findings and radiographic images what is the differential diagnosis? RADIOGRAPHIC FINDINGS Frontal and lateral radiographs of the right knee (Fig 1) revealed a 3 × 3 cm permeative mixed sclerotic and lytic process of the lateral tibial plateau and proximal tibial metaphysis, extending to the apparently intact subchondral lateral plateau articular surface and to the cortical surface of the lateral metaphysis. The medical margin was well defined through most but not all of its periphery. The lateral view (Fig 1B) showed some increased radio-density of the intraarticular fat pad posterior to the inferior patellar tendon compatible with reactive edema, although tumor extension into the soft tissues could not be excluded. A coronal image (Fig 2) from a T1 weighted MR imaging examination echo time = 500; repetition time = 30) confirms an area of decreased signal involving the lateral proximal tibial metaphysis and plateau, without evidence of intraarticular penetration. The area of lower signal tumor abouts higher signal normal marrow with relatively sharp margination. No soft tissue mass is identified. Radiographically the differential diagnosis suggest metastatic neoplasms such as breast, lung or gastrointestinal lesions; lymphoma; or possibly malignant fibrohistiocytoma. Atypical osteomyelitis carcinoid, primary sarcoma such as chondrosarcoma, or avascular necrosis are also possible. An open biopsy was performed and an intraoperative frozen section was obtained (Fig 3).Fig 3: Biopsy of the right proximal tibia (Stain, hematoxylin and eosin; magnification ×250).Based on the history, physical findings, radiographic studies, and histologic picture, what is the diagnosis and how should this patient be treated? HISTOLOGY A hematoxylin and eosin stain of the biopsy from the lesion (Fig 3) shows rounded cells in organoid clusters within a fibrous stroma. The organoid clusters are indicative of a metastatic carcinoma. Occasional signet ring cells (arrows) are present, suggesting a gastric source for the neoplasm. DIAGNOSIS The frozen and permanent sections confirmed the diagnosis of metastatic gastric carcinoma. DISCUSSION Carcinoma of the breast, prostate, and lung commonly metastasize to bone.2 Gastric carcinoma, however, is an uncommon source of clinically evident bony metastasis, and there are few reports of this in the literature. The incidence of bony metastasis from gastric carcinoma ranges from 0% to 17.5% depending on whether clinically evident or autopsy proven metastases are considered.2 The incidence of clinically evident metastasis is 0% to 2.65%, whereas the incidence of autopsy proven metastasis ranges from 2% to 17%.2 The most common sites of bony metastasis by bone scintigraphy in one series were the spine (65.9%), ribs (58%), pelvis (42.5%), femur (30.5%), skull (21.6%), shoulder girdle (16.8%), sacroiliac joint (7.2%), humerus (6%), sternum (4.2%), and tibia (3%).5 In another study from Japan the common sites of clinically apparent metastasis were the vertebrae (59.6%), pelvis (10.5%), ribs (8.8%), extremities (19.3%), and skull (1.7%).7,9 Gastric carcinoma metastatic to bone commonly causes localized, gradually worsening bone pain. Rarely, patients may present with pathologic fractures, paraplegias, or convulsions.9 The diagnosis often is delayed because of poorly localized complaints and lack of radiographic findings. Symptoms of pain occur before plain radiographic changes are evident, often preceding radiographic changes by a few months.9 Plain films often miss early metastases, because the initial change elicited by the invasion of malignant cells into bone is metabolic, resulting in increased blood flow, rather than structural bone change.4 Bone scanning agents are taken up in bone in relation to skeletal blood flow and bone cell metabolism.6 Hence, when early skeletal metastasis is suspected, Tc99 scintigraphy is more sensitive than conventional radiographs.5 Radiographically, metastatic gastric carcinoma may appear as a blastic or lytic8 bone formation or destruction.1,3,8 Lesions with a blastic appearance commonly are associated with metastatic breast cancer in women and metastatic prostate cancer in men.3 Other diagnostic considerations of this lesion include lymphoma, primary chondrosarcoma or other sarcomas, avascular necrosis, and infection. In assessing a blastic lesion in an elderly patient, gastric carcinoma must be a consideration. Although clinical history, plain radiographs, MR imaging, and bone scintigraphy can suggest a diagnosis, none of these are diagnostic of metastatic gastric cancer. A biopsy sample must be obtained to establish the diagnosis. An open biopsy generally is obtained, because a needle biopsy may not attain sufficient tissue to confirm the diagnosis. Needle biopsy, although probably a reasonable option in many suspected bony metastatic lesions, may be more reliable in purely lytic metastatic lesions such as metastatic lung cancer. The biopsy tract must be chosen carefully, as to avoid seeding other compartments and compromise definitive resection. Histologically, a poorly differentiated adenocarcinoma is found most commonly.5,8,9 The scirrhous carcinoma, found in this patient, is the most commonly found subtype. It is important, in evaluating a patient with a history of gastric carcinoma, to consider the clinical stage, gross classification (Table 1),8 and histologic type of carcinoma. This information can raise a clinician's suspicion for metastatic disease. Bone metastatic lesions most commonly are found in cancers with multiple lymph node involvement, Borrhmann Types III or IV (Table 1),8 and clinical Stages III and IV cancers.5,7,9 Most bone metastases occur within 2 years of primary surgery for gastric cancer.7,9 The patient reported here was classified as Stage III.TABLE 1: Borrmann Classification of Gastric CarcinomaThe prognosis for patients with metastatic gastric carcinoma to the bone is uniformly poor, with many patients dying within a few months of detection of the metastasis.9 External beam radiation is used to relieve pain and halt progression of the tumor. Because most metastases from gastric carcinoma have areas of reactive bone formation, structural integrity usually is preserved and prophylactic fixation is often not necessary. This patient has been treated with external beam radiation. She is now 3 months into therapy and doing well." @default.
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• W2016140516 title "Knee Pain in a 69-Year-Old Woman" @default.
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