by Joelle Simpson with Shilpa Patel on the Hot Seat
This is a case of a 12 year-old with right lower extremity pain and swelling and an abnormal ultrasound finding. For the full case presentation, click here.
Thank you to Jennifer & Kristen for your comments on the case.
Here is how you answered:
Given the findings above, what would be your next choice in management?
Given this, would you discharge this patient tonight (remembering that this is before the Thanksgiving holiday?)
Some additional comments included:
"I would discharge if I was able to get in touch with PMD"
"Cannot rule out Osteo"
To see Shilpa's Hot Seat Response - Click Here.
DENOUEMENT: The patient had an Orthopedics consult in the Emergency Department that night. Since it was 2 days before Thanksgiving, she was kept in the ER overnight for an MRI in the morning. Her clinical team wanted to ensure that she was able to complete the study in a timely fashion and get appropriate follow up.
Her MRI showed the following:
Interpretation: Large heterogeneous mass located in the area of the interosseous membrane between the right tibia and fibula measuring approximately 14.6 x 6.5 x 4.9 cm. Findings are concerning for a soft tissue sarcoma such as rhabdomyosarcoma or synovial sarcoma. No osseous involvement. No additional lesions.
Given concern for an oncologic etiology a Chest CT was obtained to rule out metastatic cancer in the ER. The Chest CT read was negative. Orthopedics arranged a follow up clinic appointment in a week for a biopsy of the mass. The case was also discussed with Oncology in the Emergency Department who agreed to outpatient follow up.
Final Pathologic Diagnosis: Soft tissue, right calf mass, needle biopsy: Undifferentiated round cell sarcoma.
Follow up thoughts from the Oncology Attending:
“Most patients with solid tumors of the extremities can be diagnosed and managed in the outpatient setting as it takes time for the path and staging work up to be completed before treatment can be initiated. The important thing is to set up appropriate follow up- primarily with surgery to obtain the biopsy for path and oncology for appropriate follow up. Reasons for admission would primarily be supportive- such pain management or if there were other clinical problems such as respiratory symptoms, etc. Staging work up can be done at the same time as other needed diagnostic tests (ie CT can often be done simultaneous to a PET/CT scan which is needed in the staging process for a soft tissue sarcoma). We can wait for the path to come back prior to full staging work up unless there were other clinical indications to do so, but I don’t think it was inappropriate to do a chest CT. She has a rare undifferentiated sarcoma. The staging of her tumor is still pending but her treatment will consist of chemo +/- radiation therapy and surgery. “ - Dr Aerang Kim
This is a case of a 12 year-old with right lower extremity pain and swelling and an abnormal ultrasound finding. For the full case presentation, click here.
Thank you to Jennifer & Kristen for your comments on the case.
Here is how you answered:
Given the findings above, what would be your next choice in management?
Some additional comments included:
"I would discuss this with hematology and orthopedics and keep for MRI"
Some additional comments included:
"I would discharge if I was able to get in touch with PMD"
"Cannot rule out Osteo"
To see Shilpa's Hot Seat Response - Click Here.
DENOUEMENT: The patient had an Orthopedics consult in the Emergency Department that night. Since it was 2 days before Thanksgiving, she was kept in the ER overnight for an MRI in the morning. Her clinical team wanted to ensure that she was able to complete the study in a timely fashion and get appropriate follow up.
Her MRI showed the following:
 |
| Right heterogenous mass between the right tibia and fibula |
Given concern for an oncologic etiology a Chest CT was obtained to rule out metastatic cancer in the ER. The Chest CT read was negative. Orthopedics arranged a follow up clinic appointment in a week for a biopsy of the mass. The case was also discussed with Oncology in the Emergency Department who agreed to outpatient follow up.
Final Pathologic Diagnosis: Soft tissue, right calf mass, needle biopsy: Undifferentiated round cell sarcoma.
Follow up thoughts from the Oncology Attending:
“Most patients with solid tumors of the extremities can be diagnosed and managed in the outpatient setting as it takes time for the path and staging work up to be completed before treatment can be initiated. The important thing is to set up appropriate follow up- primarily with surgery to obtain the biopsy for path and oncology for appropriate follow up. Reasons for admission would primarily be supportive- such pain management or if there were other clinical problems such as respiratory symptoms, etc. Staging work up can be done at the same time as other needed diagnostic tests (ie CT can often be done simultaneous to a PET/CT scan which is needed in the staging process for a soft tissue sarcoma). We can wait for the path to come back prior to full staging work up unless there were other clinical indications to do so, but I don’t think it was inappropriate to do a chest CT. She has a rare undifferentiated sarcoma. The staging of her tumor is still pending but her treatment will consist of chemo +/- radiation therapy and surgery. “ - Dr Aerang Kim
Wanted to add Radiologists perspective: hematoma and soft tissue mass/malignancy can be difficult to tell apart by US. So, absent a hx of trauma, ruptured Achilles tendon, or hemophilia, hematoma should have dropped down on the list. Even by MRI, hemangioma and sarcoma can be difficult to differentiate, even with the added enhancement of contrast. Biopsy is needed.
ReplyDeleteTake home points from 2 radiologists:
1. Most times soft tissue masses are non-specific, especially on US, unless they are clearly a cyst, fat-containing lesion, hemangioma, or vascular malformation, and end up needing biopsy.
2. Unlike lesions within bones, descriptors like "well-defined" are meaningless in the soft tissues. The most innocuous looking soft tissue masses can be sarcomas.
3. Soft tissue hematomas without a strong history of injury need to be followed to resolution or worked up for underlying neoplasm.
4. history, history, history
Jennifer: I think that's a great point about specificity in ultrasound, but really in any imaging. In reading this case, I waas anchored into it being a hematoma just because the radiologists said that is what it looks like on ultrasound. This would be a good time to talk to the radiologist to gauge certainty.
ReplyDelete