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Extragnathic fibromyxoma - البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن
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Extragnathic fibromyxoma - البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن
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Foot and Ankle
Surgery 2002 8:59-62 Case report Extragnathic fibromyxoma report of a case of the calcaneum: F.O. ABU HASSAN University of Jordan, Amman, Jordan Summary Fibromyxoma of the bone occurs mainly in the facial bones and it has not been previously reported in the calcaneum. We present a rare case of extragnathic fibromyxoma affecting the calcaneum in an adult male patient who complained of persistent heel pain. Intraoperative char-acteristics and histological examinations of the lesion demonstrated fbromyxoma. Open curettage, local application of 5% phenol and filling the cavity with bone cement relieved the patient's symptoms, with no recurrence. This case represents another type of the benign lesions affecting the calcaneum. Keywords: fibromyxoma; calcaneum; foot; tumour; extragnathic; mandible Introduction Fibromyxoma is an uncommon, intraosseus tumour composed of fibrous tissues with variable myxoid stroma, and uniform, stellate spindle cells [1-4]. It is a tumour of the facial bones but extragnathic localizations are described in the metaphysis of long bones, rarely in the non-tubular bones [4-7]. As we are concerned, this lesion was not previously repor-ted to originate in the calcaneum. We present a patient affected by such a tumour in the calcaneum, which was successfully treated by curettage and bone cement. This is an unusual case concerning the type, location and method of treatment. It illustrates the difficulty in the radiological diagnosis and the importance of biopsy before dealing with such lesions, which have to be included into the list of benign lesions of the calcaneum. Correspondence: F.O. Abu Hassan, PO Box 73, Jubaiha 11941, Jordan (e-maih freih@joinnet.com.jo). Case report A 54-year-old man presented with a 6-month history of persistent right heel pain despite conventional physiotherapy and local steroid injection. The pain was dull, started gradually and increased at night. Prolonged weight bearing mag-nified the pain, whereas bed rest did not relieve it. There was neither history of trauma to the foot, nor any recent illness, fever or weight loss. Physical examination did not reveal limping during walking. There was no swelling, flush or local skin change. The patient marked localized tenderness on the lateral aspect of the heel. Active and passive ankle and foot ranges of motion were normal compared with the uninvolved site. A lateral radiograph of the ankle demonstrated faint, lytic lesion with well defned borders, invol-ving the lower part of the calcaneum (Figure 1). The calcaneal Harris view demonstrated well defined lytic lesion in the lower lateral third of the calcaneum (Figure 2). © 2002 Blackwell Science Ltd 59
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60 F.O. ABU
HASSAN Figure 2 The calcaneal Harris view demonstrated well defined lytic lesion in the lower lateral third of the calcaneum. Figure 1 Lateral radiograph of the ankle demonstrating faint lytic lesion with well defined margins, involving the lower part of the calcaneum. Routine blood investigations did not reveal any abnormality. A bone isotope scan demonstrated increased uptake in the hindfoot, mainly related to the calca-neum. A computed tomography scan demonstrated the lytic lesion with a sclerotic, endosteal margin and disruption of the outer cortex of the calcaneum with no soft tissue invasion (Figure 3). An attempt of needle aspiration did not reveal any fluid content. Incisional biopsy of the lesion was then performed under general anaesthesia without using the tourni-quet. The primary histological findings were uniform, small, stellate, spindle-shaped cells with no mitosis or pleomorphism in the stroma of the dense, fibrous tissue, which were typical of fibromyxoma. Figure 3 Computed tomography scan demonstrating the lyric lesion with sclerotic endosteal margin and disruption of the outer cortex of the calcaneum with no soft tissue invasion. After 10 days, the lesion was explored through the extension of the original incision, under general anaesthesia, using the above ankle tourniquet. Grossly, the tumour was soft grey to white and gelatinous in consistency. Final histological diagno-sis confirmed the fibromyxoma (Figure 4). Complete curettage under direct vision was followed by local application of 5% phenol. The cavity was finally filled with bone cement. Full weight bearing was allowed 25 clays after surgery. © 2002 Blackwell Science Ltd, Foot and Ankle Surgery 2002, 8, 59-62
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FIBROMYXOMA OF THE
CALCANEUM 61 Figure 4 Final histological diagnosis confirming the fibromyxoma. There was no evidence of recurrence after 2 years of follow-up. Discussion Fibromyxoma is a benign, bony lesion mainly affecting the jaw [1-3]; extragnathic forms are uncommon [4-8]. The metaphyseal ends of long bones, especially the femoral ends, are the most extragnathic localizations, which form 30% of the cases [1,4,6]. The lesion rarely originates from the periosteum of the femur [9]. Occasionally, fibromyxoma originates from flat bones [1-3], but was not previously described in the spongy bones as in our case. Approximately 31 cases of the extragnathic variety have been reported [1,3,4,6,8]. The lesion presents with pain in various age groups. It is mainly reported during the first two decades of life and after the fifth decade [1,3,5]. The commonest radio-logical feature is a well localized, radiolucent, lytic defect or an expansile, medullary, metaphyseal defect, with cortical destruction [1,3,4]. The tumour may extend to the soft tissue but it does not cause periosteal reaction [1,7,8]. Our case demonstrated the well defined lyric lesion, and cortical destruction of the outer third of the calcaneum, with no soft tissue extension. Extragnathic fibromyxoma can be radiologically misdiagnosed with different benign lytic bone lesions, for example, intraosseus lipoma [10-12], intraosseus ganglion [13,14], chondromyxoid fibro-ma [1,15], bone cysts [16,17], desmoplastic fibroma [18,19] and giant cell tumour [15]. The cavity of the fibromyxoma lesion contains soft grey to white gelatinous tissue. The histology is distinctive, comprising uniform, small, stellate and spindle-shaped cells with no mitosis or pleo-morphism in the stroma of the dense fibrous tissue, presence of areas of chondroid and osteoid tissues, but no lobulation or fibrous capsule [1,3,4]. Secon-dary aneurysmal bone cyst has been described histologically [3]. Fibromyxoma should be differ-entiated from malignant bone tumours, for exam-ple, fibrosarcoma [15], chondrosarcoma [1,20], or metastatic lesions of bone [15,21], by prominent myxoid zones, absence of mitosis and pleomor-phism [4]. In our case, incisional biopsy was necessary to establish the presence of the typical uniform, stellate and spindle-shaped cells in their fibrous and chon-droid tissues. At a later stage, we carried out an adequate curettage, local application of 5% phenol and packed the cavity with bone cement to avoid local recurrence of the tumour. Nevertheless, fibr-omyxoma may recur after curettage [1,3,5,6]. In soft tissue involvement, en bloc excision is recommended [1,3,51. References i Fechner RE, Mills SE. Tumors of the bones and joints. In: Atlas of Tumor Pathology. Washington, Armed Forces Institute of Pathology, 1992; 156-157. 2 Abdelwahab IF, Hermann G, Klein MJ et al. Fibromyxoma of bone. Skeletal Radiol 1991; 20: 95-98. 3 Soren A. Myxoma in bone. Clin Orthop 1964; 37" 145-149. 4 Adler CP. Fibromyxoma of femoral neck. J Cancer Res Clin Oncol 1981; 101 (2): 183-189. 5 Marcove RC, Lindeque BG, Huvos AG. Fibromyxoma of bone. Surg Gynecol Obstet 1989; 169: 115-118. 6 McClure DK, Dahlin DC. Myxoma of bone. Report of three cases. Mayo Clinic Proc 1977; 52: 249-253. 7 Caballes RL. Fibromyxoma. Bone 1979; 130 (1): 97-99. 8 Goldman AB, Vigorita VJ. Fibromyxoma of the femur. Skeletal Radiol 1983; 10 (3): 197-200. 9 Chacha PB, Tan KK. Periosteal myxoma of the femur: a case report. J Bone Joint Surg 1972; 54 (5): 1091-1094. 10 Greenspan A, Raiszadeh K, Riley GM et al. Intraosseous lipoma of the calcaneus. Foot Ankle lnt 1997; 18 (1): 53-56. 11 Appenzeller J, Weitzner S. Intraosseous lipoma of os calcis. Case report and review of literature of intraosseous lipoma of extremities. Clin Orthop 1974; 101 (01): 171-175. 12 Gonzalez JV, Stuck RM, Streit NJ. Intraosseous lipoma of the calcaneus: a clinico-pathologic study of three cases. Foot Ankle Surg 1997; 36 (4): 306-310. © 2002 Blackwell Science Ltd, Foot and Ankle Surgery 2002, 8, 59-62
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HASSAN 13 Helwig U, Lang S, Baczynski M et al. The intraosseous ganglion. A clinical-pathological report on 42 cases. Arch Orthop Trauma Surg 1994; 114 (1): 14-17. 14 Murff R, Ashry HR. Intraosseous ganglia of the foot. J Foot Ankle Surg 1994; 33 (4): 396-401. 15 McGlamry DE. Comprehensive Textbook of Foot Surgery. Balti-more: Williams & Wilkins, 1987:636-645. 16 Smith SB, Shane HS. Simple bone cyst of the calcaneus. A case report and literature review. J Am Podiatr Med Assoc 1994; 84 (3): 127-130. 17 Van Linthoudt D, Lagier R. Calcaneal cysts. A radiological and anatomico-pathological study. Acta Orthop Scand 1978; 49 (3): 310-316. 18 Raatikainen TK, Kaarela OI, Holmstrom T et al.Desmoplastic fibroma of the calcaneus treated with a microvascular bone graft. Case report. Scand J Plast Reconstr Surg Hand Surg 1999; 33 (1): 111-116. 19 Yu JS, Lawrence S, Pathria Met al. Desmoplastic fibroma of the calcaneus. Skeletal Radiol 1995; 24 (6): 451-454. 20 Lewis MM, Marcove RC, Bullough PG. Chondrosarcoma of the foot. A case report and review of the literature. Cancer 1975; 36: 586-589. 21 Kumar PP, Kovi J. Metastasis to the bones of the hand and feet. J Natl Med Assoc 1978:70 (11): 837-840. © 2002 Blackwell Science Ltd, Foot and Ankle Surgery 2002, 8, 59-62
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