Presentation
Low back pain, generalized weakness, easy fatigability, reduced power in bilateral upper and lower limbs and fracture shaft of right femur.
Patient Data
A relatively well defined lucent area in the right side of the pelvis involving the head of femur and upper aspect of right acetabulum. Multiple lytic lesions are noted in the visualized bones. Visualized spine shows lytic changes with mild scoliosis. Lateral radiograph shows few areas of calcification within this lesion.
On the soft tissue window, a soft tissue density lesion is noted involving the pubic rami, ischium, acetabulum and femoral head on the right side.
Fracture of shaft of the femur is noted on the right side with multiple variable sized lytic expansile lesions are noted in the skull vault, right scapula, sternum, almost all vertebral bodies including there posterior elements and 8th rib on the left side and 3rd and 9th ribs on the right side. Features likely suggestive of metastasis.
A well defined, expansile, heterogeneous signal intensity lesion is noted involving the right iliac blade, pubic rami (both inferior and superior ramus of pubic bone), ischium, reaching up to the articular surface of the acetabulum and involving the head of the femur with adjacent soft tissue component. This lesion appears iso-intense on TIWI and predominantly hyperintense on T2WI and STIR. On postcontrast study, it shows heterogeneous enhancement.
A heterogeneously enhancing, lesion appearing isointense on T1WI, hyperintense on T2WI and STIR is seen involving the right pedicles of T4 and T5 vertebrae.
Similar multiple areas of altered signal intensity lesions are noted in the body of almost all lumbar vertebrae involving the posterior elements (spinous process, lamina and pedicles), appearing hypointense on T1WI and hyperintense on T2WI and STIR. Similar morphology altered signal intensity lesions are noted in the thoracic vertebral bodies with pedicle and lamina of few thoracic vertebrae.
On the postcontrast study, these lesions show heterogeneous enhancement.
Features likely suggestive of metastasis in the spine.
Case Discussion
A 40-year-old female presented with low back pain, generalized weakness and fractured femoral shaft with no significant history of trauma.
On CT and x-ray correlation, there is a soft tissue swelling with ring-and-arc chondroid matrix noted within it. Moth-eaten appearance of the head of femur and pelvic bones are suggestive of a high-grade tumor. Multiple aggressive lytic lesions are noted in the axial skeleton with soft tissue involvement. Thus the femoral shaft fracture is likely pathological.
On MRI correlation this lesion appears iso-intense on TIWI and predominantly hyperintense on T2WI and STIR. On the postcontrast study, it shows heterogeneous moderate enhancement. Multiple areas of altered signal intensity lesions are noted in the entire spine, largest at the level of T4-5 vertebrae causing compression over the thecal sac and leading to canal stenosis at that level likely suggestive of vertebral metastasis.
In view of the above imaging findings, the above described lesion is suggestive of a chondrosarcoma with multiple bony metastases predominantly involving the spine.
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