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Theodorou DJ, Theodorou SJ, Kakitsubata Y. Nora Lesion (Bizarre Parosteal Osteochondromatous Proliferation): An Ultrasound Diagnosis with Magnetic Resonance Imaging Correlation. J Med Ultrasound 2023; 31:327-330. [PMID: 38264603 PMCID: PMC10802862 DOI: 10.4103/jmu.jmu_53_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/28/2022] [Accepted: 11/04/2022] [Indexed: 01/25/2024] Open
Abstract
Advanced cross-sectional imaging techniques are firmly established as a means of evaluating musculoskeletal disease, and ultrasound (US) is increasingly being used for the assessment of a diversity of tendon, joint, and soft-tissue abnormalities. A benign condition - bizarre parosteal osteochondromatous proliferation (BPOP) - arises from the periosteum, typically in the small bones of the hands and feet, and grows as a surface bone lesion in the surrounding soft tissue. Proliferations can become symptomatic, exercising mass effect on adjacent structures that may require operative management. As a bone-forming process, BPOP may occasionally assume worrisome histologic features that mimic sarcoma, and a pronounced tendency to recur after primary excision. A solitary mass was growing in the middle finger of a young woman that curtailed proper hand function. With US, a partially ossified formation was revealed in the proximal phalanx situated on the outer surface of the bone. There was faint acoustic shadowing distal to the lesion, and a hypoechoic halo was seen covering part of the abnormal tissue growth. Importantly, the lesion caused significant limitation of motion of the finger, on the dynamic flexion US images with the displacement of the flexor tendon and compression of a digital nerve. To restore the range of motion in the finger, surgical excision of the juxtacortical mass was performed and histology yielded a diagnosis of BPOP. We describe the US features of digital BPOP, which were found to correspond closely to those of computed tomography and magnetic resonance imaging.
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Affiliation(s)
| | | | - Yousuke Kakitsubata
- Department of Radiology, Miyazaki Konan Hospital, Otsubo-Nishi, Miyazaki, Japan
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Hegde V, Mallya V, Tomar R, Khurana N, Maini L. Bizarre parosteal osteochondromatous proliferation Nora's lesion: Case report of two cases with review of the literature. J Cancer Res Ther 2023; 19:2090-2093. [PMID: 38376328 DOI: 10.4103/jcrt.jcrt_1897_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/19/2022] [Indexed: 02/21/2024]
Abstract
ABSTRACT Bizarre parosteal osteochondromatous proliferation (BPOP) is also known as Nora's disease. It is a benign lesion. Even though recent studies showed probable neoplastic etiology, the exact cause is unknown. BPOP commonly involves small bones of hands and feet. This condition is rare and very few cases are reported. In this report, two cases are presented with clinical, radiological, and histopathological findings. The first case was a 38-year-old female presented with 3-year history of mild painful swelling in the left middle finger and the second case was a 28-year-old male with the left leg swelling for 8 years. On radiology, both cases showed surface lesion with uninvolved medullary cavity. Excision specimen of both the lesions subjected for histopathological examination. Microscopically, there was irregular maturation of the bone and cartilage. Cartilage showed purplish-blue color (blue bone) with bizarre chondrocytes. BPOP is a rare benign condition. Awareness of clinical radiological and microscopic findings is needed for correct diagnosis and to differentiate it from other mimicking benign and malignant conditions.
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Affiliation(s)
| | - Varuna Mallya
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Reena Tomar
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Lalit Maini
- Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India
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Gitto S, Serpi F, Messina C, Albano D, Di Bernardo A, Armiraglio E, Cannavò L, Mazzoli S, Luzzati A, Parafioriti A, Sconfienza LM. Bizarre parosteal osteochondromatous proliferation: an educational review. Insights Imaging 2023; 14:109. [PMID: 37336832 DOI: 10.1186/s13244-023-01455-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/03/2023] [Indexed: 06/21/2023] Open
Abstract
Bizarre parosteal osteochondromatous proliferation (BPOP) is a surface-based bone lesion belonging to the group of benign chondrogenic tumors. The aim of this review is to familiarize the readers with imaging features and differential diagnosis of BPOP, also addressing pathological presentation and treatment options. The peak of incidence of BPOP is in the third and fourth decades of life, although it can occur at any age. Hands are the most common location of BPOP (55%), followed by feet (15%) and long bones (25%). On imaging, BPOP appears as a well-marginated mass of heterotopic mineralization arising from the periosteal aspect of the bone. Typical features of BPOP are contiguity with the underlying bone and lack of cortico-medullary continuity, although cortical interruption and medullary involvement have been rarely reported. Histologically, BPOP is a benign bone surface lesion characterized by osteocartilaginous proliferation with disorganized admixture of cartilage with bizarre features, bone and spindle cells. Differential diagnosis includes both benign-such as florid reactive periostitis, osteochondroma, subungual exostosis, periosteal chondroma and myositis ossificans-and malignant lesions-such as periosteal chondrosarcoma and surface-based osteosarcoma. Treatment consists of surgical resection. Local recurrences are common and treated with re-excision.Critical relevance statement Bizarre parosteal osteochondromatous proliferation is a benign mineralized mass arising from the periosteal aspect of bone cortex. Multi-modality imaging characteristics, pathology features and differential diagnosis are here highlighted to familiarize the readers with this entity and offer optimal patient care.
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Affiliation(s)
- Salvatore Gitto
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Francesca Serpi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
| | | | | | - Luca Cannavò
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
| | - Simone Mazzoli
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
| | - Alessandro Luzzati
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy
| | | | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, via Cristina Belgioioso 173, 20157, Milan, Italy.
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
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Kao YC, Yoshida A, Hsieh TH, Nord KH, Saba KH, Ichikawa H, Tsai JW, Huang HY, Chih-Hsueh Chen P, Fletcher CDM, Lee JC. Identification of COL1A1/2 Mutations and Fusions With Noncoding RNA Genes in Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion). Mod Pathol 2023; 36:100011. [PMID: 36853784 DOI: 10.1016/j.modpat.2022.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/14/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
Bizarre parosteal osteochondromatous proliferation (BPOP) (Nora lesion) is a benign bone surface lesion, which most commonly occurs in the digits of young patients and has a high rate of recurrence. Histologically, it is composed of a mixture of disorganized bone, cartilage, and spindle cells in variable proportions and characterized by amorphous "blue bone" mineralization. Recurrent chromosomal abnormalities, including t(1;17)(q32-42;q21-23) and inv(7)(q21.1-22q31.3-32), have been reported in BPOP. However, the exact genes involved in the rearrangements remain unknown. In this study, we analyzed 8 BPOP cases affecting the fingers, toe, ulna, radius, and fibula of 5 female and 3 male patients, aged 5 to 68 years. RNA sequencing of 5 cases identified genetic fusions between COL1A2 and LINC-PINT in 3 cases and COL1A1::MIR29B2CHG fusion in 1, both validated using fluorescence in situ hybridization and reverse transcription (RT)-PCR. The remaining fusion-negative case harbored 3 COL1A1 mutations as revealed by whole-exome sequencing and confirmed using Sanger sequencing. All these genetic alterations were predicted to cause frameshift and/or truncation of COL1A1/2. The chromosomal locations of COL1A2 (7q21.3), LINC-PINT (7q32.3), COL1A1 (17q21.33), and MIR29B2CHG (1q32.2) were consistent with the breakpoints identified in the previous cytogenetic studies. Subsequent screening of 3 BPOPs using fluorescence in situ hybridization identified 1 additional case each with COL1A1 or COL1A2 rearrangement. Our findings are consistent with reported chromosomal abnormalities and implicate the disruption of type I collagen, and perhaps of either noncoding RNA gene as a tumor suppressor, in the tumorigenesis of BPOP. The prevalence and tumorigenic mechanisms of these COL1A1/2 alterations in BPOP require further investigation.
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Affiliation(s)
- Yu-Chien Kao
- Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Akihiko Yoshida
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Tsung-Han Hsieh
- Joint Biobank, Office of Human Research, Taipei Medical University, Taipei, Taiwan
| | - Karolin H Nord
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, Lund, Sweden
| | - Karim H Saba
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, Lund, Sweden
| | - Hitoshi Ichikawa
- Department of Clinical Genomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Jen-Wei Tsai
- Department of Pathology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Hsuan-Ying Huang
- Department of Anatomical Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | | | - Jen-Chieh Lee
- Department and Graduate Institute of Pathology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Edoardo I, Elisa F, Damiano RA, Silvia DF, Rodolfo C, Lorenzo A. Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion): A Narrative Review. Acta Med Litu 2022; 29:176-193. [PMID: 37733437 PMCID: PMC9799002 DOI: 10.15388/amed.2022.29.2.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/27/2022] [Accepted: 04/29/2022] [Indexed: 11/22/2022] Open
Abstract
Background Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora lesion, is a rare proliferative disease arising from the parosteal region of bones. Although BPOP's pathogenesis is still not certain, modern literature suggests it to be a tumor-like lesion or even a benign neoplasm. Due to the extremely low incidence, to this date studies on the topic are limited to case reports and a few case series. This narrative review aims to resume literature on BPOP and provide an overview of its natural history, morphologic characteristics and prognostic horizon. Materials and methods A systematic research of the literature was done to identify studies reporting on patients who suffered from BPOP between 1983 and 2021. We collected data regarding aetiologic and pathogenetic theories, patients' personal data and anamnesis, lesions' location, clinical presentation, imaging features, pathological appearance, treatment and prognosis. Results We identified 322 cases of BPOP with a mean age of 34.3 years at the moment of diagnosis. There was no gender difference. The most involved site was the hand, followed by the foot. A history of trauma was reported for 14.7% of the cases. 38.7% of the patients had pain. Literature defined typical radiographic and microscopic patterns that characterize Nora lesions. While imaging is fundamental to orientate towards BPOP, histological evaluation is mandatory to get the definitive diagnosis. To this date, only reliable therapeutic option is represented by surgical resection. BPOP is burdened by a risk of recurrence that accounts to 37.4%. Conclusion BPOP is a rare benign disease that should be considered during the differential diagnosis of parosteal lesions, especially in the acral regions. Careful diagnostic evaluations are necessary to get the correct diagnosis and wide margins of resection are recommended to minimize the relatively high risk of local recurrence.
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Affiliation(s)
- Ipponi Edoardo
- University of Pisa: Department of Orthopedics and Trauma Surgery
| | - Ferrari Elisa
- University of Pisa: Department of Orthopedics and Trauma Surgery
| | | | - De Franco Silvia
- University of Pisa: Department of Orthopedics and Trauma Surgery
| | - Capanna Rodolfo
- University of Pisa: Department of Orthopedics and Trauma Surgery
| | - Andreani Lorenzo
- University of Pisa: Department of Orthopedics and Trauma Surgery
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Liu D, Qi B, Huang Z, Pan Z. Fibro-Osseous Pseudotumor. Orthopedics 2021; 44:e713-e718. [PMID: 34618638 DOI: 10.3928/01477447-20211001-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Fibro-osseous pseudotumor is an extremely rare subcutaneous benign ossifying lesion associated with bone formation that is most commonly seen in the hands, followed by the toes. Because the tumor has a certain degree of invasiveness, it is often mistaken for malignancy, which leads to radical, excessive treatment. Our case involved a 32-year-old man with lesions on the left index finger. We documented the detailed data of diagnosis, treatment, and follow-up. We also conducted a review and summarized the published cases to advance our understanding of the disease, provide more accurate diagnostic criteria, and avoid inappropriate surgical procedures. [Orthopedics. 2021;44(6):e713-e718.].
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Zhang F, Wang Y, Wang Y, Wang X, Zhang D, Zhao X, Jiang R, Gu Y, Yang G, Fu X, Xu L, Xu L, Zheng L, Zhang J, Li Z, Yan Q, Shi J, Roessner A, Wang Z, Li Q, Ye J, Chen CD, Guo S, Min J. Disruption of Jmjd3/p16 Ink4a Signaling Pathway Causes Bizarre Parosteal Osteochondromatous Proliferation (BPOP)-like Lesion in Mice. J Bone Miner Res 2021; 36:1931-1941. [PMID: 34173271 DOI: 10.1002/jbmr.4401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/16/2021] [Accepted: 06/20/2021] [Indexed: 11/06/2022]
Abstract
Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is a rare benign osteochondromatous lesion. At present, the molecular etiology of BPOP remains unclear. JMJD3(KDM6B) is an H3K27me3 demethylase and counteracts polycomb-mediated transcription repression. Previously, Jmjd3 was shown to be critical for bone development and osteoarthritis. Here, we report that conditional deletion of Jmjd3 in chondrogenic cells unexpectedly resulted in BPOP-like lesion in mice. Biochemical investigations revealed that Jmjd3 inhibited BPOP-like lesion through p16Ink4a . Immunohistochemistry and RT-qPCR assays indicated JMJD3 and p16INK4A level were significantly reduced in human BPOP lesion compared with normal subjects. This was further confirmed by Jmjd3/Ink4a double-gene knockout mice experiments. Therefore, our results indicated the pathway of Jmjd3/p16Ink4a may be essential for the development of BPOP in human. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Feng Zhang
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,Department of Pathology, Air Force Medical Center (Air Force General Hospital), PLA, Beijing, China
| | - Yingmei Wang
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yuying Wang
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xinli Wang
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Dawei Zhang
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiong Zhao
- Department of Orthopedics, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Runmin Jiang
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yu Gu
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Guifang Yang
- Department of Surgery, Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xin Fu
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Longyong Xu
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Longxia Xu
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Liting Zheng
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Jing Zhang
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zengshan Li
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Qingguo Yan
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jianguo Shi
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Albert Roessner
- Department of Pathology, Otto-von-Guericke University, Magdeberg, Germany
| | - Zhe Wang
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Qing Li
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jing Ye
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Charlie Degui Chen
- State Key Laboratory of Molecular Biology, Shanghai Key Laboratory of Molecular Andrology, Institute of Biochemistry and Cell Biology, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Shuangping Guo
- State Key Laboratory of Cancer Biology, Department of Pathology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jie Min
- Department of Oncology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
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Tuzzato G, Vita F, Bianchi G, Tosi D, Adani R. Fibro-osseous pseudotumor of the hand: a case report of a 22-year-old young woman. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01822-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reddy MV, Kandukuri A, Chandankere V, Joseph VM, Reddy AVG. Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in Upper and Lower Limbs: A Report of Three Cases and Review of Literature. J Orthop Case Rep 2021; 11:24-28. [PMID: 34141664 PMCID: PMC8180324 DOI: 10.13107/jocr.2021.v11.i02.2010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare bone pathology affecting small bones of hand and feet. This benign lesion needs to be distinguished from many malignant bone tumors as it poses a diagnostic dilemma due to its clinical, radiological, and histological picture. We report three cases of BPOP affecting the hand and foot. Case 1: A 21-year-old gentleman presented with painful swelling in the long finger of the right hand. A plain radiograph showed a radio dense mass which was later excised and diagnosis confirmed in histopathology. There was no recurrence in 2 years of follow-up. Case 2: A 5-year-old boy presented with painful swelling over the right ankle with no history of antecedent trauma. Following radiological evaluation, the patient was successfully treated with excision. Case 3: A 35-year-old lady presented with a painful swelling on the dorsal aspect of her hand which was gradually increasing in size. After radiological evaluation, the patient was successfully treated with excision and lesion confirmed to be BPOP on histological examination. She was symptom free without recurrence in up to 2 years of follow-up. Conclusion: Nora’s lesion is a rare pathology requiring high index of suspicion. Excision is the recommended mode of treatment. All our cases responded well with excision with immediate pain relief following surgery and no recurrence in up to 2 years of follow-up.
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Affiliation(s)
- Maryada Venkateshwar Reddy
- Department of Orthopaedics, Consultant Hand and Upper Limb Surgeon, Sunshine Hospital, Secunderabad, Telangana, India
| | - Anjaneyulu Kandukuri
- Department of Orthopaedics, Professor of Orthoapedics, SVS Medical College, Mahabubnagar, Telangana, India
| | - Vidyasagar Chandankere
- Department of Orthopaedics, Consultant Paediatric Orthopaedic Surgeon, Sunshine Hospital, Secunderabad, Telangana, India
| | - Vinay Mathew Joseph
- Department of Orthopaedics, International Training Fellow, Wrightington, Wigan and Leigh NHS Trust, Wigan, United Kingdom
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Grieser T. [Foot and ankle tumours : Part II: Malignant bone tumours and soft tissue tumours of the foot with differential diagnostic hints]. Radiologe 2019; 58:459-475. [PMID: 29492589 DOI: 10.1007/s00117-018-0361-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CLINICAL ISSUE Both benign and malignant tumours are encountered in the foot and ankle. Due to their rarity, however, diagnosis is often uncertain. Usual criteria such as tumour size, invasiveness or pain fail to differentiate benign from malignant neoplasias. STANDARD RADIOLOGICAL METHODS Plain radiography and-due to the complex foot anatomy-CT are important in the diagnostic evaluation of primary bone tumours. In the case of soft tissue tumours, ultrasonography is used to identify ganglion cysts. Tumour evaluation and staging are then performed using MRI. Nuclear imaging comes into play when multifocal, metastatic or systemic spread of the disease is suspected or if a biopsy procedure is planned. METHODICAL INNOVATIONS For the role of dual-energy CT, please refer to part I. Whether dual-energy CT is suitable to assess bone marrow oedema patterns is still debated. SPECIAL FEATURES OF FOOT AND ANKLE TUMOURS Primary bone tumours generally present in the ankle or the hindfoot. Malignant bone tumours, e. g. chondrosarcoma, are primarily found in the latter. On the other hand, soft tissue tumours generally present in the mid- and forefoot regions. ACHIEVEMENTS While the radiologic diagnostic evaluation of pedal bone tumours is quite reliable, caution is urgently needed in the case of soft tissue tumours because there are many confusing differential diagnoses. PRACTICAL RECOMMENDATIONS Proper X‑ray examination of the foot (at least in two plains) or with special views according to bony pathology is needed. All soft tissue masses that are not cysts should be evaluated further. MRI remains the diagnostic modality of choice but never stands alone! Caution: Size and well-defined margins of pedal soft tissue tumours are not considered criteria regarding whether a tumour is malignant or not.
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Affiliation(s)
- T Grieser
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Klinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
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Rottler P, Wilke A, Kasper HU, Hütter F. First presentation of a Nora-lesion of the talus in a paraossal fasciitis. Orthop Rev (Pavia) 2019; 11:7628. [PMID: 30996837 PMCID: PMC6452091 DOI: 10.4081/or.2019.7628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 01/24/2019] [Indexed: 11/23/2022] Open
Abstract
Nora-Lesion is a proliferation that normally develops out of an intact corticalis. The entity of this fibroostotic pseudotumor, as discussed in literature, is triggered from repeating trauma or reactive periosteitis. In the literature, there are more than 200 cases defined as Nora lesion. In the daily routine of medical offices or ambulances, the Nora- Lesion should be established as a differential diagnosis for a swelling of the foot. Our case report of a 49-year-old patient is the worldwide first description of a Nora lesion of the talus, as well as secondary of the calcaneus. In the immense differential diagnosis discussion for bony pathologies of the hindfoot the Nora-lesion should be now added.
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Affiliation(s)
- Philipp Rottler
- Department of Orthopedics and Orthopedic Rheumatology, Elisabeth- Klinik, Olsberg
| | - Axel Wilke
- Department of Orthopedics and Orthopedic Rheumatology, Elisabeth- Klinik, Olsberg
| | | | - Felix Hütter
- Department of Orthopedics and Orthopedic Rheumatology, Elisabeth- Klinik, Olsberg
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12
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Pérez-Palma L, Manzanares-Céspedes MC, de Veciana EG. Subungual Exostosis Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc 2018; 108:320-333. [PMID: 30156888 DOI: 10.7547/17-102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The coexistence of deformity of the nail bed and subungual exostosis (SE) is a frequent finding in podiatric practice in the fourth and fifth decades of life. However, it has been described by other specialists as being an uncommon osteocartilaginous tumor most prevalent during the second and third decades of life. This study attempts to determine the causes of this discrepancy. METHODS Two authors independently conducted a systematic bibliographic review in multiple databases, podiatry sources and others, and key words were chosen to achieve a broad search strategy. Studies reporting on epidemiology and treatment of SE lesions in lower extremities in ten or more patients were selected. Initially, 197 articles were identified through database screening, with 23 meeting all inclusion and exclusion criteria. Seven articles with the ages of all of the patients were included in the analysis of age data. A comparison was then made between the diagnostic criteria for the selected 23 articles. RESULTS Model results reveal that, although there are some significant differences between individual studies, the main factor tested (patient's age) was clearly significant ( F1,5.2 = 78.12, P < .001), showing that studies coming from the podiatry speciality were conducted on individuals with a mean age of 37 years higher than in studies from other specialties. Clinical and radiologic characteristics and treatment described in the podiatry literature also contrast with those in other specialties. CONCLUSIONS The SE described by podiatrists, in accordance with the parameters of true exostosis, is different from Dupuytren's SE and should be considered as a different pathologic entity. The authors are working on its histologic identification.
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Affiliation(s)
- Laura Pérez-Palma
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | | | - Enrique Giralt de Veciana
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Takahashi R, Matsuo T, Kawanami K, Takata T, Takahashi E, Deie M. Bizarre parosteal osteochondromatous proliferation of the femur: A case report. J Orthop 2018; 15:606-609. [PMID: 29881204 DOI: 10.1016/j.jor.2018.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/06/2018] [Indexed: 10/17/2022] Open
Abstract
A 54-year-old man initially presented with left distal thigh pain during walking. Imaging analysis revealed a diffuse calcified or ossified mass adjacent to the medial cortex of the distal femur and absence of continuity with the medulla. We performed resection biopsy. Histological examination revealed a large amount of hypercellular cartilage showing transformation to trabecular bone and BPOP was diagnosed. Postoperative course was uneventful and he remained free of recurrence. The method of resection should depend on the stage of reactive proliferation and whether the lesion is pathologically immature or mature. We also provide a brief review of the literature.
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Affiliation(s)
- Ryosuke Takahashi
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Toshihiro Matsuo
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Katsuhisa Kawanami
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuya Takata
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Emiko Takahashi
- Department of Pathology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masataka Deie
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
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Kaniewska M, Haefeli M, Laesser U, Niemann T. That's my STYLEoideum - Symptomatic os styloideum in an adolescent male. J Radiol Case Rep 2017; 11:14-19. [PMID: 29299098 DOI: 10.3941/jrcr.v11i7.2877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a 15-year-old male patient with persistent localized pain on the dorsal side of the left wrist between the base of the 2nd and 3rd metacarpal bones and over the third carpometacarpal joint. It was diagnosed as an accessory metacarpal bone -Os styloideum. This entity may be detected on plain radiographs and in ultrasound examination and is often asymptomatic. Symptomatic os styloideum occurs more frequently in the dominant hand and may be treated conservatively with corticosteroid infiltration. A palpable prominence on the dorsal side of the wrist and focal pain evoked anxiety of the adolescent patient who searched medical consultation. In the clinical examination, a bony protrusion was confirmed and different possible diagnoses have been considered. After treatment with a corticosteroid infiltration of the third carpometacarpal joint under fluoroscopy the pain resolved completely. We would like to draw attention of clinicians and radiologists to this rare anatomical variant that normally is asymptomatic, and therefore not immediately recognized. Acquaintance with this entity and its early detection may lead to conservative treatment instead of surgical excision. A comprehensive literature search, review and discussion about os styloideum are provided in the article.
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Affiliation(s)
| | - Mathias Haefeli
- Department of Hand Surgery, Kantonsspital Baden, Baden AG, Switzerland
| | - Urs Laesser
- Department of Paediatrics, Kantonsspital Baden, Baden AG, Switzerland
| | - Tilo Niemann
- Department of Radiology, Kantonsspital Baden, Baden AG, Switzerland
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Matsui Y, Funakoshi T, Kobayashi H, Mitsuhashi T, Kamishima T, Iwasaki N. Bizarre parosteal osteochondromatous proliferation (Nora's lesion) affecting the distal end of the ulna: a case report. BMC Musculoskelet Disord 2016; 17:130. [PMID: 26984018 PMCID: PMC4793759 DOI: 10.1186/s12891-016-0981-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bizarre parosteal osteochondromatous proliferation (BPOP), first described by Nora et al. in 1983 and therefore termed "Nora's lesion", is a rare lesion that occurs in the short bones of the hands and feet and eventually presents as a parosteal mass. Reports of BPOP in the long bones are very rare. A benign disease, BPOP does not become malignant, although a high rate of recurrence following surgical resection is reported. Because of its atypical imaging findings and histopathological appearance, a BPOP might be misdiagnosed as a malignant tumor such as an osteochondroma with malignant transformation, a parosteal osteosarcoma, or a periosteal osteosarcoma. CASE PRESENTATION A 58-year-old woman complained of left ulnar wrist pain at the time of her initial presentation. Plain x-rays showed ectopic calcifications in and around the distal radioulnar joint, which supported the diagnosis of subacute arthritis with hydroxyapatite crystal deposition. She was initially given a wrist brace and directed to follow-up, but her persistent pain required the administration of corticosteroid injections into the distal radioulnar joint. Increasing ulnar wrist joint pain and limited forearm pronation and wrist flexion necessitated computed tomography and contrast-enhanced magnetic resonance imaging. BPOP was diagnosed based on the preoperative imaging studies, and a resection of the lesion was performed along with the decortication of the underlying the cortical bone to reduce recurrence rates. The diagnosis of BPOP was confirmed by pathologic examination. Two years after surgery, the patient has no subsequent pain complaints and an improved range of motion. CONCLUSIONS BPOP affecting the distal end of the ulna is exceedingly rare. Because BPOP was diagnosed primarily based upon preoperative imaging findings in our patient, decortication of the underlying cortical bone was performed to reduce recurrence rates. Further careful follow-up in these patients is essential, despite the non-recurrence of the lesion.
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Affiliation(s)
- Yuichiro Matsui
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tadanao Funakoshi
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hideyuki Kobayashi
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Kita-14 Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Tamotsu Kamishima
- Faculty of Health Sciences, Hokkaido University, Kita-12 Nishi-5, Kita-ku, Sapporo, 060-0812, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
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Abstract
Pain and focal masses in the foot and ankle are frequently encountered and often initiate a workup including imaging. It is important to differentiate benign lesions from aggressive benign or malignant lesions. In this review, multiple examples of osseous and soft tissue tumors of the foot and ankle will be presented. Additionally, the compartmental anatomy of the foot and ankle will be discussed in terms of its relevance for percutaneous biopsy planning and eventual surgery. Finally, a general overview of the surgical management of benign, benign aggressive and malignant tumors of the foot and ankle will be discussed.
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Kim SM, Myoung H, Lee SS, Kim YS, Lee SK. Bizarre parosteal osteochondromatous proliferation in the lingual area of the mandibular body versus osteochondroma at the mandibular condyle. World J Surg Oncol 2016; 14:35. [PMID: 26865041 PMCID: PMC4750297 DOI: 10.1186/s12957-016-0777-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background Bizarre parosteal osteochondromatous proliferation (BPOP) is benign and usually occurs in the small tubular bones of the hands and feet, but it is extremely rare in the oral and maxillofacial region. Methods The present study compares a case of BPOP occurring in the lingual area of the right mandibular body with a representative case of osteochondroma occurring in the left mandibular condyle using immunohistochemical methods. Results BPOP showed no continuity to the cortical bone of the mandible on X-ray and was histologically composed of immature cartilage and bone tissues, whereas osteochondroma showed overgrowth of hypertrophic chondrocytes accompanied by mature bone with endochondral ossification. Although BPOP showed no features of cellular atypia or malignant transformation, it expressed more osteogenic proteins, including BMP-2, BMP-4, RUNX2, OC, AP, OPG, RANKL, CTGF, and bFGF, than osteochondroma. Furthermore, the perichondral spindle cells and marrow osteoblasts/fibroblasts of BPOP showed stronger immunoreaction of PCNA, p53, β-catenin, BCL2, pAKT, survivin, 14-3-3, CEA, EMA, pan-K, and S-100 than the tumor cells of osteochondroma. Conclusions Therefore, it was presumed that similar to embryonal osteochondroid tissue, BPOP might be activated by osteogenic and oncogenic signaling and that this increased signaling may explain the rapid growth and high recurrence of BPOP.
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Affiliation(s)
- Soung Min Kim
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea.
| | - Hoon Myoung
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea.
| | - Sang Shin Lee
- Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University, 123 Chibyun-dong, Gangneung, Korea.
| | - Yeon Sook Kim
- Department of Dental Hygiene, Cheongju University, Cheongju, Korea.
| | - Suk Keun Lee
- Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University, 123 Chibyun-dong, Gangneung, Korea.
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Imaging Diagnosis of Solitary Tumors of the Phalanges and Metacarpals of the Hand. AJR Am J Roentgenol 2015; 205:106-15. [PMID: 26102388 DOI: 10.2214/ajr.14.13340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tumors and tumorlike lesions of the tubular bones of the hand, often incidentally discovered lesions, present a unique but challenging differential diagnosis. CONCLUSION Imaging, including both radiography and cross-sectional imaging, can allow the radiologist to generate a clinically useful differential diagnosis based on the distinguishing features of these entities. Recognition of these lesions is important because clinical management and treatment by orthopedic oncologists vary depending on the diagnosis.
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Simon MJK, Pogoda P, Hövelborn F, Krause M, Zustin J, Amling M, Barvencik F. Incidence, histopathologic analysis and distribution of tumours of the hand. BMC Musculoskelet Disord 2014; 15:182. [PMID: 24885007 PMCID: PMC4048624 DOI: 10.1186/1471-2474-15-182] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 05/23/2014] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this large collective and meticulous study of primary bone tumours and tumourous lesions of the hand was to enhance the knowledge about findings of traumatological radiographs and improve differential diagnosis. Methods This retrospective study reviewed data collected from 1976 until 2006 in our Bone Tumour Registry. The following data was documented: age, sex, radiological investigations, tumour location, histopathological features including type and dignity of the tumour, and diagnosis. Results The retrospective analysis yielded 631 patients with a mean age of 35.9 ± 19.2 years. The majority of primary hand tumours were found in the phalanges (69.7%) followed by 24.7% in metacarpals and 5.6% in the carpals. Only 10.6% of all cases were malignant. The major lesion type was cartilage derived at 69.1%, followed by bone cysts 11.3% and osteogenic tumours 8.7%. The dominant tissue type found in phalanges and metacarpals was of cartilage origin. Osteogenic tumours were predominant in carpal bones. Enchondroma was the most commonly detected tumour in the hand (47.1%). Conclusions All primary skeletal tumours can be found in the hand and are most often of cartilage origin followed by bone cysts and osteogenic tumours. This study furthermore raises awareness about uncommon or rare tumours and helps clinicians to establish proper differential diagnosis, as the majority of detected tumours of the hand are asymptomatic and accidental findings on radiographs.
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Affiliation(s)
| | | | | | | | | | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistr, 52, 20246 Hamburg, Germany.
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Bizarre parosteal osteochondromatous proliferation: a new cytogenetic subgroup characterized by inversion of chromosome 7. Cancer Genet 2013; 206:402-5. [DOI: 10.1016/j.cancergen.2013.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 11/12/2013] [Accepted: 11/18/2013] [Indexed: 11/21/2022]
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21
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Asymptomatic upper arm mass in a 37-year-old woman. Clin Orthop Relat Res 2013; 471:2073-7. [PMID: 23529630 PMCID: PMC3676590 DOI: 10.1007/s11999-013-2877-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 02/15/2013] [Indexed: 01/31/2023]
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James A, Henderson S. Multiple recurrences of subungual exostosis in a child: a unique presentation of a Nora's lesion. Foot Ankle Int 2013; 34:445-7. [PMID: 23520304 DOI: 10.1177/1071100712469336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) of the Hand: A Report of Two Atypical Cases. Case Rep Med 2012; 2012:453560. [PMID: 23326274 PMCID: PMC3541688 DOI: 10.1155/2012/453560] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 12/16/2012] [Indexed: 12/04/2022] Open
Abstract
Bizarre parosteal osteochondromatous proliferation (BPOP), also called Nora's lesion, is an unusual, benign, bony lesion frequently found in the hand. Originally, two of the key radiological features used to describe such lesions were: (1) a lack of corticomedullar continuity and (2) an origin from the periosteal aspect of an intact cortex. The authors present 2 unique cases of histologically proven BPOP in which the integrity of the cortex was affected. In the first case there was medullary continuity, and in the second case there was saucerization of the underlying cortical bone. The authors support that simple X-ray evaluation is insufficient to diagnose BPOP in atypical cases. Careful axial CT scanning or MRI may prove helpful. Taking into account these new notions, histopathology gains greater importance as a diagnostic tool for this particular group of entities.
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