The child with bone pain: malignancies and mimickers

How to distinguish a benign from a malignant tumour in children and when should a biopsy be done and by whom

Bone tumours are frequent in children but most of them are benign. Moreover, the incidence and type of tumours differ from those of adults. As an orthopaedic surgeon, we will likely encounter a bone lesion in a child and we must be able to distinguish if it is a benign lesion or has malignant characteristics and it is necessary to refer it to a centre specialized in tumours. We will discuss the key points we would have to ask in the medical history, look at the physical examination and the radiological characteristics that will allow us to distinguish between a benign and a malignant bone lesion in a child. When there are doubts about the malignancy of a bone lesion or if the diagnosis is not clear, a biopsy should be performed following certain rules in a specialized centre.

Myxopapillary Ependymoma in an 11-Year-Old Patient With Right-Sided Nocturnal Thigh Pain

ABSTRACT

This case report highlights a rare type of primary spinal cord tumor, myxopapillary ependymoma, in a pediatric patient who presented to clinic with worsening chronic unilateral thigh pain and neurologic deficits. He was appropriately treated with total gross resection of the tumor and adjuvant radiotherapy and was cleared for competitive sports without any restriction within 1 year of his diagnosis and treatment. Although most musculoskeletal complaints among pediatric patients are of benign etiology, as evidenced by our case, clinicians should have a low threshold to further investigate with advanced imaging modalities should the clinical history and examination be consistent with a more concerning pathologic process.

Defining Growing Pains: A Scoping Review

BACKGROUND AND OBJECTIVES

Up to one third of children may be diagnosed with growing pains, but considerable uncertainty surrounds how to make this diagnosis. The objective of this study was to detail the definitions of growing pains in the medical literature.

METHODS

Scoping review with 8 electronic databases and 6 diagnostic classification systems searched from their inception to January 2021. The study selection included peer-reviewed articles or theses referring to "growing pain(s)" or "growth pain(s)" in relation to children or adolescents. Data extraction was performed independently by 2 reviewers.

RESULTS

We included 145 studies and 2 diagnostic systems (ICD-10 and SNOMED). Definition characteristics were grouped into 8 categories: pain location, age of onset, pain pattern, pain trajectory, pain types and risk factors, relationship to activity, severity and functional impact, and physical examination and investigations. There was extremely poor consensus between studies as to the basis for a diagnosis of growing pains. The most consistent component was lower limb pain, which was mentioned in 50% of sources. Pain in the evening or night (48%), episodic or recurrent course (42%), normal physical assessment (35%), and bilateral pain (31%) were the only other components to be mentioned in more than 30% of articles. Notably, more than 80% of studies made no reference to age of onset in their definition, and 93% did not refer to growth. Limitations of this study are that the included studies were not specifically designed to define growing pains.

CONCLUSIONS

There is no clarity in the medical research literature regarding what defines growing pain. Clinicians should be wary of relying on the diagnosis to direct treatment decisions.

Ewing's sarcoma in scapula, epidemiology, clinical manifestation, diagnosis and treatment: A literature review

Background

Ewing's sarcoma (ES) can affect any bone, but its occurrence in the scapula is extremely rare. Only 15 studies investigating this condition exist in the medical literature.

Materials and methods

A literature search was conducted in PubMed and Scopus, and studies on ES of scapula published in the English medical literature were retrieved. A total of 15 studies were found and were included in our study.

Results

ES prevalence was highest in Asia. Moreover, ES was predominant in males (60%), with a male-to-female ratio of 3:2. ES in 53.3% and 46.6% of the cases were found in the right and left scapula, respectively. The main presentation of patients with ES of scapula was swelling, which was observed in 73.33% of the cases. Of the included studies, 46.6% used plain radiography as the primary investigation method, and 60% used computed tomography for staging and metastasis detection. For definitive diagnosis, 86.6% of the studies used immunohistochemistry markers. Adjuvant chemotherapy was considered in most studies (80%). Neoadjuvant chemotherapy was given in 6 out of 10 cases who underwent surgical treatment. Complications included malignant pleural effusion, respiratory failure, and movement restriction.

Conclusion

The scapula is an extremely rare site for ES. Local invasion was found in 63.64% of the cases, whereas pre-metastases were found in 35.71% of the cases. Magnetic resonance imaging was considered to be the best radiological method used to diagnose ES of scapula. Adjuvant chemotherapy, neoadjuvant chemotherapy, and surgery were the main treatments for ES.

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The scapula is an extremely rare site for Ewing's sarcoma.

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local invasion was found in 63.64%, whereas pre-metastases were found in 35.71%.

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The prevalence of Ewing tumor has male predominance with male to female ratio (3/2).

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Asia has the highest Ewing's sarcoma prevalence.

Benign and Malignant Tumors in Child Foot

Bone tumors affecting pediatric foot are a rare occurrence. Most lesions are benign, but a thorough diagnostic evaluation must always be performed to rule out malignant tumors. Approach to benign lesions is conservative, from observation follow-up to curettage or mininvasive techniques. In malignant lesions, a wide resection must be performed and same protocols applied as in tumors affecting other skeletal sites. Reconstructive procedures should aim to mechanical stability and long-lasting results; joint motion restoring can be attempted when not negatively affecting stability. Amputation procedures should be considered as a still viable choice because of their good functional result in the foot.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Diagnosis and staging of malignant bone tumours in children: what is due and what is new?

PURPOSE

Although malignant bone tumours in children are infrequent, it is important to know how to properly diagnose and stage them, in order to establish an adequate treatment.

METHODS

We present a review of the diagnostic workflow of malignant bone tumours in children, including history and clinical examination, imaging, laboratory tests and biopsy techniques. Moreover, the two most commonly used staging systems are reviewed.

RESULTS

History, clinical examination and laboratory tests are nonspecific for diagnosing malignant bone tumours in children. Radiographs remain the mainstay for initial diagnosis, with MRI the modality of choice for local assessment and staging. Fluorine-18 labelled fluoro-deoxy-glucose-positron emission tomography scans provide a noninvasive method to assess the aggressiveness of the tumour and to rule out metastasis and is replacing the use of the bone scintigraphy. Biopsy must be always performed under the direction of the surgeon who is to perform the surgical treatment and after all diagnostic evaluation has been done. Staging systems are useful to study the extent of the tumour and its prognosis. They are expected to evolve as we better understand new molecular and genetic findings.

CONCLUSION

When a malignant bone tumour is suspected in a child, it is essential to make a correct diagnosis and referral to an experienced centre. Following an appropriate workflow for diagnosis and staging facilitates, prompt access to treatment improves outcomes.

LEVEL OF EVIDENCE

Level V Expert opinion.

Identification of 6 gene markers for survival prediction in osteosarcoma cases based on multi-omics analysis

Multiple-omics sequencing information with high-throughput has laid a solid foundation to identify genes associated with cancer prognostic process. Multiomics information study is capable of revealing the cancer occurring and developing system according to several aspects. Currently, the prognosis of osteosarcoma is still poor, so a genetic marker is needed for predicting the clinically related overall survival result. First, Office of Cancer Genomics (OCG Target) provided RNASeq, copy amount variations information, and clinically related follow-up data. Genes associated with prognostic process and genes exhibiting copy amount difference were screened in the training group, and the mentioned genes were integrated for feature selection with least absolute shrinkage and selection operator (Lasso). Eventually, effective biomarkers received the screening process. Lastly, this study built and demonstrated one gene-associated prognosis mode according to the set of the test and gene expression omnibus validation set; 512 prognosis-related genes (P < 0.01), 336 copies of amplified genes (P < 0.05), and 36 copies of deleted genes (P < 0.05) were obtained, and those genes of the mentioned genomic variants display close associations with tumor occurring and developing mechanisms. This study generated 10 genes for candidates through the integration of genomic variant genes as well as prognosis-related genes. Six typical genes (i.e. MYC, CHIC2, CCDC152, LYL1, GPR142, and MMP27) were obtained by Lasso feature selection and stepwise multivariate regression study, many of which are reported to show a relationship to tumor progressing process. The authors conducted Cox regression study for building 6-gene sign, i.e. one single prognosis-related element, in terms of cases carrying osteosarcoma. In addition, the samples were able to be risk stratified in the training group, test set, and externally validating set. The AUC of five-year survival according to the training group and validation set reached over 0.85, with superior predictive performance as opposed to the existing researches. Here, 6-gene sign was built to be new prognosis-related marking elements for assessing osteosarcoma cases' surviving state.

A Atractylodes lancea polysaccharide inhibits metastasis of human osteosarcoma U-2 OS cells by blocking sialyl Lewis X (sLex )/E-selectin binding

In this study, a new water and alkaline‐soluble polysaccharide (ALP), with an average molecular weight of 6.63 × 10⁴ Da, was successfully purified from the rhizomes of Atractylodes lancea. GC analysis demonstrated that ALP was a kind of glucan. The effect of the ALP on the interaction between E‐selectin and sialyl Lewis X (sLe^x) was examined in human osteosarcoma U‐2 OS cells. It was obvious that the expression of sLe^x antigen on the surface of U‐2 OS cells was visible under fluorescence microscopy. The addition of ALP (0.5, 1 and 2 mg/mL) resulted in a marked inhibition on the adhesion, migration and invasion of U‐2 OS cells to human umbilical vein endothelial cells (HUVECs), which was achieved by the decreased sLe^x expression on U‐2 OS cells. Additionally, the induction of apoptosis can be observed in U‐2 OS cells following ALP treatment using TUNEL staining and Annexin V‐FITC/PI double‐staining analysis on flow cytometry. In conclusion, these results indicated that ALP exerted anti‐metastatic activity towards osteosarcoma cells via inhibition of sLe^x/E‐selectin binding, which suggested that ALP could be a potent agent for human osteosarcoma intervention.

MiR-135b Induces Osteosarcoma Invasion by the Modulation of FOXO-1 and c-Myc

Background: Osteosarcoma (OS) is the most common type of bone malignancy. Many studies have attempted to find the association between microRNAs and cancer-associated processes. Alterations in miRNA expression through genetic or epigenetic changes, impairment of transcription factors, and ectopic expression of miRNAs induce the development and progression of cancer. Although miR-135b has been thoroughly documented as an oncogene in the majority of studies, some controversies remain about the conflicting role of miR-135b as a tumor-suppressor. Objectives: The present study aimed at investigating the oncogenic and/or tumor-suppressing role of miR-135b in human OS. Methods: In this study, 21 OS tissue samples, along with 21 adjacent bone tissues (normal) as control specimens were collected to analyze the expression of miR-135b. The Saos2 cell-line was transiently transfected with the miR-135b mimic and inhibitor to assess its effect on two critical transcription factors, namely FOXO-1 and c-Myc. qRT-PCR was performed to quantify the expression of miR-135b in both OS tissues and the Saos2 cell-line. The MTT, cell migration, and cell invasion assays were used to characterize the miR-135b function. The western blot analysis was carried out to monitor the targets of miR-135b. Finally, the changes in cellular functions such as migration and invasion, following the transfection of miR-135b mimic and inhibitor, were verified. Results: The results showed that in comparison with the adjacent normal bone tissues, the expression of miR-135b was higher in OS tissue samples, which inversely correlated with the expression rate of FOXO-1, whereas the expression of c-Myc had a direct relationship to miR-135b expression. Functionally, the miR-135b mimic led to an increase in cell proliferation, invasion, and migration of OS cancer cells. Conclusions: MiR-135b induces the proliferation and invasion of OS cells by the degradation of FOXO-1 and upregulation of c-Myc.

Extended field of view magnetic resonance imaging for suspected osteomyelitis in very young children: is it useful?

BACKGROUND

Osteomyelitis is a challenging diagnosis for clinicians, particularly in very young children. At our institution, the magnetic resonance imaging (MRI) protocol in suspected osteomyelitis for children 5 years of age or younger includes a large field of imaging regardless of the clinical site of concern.

OBJECTIVE

To determine if extended field of view (FOV) MRI contributes important information in young children with suspected osteomyelitis.

MATERIALS AND METHODS

A retrospective study was performed including children 5 years of age or younger with suspected osteomyelitis from January 2011 to September 2015. All children underwent coronal fluid-sensitive MRI from neck to feet. Focused imaging was performed as necessary on abnormal sites depicted on survey imaging. Two radiologists reviewed the imaging findings, which were compared to the clinical outcome.

RESULTS

We studied 51 children with a mean age of 2.2 years (range: 21 days-5.5 years); 53% were boys. Osteomyelitis was depicted by MRI in 20 subjects (39.2%). Survey coronal fluid-sensitive imaging was accomplished by adding a single fluid-sensitive series in 1 child, 2 series in 31 children, 3 series in 16 children and 4 series in 3 children. Survey imaging added a median total time of 6:51 min to the examination (range: 2.29-20.54 min). Extended FOV imaging added important information in 11/51 subjects (21.6%), in 6 cases (11.8%) of infection and in 5 cases (9.8%) by suggesting alternative diagnoses.

CONCLUSION

The addition of extended FOV MRI in young children with suspected osteomyelitis added important clinical information in 21.6% of patients while only adding a median of 6:51 min to the examination. It is our experience that in children ≤5 years of age with suspected osteomyelitis, extended FOV imaging adds important information and may result in changes in management.

Nutritional Rickets Presenting as Chronic Episodic Extremity Pain in a 9-year-old with Autism

Rickets due to vitamin D deficiency, typically presenting as bowed legs in toddlers, is uncommon in the modern era. We describe the case of a nine-year-old girl with autism and developmental delay who was evaluated for chronic intermittent extremity pain for more than one year prior to referral to the emergency department for hypocalcemia and increased alkaline phosphatase, which eventually led to the diagnosis of rickets confirmed by radiographic and laboratory findings. This report highlights the importance of the patient's history of developmental delay and autism in the evaluation and approach to limb pain, and discusses the appropriate diagnostic approach.

Carpal synovitis with capitate bone tuberculosis in a child

We present a 10-year-old boy with 2-month duration non-traumatic wrist pain and inflammatory signs. Due to elevated inflammatory markers on blood tests, with an increase in radiocarpal and intercarpal joints synovial fluid and no bony lesions, the patient was submitted to wrist arthrocentesis for the suspicion of septic arthritis. The patient did not improve on conventional treatment, however. An MRI showed synovitis around the carpus and a lytic lesion of the capitate bone due to osteomyelitis. A biopsy was able to identify the causative agent as Mycobacterium tuberculosis, and the patient was treated with antibiotics. He improved significantly, with no pain and signs of normal capitate bone remodelling on the last radiograph.

miRNA profiling identifies deregulated miRNAs associated with osteosarcoma development and time to metastasis in two large cohorts

Osteosarcoma (OS) is an aggressive bone tumor primarily affecting children and adolescents. The etiology of OS is not fully understood. Thus, there is a great need to obtain a better understanding of OS development and progression. Alterations in miRNA expression contribute to the required molecular alterations for neoplastic initiation and progression. This study is the first to investigate miRNA expression in OS in a large discovery and validation cohort comprising a total of 101 OS samples. We established the signature of altered miRNA expression in OS by profiling the expression level of 752 miRNAs in 23 OS samples using sensitive LNA-enhanced qPCR assays. The identified miRNA expression changes were correlated with gene expression in the same samples. Furthermore, miRNA expression changes were validated in a second independent cohort consisting of 78 OS samples. Analysis of 752 miRNAs in the discovery cohort led to the identification of 33 deregulated miRNAs in OS. Twenty-nine miRNAs were validated with statistical significance in the second cohort comprising 78 OS samples. miRNA/mRNA targets were determined, and 361 genes with an inverse expression of the target miRNA were identified. Both the miRNAs and the identified target genes were associated with multiple pathways related to cancer as well as bone cell biology, thereby correlating the deregulated miRNAs with OS tumorigenesis. An analysis of the prognostic value of the 29 miRNAs identified miR-221/miR-222 to be significantly associated with time to metastasis in both cohorts. This study contributes to a more profound understanding of OS tumorigenesis, by substantiating the importance of miRNA deregulation. We have identified and validated 29 deregulated miRNAs in the - to our knowledge - largest discovery and validation cohorts used so far for miRNA analyses in OS. Two of the miRNAs showed a promising potential as prognostic biomarkers for the aggressiveness of OS.

Atlantoaxial Langerhans cell histiocytosis radiographic characteristics and corresponding prognosis analysis

BACKGROUND

Langerhans cell histiocytosis (LCH) may affect atlas and axis, and there were very few published cases describing a characteristic of LCH of atlantoaxial.

OBJECTIVE

The objective of the study is to investigate the image manifestations of atlantoaxial LCH to improve the in-depth comprehension on it.

MATERIALS AND METHODS

A retrospective study was done of computed tomography (CT) and magnetic resonance imaging in atlas and axis and prognosis was analyzed.

RESULTS

The study included 41 patients (average age 12.9 years and median age 8 years) diagnosed with LCH, with 75.6% under 15 years old. Eighty-four lesions of LCH were identified including 47 in the atlas and 37 in the axis. The osteolytic bone destructions in the atlas and axis were characterized, 22% accompanied by sclerotic margins. Thirteen patients had a compression fracture, 11 in the lateral mass of the atlas and 2 in the C2 vertebral body. Sixteen and three patients had atlantoaxial malalignment and dislocation, respectively. On T2-weighted images, 68.9% showed iso- or low-signal intensity, 27.6% showed hyperintensity signal, and 3.4% showed heterogeneous signal. On postcontrast images, 81.9% showed significant enhancement, 12.5% showed moderate enhancement, and 6.3% showed mild enhancement. CT reexamination of 14 patients indicated atlantoaxial bone destruction relatively repaired in 12 patients. Thirty-three patients were a follow-up, 81.8% had no significant symptoms and 18.2% with remaining symptoms.

CONCLUSIONS

The atlas and axis were affected by LCH, mainly in children. The lateral mass was easily affected and compressed, destruction of the atlas and axis could lead to atlantoaxial joint instability. The prognosis was good in most of the patients.

Knee Pain in Children, Part II: Limb- and Life-threatening Conditions, Hip Pathology, and Effusion

On the basis of primarily consensus due to lack of relevant clinical studies, the most important evaluative step for knee pain is to identify any emergent conditions, including limb- and life-threatening disorders (septic arthritis, osteomyelitis, and malignancy), hip pathology, or conditions associated with effusions. (2)(3)(6)(8)(11)(13)(14)

Knee Pain in Children: Part I: Evaluation

• On the basis of primarily consensus, due to lack of relevant clinical studies, the information obtained from the history and physical examination is the key to establishing a diagnosis and directing initial management of knee pain. • By applying history and physical examination findings to a diagnosis and management algorithm, clinicians can efficiently and effectively determine the potential cause of the knee pain. • On the basis of primarily consensus, due to lack of relevant clinical studies, the most important step of the evaluation of knee pain is to identify emergent conditions, including limb- and life-threatening conditions (eg, septic arthritis, osteomyelitis, and malignancy), hip pathology, or conditions associated with effusions.

Langerhans cell histiocytosis of the clavicle: a case report and review of the literature

We report a rare case of solitary Langerhans cell histiocytosis (LCH) involving the clavicle of an adult female. The patient was a 32-year-old female presenting with 1 month history of progressive pain, swelling, and tenderness in the region near the left sternoclavicular joint. Radiograph, computed tomography, and magnetic resonance imaging showed an osteolytic lesion in the clavicle with tumor extension and soft tissue edema. Surgical curettage of the lesion was performed, and the histopathologic diagnosis was LCH. Because of its rarity and possibly variable presentation, LCH should be included and considered in the differential diagnosis when we encounter a clavicle lesion.

Mis- or Missed Diagnosis: A Series of Four Cases

Diagnosis forms the backbone of treatment planning. Accurate diagnosis is essential to initiate the appropriate treatment at the apt time. Diagnosis involves eliciting the signs and symptoms of the patient and their accurate interpretations. The subtle signs that can go unnoticed lead to misdiagnosis and subsequent agony to the patient. Alertness on part of the clinician is important to avoid this error. Reported in this paper are four cases that were wrongly diagnosed either due to lack of clinical experience or due to omission of careful clinical, radiographic, and histopathological examinations.