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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 85-88

The unusual demographic presentation of an osteoid osteoma


1 Lewis Katz School of Medicine at Temple University, Philadelphia, USA
2 St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Date of Submission07-Jul-2017
Date of Acceptance20-Dec-2017
Date of Web Publication23-Apr-2018

Correspondence Address:
Mr. Aliaskar Z Hasani
801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_68_17

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  Abstract 


Demographics are an important tool for narrowing down the differential diagnosis for many medical presentations, and though usually steadfast, there are exceptions in using demographics as a guideline for diagnosis. Neoplastic bony lesions are particularly reliable in their presentation within a specific age range. However, if these cases are not fully evaluated and demarcated from one another, it may lead to overevaluation and treatment or underevaluation and treatment of benign neoplastic bony lesions. In this report, we present the case of a 30-year-old male with an osteoid osteoma presenting out of the typical age range. We also include the subsequent treatment of the benign tumor with radiofrequency ablation after the initial failure in medical management. The age range of the presentation of osteoid osteomas is commonly reported in the literature as 5–25 years, and the treatment can be medical or surgical. Here, we discuss the treatment options, demographic presentation, and course of osteoid osteomas.
The following core competencies are addressed in this article: Patient care, Medical knowledge.

Keywords: Benign neoplasm, demographics, osteoid osteomas, radiofrequency ablation


How to cite this article:
Hasani AZ, Ringold MA, Thomas JL. The unusual demographic presentation of an osteoid osteoma. Int J Acad Med 2018;4:85-8

How to cite this URL:
Hasani AZ, Ringold MA, Thomas JL. The unusual demographic presentation of an osteoid osteoma. Int J Acad Med [serial online] 2018 [cited 2019 Jul 23];4:85-8. Available from: http://www.ijam-web.org/text.asp?2018/4/1/85/230852




  Introduction Top


Osteoid osteomas are benign sclerotic bone-forming neoplasms composed of a central nidus.[1],[2] The microscopic features of this tumor are woven bone surrounded by osteoblasts providing remodeling with osteoclastic bone resorption in the peripheral ends, causing its classic appearance on imaging.[3] It is reported that 75% of cases are diagnosed in children and young adults, aged 5–25 years. The classic clinical presentation is pain that increases at night which can be well controlled with nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoid osteomas account for approximately 10% of all benign bony lesions.[2],[3] Although treatment with anti-inflammatories provides a nonprocedural long-term option, the mainstay of therapy has increasingly become complete exclusion of the nidus that can be achieved through computed tomography (CT)-guided radiofrequency ablation, which leads to resolution of symptoms without the need of long-term medicinal therapy. This method provides the perfect balance between clinical efficiency and minimal trauma to the patient which leads to improved quality of life and shorter recovery times.[4] We report the case of a male who presents outside of the common demographics for osteoid osteomas, failed initial medical therapy with NSAIDs, and found relief through radiological intervention.


  Case Report Top


A 30-year-old obese male with a body mass index of 37.7 presented to a family medicine outpatient clinic complaining of severe pain for the past year in the left knee on the joint line, along the left distal femur, with concurrent swelling, and full range of motion. The patient had a history of bilateral knee pain and of schizophrenia for which he took perphenazine and benztropine. He also had a history of previous tobacco use and marijuana use “frequently.” The patient went to an urgent care center and emergency department at various hospitals which, through imaging, suggested the diagnosis of an osteoid osteoma. The pain was worse at night and he was prescribed naproxen 500 mg twice a day as needed which provided satisfactory results upon initial presentation, but the pain began to persist. On initial imaging, there was a focal cortical thickening of the medial aspect of the distal femoral diametaphysis, with a focus of a smaller internal area of lucency measuring 4.87 mm × 5.80 mm [Figure 1]. The patient was then referred for a CT-guided ablation and biopsy.
Figure 1: Osteoid osteoma on initial imaging

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The patient was placed under general anesthesia, and CT imaging was used to locate the lesion in the distal left femur [Figure 2]a. After prepping the overlying skin with local anesthetic, under CT guidance, a core needle was used to create a tract through the nidus and bone marrow space. Bone fragments were removed and sent to pathology [Figure 2]b. Radiofrequency ablation was performed through the nidus for approximately 1 min and 30 s. The patient tolerated the procedure and left under stable conditions.
Figure 2: (a) Osteoid osteoma in the distal femur preoperation. (b) Core needle insertion to create tract with computed tomography guidance

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Follow-up imaging 1 week after the treatment showed no fractures, degenerative changes, or dislocation [Figure 3]. There was evidence of cortical thickening along the medial aspect of the distal femur with a new transverse lucency congruent with recent ablation. The patient had no complaints and was satisfied with the procedure. The patient was given rehabilitation services three times a week for 4 weeks. Pathology report confirmed the diagnosis of osteoid osteoma.
Figure 3: Imaging 1 week postoperatively

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  Discussion Top


Most cases of osteoid osteomas usually present between the ages of 5 and 25 years, coinciding with hormonal-driven development of the human body. In that population, there are multiple benign lesions in the differential such as osteochondromas, osteoblastomas, hemangiomas, chondroblastomas, and enchondromas. Common malignant lesions in the younger age group include osteosarcomas and Ewing's sarcomas.[5] In the older patients aged 30–50 years, other bony lesions become more common. These include chondrosarcomas, fibrosarcomas, malignant fibrous histiocytomas, and lymphomas. After the age of 50, the most common bony lesion is multiple myeloma.[6] Our 30-year-old patient with a presentation of severe bone pain is an unusual case to the common presentation of osteoid osteoma for which there are many treatment options with a great prognosis.

Diagnosis of osteoid osteomas is done through various imaging tools including magnetic resonance imaging, X-ray, bone scintigraphy, and CT, with the latter two being the most viable. There have been case reports of finding incidental lesions using positron emission tomography (PET)-CT scans.[7] In areas with complex anatomy, neurovascular components, and fibrosis such as the cervical spine, PET-CT scanning may have increased specificity and sensitivity.[8]

Multiple treatment modalities have been available to physicians to treat patients presenting with osteoid osteomas. These tumors have been shown to have high levels of local prostaglandins and good efficacy in initial conservative treatment with NSAIDS, indicating a role of cyclooxygenase (COX) 1 and COX 2 for the pathogenesis of these tumors.[9] Conservative medical therapy, while an acceptable option, there have been reports of the evolution of osteoid osteomas into osteoblastomas in the literature in non-invasive treatment.[3],[10] When conservative management fails to provide pain relief, additional intervention is usually necessary. Other treatments currently being researched include the use of bisphosphonates which may have direct or indirect antitumor effects. These medications have been shown to relief bone pain in multiple types of osteolytic bony lesions. Current data show that bisphosphonate therapy helps initiate partial/complete pain relief in small prospective studies by accelerated nidus mineralization through conservative means. Moreover, current research is being done to compare medical management of osteoid osteomas to ablation.[11] Radiofrequency ablation is an effective intervention using long-wave electromagnetic radiation to provide thermal coagulation, which in regard to treating osteoid osteoma provides the same outcomes as operative treatment without the need for hospitalization, reducing complications and providing swift recovery.[12],[13]


  Conclusion Top


New imaging modalities and treatment options are currently being studied for osteoid osteomas to find a balance between early detection, sensitivity/specificity, and conservative versus invasive management. We share our experience of an unusual case of osteoid osteoma in a 30-year-old patient whose clinical picture initially led to delay in the diagnosis of his condition. Although the patient's initial NSAID treatment was appropriate, it failed, and the patient was referred for more invasive treatments with optimal results.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent documentation, wherein the patient(s) has/ have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient(s) understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to acknowledge the wonderful nursing, advanced care practitioners, and staff at St. Luke's Hospital for without their work none of this would be possible.

Financial support and sponsorship

This study was financially supported by St. Luke's University Hospital for equipment, drugs, etc.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jaffe HL. Osteoid-osteoma of bone. Radiology 1945;45:319-34.  Back to cited text no. 1
    
2.
Hoffmann RT, Jakobs TF, Kubisch CH, Trumm CG, Weber C, Duerr HR,et al. Radiofrequency ablation in the treatment of osteoid osteoma-5-year experience. Eur J Radiol 2010;73:374-9.  Back to cited text no. 2
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3.
Atesok KI, Alman BA, Schemitsch EH, Peyser A, Mankin H. Osteoid osteoma and osteoblastoma. J Am Acad Orthop Surg 2011;19:678-89.  Back to cited text no. 3
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4.
Sarabia Condes JM, Martínez Martínez J, Villamor Redondo P, Martínez Fernández M, Blanco Barrio A. Treatment of osteoid osteoma by means of CT-guided radiofrequency. Rev Ortop Traumatol 2010;54:20-6.  Back to cited text no. 4
    
5.
Özkan EA, Göret CC, Özdemir ZT, Yanık S, Doǧan M, Gönültaş A,et al. Pattern of primary tumors and tumor-like lesions of bone in children: Retrospective survey of biopsy results. Int J Clin Exp Pathol 2015;8:11543-8.  Back to cited text no. 5
    
6.
Teo HE, Peh WC. Primary bone tumors of adulthood. Cancer Imaging 2004;4:74-83.  Back to cited text no. 6
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7.
Castello A, Lopci E. Incidental identification of osteoid osteoma by 68Ga-PSMA PET/CT. Eur J Nucl Med Mol Imaging 2017;508:1-2  Back to cited text no. 7
    
8.
Kong J, Xiao H, Liu T, Yan W, Qian M, Song DW,et al. The valuation of using FDG PET-CT in detecting osteoid osteoma of the cervical spine. J Spinal Disord Tech 2015;28:E67-73.  Back to cited text no. 8
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9.
Mungo DV, Zhang X, O'Keefe RJ, Rosier RN, Puzas JE, Schwarz EM,et al. COX-1 and COX-2 expression in osteoid osteomas. J Orthop Res 2002;20:159-62.  Back to cited text no. 9
    
10.
Bruneau M, Polivka M, Cornelius JF, George B. Progression of an osteoid osteoma to an osteoblastoma. Case report. J Neurosurg Spine 2005;3:238-41.  Back to cited text no. 10
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11.
Bousson V, Leturcq T, Ea HK, Hauger O, Mehsen-Cetre N, Hamzé B,et al. An open-label, prospective, observational study of the efficacy of bisphosphonate therapy for painful osteoid osteoma. Eur Radiol 2017;28(2):478-486.  Back to cited text no. 11
    
12.
Nogueira Drumond JM. Benign bone tumors and tumor-like bone lesions: Treatment update and new trends. Rev Bras Ortop 2009;44:386-90.  Back to cited text no. 12
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13.
Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ,et al. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998;80:815-21.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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