Case report Extragnathic fibromyxoma report of a case
of the calcaneum:
F.O. ABU H A S S A N 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.
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 [email protected]).
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 de fned 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).
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 demonst ra ted increased uptake in the hindfoot, mainly related to the calca- neum.
A computed tomography scan demonst ra ted 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 at tempt of needle aspiration did not reveal any fluid content.
Incisional biopsy of the lesion was then per formed under general anaesthesia wi thout using the tourni- quet.
The pr imary histological findings were uniform, small, stellate, spindle-shaped cells with no mitosis or p leomorphism in the s troma of the dense, fibrous tissue, which were typical of f ibromyxoma.
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, unde r 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 f ibromyxoma (Figure 4).
Complete curettage unde r direct vision was fol lowed by local application of 5% phenol.
The cavity was finally filled with bone cement. Full weight bearing was al lowed 25 clays after surgery.
F I B R O M Y X O M A OF T H E C A L C A N E U M 61
Figure 4 Final histological diagnosis confirming the fibromyxoma.
There was no evidence of recurrence after 2 years of fol low-up.
D i s c u s s i o n
Fib romyxoma is a benign, bony lesion main ly affecting the jaw [1-3]; extragnathic forms are
u n c o m m o n [4-8]. The me taphysea l ends of long bones, especially the femoral ends, are the mos t
extragnathic localizations, which fo rm 30% of the cases [1,4,6]. The lesion rarely originates f rom the pe r ios teum of the femur [9].
Occasionally, f i b romyxoma originates f rom flat bones [1-3], but was not p rev ious ly described in the spongy bones as in our case.
Approx ima te ly 31 cases of the extragnathic var ie ty have been repor ted [1,3,4,6,8]. The lesion presents wi th pa in in var ious age groups. It is main ly repor ted dur ing the first two decades of life and after the fifth decade [1,3,5]. The commones t radio- logical feature is a well localized, radiolucent, lytic defect or an expansile, medul lary , me taphysea l defect, wi th cortical destruct ion [1,3,4]. The t u m o u r m a y extend to the soft t issue but it does not cause periosteal reaction [1,7,8]. Our case demons t r a t ed the well def ined lyric lesion, and cortical destruct ion of the outer third of the calcaneum, wi th no soft t issue extension.
Extragnathic f ib romyxoma can be radiologically misd iagnosed with different benign lytic bone lesions, for example , intraosseus l ipoma [10-12], intraosseus gangl ion [13,14], chondromyxo id fibro-
m a [1,15], bone cysts [16,17], desmoplas t ic f ibroma [18,19] and giant cell t u m o u r [15].
The cavity of the f i b r o m y x o m a lesion contains soft grey to white gelat inous tissue. The histology is distinctive, compr is ing uni form, small, stellate
and sp indle-shaped cells wi th no mitosis or pleo- m o r p h i s m in the s t roma of the dense fibrous tissue,
presence of areas of chondroid and osteoid tissues, bu t no lobulation or f ibrous capsule [1,3,4]. Secon- da ry aneurysmal bone cyst has been described histologically [3]. F ib romyxoma should be differ- entiated f rom mal ignant bone tumours , for exam- ple, f ibrosarcoma [15], chondrosa rcoma [1,20], or metastat ic lesions of bone [15,21], by p rominen t myxoid zones, absence of mitosis and p leomor- ph i sm [4].
In our case, incisional b iopsy was necessary to establish the presence of the typical uniform, stellate and sp indle-shaped cells in their fibrous and chon- droid tissues. At a later stage, we carried out an adequate curettage, local appl icat ion of 5% phenol and packed the cavity wi th bone cement to avoid local recurrence of the tumour . Nevertheless , fibr- o m y x o m a m a y recur after curet tage [1,3,5,6]. In soft t issue involvement , en bloc excision is r e c o m m e n d e d [1,3,51.
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