Peripheral Sclerosis Research Articles

Imaging Features of Intraosseous Schwannoma: A Case Series and Review of the Literature.

To characterize the imaging features of patients with pathologically confirmed intraosseous schwannoma (IOS), institutional pathology and imaging databases were searched for IOS cases over a period of 17 years. A musculoskeletal radiologist evaluated all imaging studies. Additionally, a literature search was performed to identify IOS cases that had imaging findings of at least two modalities. Six patients (one female, five males, mean age of 50 ± 14 years) with IOS were identified, with all lesions localized to the lumbosacral region. Radiographic imaging was available in four patients, while all patients underwent CT and MR imaging. Radiographs depicted lytic lesions, and CT depicted heterogeneous expansile lesions with centrally hypodense areas and peripheral sclerosis. All cases involved extra-osseous extension, producing a mass effect on adjacent soft tissues and nerve roots. On MRI, the neoplasms displayed iso- to- slightly- low signal intensity on T1-weighted images and hyperintense signal intensity on T2-weighted images with heterogeneous enhancement. The literature review resulted in 102 IOS cases, which to the best of our knowledge, is the largest review on IOS, and the imaging findings of the previously published cases were the same as our cases. IOSs are rare benign neoplasms that should be considered in the differential diagnosis of well-defined expansile lytic lesions with sclerotic borders. This is particularly important in middle-aged adults with mandibular, sacral, or vertebral body mass.

Evolution of bone metastases in patients receiving at least three months of checkpoint inhibitors.

To investigate the evolution of bone metastases in patients receiving immune checkpoint inhibitors (ICI). A single-center retrospective study included cancer patients with bone metastases treated with ICI at our institution between January 2014 and September 2019. Clinical and biological data were collected from medical records and independent expert review of imaging was performed. Target and non-target lesions were identified and followed up to 1 year. Patients were then classified as bone responder or non-responder. Comparisons between groups were performed with Student's t test or Mann-Whitney test. Among 1108 patients screened, 192 patients had bone metastases and 48 patients were included in the final analysis, with lung cancer, renal carcinoma and melanoma as most represented cancer type. Half of the patients experienced stability, condensation or peripheral sclerosis of bone lesions. Initial progression before stabilization with or without sclerosis of bone lesion occurred for 19% of patients (pseudoprogression). There was an association between bone response and global oncological outcomes. Bone responder patients had a significant decrease in morphine and co-analgesic prescription as well as a significant decrease in alkaline phosphatases compared to non-responder patients. Bone response was observed in half of patients with available imaging and follow-up after 3months of ICI treatment, with sclerosis observed in one-third of bone lesions at month 3, in all tumor types. Up to 20% of patients experienced a pseudoprogression of bone lesions such as previously described in primary tumor and other metastatic sites. Bone response was associated with improvement of pain and survival.

Primary patella tuberculosis mimicking pre-patellar bursitis: A case report and review of the literature.

Introduction and importanceThe Patella is very rare site for tuberculosis (TB). The knee is the third most common site for skeletal TB. The incidence of patella TB being 0.09 to 0.15%.Case presentationWe report a case of primary tuberculous osteitis isolated from the patella. The complaint was a mixed knee pain without notion of trauma. The CT showed a large osteolysis of the upper half of the patella. The diagnosis was established on the histological study after biopsy. The patient was operated by a medial approach without arthrotomy and the pathological tissue was resected and curetted. Complementary anti-bacillary antibiotic treatment was administered for 12 months. At the last clinical control, the knee was free and painless, and we had no recurrence.Clinical discussionAitken reported the first case in literature in 1933. The initial signs and symptoms are non-specific and sometimes confounded by a coincidental history of trauma. It is difficult to diagnose TB of patella in early stages because there are no constitutional symptoms. Sometimes serological parameters are inconclusive. CT scan can help if the osteolysis contained a central bone sequestration, bordered by peripheral sclerosis. Confirmation of patellar tuberculosis is made on biopsy.ConclusionThe tuberculous localization in the patella is rare and it can pose a problem of differential diagnosis with other affections, in particular infectious and tumors. It should always be kept in mind, especially in the face of a picture of pre-patellar bursitis which progresses slowly and whose biological inflammatory syndrome is not straightforward.

Remote Scaphoid Fracture

A 38-year-old active-duty service member self-referred to physical therapy after 1 year of increasing left dorsoradial wrist pain with insidious onset. Suspicious of a nonunion scaphoid fracture, the physical therapist ordered radiographs, revealing a left nonunion scaphoid fracture with peripheral sclerosis and remote triquetral fracture. JOSPT Cases 2021;1(1):27–28. doi:10.2519/josptcases.2021.9700

Extra Axial Chordoma of the Distal Femoral Metaphysis: A Case Report

Background Chordomas are malignant bone tumors that are derived from remnant embryonic tissue of the notochord and are typically found in the axial midline. When they are found outside of the axial skeleton, the diagnosis can be challenging and elusive. Often, they are overlooked on initial presentation in lieu of other more common lesions, including cartilage tumors (eg, enchondroma, chondrosarcoma, osteochondromatosis) due to their overlapping features. Case Report A 30-year-old female with a four-year history of intermittent left knee pain presented for initial evaluation. Physical exam of the knee was unremarkable except for moderate tenderness on palpation. Radiographs showed a lucent lesion with peripheral sclerosis, eccentrically located within the anteromedial femoral diaphysis. The patient was subsequently lost to follow-up. She presented again two years later with similar symptoms. Her physical exam remained unchanged, and repeat radiographs showed interval growth. She underwent open biopsy of the left distal femur, with pathology revealing tumor consisting predominantly of epithelioid cells set in an abundant myxoid matrix. Immunohistology showed cells that stained strongly for EMA, CK19, and brachyury. These findings support the diagnosis of extra-axial chordoma. Discussion Extra-axial chordomas remain a challenging diagnosis for clinicians due to their extreme rarity and overlapping features with other more common lesions. They are often misdiagnosed as extraskeletal myxoid chondrosarcomas or myoepitheliomas. Our patient’s insidious presentation and radiologic findings present a learning opportunity for clinicians to recognize extra-axial chordomas as a potential early diagnosis in someone presenting with a long history of intermittent and worsening knee pain.

Resection of Bone Tumor Guided by Gamma Probe and Evaluation of Postoperative Pain.

Osteoid osteoma is a benign neoplasm commonly found in young men, but that can be found in every age, which affects mainly long bones, clinically characterized by continuous and limiting pain that is relieved by salicylates. It is a small lesion composed of immature osteoid tissue, central hypervascularization and surrounding sclerotic area. Its diagnosis is performed by the clinic and aided by imaging tests, such as common radiography and computed tomography. Radiography shows a central radiolucent lesion and peripheral sclerosis. The biopsy takes place only in cases of diagnostic doubt. Surgical treatment involves resection of the niche, providing greater symptomatic relief, as well as percutaneous techniques. The technique of radioisotope-guided resection has good acceptance in the scientific community for its fast surgical procedure directed to the lesion; however, the percutaneous technique that stands out is radiofrequency ablation. In the present study, all of the patients submitted to the technique presented total improvement of the pain.

Itch in Chronic Wounds: Pathophysiology, Impact, and Management

Background: The aims of this review are to analyze the current literature regarding the characteristics and pathophysiological mechanisms of itch in chronic wounds, to assess the impact on quality of life and delayed-healing, to focus on the best strategies of prevention and treatment, to highlight the importance of on-going research in order to fully understand the pathophysiology, and to improve the management of target therapies. Methods: A systematic literature review was performed using MEDLINE, PubMed, Embase, Scopus, ScienceDirect, and the Cochrane Library. We included a total of 11 articles written in English with relevant information on the pathophysiology of itch in chronic wounds and on management strategies. Results: Itch in chronic wounds was found to be correlated with xerosis, larger wound areas, necrotic tissue and amount of exudate, peripheral tissue edema, sclerosis, granulation tissue, contact dermatitis, and bacterial burden, as well as with lower quality of life. Conclusions: Although there are several aspecific pharmacological and non-pharmacological approaches, there appears to be no validated prevention or management strategy for itch in chronic wounds. Further studies are needed to clarify the association and pathophysiology of itch in chronic wounds, to evaluate the safety and efficacy of topical treatments on perilesional skin to reduce itch, to characterize multidimensional sensations of itch in chronic wounds, to identify specific cytokine and chemokine expressions that are correlated to a tailored-based approach, and to develop practical guidelines.

The Ischemic/Septic Diabetic Hand: Review of Literature and a Case Report

The term “diabetic hand” was born to describe the complications of the diabetes mellitus on the hand resulting in a rigid hand with a poor mobility. The traumatic wounds with soft tissue involvement increase the risk of infection. Staphylococcus aureus methicillin-resistant (MRSA) is the most common bacterium isolated in the hand infections. The case report of a type 2 diabetic patient, dialysed with chronic obstructive peripheral artery disease and Monckeberg sclerosis of the vessels of the hands, ischemic necrosis of the right hand fingers is reported by the authors. In the diabetic patient the hands can be infected in the same way that feet could be infected too. Several amputation interventions have been performed with the intent of saving part of the hand. The diabetic hand syndrome (DHS) is an important pathology that requires strong antibiotics and surgery to avoid severe disability as rigidity, contracture and amputation. Apparently, in the last years good results are reported using antibiotic, surgical and hyperbaric treatment. In conclusion it would be wrong to ignore or underestimate this disease and any doctor should practice a scrupulous visit of the hands in the diabetic patient.

Computed tomographic versus radiographic assessment of the visibility and features of subchondral cystic lesions in equine limbs

Subchondral cystic lesions (SCLs) are common in horses and often cause lameness and they are commonly diagnosed by radiography. This study compares radiographic and computed tomographic (CT) features of subchondral cystic lesions in horses. It was hypothesized, that CT has a superior diagnostic value for the assessment of the features of SCLs compared to radiography. Horses diagnosed with one or two SCLs in CT and a radiographic study of the affected bone were included. SCLs were evaluated on radiographs and CT for location, size, shape, homogeneity, continuity of the subchondral bone, peripheral sclerosis, presence of a fissure, osteoarthritis (OA) and periostitis. Vascular channels were only assessed with CT. Subsequently, radiographic findings were compared to CT. Forty-two SCLs in a total of 32 horses were included in the study. Radiographic visibility of SCLs diagnosed with CT was 79% (95% CI: 0.64 to 0.88). In joints with two SCLs, the second cystic lesion was more often missed radiographically (p=0.014). A discontinuous subchondral bone was evident in CT in 40 of 42 SCLs whereas it was suspected in only 23 of 33 radiographically diagnosed SCLs. With CT, fissures were more commonly diagnosed and in 16 SCLs, vascular channels were identified. SCLs with fissures showed more periostitis with CT (p=0.01). Radiographically missed SCLs presented less peripheral sclerosis in CT (p=0.023). Intermodality agreement was borderline good (κ=0.60–0.66) for location (proximal, distal; lateral, medial, midsagittal), OA and periostitis, borderline moderate for presence of a fissure (κ=0.42), fair for homogeneity (κ=0.35), and only poor for location (dorsal, central, palmar/plantar), shape, peripheral sclerosis and continuity of the subchondral bone (κ=0.06–0.18). This study highlights the advantages of CT for the characterization of SCLs in horses. Vascular channels appear to be a frequent finding.

Differential CT and MR imaging diagnosis between low- and high-grade malignant vascular tumors of bone.

ObjectiveTo investigate the CT and MR imaging findings and differential diagnosis of malignant vascular tumors of bone. Materials and methodsCT and MR imaging findings of 18 patients with histopathology-proven malignant vascular tumors of bone were examined. Assessed image features included age, sex, location, CT findings, and MR imaging appearances and dynamic contrast-enhanced MR imaging. ResultsThe study group comprised 18 cases, of which 7 were categorized as low-grade malignant vascular tumors (LMT), and 11 were categorized as high-grade malignant vascular tumors (HMT). Malignant vascular tumors of bone showed osteolytic lesions with heterogeneous signs and enhancement, and frequently associated with soft tissue masses and peritumorous edema. The mean age of patient was respectively 34.7 years in LMT with 3 patients younger than 20 and 49.9 years in HMT with 3 patients older than 60 years. The mean lesion diameter was 3.6 cm (range 2–7.2) in LMT with two lesions <3 cm and 7.1 cm (range 3–13) in HMT with 3 lesions greater than 10 cm. LMT showed multifocal (57.1 %) and well-defined (71.5 %) lesions with residual bone (57.1 %), peripheral sclerosis (85.7 %), and slightly hetergeneous enhancement (71.4 %), compared to those of HMT with 9.1, 45.5, 27.3, and 72.7 %, and 9.1 % respectively. Also, HMT appeared as expansive (54.5 %), ill-defined (54.5 %), macroscopic necrosis/cystic (81.8 %) or hemorrhagic (27.3 %) lesion with pathological fracture (27.3 %), and often presented with obviously hetergeneous enhancement (81.8 %), compared to those of LMT with 42.9, 28.6, 42.9, 0, 14.3 and 14.3 % respectively.ConclusionsThere are some differences in the imaging features between LMT and HMT, while unifocal/multifocal, expansive, ill-defined, necrosis/cystic, hemorrhagic features with age, lesion diameter, peripheral sclerosis, residual bone tissue, pathological fracture and slightly/obviously hetergeneous enhancement highly suggest their differential diagnosis.

Palatal Swelling: A Diagnostic Enigma

Giant cell tumor (GCT) of bone is a giant-cell-rich bony lesion associated with abundant multinucleated osteoclast-type giant cells. It is a primary neoplasm of bone with characteristic clinical, radiological, and pathological features. It is an expansive and lytic lesion without periosteal reaction and prominent peripheral sclerosis. Giant cells are also seen in other diseases like giant cell granuloma of the jaws, traumatic bone cyst, aneurysmal bone cyst, and jaw tumor of hyperparathyroidism. We present a unique case of GCT of palate in a 30-year-old female.

The prediction of high-sensitivity C reactive protein for peripheral arterial sclerosis in middle-aged population

To explore the predictive value of high-sensitivity C reactive protein (hsCRP) in middle-aged population during the peripheral arteriosclerosis. Random sampling method was used in the study. In 2006-2007 Kailuan Group health examination of 101,510 employees, using stratified random sampling method to select 5,852 as observational cohort included, in the final with a standard queue 5,440 in December 2009. This study selected to participate in the 2012-2013 health examination cohort as the research object, in accordance with the inclusion criteria ultimately selected survey 3,978, select the epidemiological investigation, physical examination, laboratory testing data analysis. Of the 3 978 subjects, 2,282 were male and 1,696 were female, and the baseline age was (53.80±11.14) years. According to the baseline hsCRP quartile level was divided into four groups for comparison of baseline data, using multiple linear regression analysis between hsCRP and brachial-ankle pulse wave velocity (baPWV). Area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the prediction of hsCRP levels in peripheral arteriosclerosis. With increase of hsCRP levels, the survey of baseline levels of baPWV showed increasing trend, (1,445.49±300.55), (1,494.46±307.94), (1,547.67±320.34), (1,621.32±342.53) cm/s, respectively. Multiple linear regression results showed that age, by logarithmic transformation of hsCRP (lghsCRP) level, systolic blood pressure and fasting blood glucose for each additional unit, baPWV levels were increased 266.47, 58.00, 5.02, 39.79 cm/s (P<0.001), and BMI for each additional unit, baPWV level decreased 9.52 cm/s (P=0.030). The prediction of hsCRP in peripheral artery showed that lghsCRP level of AUC to 0.59 (95% CI: 0.57-0.61), lower than the age and systolic blood pressure predicted value AUC (95% CI) of 0.69 (0.67-0.71), 0.75 (0.73-0.77), respectively. The hsCRP level could not predict the peripheral arteriosclerosis alone, and the combined age and systolic blood pressure level could have better predictive value.

Atypical Localization of Enchondroma in the Calcaneus.

A 53-year-old man presented to the orthopedic outpatient clinic with pain and swelling in the right heel without any trauma. On physical examination and radiologic assessment, a lesion with calcification and peripheral sclerosis was detected in the medullary cavity of the calcaneus, and computed tomographic images revealed cortical thinning adjacent to the lesion. Magnetic resonance images showed a 23 × 19-mm lesion. Tru-Cut biopsy, performed to clarify the diagnosis, revealed an enchondroma. As a definitive treatment, curettage of the lesion and grafting of the cavity was performed. Although enchondromas are common pathologic abnormalities of the skeleton and are usually asymptomatic, atypical localization, such as the calcaneus, and atypical clinical manifestations, such as heel pain, should also be kept in mind.

Recurrent burner syndrome due to presumed cervical spine osteoblastoma in a collision sport athlete – a case report

We present a case of a 35-year-old active rugby player presenting with a history of recurrent burner syndrome thought secondary to an osteoblastoma involving the posterior arch of the atlas. Radiographically, the lesion had features typical for a large osteoid osteoma or osteoblastoma, including osseous expansion, peripheral sclerosis and bony hypertrophy, internal lucency, and even suggestion of a central nidus. The patient subsequently underwent an en bloc resection of the posterior atlas via a standard posterior approach. The surgery revealed very good clinical results.In this report, we will discuss in detail, the presentation, treatment, and return to play recommendations involving this patient.

Clinical and morphological characteristics of osteoid osteoma and osteoblastoma: a retrospective single-center analysis of 204 patients.

Osteoid osteoma and osteoblastoma are histologically similar, benign bone-forming tumors. In this retrospective study, we aimed to evaluate the natural history; clinical, pathologic, and radiologic findings; and treatment results in 204 patients between 1959 and 2006 in a single institution. According to the World Health Organization's definition, tumors ≤1 cm in diameter were classified as osteoid osteoma, and those ≥2 cm, as osteoblastoma. For tumors between 1 cm and 2 cm, other criteria, such as the bone involved, the site, the presence of a nidus, and presence of peripheral sclerosis, were used for diagnosis. There were 131 patients with osteoid osteoma (93 male, 38 female) and 73 patients with osteoblastoma (40 male, 33 female). The mean age in the osteoid osteoma and osteoblastoma groups was 16.4 ± 7 and 19.6 ± 9.9 years, respectively. The osteoid osteoma cases were mostly localized in the extremities, whereas the osteoblastoma cases involved the vertebral column and sacrum. The nidus size varied between 0.2 and 1.5 cm in osteoid osteoma cases, and the tumor size range was 1.3-10 cm in the osteoblastoma cases. The pain was encountered in 89% of osteoid osteoma and 45% of osteoblastoma patients. Histopathology was similar in both cases. The treatment of choice was conservative surgery for both diagnoses. In conclusion, osteoblastoma is clinically and radiologically more aggressive than osteoid osteoma.

Painful fingertip swelling of the middle finger

Osteoid osteoma (OO) is a benign bone-forming tumour that accounts for about 12% of benign and 3% of all bone neoplasms [1]. It mainly affects patients during childhood or early adulthood, with a male preponderance. Despite its predilection for the long bones of the lower limbs, this tumour can occur in any bone of the skeleton and may be found in the hand and wrist in up to 10% of cases [2]. However, OOs of the distal phalanx are relatively uncommon, with only a few case series reported in the English literature so far [3–5]. The diagnosis of distal phalangeal OO is challenging for several reasons. First, the typical clinical features may not be present [2, 3, 5]. Pain may not be worse at night, or be relieved by aspirin. Moreover, soft-tissue swelling and erythema, as well as nail deformities, may mislead the physician. Second, its imaging characteristics (i.e. a small radiolucent lesion with central calcification, peripheral sclerosis and periosteal reaction [1]) may also be atypical [3–6]. Because of the presence of thickened Sharpey’s fibres, a periosteal reaction is rarely found in the distal phalanx [6]. Besides, endosteal sclerosis may be counterbalanced by local osteopaenia. Furthermore, other bony lesions of the fingertips, such as chronic osteomyelitis, epidermoid cyst, enchondroma or glomus tumour, may mimic an OO [3, 5, 6]. Zampa et al. recently reported the added value of dynamic contrast-enhanced MR imaging for OO in atypical locations, in terms of nidus conspicuity and diagnostic confidence [7]. Third, the histological features may even be unusual [5]. All those reasons could explain the delay, sometimes of several months to years, in the diagnosis and the treatment of phalangeal OOs. The main clinical differential diagnosis of painful fingertip swelling includes whitlow or paronychia, osteomyelitis, glomus tumour, subungual exostosis, arthritis and OO [3, 5, 6]. In our case, conventional radiographs (see Fig. 1 in the Question), ultrasound and previous CT and MR imaging studies (all not shown) barely displayed a focal lesion at the base of the distal phalanx. Follow-up MRI, performed at our institution several months after the onset of symptoms and after failure of initial surgery, demonstrated persisting diffuse inflammatory changes of the distal and middle phalanges as well as in the The case presentation can be found at doi:10.1007/s00256-011-1218-z

Imaging features of bone metastases in patient with gastrointestinal stromal tumors

To determine the prevalence and imaging features of bone metastases in patients with gastrointestinal stromal tumors (GISTs). The medical records of 190 patients with pathologically proven GISTs were reviewed, and patients with bone metastases were identified. Computed tomography (CT) scans of the chest, abdomen, and pelvis were examined for features of bone metastases, and findings were correlated with the results of positron-emission tomography (PET) and histopathology. Of 190 GIST patients, six (3.2%) had bone metastases: four patients had multiple bone metastases, and two patients had a solitary metastasis. The maximum diameter of the metastases ranged from 2 to 40 mm, and they most commonly involved the vertebrae, ribs, pelvic bones, and femurs. All lesions were well-marginated and lytic. A soft tissue component was identified in three patients. The bone metastases showed intense fluorine-18 fluorodeoxyglucose (FDG) uptake. After treatment with imatinib mesylate in three patients, the bone metastases developed peripheral sclerosis on CT and became less FDG-avid on PET. All six primary tumors were morphologically high-grade with high mitotic rates and necrosis. Bone metastases from GISTs are uncommon; when detected with CT, they are characterized by single or multiple lytic lesions with or without soft tissue involvement. A sclerotic rim may appear around the metastatic lesions in response to treatment. Similar to the disease in other sites, bone metastases show intense FDG uptake, which decreases following treatment.

Voltage gated potassium channel antibodies in amyotrophic lateral sclerosis

Although overlap exists between the clinical manifestations in patients with acquired peripheral nerve hyperexcitibility and amyotrophic lateral sclerosis (ALS), the presence of VGKC antibodies has not been associated with the development or clinical manifestations of motor neuron disease. We present the finding of elevated potassium channel antibodies in a cohort of patients with ALS and demonstrate a higher number of abnormal titer levels and higher mean titer levels in ALS patients compared to a cohort of patients with peripheral nervous system disorders. These results suggest the possibility of a subset of ALS patients where autoimmunity could play a role in disease development and progression.

Giant notochordal rests misdiagnosed and treated as chordomas. A retrospective clinical, radiological and histologic study of four cases

21503 Background: Notochordal rests are found at autopsy on 10% of cadavers. They may well be the origin of chordomas. The differential histologic diagnosis is possible and difficult, but giant notochordal rests were often previously misdiagnosed as chordomas. Out of 350 chordomas found in the files of our institution, four were actually notochordal rests. A review of the clinical radiological and histologic data was made. Methods: Nonspecific pain was always the cause of the imaging examination. All patients had initial radiographs and CTs available, and two MR examinations. The location, size and borders were analyzed, as well as the MR signal. Histology compared the findings of rests (sheet like cells) and chordomas (chords of cells). Results: There were three rests, and one case associating both a notochordal rest and a chordoma. All lesions were limited to the posterior half of the vertebral body. They were lytic, with local destruction of bone trabeculae, and sclerotic. The posterior cortex of the vertebra was always involved and partially missing. The borders were well defined with a peripheral sclerosis. Minimal medial extension into the canal (2mm) and bulging of the posterior wall of the vertebra were found in the chordoma associated to a rest. Two patients had retrospectively another smaller rest visible on CT on another vertebra, and that was ignored at the time of the treatment. Each patient had an aggressive treatment with three vertebrectomies and one wide curettage, and radiotherapy. Conclusions: Notochordal rests must be recognized radiologically, to avoid biopsy, and then histologically to avoid a useless aggressive treatment. They should probably be followed regularly on CT or MR to discover a beginning chordoma. A biopsy should be performed, only if the soft tissues or the whole vertebral body are involved. No significant financial relationships to disclose.

Unusual presentation of Hodgkin disease—Painful hip

A 12-year-old girl presented with spontaneous onset of left hip pain. By plain radiographs and CT, she was found to have a femoral bone lytic lesion with peripheral sclerosis, adjacent to the physis of the left greater trochanter and no soft tissue mass. The differential diagnosis included osteomyelitis with abscess, eosinophilic granuloma, osteoid osteoma, osteoblastoma, or malignancy. Curettage of the lesion was pathologically characteristic of Hodgkin disease. A subsequent chest radiograph and CT unveiled an anterior mediastinal mass and multiple enlarged mediastinal lymph nodes. The patient is free of disease 7 years after receiving treatment with chemotherapy. Hodgkin disease should be considered in the differential diagnosis of symptomatic bone lesions. Prompt diagnosis will improve the management and effectiveness of therapy.