Posterior Rib Research Articles

Rib Osteoblastoma: A Rare Benign Primary Bone Tumor - Clinical Case Report

Objective: To present a clinical case of a rare pathology, to know its aggressive behavior, its limited ability to metastasize, and its therapeutic management, as well as to review the current literature. Clinical Case: A 22-year-old male patient, with no personal or family history of the disease, was found to have a radiating mass at the left posterior 10th rib arch, with a rounded appearance, low-density areas inside, rounded, and well-defined microspheres at the margin, measuring 4.3 cm × 4.3 cm. The surgery was performed through a left posterolateral thoracotomy, which removed nearly two-thirds of the 10th posterior arch of the left rib and with its costal-vertebral disarticulation. Anatomic and pathological studies reported a histological diagnosis of rib osteoblastoma or giant cell bone tumor. Conclusion: This is uncommon and difficult to predict bone tumor in behavior, as almost all bone tumors contain giant cells. It is a primary bone tumor with benign features that invades the local area in an aggressive manner, with a biphasic component of giant cells and a highly vascularized spindle cell component. It often relapses and has limited metastatic ability. Osteoblastoma or giant cell tumor of the bone is a rare tumor located in the ribs, making it even more unusual. However, its prognosis is good, although it can recur and metastasize.

Characteristics of rib fracture patients who require chest computed tomography in the emergency department

BackgroundThe disadvantages and complications of computed tomography (CT) can be minimized if CT is performed in rib fracture patients with high probability of intra-thoracic and intra-abdominal injuries and CT is omitted in rib fracture patients with low probability of intra-thoracic and intra-abdominal injuries. This study aimed to evaluate the factors that can identify patients with rib fractures with intra-thoracic and intra-abdominal injuries in the emergency department among patients with rib fracture.MethodsThis retrospective observational study included adult patients (age ≥ 18 years) diagnosed with rib fracture on chest radiography prior to chest CT due to blunt chest trauma in the emergency department who underwent chest CT from January 2016 to February 2021. The primary outcomes were intra-thoracic and intra-abdominal injuries that could be identified on a chest CT. Multivariate logistic regression analysis was performed.ResultsAmong the characteristics of rib fractures, the number of rib fractures was greater (5.0 [3.0–7.0] vs. 2.0 [1.0–3.0], p < 0.001), bilateral rib fractures were frequent (56 [20.1%] vs. 12 [9.8%], p = 0.018), and lateral and posterior rib fracture was more frequent (lateral rib fracture: 160 [57.3%] vs. 25 [20.5%], p < 0.001; posterior rib fracture: 129 [46.2%] vs. 21 [17.2%], p < 0.001), and displacement was more frequent (99 [35.5%] vs. 6 [6.6%], p < 0.001) in the group with intra-thoracic and intra-abdominal injuries than in the group with no injury. The number of rib fractures (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.16–1.78; p = 0.001), lateral rib fracture (aOR, 2.80; 95% CI, 1.32–5.95; p = 0.008), and posterior rib fracture (aOR, 3.18; 95% CI, 1.45–6.94; p = 0.004) were independently associated with intra-thoracic and intra-abdominal injuries. The optimal cut-off for the number of rib fractures on the outcome was three. The number of rib fractures ≥ 3 (aOR, 3.01; 95% CI, 1.35–6.71; p = 0.007) was independently associated with intra-thoracic and intra-abdominal injuries.ConclusionIn patients with rib fractures due to blunt trauma, those with lateral or posterior rib fractures, those with ≥ 3 rib fractures, and those requiring O2 supplementation require chest CT to identify significant intra-thoracic and intra-abdominal injuries in the emergency department.

The anatomical growth of the thoracic cage in adolescents with specific reference to axial growth comparing the right and left hemithorax.

This study has demonstrated the changing volume of both the anterior and posterior thorax in normal adolescents (without spinal or thoracic deformity), differentiating for both sex and age, to further understand how the thorax grows, along with the differences in growth between the anterior and posterior thorax. The thorax was measured on axial CT slices at every vertebral level from T3 to T12 in a series of scans previous taken for routine clinical care. Measurements taken were the anteroposterior thoracic distance and the area of the anterior and posterior rib prominences on either side of the thorax. Data was analyzed per vertebral level, differentiating for age and sex. There were 486 CT scans analyzed (257 males and 229 females) between the ages of 8 and 18 years. The analysis identified that for the anterior thorax, there are three phases of growth with an initial slow increase in volume, followed by a stabilization of little growth, followed by another phase of a more rapid increase in volume. For the posterior thorax, there was a gradual increase in area with increasing age. This study demonstrates that the shape of the thorax is age and sex dependent, with males having both a greater width and depth of thorax compared to females. Of particular note is the difference in patterns of growth between the anterior and posterior thorax. This information will add to the understanding of normal growth, which will aid in the management of conditions where that growth is disturbed.

FAMILY MATTERS: CHEST PAIN AS THE INITIAL PRESENTATION OF EARLY-ONSET METASTATIC PROSTATE CANCER

FAMILY MATTERS: CHEST PAIN AS THE INITIAL PRESENTATION OF EARLY-ONSET METASTATIC PROSTATE CANCER

Injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lower intercostal arterial bleeding at a level-1 trauma centre: A 10-year retrospective review.

Haemorrhagic shock is a life-threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9-11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level-1 trauma centre (2009-2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9-11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non-cavitary bleeds. Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.

Finite element analysis of different fixation methods of screws on absorbable plate for rib fractures.

Multiple rib fractures caused by trauma are common injuries and the internal fixation methods of these injuries have been paid more and more attention by surgeons. Absorbable plates and screws are the effective way to treat rib fractures, but there are no reports on which type of screw fixation method is most effective. In this study, finite element analysis was used to study the effects of five different types of screw fixation methods on anterior rib, lateral rib and posterior rib. The finite element model of the ribs was reconstructed from CT images, and the internal pressure (40 kPa) and intercostal force (30 N) on the surfaces of the ribs were simulated accordingly. An intercostal force of 30 N was applied to the upper and lower surfaces of the ribs to simulate the effect of intercostal muscle force. The pressure of 40 kPa was applied to the inner surface of the ribs, and the normal direction was applied to the inner surface of the ribs. The positive direction was considered inspiratory pressure, and the negative direction was considered expiratory pressure. The results indicate the optimal type of screw fixation on the absorbable plate for rib fractures, and provide a basis and reference for clinical application.

Semantic segmentation of bone structures in chest X-rays including unhealthy radiographs: A robust and accurate approach

The chest X-ray is a widely used medical imaging technique for the diagnosis of several lung diseases. Some nodules or other pathologies present in the lungs are difficult to visualize on chest X-rays because they are obscured byoverlying boneshadows. Segmentation of bone structures and suppressing them assist medical professionals in reliable diagnosis and organ morphometry. But segmentation of bone structures is challenging due to fuzzy boundaries of organs and inconsistent shape and size of organs due to health issues, age, and gender. The existing bone segmentation methods do not report their performance on abnormal chest X-rays, where it is even more critical to segment the bones. This work presents a robust encoder–decoder network for semantic segmentation of bone structures on normal as well as abnormal chest X-rays. The novelty here lies in combining techniques from two existing networks (Deeplabv3+ and U-net) to achieve robust and superior performance. The fully connected layers of the pre-trained ResNet50 network have been replaced by an Atrous spatial pyramid pooling block for improving the quality of the embedding in the encoder module. The decoder module includes four times upsampling blocks to connect both low-level and high-level features information enabling us to retain both the edges and detail information of the objects. At each level, the up-sampled decoder features are concatenated with the encoder features at a similar level and further fine-tuned to refine the segmentation output. We construct a diverse chest X-ray dataset with ground truth binary masks of anterior ribs, posterior ribs, and clavicle bone for experimentation. The dataset includes 100 samples of chest X-rays belonging to healthy and confirmed patients of lung diseases to maintain the diversity and test the robustness of our method. We test our method using multiple standard metrics and experimental results indicate an excellent performance on both normal and abnormal chest X-rays.

Nonaccidental Injury in the Elderly: What Radiologists Need to Know.

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented. An invited commentary by Jubanyik and Gettel is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Regional analgesia techniques for effective recovery from coronary artery bypass surgeries: a retrospective study involving the experience of a single center

BackgroundPain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, potential brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. Ineffective pain management can result in systemic and pulmonary complications and significant cardiac consequences.MethodsThis study compared the effectiveness of regional anesthesia techniques for perioperative pain management in cardiac surgery patients at our clinic. The effects of different analgesic methods, in terms of contributing to recovery, were examined.ResultsThe records of 221 patients who had undergone coronary bypass surgery were evaluated retrospectively. The extubation rate in the operating room was 91%. No patient received balloon pump support, and 20 patients were transferred to the cardiovascular intensive care unit while intubated. Regional anesthesia was performed on two of these 20 patients, but not on the remaining 18. Examination of intraoperative and postoperative opioid consumption revealed significantly lower levels among patients receiving regional anesthesia. The most effective results among the regional anesthesia techniques applied were achieved with double injection erector spinae plane block.ConclusionRegional anesthesia techniques severely limit opioid consumption during cardiac surgery. Their importance will gradually increase in terms of rapid recovery criteria. Based on our study results, double injection of the erector spinae plane block seems to be the most effective technique in cardiac surgery. We therefore favor the use of fascial plane blocks during such procedures.Trial Numbers The study is registered with ClinicalTrials (NCT05282303). Ethics committee registration and approval were Granted under Number 2021.464.IRB1.131.

Unilateral Seventh Rib Posterior Stress Fracture in a High School Baseball Pitcher

Posterior rib stress fractures may infrequently occur in baseball pitchers at the first or second rib. Lower thoracic rib stress fractures, however, are a rare phenomenon with only a few cases described at the collegiate or professional level.

Prospective randomized trial of metal versus resorbable plates in surgical stabilization of rib fractures.

Surgical stabilization of rib fractures has gained popularity as both metal and resorbable plates have been approved for fracture repair. Is there a difference between metal and resorbable plate rib fixation regarding rib fracture alignment, control of pain, and quality-of-life (QOL) scores (Rand SF-36 survey)? Eligible patients (pts) included 18 years or older with one or more of the following: flail chest, one or more bicortical displaced fractures (3-10), nondisplaced fractures with failure of medical management. Patients were randomized to either metal or resorbable plate fixation. Primary outcome was fracture alignment. Secondary outcomes were pain scores, opioid use, and QOL scores. Thirty pts were randomized (15 metal/15 resorbable). Total ribs plated 167 (88 metal/79 resorbable). Patients with rib displacement at day of discharge (DOD) metal 0/14 (one pt died, not from plating) versus resorbable 9/15 or 60% ( p = 0.001). Ribs displaced at DOD metal 0/88 versus resorbable 22/79 or 28% ( p < 0.001), 48% in posterior location. Patients with increased rib displacement 3 months to 6 months: metal, 0/11 versus resorbable, 3/9 or 33% ( p = 0.043). Ribs with increased displacement 3 months to 6 months metal 0 of 67 versus resorbable 6 of 49 or 12.2% ( p < 0.004). Pain scores and narcotic use at postoperative Days 1, 2, 3, DOD, 2 weeks, 3 months and 6 months showed no statistically significant difference between groups. QOL scores were also similar at 3 months and 6 months. Trauma recidivism in outpatient period resulted in fracture of resorbable plates in two pts requiring a second surgery. Metal plates provided better initial alignment with no displacement over time. Clinical outcomes were similar regarding pain, narcotic use, and QOL scores. Routine use of resorbable plates for posterior rib fractures is not warranted. Lateral repairs were technically most feasible for using resorbable plates but still resulted in significant displacement. Resorbable plates may not maintain rib alignment when exposed to subsequent injury. Therapeutic/Care Management; Level II.

Primary intramedullary spinal cord pilocytic astrocytoma with anaplasia in an adult: illustrative case.

BACKGROUNDPrimary intramedullary spinal cord (IMSC) pilocytic astrocytoma (PA) with anaplasia is extremely rare.OBSERVATIONSA 50-year-old man presented to our hospital with numbness of the left posterior rib region, back, and bilateral lower limbs. Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed an intramedullary lesion at T2–T3 with no contrast enhancement. The patient opted for conservative treatment. Eighteen months after the first consultation, the patient presented with slowly progressive numbness of the bilateral upper limbs, paraparesis, and dysuria, with rapid deterioration over the following 3 months. T1- and T2-weighted MRI revealed expansion of the intramedullary lesion, which extended from C7 to T5, and syringomyelia at C5–C6. Contrast-enhanced T1-weighted MRI revealed an enhancing intramedullary lesion at C7–T5. Open biopsy and C5–T5 laminectomy were performed for diagnosis and decompression. PA with anaplasia was diagnosed based on pathological and immunohistochemical findings. The patient received postoperative radiotherapy and chemotherapy.LESSONSRapidly progressive IMSC PA with a change in contrast enhancement is extremely rare in adults. PA may undergo a spontaneous malignant transformation during its natural clinical course. In this case, the change in contrast enhancement may have been associated with the malignant transformation of the PA.

Supine Counterstrain Technique for Posterior Rib Tenderpoints

Abstract Seated counterstrain techniques for the treatment of posterior rib tenderpoints are common and can be found in literature. At times, it can be extremely inconvenient or impossible to treat certain patients in a seated position. A supine treatment position could easily address these concerns; however, there is no literature that illustrates how to utilize a counterstrain technique in a supine position for posterior rib tenderpoints. This article describes how to diagnose and treat posterior rib tenderpoints with a patient in the supine position through the application of a counterstrain technique. The importance of addressing posterior rib tenderpoints is discussed along with a brief list of additional somatic dysfunctions that should be addressed in a supine patient experiencing a thoracic cage somatic dysfunction.

Vascularized Bone Flap Options for Complex Thoracic Spinal Reconstruction.

Osseous reconstruction following total spondylectomy/vertebrectomy in the thoracic spine is indicated to restore spinal stability. To assist with bony reconstruction, vascularized bone flaps including free vascularized fibula flaps and pedicled rib flaps can be used. However, there are limited data comparing various techniques. The authors aimed to evaluate the outcomes of free vascularized fibula flaps and pedicled rib flaps used for thoracic spinal reconstruction. The authors reviewed 44 vascularized bone flaps [10 anterior pedicled rib flaps, 25 posterior pedicled rib flaps, and nine vascularized fibula flaps] for corpectomy defects spanning T1 to L1 between January of 1999 and June of 2018. Mean age and follow-up were 46 ±17 years and 74 ± 52 months, respectively. The union rate was 93 percent, with a similar mean time to union among the three groups: free vascularized fibula flaps, 9 ± 4 months; anterior pedicled rib flaps, 9 ± 6 months; and posterior pedicled rib flaps, 9 ± 5 months (p = 0.95). Surgical-site complications were found in 27 vascularized bone flaps (61 percent), and reoperations and revisions were performed in 14 (32 percent) and 10 (23 percent) vascularized bone flaps, respectively. No differences were identified among anterior pedicled rib flaps, posterior pedicled rib flaps, and vascularized fibula flaps with regard to complication, reoperation, and revision rates. Free vascularized fibula flaps and pedicled rib flaps provide durable reconstruction for thoracic spinal defects. Union, time to union, revision, and reoperation rates were similar among anterior and posterior pedicled rib flaps and vascularized fibula flaps. Given the variability in indication and defect types among the flap cohorts, the authors' results should be interpreted carefully as an insight into the outcomes of different vascularized bone flaps for the unique cases of thoracic spinal reconstruction rather than to compare the different flaps used. Therapeutic, III.

Endoscopic Posterior Rotation Flap for Posterior Glottic Insufficiency.

Endoscopic Posterior Rotation Flap for Posterior Glottic Insufficiency.

Cardiopulmonary Resuscitation Induced Posterior Rib Fractures in Nontraumatic Pediatric Deaths.

Posterior rib fractures are considered suspicious for nonaccidental injury when observed in infants without significant trauma history or underlying bone disease. The biomechanical mechanism postulated for causing posterior rib fractures is anterior/posterior compression of the chest with posterior levering of the rib head over the transverse process of the vertebra creating a focal area of stress. The recommended "2-thumb" cardiopulmonary resuscitation method involves the administrator placing both thumbs on the sternum of the patient, encircling the chest with the hands, and placing the finger tips lateral to the spine. From this position, the administrator compresses the chest in an anterior/posterior direction by pressing on the sternum. Theoretically, the 2-thumb method should focus all force on the sternum while the back is supported by the fingers limiting posterior levering of the ribs and reducing the risk of posterior rib fractures. However, posterior rib fractures have been found during the autopsy of infants who received 2-thumb cardiopulmonary resuscitation, had no traumatic history, had a nontraumatic cause of death, and had no indication of underlying bone disease. This case study series presents the demographics, birth histories, circumstances surrounding death, and autopsy findings of four such medical examiner cases.

Mallomonas lusca sp. nov. (Synurales, Chrysophyceae)—a rare species from Southeast Asia

A new species of tropical chrysophyte algae, Mallomonas lusca sp. nov. is described from Vietnam based on silica-scale morphology observed using scanning and transmission electron microscopy. Scales of this species were previously found in Malaysia, but had not yet been described. Mallomonas lusca belongs to section Torquatae and is most similar to M. favosa. Its scales have a unique conspicuous rounded pit with a raised thickened central area, which develops in association with the posterior pore in the angle of the posterior submarginal rib. This rounded pit is surrounded by delicate papillae across the border on the shield. Mallomonas lusca has been observed in six localities in Vietnam and one in Malaysia.

Massive hemorrhage from the posterior intercostal artery following lower partial sternotomy

BackgroundMedian sternotomy remains the most common approach in cardiovascular surgery. Recently, minimally invasive procedures, such as minimally invasive cardiac surgery, robot surgery, and catheter therapy have been developed in cardiovascular surgery. However, all these surgeries cannot be performed by minimally invasive approaches. Several complications associated with median sternotomy have been reported, although post-sternotomy hemorrhage from the posterior intercostal artery is extremely rare.Case presentationWe present a case of posterior intercostal artery bleeding following lower partial sternotomy. A 79-year-old man underwent aortic valve replacement using lower partial median inverted L-shaped sternotomy that cut into the right second intercostal space. A postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Hence, we inserted a drainage tube immediately. Approximately 2 hours after the surgery, his blood pressure gradually decreased. Blood drainage was observed from the tube, and the amount of blood drainage was not large. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed emergency surgery. The lower partial sternotomy was repeated. We detected the origin of the bleeding that was identified in the right fourth posterior intercostal artery, and the bleeding was stopped. The postoperative course was uneventful.ConclusionsThis case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of clearly rib fracture. In our case, we did not identify the cause of bleeding, although we suggest the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.

Incidental posterior rib hyperostosis on chest CT: incidence and etiology.

Incidental rib hyperostosis is defined as asymmetric cortical thickening and sclerosis of the medial posterior ribs and is important because it may lead to unnecessary laboratory testing, additional imaging and occasionally biopsy. The purpose of this study is to identify the incidence of rib hyperostosis within different patient groups known to have an increased propensity towards osteophyte formation and ankylosis. This study was a retrospective cohort study reviewing chest CT examinations in a control group of patients over 50years old and three different patient populations: psoriatic arthritis, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis (DISH). Each CT was evaluated by an attending musculoskeletal and cardiothoracic radiologist to identify rib hyperostosis, osteophyte formation, ankylosis, and spinal curvature. Two senior radiology residents also performed consensus reads and inter-reader reliability was calculated between the two groups. Two hundred eighty-two individuals were included in the study of which 38 (13.5%) had at least one hyperostotic rib. The ankylosing spondylitis population and the DISH population had the highest incidence of rib hyperostosis with a relative risk of 5.6 (p = 0.012) and 5.3 (p = < 0.001) when compared to the control group. There was good inter-reader reliability for the presence of rib hyperostosis with a kappa estimate of 0.739. Incidentally detected rib hyperostosis is most likely the sequela of abnormal stress on the ribs secondary to rib hypomobility from fusion at the costovertebral joint. The incidence of rib hyperostosis is markedly increased in the DISH and ankylosis spondylitis study populations.

LATE DISTAL RECURRENCE OF PRIMARY BONE LEIOMYOSARCOMA PRESENTING WITH HEMOTHORAX

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: We describe a case of previously treated bone leiomyosarcoma (LMS) with unique presentation of distal recurrence after a prolonged latency period. CASE PRESENTATION: A 41-year-old woman with LMS of the left tibia treated with neoadjuvant chemotherapy and surgical resection nine years ago presented with shortness of breath and cough. Physical examination revealed dullness to percussion and lack of air entry over the right lung Laboratory work-up was significant for a hemoglobin of 7.6 g/dl (normal range 12.0 – 16.0 g/dl). A chest X-ray showed complete opacification of the right lung. Chest computed tomography angiogram revealed a right-sided mass with a prominent central vessel and a large pleural effusion. A thoracentesis drained 500 milliliters of serosanguinous fluid. Pleural fluid analysis showed a lactate dehydrogenase of 1,364 and protein of 4.0. Cytology was negative for malignancy. Coil embolization of the right eleventh intercostal artery was performed due to concern for active bleeding. A repeat chest X-ray showed poor lung expansion with a large amount of residual clot and fluid. Video-assisted thoracoscopic surgery was performed with biopsy of the mass and removal of two liters of clotted blood. Pathology was consistent with LMS compatible with metastasis from the patient's previously treated sarcoma. A PET scan showed an FDG-avid mass with involvement of the right chest wall, vertebra, and right posterior ribs. Surgical resection of the mass was performed. Final pathology showed high-grade LMS measuring 8.5 centimeters. DISCUSSION: Primary bone LMS is a rare malignancy of smooth muscle differentiation accounting for less than one percent of sarcoma cases. It is considered an aggressive malignancy with high rates of recurrence. Need for adjuvant therapies is generally dependent on size, stage, location, and success of tumor resection.2 Most recurrence occurs within five years of the original diagnosis with grade and size of the primary lesion conferring the greatest risk.4,5 Our patient's time to recurrence was unusual as she developed metastatic malignancy nine years from her original diagnosis of non-metastatic, low-grade LMS.This case was also unique in that the presenting complaints of dyspnea and cough were the result of a large hemothorax. Approximately 75 cases of soft tissue sarcoma with hemothorax have been documented in the literature. Only one case involving LMS was discovered during our search. Without this rare complication, our patient's malignancy may have been more advanced before its discovery. CONCLUSIONS: Primary bone LMS is a rare malignancy with high rates of recurrence. Our patient's case highlights the importance of maintaining long-term follow up and high clinical suspicion of recurrence due to the potential for prolonged latency periods. REFERENCE #1: Serrano, C., & George, S. (2013). Leiomyosarcoma. Hematology/Oncology Clinics Of North America, 27(5), 957-974. REFERENCE #2: Adelani, A., Schultenover, S., Holt, G., & Cates, J. (2009). Primary Leiomyosarcoma of Extragnathic Bone: Clinicopathologic Features and Reevaluation of Prognosis. Arch Pathol Lab Med, 133(9), 1448-1456. REFERENCE #3: Gladdy, R., Qin, L., Moraco, N., Agaram, N., Brennan, M., & Singer, S. (2013). Predictors of Survival and Recurrence in Primary Leiomyosarcoma. Annals Of Surgical Oncology, 20(6), 1851-1857. DISCLOSURES: No relevant relationships by Ian Jackson, source=Web Response No relevant relationships by Bryan Krajicek, source=Web Response No relevant relationships by Ali Nayfeh, source=Web Response No relevant relationships by Bryton Perman, source=Web Response