Presented by : Peter L. Kogon, DC, DACBR, FCCR (C), FICC

1. Presented by : Peter L. Kogon, DC, DACBR, FCCR (C), FICC College of Chiropractic Radiologists (Canada), Inc. September 28, 2018 Trois-Rivières (QC)

2. KOGON’S MYSTERY CASE NO. 1

3. CASE PRESENTATION: • Male • 27 years old • Presented with acute right low back pain • No known history of trauma or organic disease • No fever • Presented in a mild anteflexed antalgic posture • Physical and neurologic, including sensory, motor and deep tendon reflex examinations were normal • Restricted and painful orthopedic mouvements to the right

5. Reference: Roentgen Signs in Clinical Practice, Vol. 2, Meschan, I, W.B. Saunders Company, Philadelphia, pg. 1621

6. Diagnosis Solitary benign pedunculated osteochondroma

7. An osseous projection with a cartilaginous cap arising from the host bone cortex • The most common benign tumor involving the skeleton • Develops slowly during childhood and adolescence • Cortex continuous with the cortex of the host bone, and medullary portion is continous with the central spongiosa • Cessation of tumor development with skeletal maturity Osteochondroma

8. Osteochondromas may be solitary or multiple • 2:1 Male predominance • 75% occur prior to age 20 • The most frequent complaint is that of a painless mass • The pressure exerted by the tumor on contiguous vascular or neurologic elements may produce symptoms, or the lesion may be entirely asymtomatic • Symptoms may follow mild trauma or fracture of the lesion Clinical Presentation:

9. Osteochondromas are most often found in tubular bones near the metaphysis • The most frequent site of involvement is the knee • Flat bones such as the pelvis and scapula may also be affected, especially after radiotherapy • Two varieties are distinguished: PedunculatedandSessile Radiographic Features:

10. This variety is characterized by a long, narrow stalk (peduncle) with a cartilaginous cap • The direction of the peduncle is characteristically away from the adjacent joint because of muscle pull hence, the term coat-hanger exostosis • Pedunculated osteochondromas vary in size, extending to 8 cm. in length • The cartilaginous cap may appear flocculent and is always well-defined, thus giving rise to the term cauliflower exostosis • Irregular or streaky calcification with an ill-defined margin may suggest malignant degeneration into chondrosarcoma Pedunculated:

11. Sessile: • This variety is characterized by a broad-based lesion that forms a local widening or « bump » on the cortex • Although more commonly seen in the pelvis, it is occasionally noted in long bones or the costal elements • It may be extremely large and of an extremely irregular shape

12. Clinical Importance: • The clinical importance of the tumor depends on the cartilage cap, which may represent a small risk of malignant transformation to chondrosarcoma ; the risk is probably less than 1% in solitary lesions but is significantly higher (20%) in multiple osteochondromatosis (hereditary multiple exostosis, diaphyseal aclasis) • The patient with hereditary multiple exostosis may exhibit pedunculated and sessile varieties simultaneously

13. Epichondylar process Differential Diagnosis

14. Takeaways! • Always view the A/P image first and trust your knowledge of anatomy • When all else fails…..return to the basics C.A.T.B.I.T.E.S. • Any benign lesion exceeding 5 cm. should be considered for medical consultation • When it doubt CONSULT!!

15. The Portable Skeletal X-Ray Library, Deltoff, MN, Kogon, PL, Mosby Year- Book, Inc., St. Louis, 1998, pgs. 128 to 135 Essentials of Skeletal Radiology Third Edition Yochum, TR, Rowe, LJ Lippincott Williams & Wilkins Philadelphia 2005, pg. 1237 References:

16. An overview of metastatic neoplastic bone disease:

17. Three Pathways of Dissemination • Hematogenous spread (red bone marrow); • Lymphogenous spread; • Direct extension

18. In order of descending frequency: • Vertebral column; • Costal elements; • Pelvis; • Proximal humerus; • Femurs; • Sternum; • Calvarium.

19. METASTATIC NEOPLASTIC OSSEOUS DISEASE Clinical Features • Favors the older population ie. after 4th decade • * Back discomfort of insidious onset is the most • commonly reported symptom • Pain is not always apparent at night but may be • related too physical exertion • Symptoms may be relieved by rest • Pathologic fractures occur in 15 to 20% of patients • *Patients may be relatively asymtomatic until • secondary lesions have already disseminated • Some tumors possess a distinct tendency to skeletal metastasis i.e. bronchogenic, breast, prostate and renal.

20. ZONE OF TRANSITION • The zone of transition is the most reliable indicator in determining benign versus malignant lesions in 90% of cases. • The zone of transition is defined as the interface between the lesion and adjacent normal bone. • The zone of transition is usually easier to characterize than periostitis • In addition, it is always present to evaluate, whereas many lesions (benign or malignant) produce no periostitis.

21. NARROW ZONE OF TRANSITION • It is so well-defined that it can be traced with a find-point pen. • If a lesion possesses a narrow sclerotic border, it is an exemple of a narrow (short) zone of transition and is likely benign. WIDE ZONE OF TRANSITION • A wide zone of transition is an imperceptable merging of normal and abnormal bone. • If a lesion has a wide (long) zone of transition, it is considered to be agressive but not necessarily malignement (i.e., infection). • Lesions exhibiting a wide zone of transition tend to display a moth-eaten or permeative pattern of destruction.

22. Osteolytic Metastatic Disease • Accounts for 75% of lesions • Primary tumors usually arise within the bronchus, breast, renal, thyroid and gastrointestinal tract • In females – breast or bronchus is favoured • Characterized by a loss of one or both pedicles or vertebral body osteolysis and destruction • Lesions may form a « motheaten » or « permeative » lytic pattern • Periosteal reactions are likely secondary to underlying pathologic fractures rather than the tumor itself

23. OSTEOBLASTIC METASTATIC DISEASE • Lesions are characterized by local or widespread increases in bone density. • This variety accounts for approximately 15% of all skeletal metastasis. • Primary tumours originating in the prostate in males and the breast following radiotherapy in females, frequently produce this pattern. • Other tumours related to bone forming change include those originating in the urinary bladder, stomach, gastrointestinal tract and osteosarcoma. • In the spine, dense or « ivory vertebrae» may be identified.

24. OSTEOLYTIC/OSTEOBLASTIC METASTATIC DISEASE : • This variety accounts for approximately 10% of all skeletal metastasis. • It arises as a simultaneous and continuous combination of equal bone destruction and bone reformation resulting in both destructive and dense lesions. • Primary tumours arising from the breast, lung, kidney, liver and following destructive lesion irradiation, may produce this pattern.

25. Metastatic foci occur at multiple sites in 90% of cases

26. OSTEOBLASTIC METASTISIS (15%) • Prostate • Breast (post radiotherapy) • Urinary bladder • Gastric • Pulmonary • Gastrointestinal tract • Osteosarcoma OSTEOLYTIC METASTISIS (75%) • Pulmonary • Breast • Renal • Thyroid • Gastrointestinal tract MIXED OSTEOLYTIC/ OSTEOBLASTIC METASTISIS (10%) • Breast • Pulmonary • Renal • Hepatic • Following lytic lesion irradiation MOST FREQUENT SITES OF MALIGMENT METASTATIC EMINATION

27. LABORATORY • Elevated E.S.R., serum calcium, P.S.A., alkaline and acid phosphatase are unreliable diagnostic features • Tc 99m imaging sensitivity approaches 97% accuracy • C.A.T. is especially diagnostic for pelvic, sacral and spinal disease • M.R.I. allows evaluation of tumor resection feasability • Osseous biopsy remains the only diffinitive diagnostic method but is seldomly required to render a diagnosis

28. COMMENTS • It is never unreasonable to assume that one can have back pain produced by metastatic disease. • Patients suffering from skeletal pain and a history of primary malignant disease should always be suspiciously regarded metastasis. • Appropriate history, physical examination, laboratory analysis and diagnostic imaging studies, will usually be revealing.

29. COMMENTS con’d • Unexplained skeletal pain in patients with known primary malignant disease, in which the usual diagnostic processes prove inconclusive, also warrant more elaborate testing and treatment. • Due to the natural growth of the Canadian population and the oncoming wave of the now aging « baby-boomer » generation, metastatic disease will be discovered in ever increasing numbers of patients seeking care. • Primary malignant and matastatic disease still portend disastrous consequences, particularly if left untreated.

30. The Portable Skeletal X-Ray Library, Deltoff, MN, Kogon, PL, Mosby Year- Book, Inc., St. Louis, 1998 Essentials of Skeletal Radiology Third Edition Yochum, TR, Rowe, LJ Lippincott Williams & Wilkins Philadelphia 2005 References:

31. KOGON’S MYSTERY CASE NO. 2

32. HISTORY • 25 year old healthy female • Avid soccer player • Presented with acute right neck pain and stiffness following a ball strike one week earlier during a soccer match • Attended M.D. who prescribed analgesics and antispasmodics one day following the traumatic event • After one week without resolution, attended her chiropractor • The chiropractor administered three manipulations over the period of one week to which the patient made a complete and uneventful recovery

38. Reference: Essentials of Skeletal Radiology, Third Edition, Vol. 1, Yochum, TR, Rowe, LJ, Lippincott Williams & Wilkins, Philadelphia, 2005, pg. 213

39. Reference: Essentials of Skeletal Radiology, Third Edition, Vol. 1, Yochum, TR, Rowe, LJ, Lippincott Williams & Wilkins, Philadelphia, 2005, pg. 2013

44. Reference: Roentgen Signs in Clinical Practice, Vol. 2, Meschan, I, W.B. Saunders Company, Philadelphia, pg. 995

45. LYMPHOMA • Definition: • Malignant transformation within the lymphatics • 2 varieties: Hodgkin’s lymphoma (HL) • Non-Hodgkin’s lymphoma (NHL) • Hodgkin’s lymphoma is based on the presence of Reed-Sternberg cells. • Clinical Features: Complex study of disease • Musculoskeletal symptoms • Night sweats, often no pain • Enlarged lymph nodes on palpation during physical examination • Hodgkin’s lymphoma slightly more comment in females • Non-Hodgkin’s lymphoma more frequent in males

46. Imaging Features: - Chest x-ray is the mainstay - Lesions less than 2 cm. in diameter may be radiographycally occult - Low-dose CT is best for staging treatment - Positron emission tomography (PET) scans are the most sensitive for detecting lymph node involvement - NHL- involves mediastinal and hilar nodes - HL- implicates anterior mediastinal adenopathy - Careful scrutiny of the pulmonary–pleural- vertebral interfaces (paraspinal line) may demonstrate displacement as a subtle sign of abnormality

47. Treatment: Chemotherapy and radiotherapy are employed as the lymphogenous tissues are radiosensitive NHL- survival rate: 70% for 5 years 60% for 10 years dependent on stage of discovery HL- survival rate: 91% for 5 years Age of implication: 15 to 40 years but most frequently 20 to 30 years

48. REFERENCES Rambam Maimonides Medical Journal, October 2014 Does Gender Matter in Non-Hodgkin’s Lymphoma? Differences in Epidemiology, Clinical Behavior and Therapy Horesh, N, Horwitz, NA

49. KOGON’S MYSTERY CASE NO. 3