Sunday, March 23, 2008

Standing on the Shoulders of Giants

No less a luminary than Isaac Newton said, "If I have seen further it is by standing on the shoulders of giants." Physicians, too, rely upon the work of our predecessors.

Henry Jaffe MD is considered by many to be the most distinguished bone pathologist of modern times. With Louis Lichtenstin MD, he established the nature of osteoid osteoma, osteoblastoma, giant cell tumor, eosinophilic granuloma, pigmented villonodular synovitis, chondroblastoma, nonossifying fibroma, chondromyxoid fibroma, and aneurysmal bone cyst. Describing any one of these entities would be a fine achievement, but he also developed a system for the evaluation and classification of bone lesions.

All of these diseases are seen by the musculoskeletal radiologist. Here are images from a 16 year-old boy, who presented with 2 months of leg pain. An X-ray showed dense cortical sclerosis:

Coronal STIR images show striking marrow edema in the mid right tibia:

Axial images were performed through the area of bone marrow edema:

(click on image to enlarge)
(A,B,C) MRI images reveal a 6 mm enhancing lesion (red arrow) in the peripheral medullary cavity of the tibia. There is extensive medullary sclerosis (yellow arrows) that is hypointense on all pulse sequences. There is thickening of the cortex (green arrow) of the adjacent tibia. (D) CT image at same level shows a lucent nidus (red arrow) with a central calcification.

The findings are diagnostic of an osteoid osteoma. The differential diagnosis for a lucent lesion surrounded by a rim of sclerosis is relatively brief: stress fracture, Brodie's abscess, intracortical hemangioma, and osteogenic sarcoma. The combination of MRI and CT will often strongly favor one diagnosis.

Osteoid osteoma was described by Jaffe in 1935. It's nice to remember the work of our predecessors now and then, as we work in the present, and seek to find truth in the future.

Vic David MD

1 comment:

Anonymous said...

I am always amazed at how important advanes are linked together. For me, as a lay person, helping to fund reserarch in the Histiocytic Disorders, it validates our strassing efforts to ensure that our grant recipients publish their work. One great discovery leads to another.

Jeff Toughill, President
Histiocytosis Association of America