Rev. bras. ortop. vol.50 número5

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Case

report

Parosteal

aneurysmal

bone

cyst

夽

Walter

Meohas,

Ana

Cristina

de

Sá

Lopes,

João

Victor

da

Silveira

Möller

_,

Luma

Duarte

Barbosa,

Marcelo

Braganc¸a

dos

Reis

Oliveira

InstitutoNacionaldeTraumatologiaeOrtopedia(Into),RiodeJaneiro,RJ,Brazil

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Articlehistory:

Received4June2014 Accepted23October2014 Availableonline1September2015

Keywords:

Aneurysmalbonecyst Calcitonin

Corticosteroids Infiltration

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The incidenceofaneurysmalbonecystsis0.14casesper100,000individuals.Parosteal aneurysmalbonecystsaretheleastprevalentsubtypeandrepresent7%ofallaneurysmal bonecysts.We presentthecaseofa38-year-oldmale patientwithpain andbulgingin hisrightarm foreightmonths.Hehadpreviouslybeendiagnosedaspresenting giant-celltumor,buthisslideswerereviewedandhisconditionwasthendiagnosedasparosteal aneurysmalbonecyst.Thepatientwastreatedwithcorticosteroidandcalcitonininfiltration intothelesionandevolvedwithclinicalandradiologicalimprovementwithinthefirstfive weeksaftertheoperation.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Cisto

ósseo

aneurismático

parosteal

Palavras-chave:

Cistoósseoaneurismático Calcitonina

Corticosteroides Infiltrac¸ão

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Ocistoósseoaneurismáticotemumaincidênciade0,14acada100milindivíduos.Osubtipo parostealéomenosprevalente,representa7%detodos.Apresentamosumpaciente mas-culino,38anos,comdoreabaulamentoembrac¸odireitohaviaoitomeses.Diagnosticado previamentecomotumordecélulasgigantes,tevesualâminarevisadaeentãofoifeitoo diagnósticodecistoósseoaneurismáticoparosteal.Opacientefoitratadocominfiltrac¸ão intralesionaldecorticosteroideecalcitoninaeevoluiucommelhoriaclínicaeradiológicajá nasprimeirascincosemanaspós-operatórias.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

WorkperformedattheInstitutoNacionaldeTraumatologiaeOrtopedia(INTO),RiodeJaneiro,RJ,Brazil. ∗ _{Correspondingauthor.}

E-mails:[email protected],[email protected](J.V.daSilveiraMöller).

http://dx.doi.org/10.1016/j.rboe.2015.08.008

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Introduction

AneurysmalbonecystswerefirstdescribedbyJaffeand Lich-tensteinin1942.1_{Theyaccountfor1–2%ofallprimarybone} tumorsand affectthemetaphyseal regionoflong bonesin children,adolescentsandyoungadults.2,3

Thislesiontypicallydevelopsinsidebones.4_Cystslocated inthe cortical boneare rare and account for7–9.3% ofall aneurysmalbonecysts.5,6

Few cases have been reported in the literature. The approachusedisindividualizedandvariesaccordingtothe experience ofeach service.We presenta caseofparosteal aneurysmalbonecystthatwastreatedinaccordancewithour experience.

Case

report

Thepatientwasa38-year-oldmanofmixedracewitha com-plaintofpainandbulginginhisrightarm.Itwasofprogressive natureand the patient had had the complaintforat least eightmonths.Hesaidthathehadnotsufferedanytrauma orundergoneprevioussurgery.

Thepatient,whohadbeenattendedpreviouslyatanother service,underwentabiopsyfromwhichthehistopathological diagnosiswascompatiblewithagiant-celltumor.Whenhe arrivedatourservice,becauseoftheclinicalandradiological characteristicsoftheslides(Figs.1–4),areviewofthemwas requested.

Fig.1–Radiographsoftherighthumerusinanteroposteriorandlateralview.

Thisreview showedthe presenceofalesion formedby cystmembranesthatsometimesshowedcompleteseptation constitutedbyfusiformandmultinucleatedgiantcells.Bone trabeculaedissociatedbyconnectivetissuewerenoted,along withneoformedbonetrabeculaeofreactivepattern,whichled tothediagnosisofparostealaneurysmalbonecyst.

Infiltration intothe lesionusingcalcitonin and corticos-teroidwasindicatedafterreachingagroupdecision.Inthe fifthpostoperativeweek,the lesionwasalready seentobe undergoinganossificationprocess(Fig.5).

Discussion

AneurysmalbonecystswerefirstdescribedbyJaffeand Lich-tensteinin1942.AccordingtotheWorldHealthOrganization, theyarecharacterizedasbenigncysticbonelesionscomposed ofbonevoidsthatarefilledwithbloodandseparatedbysepta ofconnectivetissuecontainingfibroblasts,osteoclasticgiant cellsandreactivebonetissue.1–3,7

Thesecystsaccountfor1–2%ofallprimarybonetumors and their incidence is 0.14 per 100,000 individuals.8 _The lesions affect the metaphyseal regionofthe long bonesof children,adolescentsandyoungadults.2,3

Fig.2–Tomographicfeatures.

subperiostealgiantcells,hemangiomasand osteogenic sar-comas.

In1957,ShermanandSoong5_{classifiedaneurysmalbone} cystsintothreetypes:eccentric,parostealand central.The parostealsubtypeistheleastfrequentsubtype,accounting for7–9.3%ofallaneurysmalbonecysts.5,6

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Fig.3–Magneticresonance.

Tomography helps in making the differential diagnosis ofthese lesions.Theyshow liquiddensityand mayclearly demonstratetheliquidlevels.2,6_{Scintigraphyshowsthatthere} isgreateruptakeattheperipheryofthelesion.2_Inmagnetic resonanceimaging,thelesioniswelldefined,withlobulated outlinesandliquidlevels.2

The histology of aneurysmal bone cysts is character-ized by voids filled with blood. These voids are covered bya singlelayer ofundifferentiated cells.The solid tissue surrounding the lesion is composed ofrichly vascularized fibrosis.2_{Diagnosticdifferentiationbetweengiant-celltumors} andosteosarcomawithtelangiectasiais anatomopathologi-callycomplex.2

Becausetheseareaggressivelesions,thetreatment con-sistsofcurettage,withorwithoutsubsequentadjuvantssuch

as bone grafts, bone marrow aspirate, cryotherapy, argon, phenol or calcitonin with corticosteroid injection into the lesion.7,10 _{In our service, use ofcorticosteroids in} associa-tionwithcalcitonin,injectedintothelesion,isthepreferred methodfortreating thistypeoflesion.Casesofresolution oflesionsafteranepisodeoffracturingorafterabiopsy,or evenspontaneously,havebeendescribed.7,8_{Lesionrecurrence} isassociatedwithyoungpatients,previousaneurysmalbone cysts,locationadjacenttoajointorgrowthplate,lowmitotic countandpresenceofotheropengrowthplates.8

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Fig.5–Postoperativeradiographs.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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NiederhagenM,Baur-MelnykA,etal.Aneurysmalbonecysts ofsofttissuerepresenttrueneoplasm.Areportoftwocases.J BoneJointSurgAm.2011;93(45):1–8.

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8.SteffnerRJ,LiaoC,StacyG,AtandaA,AttarS,AvedianR,etal. Factorsassociatedwithrecurrenceofprimaryaneurysmal bonecysts:isargonbeamcoagulationaneffectiveadjuvant treatment?JBoneJointSurgAm.2011;93(21):e1221–9.

9.LichtensteinL.Aneurysmalbonecyst:apathologicalentity commonlymistakenforgiantcelltumorandoccasionallyfor hemangiomaandosteosarcoma.Cancer.1950;3(2):279–89.