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[Background:] Patients with osteosarcoma who experience relapse or progression [R/P] have a poor prognosis. [Methods:] Data from 30 patients who experienced R/P among 59 with a diagnosis of high-grade osteosarcoma, who were younger than 40 years old between 2000 and 2019, were retrospectively analyzed to identify prognostic and therapeutic factors influencing their outcomes. [Results:] The 5-year overall survival [OS] rates after the last R/P of patients experiencing first [n=30], second [n=14], and third [n=9] R/P were 50.3%, 51.3%, and 46.7%, respectively. Multivariate analysis did not identify any independent risk factors affecting OS. The 5-year PFS rate of the 30 patients after first R/P was 22.4%, and multivariate analysis identified histologic subtype and curative local surgery as independent risk factors influencing PFS. Long [>6 mo] partial response was observed in three patients treated using temozolomide+etoposide, irinotecan+carboplatin, or regorafenib. [Conclusions:] OS rate in the patients with osteosarcoma experiencing R/P included in this study was markedly higher than that reported previously, mainly due to the surgical total removal of tumors, even after subsequent R/P. The recent establishment of salvage chemotherapy or molecular targeted therapy may also increase survival rates in a subgroup of patients.

Giant cell tumors of bone (GCTBs) are locally aggressive tumors with the histological features of giant cells and stromal cells. Denosumab is a human monoclonal antibody that binds to the cytokine receptor activator of nuclear factor–kappa B ligand (RANKL). RANKL inhibition blocks tumor-induced osteoclastogenesis, and survival, and is used to treat unresectable GCTBs. Denosumab treatment induces osteogenic differentiation of GCTB cells. In this study, the expression of RANKL, special AT-rich sequence-binding protein 2 (SATB2, a marker of osteoblast differentiation), and sclerostin/SOST (a marker of mature osteocytes) was analyzed before and after treatment with denosumab in six cases of GCTB. Denosumab therapy was administered a mean of five times over a mean 93.5-day period. Before denosumab treatment, RANKL expression was observed in one of six cases. After denosumab therapy, spindle-like cells devoid of giant cell aggregation were RANKL-positive in four of six cases. Bone matrix–embedded osteocyte markers were observed, although RANKL was not expressed. Osteocyte-like cells were confirmed to have mutations, as identified using mutation-specific antibodies. Our study results suggest that treatment of GCTBs with denosumab results in osteoblast–osteocyte differentiation. Denosumab played a role in the suppression of tumor activity via inhibition of the RANK–RANKL pathway, which triggers osteoclast precursors to differentiate into osteoclasts.

Background We newly developed a muscle graft that employs a doxorubicin pretreatment technique. The aims of this study were to reveal the biological and morphological features of the muscle tissue in the second week (Study I), to reveal the regeneration outcomes of functional and kinematic assessments of longer-term follow-up (16 weeks, Study II), and to make assessments of the muscle graft with doxorubicin pretreatment in the critical-sized nerve defect model (20 mm, Study III). Methods A total of 26 adult rats were used in this study. Doxorubicin treatment was accomplished by immersion in a doxorubicin solution for 10 minutes followed by a rinsing procedure. The rats were divided into three groups: the muscle graft with and without doxorubicin pretreatment (M-graft-w-Dox and M-graft-w/o-Dox) groups and the autologous nerve graft (N-graft) group. Assays of apoptosis, immunofluorescent histochemistry including CD68 (macrophage marker), scanning electron microscopy (SEM), morphometrical studies of the regenerated axons, nerve conduction studies, and kinematic studies were performed. Results The M-graft-w-Dox group contained significantly larger numbers of apoptotic cells and CD68-positive cells. SEM revealed the existence of the basal lamina, so called “empty tubes,” in the M-graft-w-Dox group. Study II showed contentious maturation of the regenerated axons, especially in the compound muscle action potentials. Study III showed that even at 20 mm, the M-graft-w-Dox group promoted axonal regeneration and functional regeneration. Conclusion The M-graft-w-Dox group showed superior regeneration results, and this easy and short-term procedure can expand the muscle graft clinical indication for the treatment of peripheral nerve defects.

In this study, timber column–sill joints strengthened with carbon fiber-reinforced plastic (CFRP) plates using bonds and screws were subjected to loading tests. Twelve joint specifications were considered depending on different combinations of the CFRP plate surface finish and thickness and the type of bond, and the corresponding effects on the load–displacement behavior of the joints were investigated. Three failure modes were observed in addition to the peeling of the CFRP plate. The specimens that failed owing to screw tear out and screw head pull-through in the CFRP plate or splitting of the sill showed load–displacement curves of a similar shape. Those that failed owing to buckling of the CFRP plate showed a rapid and substantial load decrease due to failure. This failure mode was only observed in 0.50 mm thick CFRP plate specimens. When a peel-ply CFRP plate was installed in the column–sill joint specimens, similar secant stiffnesses were observed in the silicon and epoxy resin-bonded specimens, both with high shear strength. Although the specimens with bonds with a high shear strength showed lower deformation performance, the specimens' maximum load increased with the bond's shear strength. The maximum load improved for a 0.75 mm thick peel-ply silicon- or epoxy-bonded CFRP plate. The load's maximum value after peeling the CFRP plate was 0.79–1.23 times as large as the maximum load of the no-bond specimens and did not change significantly.

Reconstruction with a pedicled latissimus dorsi flap is used for a large defect after resection of soft tissue sarcoma of the shoulder. Primary donor site closure is sometimes difficult and a skin graft is necessary, possibly delaying postoperative chemotherapy. Combined latissimus dorsi and scapular flaps are used for free flaps in head and neck reconstruction. Myxofibrosarcoma resection in the shoulder of a 76-year-old man resulted in a 16 cm diameter skin resection. The defect was reconstructed with a scapular flap (width = 5 cm) for the distal defect and a pedicled latissimus dorsi muscle flap (flap size, 10 × 7 cm) for the proximal defect. Primary closure of the donor site in the latissimus dorsi flap was easy. By adding a scapular flap to the latissimus dorsi flap, the latissimus dorsi flap area can be reduced, making it easy for primary suture and contributing to less invasive surgery.

Background: Multifocal osteosarcoma is a rare condition that may be either synchronous or metachronous. Spine involvement of multifocal osteosarcoma is very rare. Synchronous multifocal osteosarcoma is typically described as the occurrence of tumors at two or more sites in the absence of pulmonary metastases. Methods: A 55-year-old man initially presented with low back pain. Multiple osteosclerotic lesions were observed, primarily in the spine and pelvis, as well as in soft tissues. Lung lesions were observed, but they were relatively small at reference. Laboratory tests showed a markedly elevated alkaline phosphatase (ALP) level of 36, 416 U/L (normal range, 115-359 U/L). Based upon a diagnosis of osteosarcoma on biopsy, chemotherapy was administered, resulting in a decrease in ALP to 17, 833 U/L. Results: Decompression of the symptomatic compressed spinal cord and posterior spinal stabilization of T8-12 were performed. However, progressive extensions of multiple lesions to the spinal canal led to paraplegia with urinary dysfunction. Eleven months after the first visit to our hospital, the patient died due to multiple organ failure. Conclusions: Multifocal osteosarcoma accompanied by spinal lesions may lead to paraplegia, a clinical problem that negatively affects the quality of activities of daily living. Level of Evidence 4. Clinical Relevance: Multifocal osteosarcoma accompanied by spinal lesions may lead to paraplegia, a clinical problem that negatively affects the quality of life and activities of daily living.

Chondroblastoma is a locally aggressive tumor, commonly occurring in the epiphysis of long bones. Damage after curettage at the joint surface can occur. Low porosity β-tricalcium phosphate (β-TCP) blocks are characterized by their high compression resistance. Reconstruction in which low-porosity β-TCP blocks are used as a strut have been reported for bone tumors around the knee. In the current report, a 13-year-old female with a chondroblastoma that extended to the subchondral bone of the proximal humeral epiphysis was treated with curettage and strut reconstruction using low-porosity β-TCP blocks. The implanted β-TCP blocks were incorporated without damage or shoulder dysfunction. Application of the strut reconstruction method using low-porosity β-TCP blocks is suitable for a chondroblastoma of the epiphysis in the humerus.

The prognosis of patients with osteosarcoma recurring at extrapulmonary/extraosseous sites, especially those with unresectable tumors, is generally dismal due to high resistance to chemotherapy. The present study describes a pediatric patient with osteosarcoma recurring to the liver and stomach. Complete remission was achieved by long-term systemic chemotherapy with temozolomide+etoposide, local irradiation of the stomach, and radical surgical removal of multiple liver metastases following percutaneous transhepatic portal embolization. Second-line multimodal therapy, consisting of salvage chemotherapy and curative local treatment of metastases, may enhance disease-free survival of patients with osteosarcoma experiencing relapse to uncommon sites.

Desmoid-type fibromatosis (DF) is a locally aggressive but non-metastatic (myo)fibroblastic neoplasm. A hallmark of the tumor is nuclear positivity for beta-catenin in immunohistochemistry due mostly to CTNNB1 mutations. However, a recent study has reported that even beta-catenin 'nuclear-negative' DFs can harbor CTNNB1 mutations and that the positive ratio of nuclear beta-catenin in DF is different among antibodies. Here, we reviewed soft tissue lesions for which the possibility of DF was considered and compared the sensitivity and specificity of nuclear beta-catenin for the diagnosis of DF among commonly used anti-beta-catenin antibodies, i.e., clone beta-catenin 1, 17C2 and 14. We analyzed 26 cases of DF, 28 cases of benign fibroblastic lesions, and 27 cases of other soft tissue tumors. The sensitivity and specificity of nuclear beta-catenin for the diagnosis of DF were different among antibodies; 54% and 98% in clone beta-catenin 1, 85% and 84% in 17C2, and 96% and 62% in 14. IHC of LEF1 showed comparable results with IHC of beta-catenin, with a sensitivity of 88% and specificity of 76%. Additionally, when beta-catenin 1 was used, DFs showed characteristic dotted cytoplasmic staining, often appearing as rings. Our results might be helpful for making a correct diagnosis of DF.

Objectives The aim of JCOG1610 (randomized controlled phase III trial) was to confirm the superiority of preoperative denosumab to curettage with adjuvant local therapy for patients with giant cell tumor of bone without possible post-operative large bone defect. Methods The primary endpoint was relapse-free survival and the total sample size was set at 106 patients. Patient accrual began in October 2017. However, the accrual was terminated in December 2020 due to a recommendation from the Data and Safety Monitoring Committee because of poor patient accrual. Now, we report the descriptive results obtained in this study. Results A total of 18 patients had been registered from 13 Japanese institutions at the time of termination on December 2020. Eleven patients were assigned to Arm A (curettage and adjuvant local therapy) and 7 to Arm B (preoperative denosumab, curettage and adjuvant local therapy). Median follow-up period was 1.6 (range: 0.5–2.8) years. Protocol treatment was completed in all but one patient in Arm A who had a pathological fracture before surgery. All patients in Arm B were treated with five courses of preoperative denosumab. Relapse-free survival proportions in Arm A and B were 90.0% (95% confidence interval: 47.3–98.5) and 100% (100–100) at 1 year, and 60.0% (19.0–85.5) and 62.5% (14.2–89.3) at 2 years, respectively [hazard ratio (95% confidence interval): 1.51 (0.24–9.41)]. Conclusion In terms of relapse-free survival, the superiority of preoperative denosumab was not observed in patients with giant cell tumor of bone without possible post-operative large bone defect.

Resection of malignant bone tumors in the posterior ilium may result in pelvic ring disruption. Preserving the pelvic ring and keeping an adequate surgical margin is ideal, but is challenging, especially when the tumor extends to the sacroiliac joint. The current report proposes a line from the lateral point of the second sacral dorsal foramen to the anterior surface of sacral ala (S2‐sacral ala line), and cutting from the line to the ilium over the sciatic notch and to the sacral wing using thread saws. This preserves the cortex at the sciatic notch and the distal sacroiliac joint. Two posterior iliac tumors extending to the sacroiliac joint, a metastatic melanoma in a 75‐year‐old male, and an osteosarcoma in a 56‐year‐old male were resected. The resections were performed along the S2‐sacral ala line, and consequently lumbo‐sacro‐pelvic fusions were performed. Both patients were able to walk with one crutch. Indications for the method using the S2‐sacral ala line for iliac tumors may be limited. However, the method can increase pelvic ring preservation in cases with posterior iliac malignant bone tumors., Preserving the pelvic ring at the sciatic notch during resection of a malignant bone tumor (brown) at the posterior ilium, with a resection line (red dotted line) and S2‐sacral ala points (green dot) of the lateral point of the second sacral dorsal foramen (S2 point: left illustration) and the anterior surface of sacral ala (sacral ala point: right illustration).

The prognosis of patients with relapsed osteosarcoma is extremely poor and the optimal treatment remains to be identified. Here, we retrospectively analysed the clinical outcomes of nine patients with relapsed osteosarcoma treated with temozolomide/etoposide. Of the two patients who received temozolomide/etoposide as palliative therapy for unresectable tumours, one remained alive with stable disease for >4 years. The remaining seven patients received temozolomide/etoposide as adjuvant therapy following resection of relapsed metastatic disease; of these, one was free from disease for 41 months. Potentially beneficial effects were observed in two of three O6-methylguanine-DNA methyltransferase protein-negative patients, whereas all five O6-methylguanine-DNA methyltransferase-positive patients experienced subsequent relapse. None of the patients experienced severe adverse effects requiring hospitalization. Temozolomide/etoposide is a feasible candidate as salvage therapy for relapsed osteosarcoma. Further studies are needed to verify the utility of O6-methylguanine-DNA methyltransferase protein expression as a biomarker for predicting the response to this treatment.

Introduction:Large defects following resection in the gluteal region are challenging. Of note, there are a limited number of fairly morbid options for reconstruction. Case Report:A 65-year-old female presented with complaints of an enlarging mass in the left buttock over the past several months. A high-grade sarcoma was diagnosed based on a biopsy. The final diagnosis was an undifferentiated pleomorphic sarcoma based on the resected tumor. An 11-cm tumor with surrounding tissues, including the great gluteal muscle, was resected, which resulted in a 17-cm full thickness defect. The defect was reconstructed with a transposition flap elevated from the lateral thorax. A transposition flap can cover large buttock defects without sacrificing other muscles. Conclusion:Moreover, a transposition flap is esthetically acceptable because most of the operative scar is within the buttock area. A transposition flap reconstruction is one of the several options for large defects after soft-tissue sarcoma resection in the buttock. Keywords:Buttock, resection, reconstruction, musculocutaneous flap, soft-tissue sarcoma.

Resection of malignant tumors in the posterior pelvis requires multidirectional approaches for the resection and the subsequent spine-pelvic fixation. The multifidus muscle can be scarified during the operation. This is a case report of a 44-year-old male with a secondary chondrosarcoma arising from an osteochondroma in the sacral ala. Recurrence occurred 11 months after the initial operation, and the resected tissue from the recurrence was diagnosed as a chondrosarcoma. In both operations, the multifidus muscle was elevated from its distal attachment to provide an adequate view of the tumor resection and insertion of spine-pelvic instrumentation. An adequate view by elevation of the multifidus muscle is useful for a safe operation. A preserved multifidus muscle covering the instrumentation may reduce the risk of infection. The elevation and preservation of the multifidus muscle is an easy and simple method that contributes to successful resection of a malignant tumor of the pelvis.

Following resection of a sternal tumor, respiratory dysfunction can occur and rigid reconstruction is necessary. An 82-year-old woman noted a mass in the anterior chest wall that was increasing in size. The tumor was located on the left aspect of the sternum at the level of the third rib. A radiation-induced malignant spindle cell tumor was diagnosed because of a history of irradiation for hilar lymph node carcinoma. The tumor was resected with the surrounding tissues of the second-to-fourth ribs and sternum. The posterior sternal cortex was preserved by cutting with a curved chisel under fluoroscopy. The chest wall defect was reconstructed with a 2-mm thick Gore-Tex® sheet and a local transpositional flap. Sternal resection with a chisel under fluoroscopy avoids damage to the internal thoracic artery. Preserving the posterior sternal cortex does not require rigid reconstruction. The procedure is minimally invasive.

Patient: Female, 49 Final Diagnosis: Chronic expanding hematoma Symptoms: Thigh swelling Medication: — Clinical Procedure: — Specialty: Orthopedics and Traumatology Objective: Rare disease Background: Chronic expanding hematoma is characterized by a continuous growing hematoma lesion. Case Report: The present case is of a patient who had undergone resection of synovial sarcoma in the posterior thigh and subsequent intraoperative radiation to the region at the age of 18 years. The patient observed swelling at the surgical site 31 years later at the age of 49 years. Magnetic resonance imaging revealed a growing hematoma with a cystic appearance. Partial resection of the wall and electrocoagulation of bleeding from the remaining wall were performed at the age of 50 years. Conclusions: Chronic expanding hematoma occurred as a late complication of tumor treatment.

Background The treatment of peripheral nerve defects requires bridging materials. Skeletal muscle grafts have been studied as an alternative to nerve autografts because they contain longitudinally aligned basal laminar tubes that are similar to axons. Several pretreatment methods for muscle grafts have promoted axonal regeneration. Here, a new method of doxorubicin pretreatment was used, and the efficacy of the pretreated muscle graft was evaluated in a rat model of a sciatic nerve defect. Methods A rat model of a 10-mm sciatic nerve defect was analyzed in three settings: muscle grafts with and without doxorubicin pretreatment (M-graft-w-Dox and M-graft-w/o-Dox groups, respectively) and a nerve autograft group (N-graft) (n = 6/group). The M-graft-w-Dox group was immersed in a doxorubicin solution for 10 minutes and rinsed with saline. Analyses of target muscle atrophy, electrophysiology, and histology were performed 8 weeks after grafting. Results Electrophysiological parameters and target muscle atrophy were significantly superior in the M-graft-w-Dox group compared with the M-graft-w/o-Dox group. Histological assessment revealed the presence of a significantly greater number of regenerated axons in the M-graft-w-Dox group versus the M-graft-w/o-Dox group, while there were no significant differences between the M-graft-w-Dox and N-graft groups. The diameter of myelinated axons of the regenerated nerve in the M-graft-w-Dox group was significantly larger than that in the M-graft-w/o-Dox group, while it was not significantly different compared with the N-graft group. Conclusion Pretreatment of muscle grafts with doxorubicin promoted significant peripheral nerve regeneration. This method may represent a new option for the treatment of peripheral nerve defects.

Solitary muscle metastasis of hepatocellular carcinoma (HCC) is extremely rare, and late metastasis is also rare. We present a 59-year-old man who had received initial treatment for HCC 13 years previously. Ultrasonography revealed a tumor between the abdominal wall and the liver surface. Tumor resection was performed with suspected intrahepatic metastasis or abdominal wall metastasis of HCC, and the tumor was found to be within the rectus abdominis without an association with the liver. Histologically, the resected material was confirmed to be a muscle metastasis of HCC. We discuss the management of muscle metastasis of HCC.

Patient: Female, 27-year-old Final Diagnosis: Giant cell tumor of bone Symptoms: No symptom Medication:— Clinical Procedure: — Specialty: Oncology Objective: Rare disease Background: Giant cell tumor of bone (GCTB) is a locally aggressive, intermediate tumor that rarely metastasizes. GCTB typically affects the ends of long bones and rarely involves the ribs. Curettage is typically the treatment of choice for GCTB in long bones. However, the optimal treatment of GCTB in ribs remains unclear. We report the case of a patient with asymptomatic GCTB of the first rib that was successfully treated with combined preoperative denosumab therapy and surgery via a transmanubrial approach without resection of the clavicle. Case Report: A healthy 27-year-old woman presented with a bone tumor involving the left first rib that was incidentally discovered on routine chest X-ray. Histological examination of core-needle biopsy specimens of the lesion led to a pathological diagnosis of GCTB. After preoperative denosumab treatment for 6 months, en bloc resection via a transmanubrial approach was performed. There were no serious postoperative complications. The patient remained free of symptoms and had no recurrence 4.5 years after surgery. Conclusions: Compared with other ribs, masses located in the first rib can be challenging to treat surgically because of the clavicle and neighboring neurovascular structures. This report is the first to describe GCTB located on the anterior aspect of the first rib that was successfully treated with combined preoperative denosumab therapy and surgery via a transmanubrial approach, with no recurrence or functional impairment of the shoulder girdle.

Reconstruction of the pelvic ring after the resection of pelvic tumours involving the sacroiliac joint is challenging. Although pedicle screw and rod system reconstructions are commonly performed, failure at the early stage has been reported. Surgical procedures Reconstruction involving two or more strong anchor screws (iliac, ischial, and pubis screws) into the residual pelvis, connecting with at least two rods with minimal bending to the residual lumbosacral vertebra and contralateral pelvis. The above reconstruction was performed for six malignant bone and soft-tissue pelvic tumours requiring Enneking type I + IV resection. A double-barreled free non-vascularized fibular graft was used in all patients, except for one. Patients were followed up for a mean period of 51 months (range, 9 to 96 months), and peri-operative complications, implant failure within the follow-up period, and the clinical results of surgery were investigated. The mean age of four females and two males at the initial surgery was 37.2 years. One patient developed a deep wound infection. Two patients died due to metastasis of the tumor. All patients were able to walk on their own within 12 weeks of surgery. There was no implant failure, except in two patients with contralateral lumbosacral rod fracture three and four years after surgery, for which one patient required rod replacement. The incidence of implant failure, particularly around the resection site, was low, which may be attributed to multiple periacetabular screws and rods with minimal bending. Our rigid reconstruction method enables the rapid resumption of walking.

The thoracoabdominal flap is a rotation flap, and is well known for reconstruction of defects following resections for breast cancer, but the flap is not well known for reconstructing defects following resections of soft-tissue sarcomas involving the chest wall. Here we present two patients with superficial chest wall sarcomas consisting of a dermatofibrosarcoma protuberans in a 42-year-old man and a recurrent myxofibrosarcoma in a 76-year-old man. The tumors were resected with the surrounding tissue. The defect was reconstructed with a thoracoabdominal flap elevated from the ipsilateral thorax (medially-based flap). Neither case developed necrosis of the flap or reduced shoulder range of motion. The chest wall presents few options for a donor vessel. The thoracoabdominal flap has an axial blood supply and does not require a microsurgical procedure. A thoracoabdominal flap is a suitable reconstruction option for a defect after the resection of a superficial soft-tissue sarcoma in the chest wall.

Hemangioma in the patella is rare, and the osteolytic finding mimics a solid tumor. In the current report, a 69-year-old male with hemangioma in the patella had pain in the anterior left knee when kneeling. The osteolysis was not obvious on plain radiographs in the anteroposterior or lateral views, but was clear in the axial view, as well as with computed tomography. Bone scintigraphy showed uptake of technetium. Magnetic resonance imaging suggested a cystic lesion, but a primary solid tumor with cystic changes could not be ruled out. After confirmation of the diagnosis by biopsy, curettage and beta-tricalcium phosphate grafting was performed. Preoperative symptoms disappeared 6 months after the operation. It is easy to miss these lesions on plain radiographs. Even after identification of the lesion, a solid tumor with a destructive nature would have been suspected because of the uptake on bone scintigraphy. In a previous report, patellectomy was performed, but curettage may be sufficient for a benign tumor, as in the current case.

The giant cell tumor of bone (GCTB) is a locally aggressive tumor. Reconstruction methods using β-tricalcium phosphate (β-TCP) blocks with strong compression resistance in and around the knee joint for GCTB have been reported. Among six cases of GCTB treated using this method, two recurrent cases revealed osteolysis, predominantly within the β-TCP block based on plain radiographs or computed tomography, while remodeled host bones were preserved. Implanted β-TCP blocks can function as a placeholder to preserve host bone in recurrent cases, leading to a higher probability of joint preservation.

Background: Epidermal cysts are lined with stratified squamous epithelium and filled with keratinous material.Magnetic resonance imaging (MRI) findings can be used for the diagnosis of epidermal cysts, but characteristic MRI findings related to cyst size in particular go unreported. Objective: To analyse characteristic MRI findings of epidermal cysts categorized by size. Materials and Methods: Unruptured epidermal cyst cases were analyzed according to 3 cyst size categories: large (≥4 cm), medium (≥2 to Results: Thirty-three patients (26 males and 7 females; average age, 52.2 years; 33 cases) were grouped by cyst size: large (13 cases), medium (12 cases), and small (8 cases). MRIs revealed cyst walls via low signal intensity on T1- and T2-weighted images. On T1-weighted images, the signal intensity of cysts relative to that of muscle was hypointense (1 case, 3%), isointense (4 cases,12%), and slightly hyperintense (28 cases, 85%). On T2-weighted images, cysts were hyperintense in muscle relative to adipose tissue (20/33 cases, 61%) and isointense relative to adipose tissue (7/33, 21%) or hyperintense relative to adipose tissue (6/33, 18%). Overall, signal patterns were similar among groups. Signs of inner debris were observed in all large (13, 100%) and medium (2/12, 17%) cysts, but not in small cysts (0/8). Large, medium, and small cysts had signs of peripheral linings (12/13, 92%; 9/12, 75%; and 4/8, 50%, respectively). Conclusion: Slightly hyperintense signals on T1-weighted images were characteristic, even in small epidermal cysts. Signs of intracyst debris and a peripheral lining reflect the pathology and were considered useful for diagnosis. Larger cysts were more frequently positive for keratinous debris.

Background: Red bone marrow develops early in life and converts into yellow bone marrow with aging. Reconversion occurs when yellow bone marrow reconverts into red bone marrow due to increased oxygen demands. Objective: Diffuse appearance of red bone marrow on Magnetic Resonance Imaging (MRI) is rarely encountered. Materials and Methods: Seven patients, five male and two female, with the diffuse appearance of red bone marrow were evaluated. The average age was 71.4 (47-86) years old. All patients had been referred based on a working diagnosis of cancer metastasis. All patients were eventually rediagnosed with bone marrow reconversion. Results: Spinal MRI was evaluated in all patients, including the whole spine in four patients and lumbar spine in three patients. Six patients had slight anemia or close to the lower limit of normal hemoglobin (within 1mg/dl). Six patients were heavy smokers, having more than 20 cigarettes per day. Four patients had a history of stomach or bladder cancer (2 cases each). MRI revealed red bone marrow with a diffuse appearance and low signal intensity on T1- and T2-weighted images. Compared with the spinal cord/conus, the red bone marrow appeared isointense in about half of the cases, and in the other cases, the intensities were either slightly high or low. The signal of yellow bone marrow was isointense with the retroperitoneal fat. Conclusion: Diffuse red marrow can be difficult to differentiate from cancer metastasis. Compared to the MRI, signal intensity of the cord/conus is useful in the diagnosis of red marrow. Slight anemia may also be present. Heavy smoking might be related to the appearance of diffuse red marrow.

Patient: Female, 40 Final Diagnosis: Ischemic fasciitis Symptoms: A mass physical deterioration Medication: — Clinical Procedure: Observation Specialty: Oncology Objective: Rare co-existance of disease or pathology Background: Ischemic fasciitis is a rare condition that occurs in debilitated and immobilized individuals, usually overlying bony protuberances. Because the histology shows a pseudosarcomatous proliferation of atypical fibroblasts, and because the lesion can increase in size, ischemic fasciitis can mimic sarcoma. Beta-propeller protein-associated neurodegeneration (BPAN) arises in infancy and is due to mutations in the WDR45 gene on the X chromosome. BPAN results in progressive symptoms of dystonia, Parkinsonism, and dementia once the individual reaches adolescence or early adulthood, and is usually fatal before old age. A case of ischemic fasciitis of the buttock is presented in an adult woman with BPAN. Case Report: A 40-year-old woman with BPAN and symptoms of mental and physical deterioration, had become increasingly wheelchair-dependent and presented with a mass in her buttock that had been increasing in size for two months. Computed tomography (CT) imaging showed an ill-defined subcutaneous lesion between the dermis and the gluteal muscle, which was suspicious for malignancy. A needle biopsy of the mass was performed. The histology examination showed benign ischemic fasciitis. A follow-up CT scan performed 3.5 months after identification of the lesion showed that it had decreased in size. Conclusions: Ischemic fasciitis is a rare condition that is associated with immobility. Because BPAN is a neurodegenerative disease that can cause immobility, a history of BPAN in patients of all ages may be associated with an increased risk of developing ischemic fasciitis. The correct diagnosis is essential, as ischemic fasciitis, although benign, can mimic malignancy.