Presumed osteosarcoma

A 76-year-old dialysis patient developed sudden pain in his left arm. He consulted an orthopaedic surgeon who determined a fractured left humerus with an osteolytic lesion (Figure 1). The patient was referred to our department for further evaluation of a possible osteoscarcoma. He had required haemodialysis treatment for 4 years because of an unknown renal disease that left him with small end-stage kidneys. The patient had come to Germany from Russia, spoke only Russian and was relatively non-adherent to his dialysis treatments and medications. The physical examination revealed a systolic murmur, a functioning dialysis access, a painful immobilized left arm, but no other musculoskeletal lesions. Pertinent laboratory findings included some residual renal function, serum creatinine 345 μmol/L, calcium 2.78 mmol/ L, phosphate 1.41 mmol/L, C-reactive protein 99 mg/L and parathyroid hormone 286 pg/mL. We consulted our orthopaedic surgeons who were convinced that the patient had a malignant tumour. They requested a magnetic resonance imaging scan (Figure 2) and suggested a wide excision with insertion of a humoral head prosthesis. We obtained a bone scan (not shown) that was interpreted as showing a lesion in the humeral head, as well as probable metastases in the left distal femur and left mid-tibial shaft and skull. We negotiated a compromise and agreed to settle on a biopsy of the humeral lesion together with plate fixation to stabilize the humerus. Before we transferred the patient to surgery, we performed a Tc-MIBI parathyroid gland scintigraphy. That study raised the possibility of a parathyroid adenoma. The surgeons performed, as promised, a limited biopsy of the humeral lesion. We had alerted the pathology department of our suspicion. The Fig. 1. Roentgenogram of the left shoulder shows a destructive process immediately below the humeral head. The cortical bone is disrupted suggesting a malignant process.