J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 5, Number 6, June 2014, pages 315-325

Bizarre Parosteal Osteochondromatous Proliferation of Long Bones: Two New Cases and Literature Study

Figure 2. At the end of the second year, plain radiographs demonstrated a calcified, osseous mass extending to the anterolateral and posterior aspects of the distal femur.

Figure 3. A computed tomography (CT) scan of the distal femur showing cortical destruction, periosteal reaction and cortical perforation.

Figure 4. On the MRI, a heterogeneous, lobulated mass wrapped around the knee anteriorly, laterally, and posteriorly. Fig. 3 The necrotic area was of low signal intensity on T1-weighted images and of high signal intensity on T2-weighted images. Femoral cortical destruction as well as lateral, anterior, and posterior irregularity and medullary invasion were present due to the mass. New ossification extended from the femoral cortex into the mass. On T2-weighted gradient imaging, the central portion of the lesion had an inhomogeneous intermediate signal, with a uniformly high signal in the periphery.

Figure 5. At a macroscopic level, the multilobular mass had wrapped the distal femur, causing destruction in the cortex. In addition, the mass had perforated the lateral cortex, and a medullary infiltration was present.

**Table 1.** Patient Demographics and Symptoms
No. of papers	Study	Year	No. of patients	Sex/age	Trauma	Symptom	Involved bone	Localization
S&P: swelling and pain; PM: proximal metaphysic; DM: distal metaphysic; PEM: proximal epyphisiometaphysis; DEP: distal epyphisiometaphysis.
1	Gruber [16]	2008	1	M/16	No	S&P	Ulna	DM
2	Bhalla [18]	2012	1	M/10	Yes	S&P	Femur	DM
3	Kershen [21]	2012	1	F/37	No	S&P	Tibia	Diaphysis
4	Rybak [10]	2007	2	F/16	No	S	Ulna	DM
				M/36			Radius	DM
5	Abramovici [3]	2002	2	F/12	No	S&P	Femur	DM
				M/27	Yes	S&P	Tibia	PM
6	Joseph [9]	2011	1	F/22	Yes	S	Tibia	PM
7	Meneses [2]	1993	17	-	-	-	Humerus (1) Ulna (6) Radius (3) Femur (3) Fibula (2) Tibia (2)	Not defined
8	Berber [6]	2011	5	Not defined	Not defined	No	Radius	PM DM PM DM
							Ulna	DM
							Tibia	PM
							Femur (2)	DM
9	Cooper [11]	1993	1	M/37	No	S	Radius	Diaphysis
10	Helliwell [17]	2001	1	M/15	Yes	S	Radius	Diaphysis
11	Bush [4]	2007	1	F/51	Yes	S&P	Humerus	PEM
12	Boudova [19]	1999	1	M/52	Yes	P&S	Femur	PM
13	Vlychou [5]	2008	1	F/30	No	S&P	Clavicle	DM
14	Ly [20]	2004	1	M/18	Yes	S&P	Humerus	Diaphysis
15	Hefferman [14]	2008	1	F/41	No	S	Ulna	DM
16	Nora [1]	1983	2	M/24 F/21	Not defined	S	Humerus Radius	DM DM
17	Author cases	New case	1	M/19	Yes	P	Femur	DEP
		New case	1	M/21	Yes	S&P	Femur	DM
		2006[12]	1	F/27	No	S&P	Femur	DM
18	Choi [15]	2001	1	F/18	No	S	Fibula	DM

Table 1. Patient Demographics and Symptoms

No. of papers

Study

Year

No. of patients

Sex/age

Trauma

Symptom

Involved bone

Localization

S&P: swelling and pain; PM: proximal metaphysic; DM: distal metaphysic; PEM: proximal epyphisiometaphysis; DEP: distal epyphisiometaphysis.

Gruber [16]

2008

M/16

S&P

Ulna

Bhalla [18]

2012

M/10

Yes

S&P

Femur

Kershen [21]

2012

F/37

S&P

Tibia

Diaphysis

Rybak [10]

2007

F/16

Ulna

M/36

Radius

Abramovici [3]

2002

F/12

S&P

Femur

M/27

Yes

S&P

Tibia

Joseph [9]

2011

F/22

Yes

Tibia

Meneses [2]

1993

Humerus (1)
Ulna (6)
Radius (3)
Femur (3)
Fibula (2)
Tibia (2)

Not defined

Berber [6]

2011

Not defined

Radius

PM
DM
PM
DM

Ulna

Tibia

Femur (2)

Cooper [11]

1993

M/37

Radius

Diaphysis

Helliwell [17]

2001

M/15

Yes

Radius

Diaphysis

Bush [4]

2007

F/51

Yes

S&P

Humerus

PEM

Boudova [19]

1999

M/52

Yes

P&S

Femur

Vlychou [5]

2008

F/30

S&P

Clavicle

Ly [20]

2004

M/18

Yes

S&P

Humerus

Diaphysis

Hefferman [14]

2008

F/41

Ulna

Nora [1]

1983

M/24 F/21

Not defined

Humerus
Radius

DM
DM

Author cases

New case

M/19

Yes

Femur

DEP

New case

M/21

Yes

S&P

Femur

2006[12]

F/27

S&P

Femur

Choi [15]

2001

F/18

Fibula

**Table 2.** Radiological Features and Stages of the Lesions
No. of papers	X-ray	CT	MRI	Size of tumor (cm)	C. Dest	M. Inv	Stage
C. Dest: cortical destruction; M. Inv: medullary invasion.
1	Cortical-based calcified and osseous masses	Intensely calcified and ossified masses	Marrow involvement: No Soft-tissue extension: No	Not defined	No	No	II
2	Broad-based osseous protuberance masses, Cortical reactive sclerosis	Exostotic appearing lesion	Marrow involvement: No Soft-tissue extension: No	3	Yes	No	III
3	Cortical-based calcified and osseous masses	Not defined	Marrow involvement: No Soft-tissue extension: No	5	No	No	II
4	1. Pedunculated mass	Pedunculated mass of mature ossification with distinct medullary and cortical components	Not defined	3	Yes	Yes	IV
	2. Cortical-based calcified and osseous masses	Not defined	Not defined	Not defined	Yes	Not defined	II
5	1. Cortical involvement and destruction as well as focal calcification	Cortical destruction, Cortical reactive sclerosis	Marrow involvement: No Soft-tissue extension: No	4	Yes	No	III
	2. Soft-tissue density mass		Marrow involvement: No Soft-tissue extension: No	2 cm	No	No	I
6	Well-defined ossified parosteal lesion	Not defined	Not defined	4 cm	Yes	Not defined	III
7	Not defined	Not defined	Not defined	Not defined	Not defined	Not defined	No
8	Not defined	Not defined	Not defined	Not defined	Not defined	Not defined	II
9	Mushroom-shaped calcified mass, thickening cortex	Not defined	Not defined	2	Yes	No	III
10	Mushroom-shaped calcification mass	Cortical involvement and destruction	Marrow involvement: Yes Soft-tissue extension: Yes	4 cm	Yes	Yes	IV
11	A surface based, radiodense lesion	No intramedullary extension and no cortical disruption	Marrow involvement: No Soft-tissue extension: No	6	No	No	II
12	Egg-shaped calcification	No intramedullary extension and no cortical disruption	Not defined	5	No	No	I
13	Ill-defined, radiodense mass	Not defined	Marrow involvement: No Soft-tissue extension: No	Not defined	Yes	No	II
14	Cortical-based calcified	Calcified soft-tissue mass	Not defined	Not defined	No	No	I
15	Well-defined ossified lesion	Cortical involvement and destruction	Marrow involvement: No Soft-tissue extension: No	2	Yes	No	III
16	Not defined	Not defined	Not defined	Not defined	Not defined	Not defined	No
17	1. Well-defined ossified parosteal lesion, thickening cortex	Not defined	Marrow involvement: No Soft-tissue extension: No	10	Yes	No	III
	2. Normal	Cortical involvement and destruction	Marrow involvement: Yes Soft-tissue extension: Yes	3	Yes	Yes	IV
	3. Ossified parosteal lesion	Cortical involvement and destruction	Marrow involvement: Yes Soft-tissue extension: No	10	Yes	Yes	IV
18	Cortical-based calcified mass	Not defined	Not defined	5	Not defined	No	No

Table 2. Radiological Features and Stages of the Lesions

No. of papers

X-ray

MRI

Size of tumor (cm)

C. Dest

M. Inv

Stage

C. Dest: cortical destruction; M. Inv: medullary invasion.

Cortical-based calcified and osseous masses

Intensely calcified and ossified masses

Marrow involvement: No
Soft-tissue extension: No

Not defined

Broad-based osseous protuberance masses, Cortical reactive sclerosis

Exostotic appearing lesion

Marrow involvement: No
Soft-tissue extension: No

Yes

III

Cortical-based calcified and osseous masses

Not defined

Marrow involvement: No
Soft-tissue extension: No

1. Pedunculated mass

Pedunculated mass of mature ossification with distinct medullary and cortical components

Not defined

Yes

2. Cortical-based calcified and osseous masses

Not defined

Yes

Not defined

1. Cortical involvement and destruction as well as focal calcification

Cortical destruction, Cortical reactive sclerosis

Marrow involvement: No
Soft-tissue extension: No

Yes

III

2. Soft-tissue density mass

Marrow involvement: No
Soft-tissue extension: No

2 cm

Well-defined ossified parosteal lesion

Not defined

4 cm

Yes

Not defined

III

Not defined

Mushroom-shaped calcified mass, thickening cortex

Not defined

Yes

III

Mushroom-shaped calcification mass

Cortical involvement and destruction

Marrow involvement: Yes
Soft-tissue extension: Yes

4 cm

Yes

A surface based, radiodense lesion

No intramedullary extension and no cortical disruption

Marrow involvement: No
Soft-tissue extension: No

Egg-shaped calcification

No intramedullary extension and no cortical disruption

Not defined

Ill-defined, radiodense mass

Not defined

Marrow involvement: No
Soft-tissue extension: No

Not defined

Yes

Cortical-based calcified

Calcified soft-tissue mass

Not defined

Well-defined ossified lesion

Cortical involvement and destruction

Marrow involvement: No
Soft-tissue extension: No

Yes

III

Not defined

1. Well-defined ossified parosteal lesion, thickening cortex

Not defined

Marrow involvement: No
Soft-tissue extension: No

Yes

III

2. Normal

Cortical involvement and destruction

Marrow involvement: Yes
Soft-tissue extension: Yes

Yes

3. Ossified parosteal lesion

Cortical involvement and destruction

Marrow involvement: Yes
Soft-tissue extension: No

Yes

Cortical-based calcified mass

Not defined

**Table 3.** Applied Surgical Technique for Lesions and Results
No. of papers	Diagnosis	Treatment	Time and No. of recurrence	Recurrence treatment	Complication	Follow-up (months)	Result
HE: histopathologicexamination; LAT: local adjuvant therapy; ND: not defined; NR: no recurrence; IE: intralesional curetage.
1	HE	Excision	10 months	Second IE	No	26	NR
2	HE	Excision	ND		Popliteal aneurysm	ND	ND
3	HE	Excision	ND		No	ND	ND
4	HE	Not defined	3 years	Excision	No	ND	ND
	HE	Excision	No	No	No	ND	ND
5	HE	Not defined	No	No	No	12	NR
	HE	Not defined	No	No	No	60	NR
6	HE	M. Resection	No	No	No	24	NR
7	ND	Not defined	ND	ND	ND	ND	ND
8	HE	Shark-bite	ND	ND	ND	ND	NR
		Shave exc.
		M. Resection
		M. Resection
		M. Resection
9	HE	W. Resection	No	No	No	24	NR
10	HE	W. Resection	No	No	No	24	NR
11	HE	M. Resection	No	No	AVN	42	NR
12	HE	Excision	Four time	Wide excision	No	18	NR
13	HE	Excision	No	No	No	48	NR
14	CT	No surgery	No surgery	No surgery	No surgery	No surgery	No surgery
15	HE	M. Resection	No	No	No	12	NR
16	HE	Not defined	ND	ND	ND	ND	ND
17	HE	M. Resection	No	No	No	90	NR
		Curettage LAT	No	No	No	10	NR
		Curettage LAT	No	No	No	12	NR
18	HE	Excision	ND	No	Fibrosarcoma	ND	ND

Table 3. Applied Surgical Technique for Lesions and Results

No. of papers

Diagnosis

Treatment

Time and No. of recurrence

Recurrence treatment

Complication

Follow-up (months)

Result

HE: histopathologicexamination; LAT: local adjuvant therapy; ND: not defined; NR: no recurrence; IE: intralesional curetage.

Excision

10 months

Second IE

Excision

Popliteal aneurysm

Excision

Not defined

3 years

Excision

Not defined

M. Resection

Not defined

Shark-bite

Shave exc.

M. Resection

W. Resection

M. Resection

AVN

Excision

Four time

Wide excision

Excision

No surgery

M. Resection

Not defined

M. Resection

Curettage LAT

Excision

Fibrosarcoma