I reported the case late in the workday at which point I received the comments assuming (along with me) that it is a chondroid lesion.
The baseline XR definitely look more chondroid…and I believe the f/u XRs look more chondroid-ish.
Based on the advice, I reported what I saw and the interval growth and advised orthopedic oncologic consultation to guide follow-up imaging / management.
But the last two comments where from people who clearly think this looks like an infarct…..and I took another look this morning…and agree it’s at best indeterminate.
Since an infarct would not require a consultation or follow up, I advised MRI….which should settle that particular question.
I’ll look for and share that MRI if/when I see it.
Thanks.
Hilary
Pro Chondroid Lesion comments / advice:
I’ll be curious to see what the rest of the group says. In my practice for a lesion which is enlarging like this, even though it appears non-aggressive, we usually refer them to the orthopedic oncologist so that they can fully interview and examine the patient and do any additional imaging that they would like to do and most importantly, so they can direct the work up and follow up.
I was taught in fellowship that they can enlarge and as long as there are no aggressive features, that’s OK. I was taught to look out for loss of previously present chondroid matrix (as well as our more standard aggressive features) as a marker for change into a more aggressive lesion. That being said, Given a big interval change, I do not think that it’s overkill to put this thing in surveillance or even have a baseline visit with an orthopedic oncologist.
Because of the size and change, we would recommend a) a baseline MRI in case the non-mineralized lesion is significantly larger than the mineralized lesion since we know it is growing, AND b) ortho onc consultation
Without associated osteolysis or cortical change, the increased mineralization doesn’t bother me. If shaft is painful, get nuclear scan or MRI. Otherwise, yearly x-ray at most.
Pro Infarct comments:
Article by Stacy 2015 says:
Pain is the most common presenting symptom and should alert the radiologist to carefully examine the bone surrounding the infarct for signs of malignancy; these signs can be extremely subtle and initially overlooked amid the distracting appearance of the sclerotic infarction. The radiologist must be vigilant for this rare occurrence and should be suspicious when poorly defined areas of osteolysis (or mineralization) with cortical thinning and bone destruction arise next to a bone infarct. https://ajronline.org/doi/10.2214/AJR.14.13871
Based upon the most recent study I’m wondering if this could be an infarct rather than cartilaginous lesion? Might be reasonable to get an MRI to show it one way or the other.
Mineralized lesion currently 6.1 x 1.8 x 2.2 cm
XR from July 2015
Mineralized lesion measures 4.3 x 1.8 x 2.2 cm
Her symptoms are bilateral knee pain and clicking…she had previous Rt knee arthroscopy and MRI in 2021, which suggests the other knee is or was more symptomatic….though I don’t know if that’s true now.
There are no aggressive features: no endosteal scalloping, cortical thinning / destruction.
One possibility is that the lesion is just more extensively mineralized rather than larger…but I don’t think I can know.
It has been 8 years….I don’t know if this degree of growth over such a long time is meaningful.
How should I report this?
Currently my report reads "densely mineralized chondroid lesion without aggressive features, currently measures 6.1 x 1.8 x 2.2 cm compared to 4/3 x 1.8 x 2.2 cm 8 years prior"
Do I need to recommend continued XR surveillance?
A colleague recommended orthopedic oncologic consultation….is that reasonable, or unnec
