A 65 years old female presented in September 2010, to our department with chief complaints of severe pain and swelling in left thigh since last 2 years. She was unable to walk and had loss of appetite since 11/2 years.
According to the patient she was apparently asymptomatic 2 years back when she developed pain in left thigh. Pain was present at the middle of flank and lateral aspect of thigh. It was constant in nature and was present even at rest, dull aching type aggravated by hip movements. It was accompanied with difficulty in walking due to pain. It was also associated with swelling over the upper part of thigh. For the above complaints patient took some local treatment but was not relieved. After six months patient was unable to bear weight even partially and was completely bed ridden. Patient also had loss of appetite and loss of weight for 1 1/2 years.
She was not having any complaint of cough, fever, haemoptysis or hoarseness of voice, difficulty in swallowing for solids or liquids. Patient was having a history of intermittent pain in right side of middle chest, which used to relieve on taking non steroidal antiinflammatory drugs. There was no history of any gastrointestinal upset or urinary problem, any breast lump, trauma syphilis, leprosy, diabetes and hypertension. Patient was a housewife with no history of tobacco or drug intake. No sensitivity or allergy to any drug. There was no family history of tuberculosis or malignancy. Patient was postmenopausal.
On examination there was a 10 cm x 5 cm swelling over antero-lateral aspect of upper part of left thigh. The swelling was diffuse, hard, localized to upper part of thigh, immobile, non-translucent, non-illuminant, non-fluctuant, non-pulsatile and fixed to the bone. There was deep tenderness over the swelling. The skin overlying the swelling was neither warm nor inflamed. The hip was in flexion, adduction and external rotation. Exaggerated lumbar lordosis was present. There was apparent shortening of 2 cm and true shortening of 1 cm. Straight leg raising test was negative. There was restriction of all movements of the affected hip. The inguinal lymph nodes were enlarged but seem too benign. Distal neurovascular status of the limb was intact.
Routine blood investigations were under normal limits. Serum lactate dehydrogenase - 154 U/L; Serum alkaline phosphatase - 320 U/L. Serum calcium - 10.2 mg/dl. Plain radiographs of the affected part showed ill-defined osteolytic permeative pattern or moth eaten type of lesion with destruction of bone involving the diaphyseal and metaphyseal region of proximal femur and extension into the soft tissues (Fig. 1A, B).
There was pathological fracture of femur at the distal margin of the tumor lesion with no periosteal new bone formation. The hip joint of the affected side appeared normal. Magnetic resonance imaging revealed a large expansile intramedullary osteogenic hypo intense vascular primary mitotic lesion of upper metadiaphyseal aspect of left femur with extra osseous extension of soft tissue in anterior and lateral myofascial compartment without any involvement of adjacent hip joint or neurovascular bundle.
Chest radiograph was showing a small ill defined area in right lower lobe. Contrast enhanced computed tomography scan of thorax was done to know about the nature of ill-defined opacity and it revealed a lobulated soft tissue density mass lesion measuring 26x30 mm noted in apical segment of right lower lobe. Mild adjacent pleural thickening is noted (Fig. 2).
Computed tomography guided Fine needle aspiration cytology from the lung lesion revealed-adenocarcinoma. Ultrasound of whole abdomen was normal. Fluoroscopic guided needle biopsy of the femoral lesion revealed it to be a metastatic adenocarcinoma.
As patient was symptomatic due to metastatic lesion but not due to primary lesion so priority was given to metastatic site. The patient was planned for surgery, but as tumor was very vascular so to reduce the risk of bleeding at the time of surgery pre-operatively Radiotherapy was planned. Palliative Radiotherapy was given at a dose of 30 Gy in10 fractions in 2 weeks with cobalt 60 in department of Radiotherapy of our institution to relive pain and to reduce vascularization of tumor.
3 weeks after the completion of radiotherapy, hip was exposed by the postero-lateral approach extending the incision more distally. Careful dissection of the soft tissues was performed to avoid spilling of tumor cells. Wide local excision of the tumor was done. 17 cm of the affected bone including the head of the femur was resected out (Fig. 3). Involved soft tissues were also resected. First a trial of the prosthesis was performed and checked for stability. Then it was replaced by customised steel bipolar cemented proximal femoral mega prosthesis. The cut muscles were tied at the ports at the upper end of the prosthesis. Wound was closed over suction drain. High groin slab with abduction bar was applied. Stitches were removed on 12th post-operative day and patient was allowed to walk with the help of walker.
After operative procedure for bone lesion patient was planned for chemotherapy and Radiotherapy for primary lung lesion. She received 4 cycles of chemotherapy in the form of inj. Gemcitabine and Cisplatin intravenous on day 1 and day 8, q-3wks followed by radical dose of loco-regional Radiotherapy (60 Gy/30 fractions). There were no wound problems or any other complications. She completed her treatment in April 2011. She has completed 11 months of follow up and is totally asymptomatic, pain free and walks independently with support (Fig. 4A, B).
Contrast enhanced CT Scan of thorax-showing mass lesion in the apical segment of right lower lobe.