Click on images to view larger radiographs and clinical pictures.

 Introduction

This 43 year old man noticed a right sided mass on the posterior part of his thigh.  It had been enlarging over the course of three months.  He reported pain on activities which had progressed to the point where climbing stairs would cause pain overlying the mass.  There was no radiation, and he took Acetaminophen to relieve the pain.  However, he had stopped playing golf because the pain would be uncontrolled by over-the-counter analgesics.

Physical examination revealed a tender rubbery mass on the posterolateral aspect of the right mid thigh.  The 5cm x 7cm egg-shaped mass was mobile with respect to the overlying skin, but fixed to the underlying tissue.  There was no local or regional lymphadenopathy, and no evidence of infection. 

 

What is the Differential Diagnosis ?

 

 

What other questions are important to ask on the history ? 

 

This man had no anorexia, weight change, fevers, chills, or night sweats.  There was no history of local  trauma or surgery, and no congenital abnormality.Past medical history revealed that this man was a 50 pack year smoker but had quit three years prior.   One year prior he complained of a "lump in the neck" and was referred to a dermatologist by his family physician.  He then saw a general surgeon for an excisional biopsy.

 

head_01.jpg (27902 bytes)  head_03.jpg (23504 bytes) What preliminary investigations would you order ?

  • AST / ALT / ALP / Bilirubin: Normal
  • CBC: Normal
  • Calcium: Slightly Elevated
  • ESR: Elevated
  • Radiographs: Normal except for small soft tissue mass

 

What further investigations would you order ?  

Bone Scan:

bonescn1.jpg (15476 bytes) bonescn4.jpg (16984 bytes)

MRI:

Axial Images
T1mri_01.jpg (18009 bytes)      T2mri_01.jpg (22256 bytes)      T2FSEmri_02.jpg (18601 bytes) 
Coronal Images
T2FSEmri_01.jpg (19974 bytes)       T2FSEmri_03.jpg (19259 bytes)
How would you now manage this issue ?
Management
 
The mass appeared to be contained in the substance of semitendinosus muscle on the left side.  Since there was no other laboratory or radiographic evidence of local, regional, or distant metastasis, an excisional biopsy was thought to be the best management.

Under general anaesthesia, and following tumour principles, an excisional biopsy of Semitendinosus was carried out, taking great care to identify and spare the Sciatic Nerve.  Gross pathology is shown below with the indentation of the Sciatic Nerve evident (also see T2 weighted MRIs on the previous page). 
path_04.jpg (26162 bytes)
 
Histology confirmed the diagnosis of Squamous Cell Carcinoma with negative margins.  The previous diagnosis of this patient's neck mass was also SCC.  Four months later, investigations including blood analyses outlined previously, and a bone scan were repeated and found to be negative for recurrence.

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