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LETTER TO EDITOR
Year : 2013  |  Volume : 50  |  Issue : 4  |  Page : 301
 

Enlarging nonossifying fibroma mimicking aggressive bone tumour


The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

Date of Web Publication24-Dec-2013

Correspondence Address:
A Chhabra
The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.123634

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How to cite this article:
Wadhwa V, Thakkar R S, Carrino J A, Chhabra A. Enlarging nonossifying fibroma mimicking aggressive bone tumour. Indian J Cancer 2013;50:301

How to cite this URL:
Wadhwa V, Thakkar R S, Carrino J A, Chhabra A. Enlarging nonossifying fibroma mimicking aggressive bone tumour. Indian J Cancer [serial online] 2013 [cited 2020 May 28];50:301. Available from: http://www.indianjcancer.com/text.asp?2013/50/4/301/123634


Sir,

Nonossifying fibroma (NOF) (syn-Nonosteogenic fibroma, fibroxanthoma, xanthogranuloma of bone) is one of the most common types of benign cortical defects that arise in the metaphysis of long bones, particularly the distal femur and tibia. On plain radiographs, NOFs are identified by a sclerotic border that is usually scalloped and slightly expansile. Since the tumor is benign, it usually doesn't enlarge substantially and is asymptomatic in the majority of cases. Serial enlargement of the lesion mimicking an aggressive lesion has not been reported before.

A 15-year-old girl with growth hormone deficiency was imaged with knee radiographs to monitor her growth, while on replacement therapy. She was incidentally found to have a new left proximal posteromedial tibia lesion with features suggesting a NOF [Figure 1]a and b. On examination, she had no local tenderness or weakness. Follow-up imaging at 6, 11 and 13 months showed gradual increase (up to three times) in the size of the lesion [Figure 2]a-c. Therefore, she was referred to the orthopedic oncologist for further management. Since the lesion appearance still suggested a non-aggressive lesion, it was simply followed while the growth hormone replacement was withheld. Radiograph 5 months later confirmed healing of the lesion and progressive sclerosis without further enlargement [Figure 3].
Figure 1(a and b): Initial radiographs of the left knee (AP View) taken six months apart in 2008 show a new well defi ned lytic lesion with a narrow zone of transition in the metaphyseal region of the proximal tibia. It measures 1 cm. The lesion shows typical features of a nonossifying fi broma

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Figure 2: (a-c) Serial radiographs of the left knee (AP views) obtained 6, 11 and 13 months later show similar lesion morphology. The lesion has progressively increased in size to 1.25, 1.75 and 2.75 cm, respectively. The patient was on growth hormone therapy during this time

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Figure 3: Plain radiograph of the left knee (AP view) following withdrawal of the growth hormone shows that the lesion has started healing with progressive sclerosis with no further increase in size

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NOF belongs to "tumor-like lesions" according to the World Health Organization classification. [1] It is common in children with 30 to 40% cases harboring multiple lesions. The etiology is unknown and the lesion is believed to be caused by developmental defect. [2] Due to the asymptomatic nature, these lesions are incidentally discovered on imaging. [3] Given the characteristic radiographic appearance of a well circumscribed subcortical lytic lesion with narrow zone of transition, peripheral sclerosis and scalloped margins, these lesions are classified as "do not touch lesions," implying that biopsy is considered to be excessively invasive. In our case, the lesion was new, however, characteristic appearance warranted only follow-up imaging. These lesions usually spontaneously regress (sclerose). Curettage and bone grafting may be performed for large lesions that may cause pathologic fracture and symptomatic lesions. [4]

Expansion while on a growth replacement therapy has not been reported before. It may raise a false alarm of the lesion being aggressive however; characteristic imaging features should deter the radiologist from being overly aggressive to avoid unnecessary biopsy. Withholding the hormonal treatment halts its spurious growth and subsequent healing of the lesion confirms its otherwise benign nature as observed in this case.

To conclude, NOF can enlarge on growth hormone treatment and may masquerade aggressive bone tumor. Withholding hormonal treatment results in healing of the lesion.

 
  References Top

1.Schajowicz F. International histological classification of tumors. Histological typing of bone tumors. Geneva: World Health Organization; 1993. p. 36-8.  Back to cited text no. 1
    
2.Betsy M, Kupersmith LM, Springfield DS. Metaphyseal fibrous defects. J Am Acad Orthop Surg 2004;12:89-95.  Back to cited text no. 2
[PUBMED]    
3.Hetts SW, Hilchey SD, Wilson R, Franc B. Case 110: Nonossifying fibroma. Radiology 2007;243:288-92.  Back to cited text no. 3
[PUBMED]    
4.Hatcher CH. The Pathogenesis of localized fibrous lesions in the metaphyses of long bones. Ann Surg 1945;122:1016-30.  Back to cited text no. 4
[PUBMED]    


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