Index of Case Report: Volume 1: Issue 1
Affiliations: Dr Abdurrahman Yurtaslan Oncology Training And Research Hospital, Mehmet Akif Ersoy Neighborhood, 13. Street, No:56 06200 Ankara, Turkey . Tel : +905054634794
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Simple bone cyst rarely occur in scapula and to our knowledge, these cysts have not been reported in acromion. In this report, we present a 24 year old female patient who was successfully treated by curettage and grafting using xenografting. It was seen in the postoperative follow-up that no recurrence findings were not seen in the 6-month follow-up, the patient had got full range of motion, and she was able to do all routine activities in a satisfactory way.
Level of evidence : V (case report)
Keywords : Simple bone cyst, scapula, acromion
Unilateral bone cysts (UBC’s) that are also known as simple bone cyts are benign lesions filled with fluid that involve the metaphyses of long bones.On the plain radiograph, they are well contoured lytic lesions with a cyst wall covered by a fibrous membrane containing some yellow serous fluid. Most simple bone cysts are frequently seen in childhood. It is a lesion of unknown etiology, which the most frequently seen in the age range of 5 to 15. Even if it has been reported that they may be seen in all bones, these cysts are quite common in the proximal humerus and proximal femur[4-6].
The roentgenographic differential diagnosis of a cystic lesion in the scapula of an adolescent includes fibrous dysplasia, aneurysmal bone cyst, eosinophilic granuloma, osteoblastoma or an infectious process.
There is no any standard approach for the treatment. Just follow up without treatment, injection of local corticosteroids, multiple drill holes, curetage plus grafting and many other treatment modalities have been described[3,6,7].
Herein, we report a case of simple bone cyst localized in the acromion. We could not find any other case of symptomatic single radiolucent lesion localized in acromion in the literature. Our patient was successfully treated by curetage and grafting.
A 24 year-old female patient presented to our orthopedic outpatient clinic with a pain on the lateral side of the right shoulder. The patient reported that she had occasional pain for about one year, but the pain was exacerbated recently. The patient had no any history of trauma or overusage. There was no a systemic disease. On the physical examination, there was no edema or hyperemia on the lateral side of shoulder. Her pain was associated with limitation of the right shoulder movement. There was pain with palpation on the anterior acromion. The patient was asked if data concerning the case could be submitted for publication, and he consented.
The plain two plane radiograph of the right shoulder revealed a well contoured lytic lesion with minimal sclerotic margins and narrow transitione zone benign lesion, which did not lead to expansion in the acromion. Lesion suppressed T2 weighted MRI images showed a cystic lesion with was not supressed and had an equal intensity with the fluid, homogenous hypointense on T1 series, which had a slight contrast enhancement in the wall after the injection of contrast agent, and had no enhancing in the central region, and septa or leveling (Figures 1-2).
Incisional biopsy was planned. On the intraoperative evaluation; a frozen section was performed since the macroscopy of the lesion reminds benign cystic lesion just in line with the radiographs, findings similar to simple bone cyst were seen, and curettage of the cavity with high speed burring of the wall was carried out in the same session. The lesion was grafted with a 10 cc xenograft (Figure 3). Curretted material from the cyst sent for histopathological examination confirmed the identity of the simple bone cyst.
The exercises of active range of shoulder motion were started at the postoperative week 3 and the patient gained full range of motion without pain. There was no recurrence in the MRI and plain radiograph on the postoperative 6th month (Figure 4). During the 6 month of follow up, there was no additional complications or pain. The patient was doing all routine activities satisfactorily.
Scapula tumors are rare and are frequently malignant. The benign and malignant lesions that may ocur in the scapula are frequently seen in childhood. Males are affected twice as often as females. Unlike the all these symptoms, our case was a benign tumour in adult women as a rare case.
Simple bone cysts were described for the first time by Virchow in 1876.Most of simple bone cysts are frequently seen in childhood and defined as a developmental/reactive lesion[3,6].The etiology is unknown.
Simple bone cysts usually involve the metaphysis of long bones, and have a predilection for the proximal humerus and proximal femur. In older ages, ilium and calcaneus are also the regions where cysts are seen frequently[3,6]. The involvement of the scapula is infrequent. The lesion in our case was localized in process of acromion.
The patients usually present with pathological fracture or mild pain in simple bone cysts.
The involvement of the acromion by benign and malignant tumours is rare with the form of case reports in literature. There are previous case reports such as aneurysmal bone cyst, giant cell tumors, chondroblastoma, and multiple myeloma reported in the past[10-13].
There is stil no consensus on whether there is a need for treatment (because there may be spontanous resolution) and which treatment is the most appropriate for simple bone cyst cases.The main goal in the treatment is to prevent pathological fracture, provide cyst eradication and relieve the pain.Local corticosteroid injections, autologous bone marrow transplantation or demineralized bone matrix injections, cortical-cancellous bone auto-allografts and many other procedures have been described in the literature[3,6,7,8].
There are no defined principles about how to treat which simple bone cysts, and there are success rates and complications specific to each treatment method. The indications for surgery in our case were the radiographic findings implying cystic lesion in the acromion and the clinical history related to the lesion.
To the best of our knowledge, no other unicameral bone cyst of acromion has been reported in the literature.
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Conflict of Interest: The authors declare that they have no conflict of interest.
Funding: There is no any funding source.
Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors.
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Figure 1: Right shoulder AP radiograph,: a well countered, minimally sclerotic lytic lesion, which does not lead to expansion in the acromion
Figure 2a : Right shoulder preop MRI coronal T1 weighted, well countered homogenous hypointense lesion without making expansion in the acromion. Figure 2b : Preop MRI coronal postcontrast T1 weighted image, peripheral thin contrast keeping lesion without keeping conrast centrally Figure 2c,d : Preop MRI coronal lipid suppressed T2 weighted image, homogenous hyperintense well countered lesion with a thin sclerotic wall in the acromion.
Figure 3 : Right shoulder AP radiograph: postoperative changes in the acromion and there is no lytic lesion, there are dense areas with rough contoures related to the graft material.
Figure 4a-d : MRI images on the 6th month post-operative; axial t1 weighted images, heterogenous hypointense partially signal voiding area related to postoperative changes in the acromion.Coronal and sagittal lipid suppressed T2 weighted images, postoperative granulation tissue, sclerosis and rough bordered heterogenous hyperintense image secondary to surgical graft material.
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