Clinical Oncology (1991) 3:49-50 © 1991 The Royal College of Radiologists
Clinical Oncology
Case Report Osteomyelitis of the Rib Presenting as an Apical Lung Cancer S. A. Costello, M. Russell and D. Cumming Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow
Abstract. Bronchial carcinoma was initially diagnosed in a 48-year-old man on the basis of radiology showing an apical lung lesion with erosion of the first rib. Biopsy ultimately showed this to be osteomyelitis.
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Keywords: Osteomyelitis
CASE REPORT
In December 1988 a 48-year-old male labourer presented with pain in his left sternoclavicular joint of three months duration, unresponsive to broad spectrum antibiotics. There was no history of trauma nor did he complain of any symptoms attributable to infection. He had been a heavy smoker. On clinical examination he was generally fit and apyrexial. There was a 4 x 5 cm hard discrete mass with surrounding erythema arising from the chest wall (Fig. 1). The chest was clinically clear apart from some apical dullness and reduced breath sounds. There was no finger clubbing. There were no neurological abnormalities and the remainder of the examination was normal. Chest X-rays showed a clearly defined left apical mass, with bone erosion (Fig. 2). The bone involvement was later confirmed on bone scan. Sputum cytology and cultures (including acid-alcohol fast bacilli) were negative. Biopsy of the lesion was performed and histological examination showed a 'Dense fibrous stromal reaction commonly seen in the vicinity of tumours'. The patient was referred for an oncological opinion. A C T scan of his thorax revealed a homogeneous pleural mass extending anteriorly into the Correspondence and offprint requests to: Dr S. A. Costello, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, UK.
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Fig. 1. Chest wall. Showing swelling and surrounding erythema.
Fig. 2. P.A. Chest X-ray showing left apical opacity and bone erosion.
chest wall involving the first rib and posteriorly into the lung parenchyma. The presumptive diagnosis was bronchial carcinoma or pleural mesothelioma (Fig. 3). Multiple Tru-Cut biopsies of the mass were taken under general anaesthesia and the head of the first rib excised. The surgeon reported gross thickening and fibrosis of the underlying tissue. Despite the use of immunohistochemical techniques histology
50
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F~. 3. CAT-scan of thorax showing chest wall swelling, bone destruction and apical mass.
failed to show anything more sinister than chronic inflammatory change. Bacteriological examination of part of the rib produced a pure growth of Staphylococcus aureus suggesting osteomyelitis. Postoperatively the patient was left with a sinus discharging small quantities of pus. Treatment with antistaphylococcal agents reduced the pain and erythema. Twelve months' treatment was required before the sinus completely healed.
DISCUSSION
Osteomyelitis of the ribs is an uncommon problem occurring mainly in children, comprising only 1% of all cases of osteomyelitis (Donovan and Shah, 1982). The aetiological factors vary, including haematological spread, particularly in children, subclavian vein catheterization, empyema and blunt chest trauma. In 50% of cases the causative organism is Staphylococcus aureus (Donovan and Shah, 1982; Osinowo et al., 1986). Bar-Ziv et al. (1985) described ultrasound scan appearances of pericostal oedema and soft tissue swelling of the chest wall with inward pleural displacement occurring one to two weeks in advance of the overt bony lesion. This report emphasizes the importance of obtaining adequate material for histological and bacteriological examination in the investigation of pulmonary opacities. Even an apical lung lesion with bone erosion may not be a bronchial carcinoma.
References Bar-Ziv J, Barki Y, Maroko A, Mares AJ (1985). Rib osteomyelifts in children. Early radiologic and ultrasonic findings. Pediatric Radiology, lS, 315-318. Donovan RM, Shah KJ (1982). Unusual sites of acute osteomyelifts in childhood. Clinical Radiology, 33, 222-230. Osinowo O, Adebo OA, Okubanjo AO (1986). Osteomyelitis of the ribs in Ibadan. Thorax, 41, 58--60.
Received for publication May 1990 Accepted July 1990
Clinical Oncology
Case Report Osteomyelitis of the Rib Presenting as an Apical Lung Cancer S. A. Costello, M. Russell and D. Cumming Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow
Abstract. Bronchial carcinoma was initially diagnosed in a 48-year-old man on the basis of radiology showing an apical lung lesion with erosion of the first rib. Biopsy ultimately showed this to be osteomyelitis.
~!~~'ii ~ ~! i ~•i ~ '~'~ '~, :
;
,,5"-
Keywords: Osteomyelitis
CASE REPORT
In December 1988 a 48-year-old male labourer presented with pain in his left sternoclavicular joint of three months duration, unresponsive to broad spectrum antibiotics. There was no history of trauma nor did he complain of any symptoms attributable to infection. He had been a heavy smoker. On clinical examination he was generally fit and apyrexial. There was a 4 x 5 cm hard discrete mass with surrounding erythema arising from the chest wall (Fig. 1). The chest was clinically clear apart from some apical dullness and reduced breath sounds. There was no finger clubbing. There were no neurological abnormalities and the remainder of the examination was normal. Chest X-rays showed a clearly defined left apical mass, with bone erosion (Fig. 2). The bone involvement was later confirmed on bone scan. Sputum cytology and cultures (including acid-alcohol fast bacilli) were negative. Biopsy of the lesion was performed and histological examination showed a 'Dense fibrous stromal reaction commonly seen in the vicinity of tumours'. The patient was referred for an oncological opinion. A C T scan of his thorax revealed a homogeneous pleural mass extending anteriorly into the Correspondence and offprint requests to: Dr S. A. Costello, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, UK.
i
i
Fig. 1. Chest wall. Showing swelling and surrounding erythema.
Fig. 2. P.A. Chest X-ray showing left apical opacity and bone erosion.
chest wall involving the first rib and posteriorly into the lung parenchyma. The presumptive diagnosis was bronchial carcinoma or pleural mesothelioma (Fig. 3). Multiple Tru-Cut biopsies of the mass were taken under general anaesthesia and the head of the first rib excised. The surgeon reported gross thickening and fibrosis of the underlying tissue. Despite the use of immunohistochemical techniques histology
50
S . A . CosteUo et al.
....
~ ~i: +2S7
L ! ,
i~l
'
(i ,,
,
.
•
'~*'
...,
L'I'.&lXI~
F~. 3. CAT-scan of thorax showing chest wall swelling, bone destruction and apical mass.
failed to show anything more sinister than chronic inflammatory change. Bacteriological examination of part of the rib produced a pure growth of Staphylococcus aureus suggesting osteomyelitis. Postoperatively the patient was left with a sinus discharging small quantities of pus. Treatment with antistaphylococcal agents reduced the pain and erythema. Twelve months' treatment was required before the sinus completely healed.
DISCUSSION
Osteomyelitis of the ribs is an uncommon problem occurring mainly in children, comprising only 1% of all cases of osteomyelitis (Donovan and Shah, 1982). The aetiological factors vary, including haematological spread, particularly in children, subclavian vein catheterization, empyema and blunt chest trauma. In 50% of cases the causative organism is Staphylococcus aureus (Donovan and Shah, 1982; Osinowo et al., 1986). Bar-Ziv et al. (1985) described ultrasound scan appearances of pericostal oedema and soft tissue swelling of the chest wall with inward pleural displacement occurring one to two weeks in advance of the overt bony lesion. This report emphasizes the importance of obtaining adequate material for histological and bacteriological examination in the investigation of pulmonary opacities. Even an apical lung lesion with bone erosion may not be a bronchial carcinoma.
References Bar-Ziv J, Barki Y, Maroko A, Mares AJ (1985). Rib osteomyelifts in children. Early radiologic and ultrasonic findings. Pediatric Radiology, lS, 315-318. Donovan RM, Shah KJ (1982). Unusual sites of acute osteomyelifts in childhood. Clinical Radiology, 33, 222-230. Osinowo O, Adebo OA, Okubanjo AO (1986). Osteomyelitis of the ribs in Ibadan. Thorax, 41, 58--60.
Received for publication May 1990 Accepted July 1990
