1990, The British Journal of Radiology, 63, 303-304 Case reports underlying pectoralis major, true breast hypoplasia may exist.
GOLDBERG, M. & MAZZEI, R., 1977. Poland syndrome: a
concept of pathogenesis based on limb bud embryology. Birth Defects, 13, 103-115. HOLMSTROM, H., SUURKULA, M. & LOSSING, C , 1986. Absent
References BEALS, R. K. & CRAWFORD, S., 1976. Congenital absence of the
pectoral muscles. A review of twenty-five patients. Clinical Orthopedics, 119, 166-171. DAVID, T., 1972. Nature and etiology of the Poland anomaly. New England Journal of Medicine, 287, 487-489. DEMOS, T., JOHNSON, C ,
LOVE, L. & POSNIAK, H., 1985.
Computed tomography of the partial unilateral agenesis of the pectoralis muscles. Journal of Computerized Axial Tomography, 9(3), 558-559.
latissimus dorsi muscle and anhidrotic axilla in Poland's syndrome. Scandinavian Journal of Plastic and Reconstructive Surgery, 20, 313-318. HOPPER, K., HAAS, D., RICE, M., FREELEY, D., TAUBNER, R. &
GHAED, N., 1985. Poland-Mobius syndrome: evaluation by computerized tomography. Southern Medical Journal, 78(5), 523-527. POLAND, A., 1841. Deficiency of the pectoralis muscle. Guy's Hospital Reports, 6, 191-193. SEYFER, A., ICOCHEA, R. & GRAEBER, G.,
1988. Poland's
anomaly. Annals of Surgery, 208(6), 776-782.
Spontaneous disappearance of tuberculous psoas abscess calcification By S. C. Whitaker, FRCR, B. J . Preston, FRCR and * H . McKim-Thomas, FRCS Departments of Radiology and *Orthopaedic Surgery, University Hospital, Nottingham
{Received July 1989)
Calcified psoas abscesses are a characteristic feature of tuberculosis of the thoraco-lumbar spine. We present a case in which well established calcification has almost completely disappeared, several years after any antituberculous treatment. A review of the English literature has revealed no previous report of this finding. Case report The patient, now a 48-year-old woman, first presented at the age of 6 with back pain and radiographic features of spinal tuberculosis at T12/L1. Bilateral calcined psoas abscesses developed over the next few months. Management was first by bed rest and later, at the age of 12, by postero-lateral drainage with spinal fusion. By this time abscess calcification was well established. The patient then remained relatively well until the age of 33, when she developed girdle pain due to further vertebral destruction at a higher level (T8-T12). This new focus was drained via a trans-thoracic approach and a small abscess cavity was found which did not communicate with the original psoas abscesses. Tubercle bacilli were cultured. Radiographs of the lumbar spine at this time still showed a large calcified psoas abscess on the right side and a small one on the left. Appropriate antibiotic cover was given for 2 years until 1975 when it was noted that the calcification in the left psoas abscess had decreased. Routine follow-up radiographs in 1981 (Fig. 1) still showed calcification in both psoas abscesses but subsequent films (Fig. 2) have shown a dramatic reduction in calcification at a time when the patient had not received any anti-tuberculous treatment for many years. During this time, the patient remained well, apart from symptoms due to the menopause, for which she was given a short course of hormone replacement therapy. Discussion Psoas abscess formation has been reported in up to 12% of cases of spinal tuberculosis (Seddon et al, 1973).
Vol. 63, No. 748
Figure 1. Bilateral psoas abscess calcification on a radiograph taken in 1981, 6 years after any anti-tuberculous treatment. 303
1990, The British Journal of Radiology, 63, 304-305
Case reports
The mechanism whereby the calcification has cleared in our patient is uncertain. Theoretically, spontaneous reduction in the amount of observed calcification could occur if a fistula developed, and intestinal perforation by a tuberculous psoas abscess has been reported (Blumenthal et al, 1981). However, no evidence for this was seen in our patient. At no time did either abscess contain air, and there has been no disturbance of bowel function. Similarly, surgical or percutaneous drainage of an abscess could also cause a reduction in the amount of calcification, but no such intervention was undertaken. Furthermore, colleagues who have had considerable experience in the field of spinal tuberculosis cannot recall seeing such an event (Griffiths, 1988; Murray, 1988). References BLUMENTHAL, D. H., MORIN, M. E., TAN A. & Li, Y. P.,
Figure 2. A radiograph taken in 1989 showing bilateral psoas abscesses but the calcification, particularly on the right side, is considerably less.
Calcification commonly occurs, and without intervention remains static.
1981.
Intestinal penetration by tuberculous psoas abscess. American Journal of Roentgenology, 136, 995-997. GRIFFITHS, D. LL., 1988. Personal communication. MURRAY, R. O., 1988. Personal communication. SEDDON, H. ET AL, 1973. Medical Research Council Working Party on Tuberculosis of the Spine, Second Report. Tubercle, 54, 261-282.
Osteosarcoma: an unusual thoracic metastasis By M. J. Charig, BSc, MRCP, FRCR, *S. J. Golding, FRCR and D. R. M. Lindsell, FRCR Department of Radiology, John Radcliffe Hospital, Oxford and *Regional CT Unit, Churchill Hospital, Oxford (Received July 1989)
Metastases from osteosarcoma often occur in the lungs, usually as multiple nodules but sometimes as a solitary mass. Lymph node involvement is unusual. We present a case of metastatic recurrence as a solitary, stellate, ossified, pulmonary mass extending across the pleura associated with ossified hilar lymphadenopathy. Case report A 15-year-old male, whose only previous medical history was resection of a right ventricular infundibular stenosis 18 months earlier, presented in November, 1987 with pain and swelling in the distal right femur. This proved on biopsy to be caused by an osteosarcoma, and after staging with chest radiograph, computed tomography (CT) and bone scintigraphy, no spread was evident. After three courses of cisplatinum and adriamycin, the distal femur containing the primary tumour was resected and a knee prosthesis inserted. Following three further courses of chemotherapy he. remained well for nearly a year, until March, 1989. A follow-up chest radiograph at this time revealed right paratracheal lymphadenopathy and an upper lobe mass (Fig. 1). A chest radiograph 2 months earlier had been normal. Computed tomography demonstrated an irregular, stellate mass with central ossification in the right upper
304
lobe, extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus (Fig. 2). The latter was connected to the mass by strands of ossified material. Scintigraphy with "Tcm-hydroxy methylene diphosphonate ("TcmHMDP) revealed intense uptake in the mass and nodes but no skeletal metastases (Fig. 3). At thoracotomy ossified tumour was found to be invading through the pleura into the superior sulcus and was resected together with the involved nodes. Histology showed an osteoblastic osteosarcoma consistent with spread from the femoral primary. Discussion
The lungs are the most frequent site for metastases from osteosarcomas (Jeffree et al, 1975; Weiss & Gilbert, 1978). Pulmonary nodules are seen in 10% of patients at presentation and more than 70% at death (McKenna et al, 1966). The nodules are usually multiple and bilateral but in 35% of patients may be unilateral, as in this case. The usual appearance of pulmonary metastases from any primary is of well-circumscribed, spherical nodules (Crow et al, 1981) and those from osteosarcomas may contain calcification or ossification. The British Journal of Radiology, April 1990
GOLDBERG, M. & MAZZEI, R., 1977. Poland syndrome: a
concept of pathogenesis based on limb bud embryology. Birth Defects, 13, 103-115. HOLMSTROM, H., SUURKULA, M. & LOSSING, C , 1986. Absent
References BEALS, R. K. & CRAWFORD, S., 1976. Congenital absence of the
pectoral muscles. A review of twenty-five patients. Clinical Orthopedics, 119, 166-171. DAVID, T., 1972. Nature and etiology of the Poland anomaly. New England Journal of Medicine, 287, 487-489. DEMOS, T., JOHNSON, C ,
LOVE, L. & POSNIAK, H., 1985.
Computed tomography of the partial unilateral agenesis of the pectoralis muscles. Journal of Computerized Axial Tomography, 9(3), 558-559.
latissimus dorsi muscle and anhidrotic axilla in Poland's syndrome. Scandinavian Journal of Plastic and Reconstructive Surgery, 20, 313-318. HOPPER, K., HAAS, D., RICE, M., FREELEY, D., TAUBNER, R. &
GHAED, N., 1985. Poland-Mobius syndrome: evaluation by computerized tomography. Southern Medical Journal, 78(5), 523-527. POLAND, A., 1841. Deficiency of the pectoralis muscle. Guy's Hospital Reports, 6, 191-193. SEYFER, A., ICOCHEA, R. & GRAEBER, G.,
1988. Poland's
anomaly. Annals of Surgery, 208(6), 776-782.
Spontaneous disappearance of tuberculous psoas abscess calcification By S. C. Whitaker, FRCR, B. J . Preston, FRCR and * H . McKim-Thomas, FRCS Departments of Radiology and *Orthopaedic Surgery, University Hospital, Nottingham
{Received July 1989)
Calcified psoas abscesses are a characteristic feature of tuberculosis of the thoraco-lumbar spine. We present a case in which well established calcification has almost completely disappeared, several years after any antituberculous treatment. A review of the English literature has revealed no previous report of this finding. Case report The patient, now a 48-year-old woman, first presented at the age of 6 with back pain and radiographic features of spinal tuberculosis at T12/L1. Bilateral calcined psoas abscesses developed over the next few months. Management was first by bed rest and later, at the age of 12, by postero-lateral drainage with spinal fusion. By this time abscess calcification was well established. The patient then remained relatively well until the age of 33, when she developed girdle pain due to further vertebral destruction at a higher level (T8-T12). This new focus was drained via a trans-thoracic approach and a small abscess cavity was found which did not communicate with the original psoas abscesses. Tubercle bacilli were cultured. Radiographs of the lumbar spine at this time still showed a large calcified psoas abscess on the right side and a small one on the left. Appropriate antibiotic cover was given for 2 years until 1975 when it was noted that the calcification in the left psoas abscess had decreased. Routine follow-up radiographs in 1981 (Fig. 1) still showed calcification in both psoas abscesses but subsequent films (Fig. 2) have shown a dramatic reduction in calcification at a time when the patient had not received any anti-tuberculous treatment for many years. During this time, the patient remained well, apart from symptoms due to the menopause, for which she was given a short course of hormone replacement therapy. Discussion Psoas abscess formation has been reported in up to 12% of cases of spinal tuberculosis (Seddon et al, 1973).
Vol. 63, No. 748
Figure 1. Bilateral psoas abscess calcification on a radiograph taken in 1981, 6 years after any anti-tuberculous treatment. 303
1990, The British Journal of Radiology, 63, 304-305
Case reports
The mechanism whereby the calcification has cleared in our patient is uncertain. Theoretically, spontaneous reduction in the amount of observed calcification could occur if a fistula developed, and intestinal perforation by a tuberculous psoas abscess has been reported (Blumenthal et al, 1981). However, no evidence for this was seen in our patient. At no time did either abscess contain air, and there has been no disturbance of bowel function. Similarly, surgical or percutaneous drainage of an abscess could also cause a reduction in the amount of calcification, but no such intervention was undertaken. Furthermore, colleagues who have had considerable experience in the field of spinal tuberculosis cannot recall seeing such an event (Griffiths, 1988; Murray, 1988). References BLUMENTHAL, D. H., MORIN, M. E., TAN A. & Li, Y. P.,
Figure 2. A radiograph taken in 1989 showing bilateral psoas abscesses but the calcification, particularly on the right side, is considerably less.
Calcification commonly occurs, and without intervention remains static.
1981.
Intestinal penetration by tuberculous psoas abscess. American Journal of Roentgenology, 136, 995-997. GRIFFITHS, D. LL., 1988. Personal communication. MURRAY, R. O., 1988. Personal communication. SEDDON, H. ET AL, 1973. Medical Research Council Working Party on Tuberculosis of the Spine, Second Report. Tubercle, 54, 261-282.
Osteosarcoma: an unusual thoracic metastasis By M. J. Charig, BSc, MRCP, FRCR, *S. J. Golding, FRCR and D. R. M. Lindsell, FRCR Department of Radiology, John Radcliffe Hospital, Oxford and *Regional CT Unit, Churchill Hospital, Oxford (Received July 1989)
Metastases from osteosarcoma often occur in the lungs, usually as multiple nodules but sometimes as a solitary mass. Lymph node involvement is unusual. We present a case of metastatic recurrence as a solitary, stellate, ossified, pulmonary mass extending across the pleura associated with ossified hilar lymphadenopathy. Case report A 15-year-old male, whose only previous medical history was resection of a right ventricular infundibular stenosis 18 months earlier, presented in November, 1987 with pain and swelling in the distal right femur. This proved on biopsy to be caused by an osteosarcoma, and after staging with chest radiograph, computed tomography (CT) and bone scintigraphy, no spread was evident. After three courses of cisplatinum and adriamycin, the distal femur containing the primary tumour was resected and a knee prosthesis inserted. Following three further courses of chemotherapy he. remained well for nearly a year, until March, 1989. A follow-up chest radiograph at this time revealed right paratracheal lymphadenopathy and an upper lobe mass (Fig. 1). A chest radiograph 2 months earlier had been normal. Computed tomography demonstrated an irregular, stellate mass with central ossification in the right upper
304
lobe, extending supero-posteriorly, and ossifying lymphadenopathy around the upper lobe bronchus (Fig. 2). The latter was connected to the mass by strands of ossified material. Scintigraphy with "Tcm-hydroxy methylene diphosphonate ("TcmHMDP) revealed intense uptake in the mass and nodes but no skeletal metastases (Fig. 3). At thoracotomy ossified tumour was found to be invading through the pleura into the superior sulcus and was resected together with the involved nodes. Histology showed an osteoblastic osteosarcoma consistent with spread from the femoral primary. Discussion
The lungs are the most frequent site for metastases from osteosarcomas (Jeffree et al, 1975; Weiss & Gilbert, 1978). Pulmonary nodules are seen in 10% of patients at presentation and more than 70% at death (McKenna et al, 1966). The nodules are usually multiple and bilateral but in 35% of patients may be unilateral, as in this case. The usual appearance of pulmonary metastases from any primary is of well-circumscribed, spherical nodules (Crow et al, 1981) and those from osteosarcomas may contain calcification or ossification. The British Journal of Radiology, April 1990
