Adamantinoma of the Right Tibia Case Study

Adamantinoma of the Right Tibia Case Study INTRODUCTION: Adamantinoma is low grade malignant tumor of fibroblast origin. Also called as primary epidermoid carcinoma of bone, malignant angioblastoma or epithelial tumor of bone. It was first described by Fischer in 1913.1 It represents less than 0.4% of all malignant bone tumors.2 The exact origin of adamantinoma is unknown, the classic variant is composed of epithelial cells and osteofibrous components. It is more prevalent in men than in women, ratio being 5:4. The common age of presentation is in the second decade, though it can vary greatly between the second to fifth decades.3 The common site of occurrence is the ramus of the mandible. The other uncommon locations include shaft of long bones (97%), mid-shaft of tibia (80%-85%).4 Other rare locations includes the humerus, ulna, femur, fibula and radius but ribs, spine, metatarsal and carpal bones.5 The characteristic features of adamantinoma is slow, gradual development with high chances of local recurrences and also metastases to lungs .6 In this case study, we have presented a rare histological acanthomatous variant of adamantinoma of the right tibia with metastases to the right inguinal region. CASE REPORT: A 45 year old male patient presented with history of pain in right leg since 3-4 months, insidious onset, gradually progressive, aggravated on exercise, relieved on rest and medication. Later patient had no relief on medication. There was no history of trauma or fall preceeding to onset of symptoms. The patient also complained of swelling in the right groin since 1 month, without pain. On examination, the patient was stable. Local examination showed, a swelling of about 5X3cm in the upper end right leg, tender, well defined, hard in consistency, smooth surface, involving the right knee joint line. There was restriction of movement, but range of movements was present. Examination of right inguinal region revealed a 7X6cm firm, non-matted mass, immobile, non-tender, non-reducible, non-pulsatile mass. Local examination of penis, scrotum, anal canal, hernia orifices was normal. Baseline investigations were done, all the haematological parameters were normal, ultrasound abdomen and chest radiograph was normal. Plain radiograph of right tibia showed large central lytic lesion with sclerotic margins, involving the upper end and shaft of tibia without involvement of right knee joint. Supra-patellar amputation of right leg with right inguinal and right external iliac nodal dissection was done. Histopathological examination of the mass was done. The reported was suggestive of acanthomatous adamantionoma. The features are as described, central area of squamous cell nests which were well differentiated with keratinization surrounded by a rim of myxoid cells. Further immunohistochemistry(IHC) study was done to confirm the diagnosis. IHC was also consistent with the diagnosis and confirmed the diagnosis. Positivity was found for cytokeratin(CK), EMA, CK-19, CK-5, CK-6, P-63, and Ki-67 and vimentin. Also metastases to right inguinal lymph node was confirmed. DISCUSSION: The first bone tumor with epithelial characteristic was reported by Maier in 1900, later in 1913 Fischer termed it as adamantinoma. It is more common in men than in women. The age of presentation varies between the second to fifth decade. The uncommon sites includes the shaft of long bones(97%), of which the mid-shaft of tibia being the most common site(80-85%). The symptoms at presentation include pain with localised swelling. Swelling is the most common symptom. Pain may be present due to history of repetitive trauma associated with adamantinoma.7 Adamantinoma is low grade malignant tumor, and can metastasize to loco-regional nodal areas and to lungs at presentation. The patient in the case report was also a middle aged man in the fifth decade with pain and swelling in the right tibia since 3-4 months and swelling in the right groin. Three theories have been proposed for the source of cell of origin, 1) epithelial, 2) angioblasts, and 3) synovial tumors from uncommon ectopic sites. This was done because the tumor tissue is composed of both epithelial and osteofibrous components.8 In different combinations, different patterns are formed. On microscopy, the commonest form is the classical variant, followed by the osteofibrous pattern. In the classic variant, the types are basaloid, spindle cell, tubular, and squamous patterns. In the classical variant, central epithelial component with surrounding zone of fibrous tissue containing few immature trabecuated bone components are seen. In the osteofibrous variant, cental area of fibrous tissue, surrounded by peripheral zone of epithelial components are seen. Spindle cell variant is most commonly seen with recurrent lesion and metastatic lesions. The typical findings of classical variant were consistent in our case as well, which showed a well differentiated keratinizing pattern of squamous cell nests surrounded by a rim of myxoid cells. Immunohistochemistry exhibits positivity for both epithelial and osseous elements. Fibrous components are positive for vimentin. Epithelial components show positivity for cytokeratin(CK) 5, 14, 19; rarely positive for CK 1,13,17. It is usually negative for CK 8 and 18. Also shows positivity for epithelial growth factor, fibroblast growth factor, fibroblast growth factor receptor. Our case had features as described, also positivity was found for p-63, Ki-67 and CK-6, which favour our diagnosis of acantomatous adamantinoma. Genetic studies reveal chromosomal abberations on chr 7,8,12,19.9 Also aneuploidy has been associated with epithelial components.10 There is loss of heterozygosity of p53 gene. Rarely,(11;22) translocations have been reported in case of adamantinoma, and is termed adamantinoma-like ewing’s sarcoma.11 11;22 translocation is not seen is in adamantinoma. Radiological investigations include radiographs, computer tomography(CT), magnetic resonace imaging(MRI). All the modalities are necessary not only to confirm the diagnosis, also to define the extent of involve and the aggressiveness of the tumor. On plain radiographs usually eccentric, lobulated, cental lytic lesions with a peripheral sclerosis is present in the diaphyseal or metaphyseal ends of long bones. These lesion tend to appear on tibia with a typical picture of soap-bubble appearance.12 CT shows osteolytic lesion in the bone. MRI is the investigation of choice. It helps not only in defining the extent of cortical involvement of bone, soft tissue involvement, but also helps in ruling out other etiologies such as ewing’s sarcoma, adamantinoma, osteosarcoma, metastatic disease, fibrous dysplasia of bone.13 The typical features as described in the literature was true in our case as well. Treatment of adamantinoma has no definitive guidelines. Excisional biopsy is preferred rather than curratage of bone. Curratage of bone is associated with recurrence’s, upto 30% recurrence has been reported with curettage.14 Radical excision of the bone is associated with better outcome and prognosis. Limb salvage procedures include en-block resection, followed by reconstruction of the bony defect which includes vascularised or non-vascularised bone grafts, custom made protheses, intercalary allografts and distraction osteogenesis.15 When limb salvage is not possible, amputation is the definitive treatment of choice. The incidence of mortality with adamantinoma is about 17%, and increases to about 20% when pulmonary metastasis is present. In our patient work up was done and right supra patellar amputation was done, with right inguinal and right external iliac lymph nodal dissection was done and histopathological examination further showed metastases to right inguinal region.

Reading Report

From my experiences reading novels, dramas, poetry, and short stories, I think the purpose of fiction is to entertain; to provoke thought. I think students study fiction because it is very entertaining, and can teach many different lessons. People read fiction stones because it lets them get lost In a story that's not theirs. I believe people tell stones to express their Imagination and thoughts. B. A â€Å"take away† value I have learned from this concentration on fiction would be many life lessons. I feel Like the fiction stones we read In school relate to us somehow, and teach us lessons.They also teach us different vocabulary terms and how to use them. Reading stories Like Romeo and Juliet and Lice's Adventures In Wonderland also let us experience different types of literature. II. Nonfiction A. My English II class this year studied three very different examples of nonfiction. 1. The World Geography Textbook- Our geography textbook has a professional tone. The organization of the textbook had headers and sections, which makes finding the information you need easier to find. The purpose of this nonfiction is to inform. 2.The Burden of Womanhood- 3. MASS- This personal memoir about WIN has a serious, melancholy tone. The organization of this book is set up like a story, with pictures. I believe the purpose of MASS is to not only to inform about the events during WI, but to also entertain. B. Studying nonfiction in classes, such as an English II class, would be very beneficial. There are so many different values gained from studying nonfiction, such as how it helps develop critical thinking as well as literary skills, broadens students vocabulary ND world knowledge.Reading Report By theologically read fiction stories because it lets them get lost in a story that's not theirs. I believe people tell stories to express their imagination and thoughts. B. A â€Å"take away' value like the fiction stories we read in school relate to us somehow, and teach us lessons. Like Romeo and Juliet and Lice's Adventures in Wonderland also let us experience A. My English II class this year studied three very different examples of nonfiction. 1 . 3. MASS- This personal memoir about WI has a serious, melancholy tone.

Moral Self-Knowledge in Kantian Ethics Essay

In the article titled, Moral Self-knowledge in Kantian Ethics, Emer O’Hagan discusses Kant’s views and ideas concerning self-knowledge and the role it plays in duty and virtuous action. O’Hagan first introduces a key feature of Kant’s ethical theory which is its recognition of the psychological complexity of human beings. O’Hagan uses this recognition of psychological complexity by Kant to dive into Kant’s feeling on self-knowledge. Once a basic understanding of Kant’s attitude towards self-knowledge has been established, O’Hagan then uses Kant’s ethical theory to show how self-knowledge can be used as a means to help determine the goodness of an action. The arguments presented by O’Hagan are logical and clearly supported and verified through the presented evidence. Kant is shown to have recognized the psychological complexity of the human being in recognizing that, â€Å"judgments concerning the rightness of actions are vulnerable to corruption from self-interested inclination† (O’Hagan 525-537). Kant is saying that that even though an action may start out as from duty, our internal feelings as human beings can create a beneficial end as a means for the action, thus rendering it not from duty. Kant also recognizes that our own judgments about us may not be accurate. Moral self-development is a practice to develop accuracy for our self-judgments and takes into consideration one’s motives for action. O’Hagan tells us that this moral practice requires moral self-knowledge which is a form of self-awareness disciplined by respect for autonomy, the theoretical foundation of Kantian ethics. According to Kant, the first command of the duties to oneself as a moral being is self-knowledge. This is the ability to know yourself in terms of whether your heart is for good or evil and whether your actions are pure or impure. Kant describes duties of virtue to be wide duties, in that there is not a clear standard for how one should go about performing action for an end that is also a duty. O’Hagan tells us that Kant’s duty of moral self-knowledge is the duty to know one’s own heart. Kant tells us that moral self-knowledge is quite difficult because it involves abstracting, or taking a non-biased analysis of one’s self. Because we are bound to our own feelings and inclinations, we cannot completely separate ourselves from our own bias. The power of self-knowledge is the power to see things in objectivity instead of subjectivity. The final step of the argument is relating self-knowledge to determining the goodness of an action. O’Hagan tells us that developing self-knowledge will develop one’s self-understanding and will develop guards against self-deception. Using these skills to truly understand one’s heart allows for one to know one’s motives, and thus practical stance in action. According to Kant, the goodness of an action is determined by one’s motives, so the goodness of one’s action can now be evaluated. O’Hagan clearly demonstrates the importance of self-knowledge in Kant’s theory of ethics and validates its importance by describing application for use of the practice of self-knowledge (O’Hagan 525-537).

Social And Race And Ethnicity - 968 Words

Which is a bigger impact, social or race/ethnicity? I am leaning toward social life chances would be the biggest impact. I believe that race and ethnicity can also be a big impact, society plays an even bigger role on how people are molded. In the book it says race and ethnicity still matter, minorities have less power, privilege, and social status. This is where I believe that if society could change we could try to be more equal and with that I believe we can assume that how we feel, what we feel, who we have become are all part of what society has done to us. Social classes are the hierarchical arrangement of people in society as economic or cultural groups. Elements which can represent and determine ones class, wealth, prestige, power and education. The term â€Å"life Chances† was brought on by Max Weber and his definition is : to improve their quality of life or the extent to which an individual has access to important social resources, such as healthy affordable food, shelter, education, unemployment and health care (thesciencecartforum.com/viewtopic.php?f=82t=18523). Each individual begins a travel through their life as a member of a class. There are differences in class not only between countries but also within countries we have upper class, middle class and lower class and the non-working class. The upper class usually refers to the higher status members of upper class, most are well educated professionals with graduate degrees and comfortable income. Children ofShow MoreRelatedSocial Class And Race And Ethnicity Essay2005 Words   |  9 Pagesthat I have become today. 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