Case Report
Ganglion cyst of the proximal humerus: A case report and review of the literature Yasemin Yuyucu Karabulut, Yasemin Dölek1, İlker Ganal2 Department of Pathology, Mersin University, Departments of 1Pathology, 2Orthopedia, Çankırı State Hospital, Çankırı, Turkey
ABSTRACT Intraosseous ganglia of the proximal humerus are rare and their etiology is unknown. This report describes a case of an intraosseous ganglion of the proximal humerus. The patient was a 47-year-old woman with a painful left shoulder with a limited range of motion. On magnetic resonance imaging a cystic lesion of the proximal humerus was detected. There was no communication between the cyst and the joint space. On macroscopic examination, a multiloculated cystic lesion was seen. Microscopically it was clear that it was a cyst of intraosseous ganglia. At 2 weeks after the surgery, the patient was almost free of pain. Though there were few reports earlier, the pathological feaures were not highlighted. We describe here more about the pathologic features of the lesion. Key words: Bone cysts, ganglion cyts, proximal humerus
INTRODUCTION An intraosseous ganglion is a relatively uncommon, benign cystic lesion that occurs in young and middleaged adults. It is defined as benign cystic and often multiloculated lesions composed of fibrous tissue with extensive mucoid change, located in the subchondral bone adjacent to a joint. [1,2] The medial malleolus and proximal femur are the most commonly affected and intraosseous degenerative cysts of the proximal humerus are rare.
CASE REPORT Intraosseous ganglion cyst is benign bony cyst that mainly involves epiphysis and metaphysis of long bones.[3] Mean average age of patients is 42 years.[4] Address for correspondence Dr. Yasemin Yuyucu Karabulut, Department of Pathology, Çankırı State Hospital, Aksu Street, Çankırı, Turkey. E-mail:
[email protected] Access this article online Quick Response Code: Website: www.jdrntruhs.org DOI: 10.4103/2277-8632.128439
Journal of Dr. NTR University of Health Sciences 2014;3(1): 45-47
It is more prevalent in men. It can be symptomatic in A 47-year-old female patient presented at the Cankiri state hospital complaining of pain and restricted motion in the righ arm since 2 months. She had difficulty in coombing hair and housekeeping. She had no history of trauma. There was no swelling, tenderness, or muscle atrophy over the right arm. Neurologic examination was normal. On magnetic resonance imaging (MRI), the lesion presented as a well-defined fluid collection with low intensity on T1-weighted images and very high intensity on T2-weighted images [Figure 1]. A diagnosis of simple bone cyst was made and the lesion surgically excised through a longitudinal incision between the anterior and middle part of the deltoid. The periosteum and the cortex were normal. There was no communication between the cyst and joint. On macroscopic examination 1.5 cm × 1 cm × 1 cm bone material was seen. After decalcification with 10% hydrochloric acid solution, an intact, slightly lobulated and bulging cyst was observed. On sectioning the cyst the stringy, thick mucinous fluid oozed out. The mucinous material was seen in pools of differing sizes surrrounded by fibrous tissue. Histologic sections showed fragments of reactive and dense fibrous tissue and a pool of mucinous material was seen in some areas. No synovial layer was seen lining the cyst wall [Figures 2a-c]. Viable and reactive bony fragments were seen on decalcified sections. The morphologic features consistent with an intraosseous ganglion. At 45
Karabulut, et al.: Ganglion cyst of the proximal humerus
6 months post-operative follow-up, the patient had full resolution of symptoms and post-operative MRI showed the total excision of the mass [Figure 3].
Figure 1: MRI of the humerus shows a high signal intensity area on the T2-weighted image
b
a
c Figure 2: (a) A dense and reactive fibrous connective tissue with no synovial cell lining (H and E, ×100). (b and c) Modered sized mucinous material in and around of the cyst (H and E, ×100)
DISCUSSİON more than 50% of cases, especially when located close to neurovascular structures or articular surfaces. [5] They can be causing pain, neurologic dysfunction, or articular fractures. It is more common in lower extremities, especially around the ankle. Upper extremity is rarely involved.[4] It is rare to see this lesion at proximal humerus. It could be because of intramedullary metaplasia, trauma or secondary to degeration.[3,6,7] In this case, the patient had no history of trauma. In general, the diameter of the lesion is about 1 cm, rarely it can grow up to 5 cm.[8] Rarely, it may enlarge, destroy cortex, can cause nerve compression symptoms.[8] On MRI, an intraosseous ganglion cyst presents as a single to multiloculated, well-circumscribed, eccentric focus of lysis.[9] Although its radiographic appearance may suggest chronic osteomyelitis, a chondroblastoma, a giant cell tumour, or a synovial cyst, the diagnosis can be easily made because of its pathognomonic gross pathology and histological features. In contrast to osteoarthritic cysts, the adjacent joint seldom shows degenerative changes or communication with the lesion.[9,10] Histologically intraosseous ganglion cyst has to be differentiated from subchondral cyst secondary to degenerative joint disease.[8] Treatment is surgery including curettage and bone graft.[8] A total of 11 cases of intraosseous ganglion of the proximal humerus have been reported in the literature so far. [9,10] Intraosseous and soft-tissue ganglia share some pathological and histological features and may have a similar pathogenesis, i.e., mucoid transformation of connective tissue in the bone, which is observed in the juxta-articular sites of adults.[10]
CONCLUSION Intraosseous ganglion cyst is benign bony cyst and it’s diagnosis can only be made with its gross pathology and histological features.
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Figure 3: Post-operative axial T2 image showing the total excision of the mass 46
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How to cite this article: Karabulut YY, Dölek Y, Ganal I. Ganglion cyst of the proximal humerus: A case report and review of the literature. J NTR Univ Health Sci 2014;3:45-7. Source of Support: Nil. Conflict of Interest: None declared.
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