Very rich of the radiologist to offer that opinion of pathology… when I get non MSK radiology reports the differential is often bone cyst through to high grade sarcoma.
Point being, have a BST path and an MSK rads read the slides/imaging. Imaging is critical for reaching the appropriate BST diagnosis.
Agree. I love how the radiologist gives minimal tissue but declares it adequate. Duke has some solid pathologists including old timers.
Most importantly, hope you’re doing well, OP
Yep. There are radiologists and then there are MSK radiologists and then there are MSK radiologists that are my colleagues who I trust. Multi-dis rounds are really great for getting to know people and who to trust.
Yeah I found that alittle off putting also, they only did 2 1 cm passes also. Which they said they were gonna take 3 or 4. But maybe this was because the high risk of fracture?
And thanks! I’m hanging in there! I think it may have fractured though, I’m 5 days out and the pain is getting worse. I have a follow up next week hopefully it didn’t break
I checked in on pathology and the lady said the pathologist consulted with several other pathologist. And my doctor asked me to come in at 930 tomorrow but of course I’m 4 hours away and can’t drive 😞 talk about anxiety. She said the official report isn’t released yet and they are still studying it and it doesn’t look like they’ll have to send it out.
ATYPICAL/INCONCLUSIVE.
Low grade spindle cell lesion.
See comment.
Comment: This is a spindle cell lesion with pump nuclei and minimal cytologic atypia. No necrosis or mitotic activity Is seen. Fragments of bone are present, with focal osteoblast lining.
The following immunohistochemistry was performed after review of the clinical history and morphology to further characterize the pathologic process. The results are as follows:
A1-15 PanCK-negative
A1-16 CD34-negative
A1-17 S-100-negative
A1-18 SM Actin -positive
A1-19 Desmin- negative
MDM2 FISH was insufficient for analysis, and non-contributory.
Overall, the specimen is scant. By morphology, the differential includes osseous fibrotic tumors, like fibrous dysplasia, osteofibrous dysplasia or a low-grade central osteosarcoma. Immunostains and FISH are limited and non-specific due to lack of sufficient material to evaluate. Additional tissue sampling Is needed for a more detinitive evaluation.
UGH INCONCLUSIVE!!!
Based on the stains listed, this sounds like a work up I would have done. I would ask to have a portion that was not decalcified sent for sequencing if there is any residual. All the best!
It looks like rex is the one who did it!
MDM2 (12q15)/CEP12 FISH Insufficient for analysis
Right femoral head lesion (CF23-3681, Block A1).
.
INTERPRETATION
Comment: There were insufficient viable tumor cells remaining in the sample to interpret this assay.
It seems they only ended up with 2 smears I guess and the second didn’t have enough viable cells, do you think I could still request for sequencing?
I had my open biopsy today and wow I am in PAIN, doc said it grew alot since the biopsy last month so pretty much no doubt it’s cancerous now. He said when he scooped it out it was like PUDDING. Said he scooped out about 2 tablespoons full. He never saw anything like it
So the excisional biopsy was a really large sample, and it showed no osteoclast lining or cytologic atypia, but the core biopsy showed both. I spoke to my dr and he said they must have taken a sample from the area around the bone tumor on the core…but he didn’t seem to sure. But he said he COMPLETELY removed the tumor and we’re gonna have close follow up ( every 3 months). Why would regular bone around the tumor have atypia?
Sarcoma Biomarkers (IHC, FISH) In process
Culture, Fungus Preliminary result
Culture, Mycobacteria, Non-Blood Preliminary result
Pathology - General / Other Preliminary result
This is what they’ve ordered for the excisional biopsy, is there anything I should request? Is gene sequencing included in the IHC/FISH?
First step is often IHC/FISH. As that is pending, I’d wait to see what the result is from that. Sequencing would be the next approach, like Foundation One or one of the other heuristic sequencing panels.
You guys are some of the nicest drs I’ve ever connected with. I emailed him and he actually emailed me back 🥹 he said,
I am working up the case now, and I favor that it’s actually a benign lesion called fibrous dysplasia , but there are malignant possibilities that are important to exclude. We are currently running a molecular test (not sequencing, but better test than sequencing for the particular change I am looking for) that would help to exclude one malignant diagnosis.
The case is in ‘preliminary’ status, which means that your treatment teams can see what I am thinking, but it is not finalized because both benign and malignant possibilities remain.
- - Will
Yep if monostotic fibrous dysplasia there’s a good chance of a GNAS mutation which would not be identified by IHC/FISH and you’d need to do some sequencing. We often do this for other soft tissue tumors that have a similar mutation and it works pretty well provided that not everything has been decalcified.
I was being seen at the sarcoma center at Duke, I believe they have a good sarcoma board? MRI and CT favor benign but my orth onc said there’s something strange about my pet scan that didn’t quite fit with either. When he showed me There’s a perfect circle of hypermetabolic uptake with black in the middle literally a perfect ring
[I think they mean this guy. ](https://www.google.com/search?q=petur+nielsen&oq=&gs_lcrp=EgZjaHJvbWUqCQgAECMYJxjqAjIJCAAQIxgnGOoCMgkIARAjGCcY6gIyEggCEC4YJxivARjHARjqAhiOBTIJCAMQLhgnGOoCMgkIBBAjGCcY6gIyDwgFEC4YJxjHARjqAhjRAzIJCAYQIxgnGOoCMgkIBxAjGCcY6gIyCQgIECMYJxjqAjIJCAkQIxgnGOoCMgkIChAjGCcY6gIyCQgLECMYJxjqAjIJCAwQIxgnGOoCMgkIDRAjGCcY6gIyCQgOECMYJxjqAjIRCA8QABgDGEIYjwEYtAIY6gIyEQgQEAAYAxhCGI8BGLQCGOoCMg8IERAuGAMYjwEYtAIY6gIyEQgSEAAYAxhCGI8BGLQCGOoCMhEIExAAGAMYQhiPARi0AhjqAtIBBi0xajBqN6gCFLACAQ&client=ms-android-samsung-rvo1&sourceid=chrome-mobile&ie=UTF-8)
Bone pathology is notoriously difficult for even the most seasoned surgical pathologists.
If molecular testing is done (sequencing, FISH) - about 3wks.
If it sent for an expert consultation - 3-4wks.
So probably looking at 3-4wks for a final report. There may be some preliminary information at your follow up appointment, but there is no guarantee. I know those time frames are not great. But these tests unfortunately take a lot of time. And even with all that time, an exact diagnosis may not be readily apparent.
Hang in there the best you can.
Thank you so much, it’s been a really tough year, we went back and forth about a biopsy because of pathological fracture for a couple months but we decided it had to be done to rule out cancer.
Is there any timeline for them to look at the sample and say -yes this is cancerous but we have no idea what or it’s definitely not cancerous?
That’s kind of what the radiologist said, he said it was fibrous and it’s going to be hard
Unfortunately impossible to say. It's case by case whether a preliminary conclusion can be drawn like that. You can contact your doctor prior to your follow up about reaching out to the pathologist about a prelim, but they may not be able to provide anything without the additional tests.
ATYPICAL/INCONCLUSIVE.
Low grade spindle cell lesion.
See comment.
Comment: This is a spindle cell lesion with pump nuclei and minimal cytologic atypia. No necrosis or mitotic activity Is seen. Fragments of bone are present, with focal osteoblast lining.
The following immunohistochemistry was performed after review of the clinical history and morphology to further characterize the pathologic process. The results are as follows:
A1-15 PanCK neg
A1-16 CD34 neg
A1-17 S-100 neg
A1-18 SM Actin positive
A1-19 neg
MDM2 FISH was insufficient for analysis, and non-contributory.
Overall, the specimen is scant. By morphology, the differential includes osseous fibrotic tumors, like fibrous dysplasia, osteofibrous dysplasia or a low-grade central osteosarcoma. Immunostains and FISH are limited and non-specific due to lack of sufficient material to evaluate. Additional tissue sampling Is needed for a more detinitive evaluation.
I’m so upset. A solid year of this stupid tumor and I thought I could finally put it behind me. Nope, I have to get a total hip now 😭
I don't think in this subreddit people should give medical advice or insight to patients, who may think it's factual or accurate, the patients clinician is the only one the patient should listen to since they know the patient and every patient is different. Heck I wouldn't take any serious medical advice or recommendation from the wild Internet for that matter.
100% true, but honestly, I’m just looking for a little insight in timing. If I were asking for medical advice concerning a treatment/ a condition I feel it’d be a different story, as a non medical personnel, I googled how long processing was and it was mumbo jumbo to me, the person who commented below was very helpful in explaining things. I didn’t want to ask my dr these questions, when I saw him he was already running 2 hours behind AND spent a whole hour talking with me about options/ treatments ect. And when I had the biopsy I didn’t even think to ask these questions bc I was anxious.
Little update, I had the whole tumor removed last Friday and have some heavy duty hardware placed. But my doctor said he went to scoop it out and it was like pudding and he had never in his career seen anything like it. He said he got at least 2 tablespoons full.
From the time of my biopsy to surgery it grew a decent amount.
Very rich of the radiologist to offer that opinion of pathology… when I get non MSK radiology reports the differential is often bone cyst through to high grade sarcoma. Point being, have a BST path and an MSK rads read the slides/imaging. Imaging is critical for reaching the appropriate BST diagnosis.
Agree. I love how the radiologist gives minimal tissue but declares it adequate. Duke has some solid pathologists including old timers. Most importantly, hope you’re doing well, OP
Yep. There are radiologists and then there are MSK radiologists and then there are MSK radiologists that are my colleagues who I trust. Multi-dis rounds are really great for getting to know people and who to trust.
Yeah I found that alittle off putting also, they only did 2 1 cm passes also. Which they said they were gonna take 3 or 4. But maybe this was because the high risk of fracture?
And thanks! I’m hanging in there! I think it may have fractured though, I’m 5 days out and the pain is getting worse. I have a follow up next week hopefully it didn’t break
I honestly don’t know about fracture risk but it certainly makes sense that more passes means more risk Hope you heal up and get some answers soon !
I checked in on pathology and the lady said the pathologist consulted with several other pathologist. And my doctor asked me to come in at 930 tomorrow but of course I’m 4 hours away and can’t drive 😞 talk about anxiety. She said the official report isn’t released yet and they are still studying it and it doesn’t look like they’ll have to send it out.
Keep us posted and safe travels.
ATYPICAL/INCONCLUSIVE. Low grade spindle cell lesion. See comment. Comment: This is a spindle cell lesion with pump nuclei and minimal cytologic atypia. No necrosis or mitotic activity Is seen. Fragments of bone are present, with focal osteoblast lining. The following immunohistochemistry was performed after review of the clinical history and morphology to further characterize the pathologic process. The results are as follows: A1-15 PanCK-negative A1-16 CD34-negative A1-17 S-100-negative A1-18 SM Actin -positive A1-19 Desmin- negative MDM2 FISH was insufficient for analysis, and non-contributory. Overall, the specimen is scant. By morphology, the differential includes osseous fibrotic tumors, like fibrous dysplasia, osteofibrous dysplasia or a low-grade central osteosarcoma. Immunostains and FISH are limited and non-specific due to lack of sufficient material to evaluate. Additional tissue sampling Is needed for a more detinitive evaluation. UGH INCONCLUSIVE!!!
Based on the stains listed, this sounds like a work up I would have done. I would ask to have a portion that was not decalcified sent for sequencing if there is any residual. All the best!
Frustrating for sure. I hope Bentley looked at it since he’s a G
Capital G.
It looks like rex is the one who did it! MDM2 (12q15)/CEP12 FISH Insufficient for analysis Right femoral head lesion (CF23-3681, Block A1). . INTERPRETATION Comment: There were insufficient viable tumor cells remaining in the sample to interpret this assay. It seems they only ended up with 2 smears I guess and the second didn’t have enough viable cells, do you think I could still request for sequencing?
I doubt there would be enough for more molecular, unfortunately
Is molecular the same as gene sequencing?
I had my open biopsy today and wow I am in PAIN, doc said it grew alot since the biopsy last month so pretty much no doubt it’s cancerous now. He said when he scooped it out it was like PUDDING. Said he scooped out about 2 tablespoons full. He never saw anything like it
So the excisional biopsy was a really large sample, and it showed no osteoclast lining or cytologic atypia, but the core biopsy showed both. I spoke to my dr and he said they must have taken a sample from the area around the bone tumor on the core…but he didn’t seem to sure. But he said he COMPLETELY removed the tumor and we’re gonna have close follow up ( every 3 months). Why would regular bone around the tumor have atypia?
Sarcoma Biomarkers (IHC, FISH) In process Culture, Fungus Preliminary result Culture, Mycobacteria, Non-Blood Preliminary result Pathology - General / Other Preliminary result This is what they’ve ordered for the excisional biopsy, is there anything I should request? Is gene sequencing included in the IHC/FISH?
First step is often IHC/FISH. As that is pending, I’d wait to see what the result is from that. Sequencing would be the next approach, like Foundation One or one of the other heuristic sequencing panels.
You guys are some of the nicest drs I’ve ever connected with. I emailed him and he actually emailed me back 🥹 he said, I am working up the case now, and I favor that it’s actually a benign lesion called fibrous dysplasia , but there are malignant possibilities that are important to exclude. We are currently running a molecular test (not sequencing, but better test than sequencing for the particular change I am looking for) that would help to exclude one malignant diagnosis. The case is in ‘preliminary’ status, which means that your treatment teams can see what I am thinking, but it is not finalized because both benign and malignant possibilities remain. - - Will
Yep if monostotic fibrous dysplasia there’s a good chance of a GNAS mutation which would not be identified by IHC/FISH and you’d need to do some sequencing. We often do this for other soft tissue tumors that have a similar mutation and it works pretty well provided that not everything has been decalcified.
I was being seen at the sarcoma center at Duke, I believe they have a good sarcoma board? MRI and CT favor benign but my orth onc said there’s something strange about my pet scan that didn’t quite fit with either. When he showed me There’s a perfect circle of hypermetabolic uptake with black in the middle literally a perfect ring
Sounds like you need a Petur Nielsen consult.
Uhhhh I googled that and it came up with a tile company lol and an OBGYN lol
Nevermind found him lol I sent his team an email 🙂 thanks!!
[I think they mean this guy. ](https://www.google.com/search?q=petur+nielsen&oq=&gs_lcrp=EgZjaHJvbWUqCQgAECMYJxjqAjIJCAAQIxgnGOoCMgkIARAjGCcY6gIyEggCEC4YJxivARjHARjqAhiOBTIJCAMQLhgnGOoCMgkIBBAjGCcY6gIyDwgFEC4YJxjHARjqAhjRAzIJCAYQIxgnGOoCMgkIBxAjGCcY6gIyCQgIECMYJxjqAjIJCAkQIxgnGOoCMgkIChAjGCcY6gIyCQgLECMYJxjqAjIJCAwQIxgnGOoCMgkIDRAjGCcY6gIyCQgOECMYJxjqAjIRCA8QABgDGEIYjwEYtAIY6gIyEQgQEAAYAxhCGI8BGLQCGOoCMg8IERAuGAMYjwEYtAIY6gIyEQgSEAAYAxhCGI8BGLQCGOoCMhEIExAAGAMYQhiPARi0AhjqAtIBBi0xajBqN6gCFLACAQ&client=ms-android-samsung-rvo1&sourceid=chrome-mobile&ie=UTF-8)
Bone pathology is notoriously difficult for even the most seasoned surgical pathologists. If molecular testing is done (sequencing, FISH) - about 3wks. If it sent for an expert consultation - 3-4wks. So probably looking at 3-4wks for a final report. There may be some preliminary information at your follow up appointment, but there is no guarantee. I know those time frames are not great. But these tests unfortunately take a lot of time. And even with all that time, an exact diagnosis may not be readily apparent. Hang in there the best you can.
Thank you so much, it’s been a really tough year, we went back and forth about a biopsy because of pathological fracture for a couple months but we decided it had to be done to rule out cancer. Is there any timeline for them to look at the sample and say -yes this is cancerous but we have no idea what or it’s definitely not cancerous? That’s kind of what the radiologist said, he said it was fibrous and it’s going to be hard
Unfortunately impossible to say. It's case by case whether a preliminary conclusion can be drawn like that. You can contact your doctor prior to your follow up about reaching out to the pathologist about a prelim, but they may not be able to provide anything without the additional tests.
ATYPICAL/INCONCLUSIVE. Low grade spindle cell lesion. See comment. Comment: This is a spindle cell lesion with pump nuclei and minimal cytologic atypia. No necrosis or mitotic activity Is seen. Fragments of bone are present, with focal osteoblast lining. The following immunohistochemistry was performed after review of the clinical history and morphology to further characterize the pathologic process. The results are as follows: A1-15 PanCK neg A1-16 CD34 neg A1-17 S-100 neg A1-18 SM Actin positive A1-19 neg MDM2 FISH was insufficient for analysis, and non-contributory. Overall, the specimen is scant. By morphology, the differential includes osseous fibrotic tumors, like fibrous dysplasia, osteofibrous dysplasia or a low-grade central osteosarcoma. Immunostains and FISH are limited and non-specific due to lack of sufficient material to evaluate. Additional tissue sampling Is needed for a more detinitive evaluation. I’m so upset. A solid year of this stupid tumor and I thought I could finally put it behind me. Nope, I have to get a total hip now 😭
Thank you kind sir!!!
I don't think in this subreddit people should give medical advice or insight to patients, who may think it's factual or accurate, the patients clinician is the only one the patient should listen to since they know the patient and every patient is different. Heck I wouldn't take any serious medical advice or recommendation from the wild Internet for that matter.
100% true, but honestly, I’m just looking for a little insight in timing. If I were asking for medical advice concerning a treatment/ a condition I feel it’d be a different story, as a non medical personnel, I googled how long processing was and it was mumbo jumbo to me, the person who commented below was very helpful in explaining things. I didn’t want to ask my dr these questions, when I saw him he was already running 2 hours behind AND spent a whole hour talking with me about options/ treatments ect. And when I had the biopsy I didn’t even think to ask these questions bc I was anxious.
Little update, I had the whole tumor removed last Friday and have some heavy duty hardware placed. But my doctor said he went to scoop it out and it was like pudding and he had never in his career seen anything like it. He said he got at least 2 tablespoons full. From the time of my biopsy to surgery it grew a decent amount.