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CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 168-171

Benign fibrous histiocytoma of olecranon process of right ulna


Department of Orthopaedics, Alluri Sita Ramaraju Academy of Medical Sciences, Eluru, Andhra Pradesh, India

Date of Web Publication15-Oct-2012

Correspondence Address:
Geddam K Roy
Department of Orthopaedics, A-6, ASRAM Quarters, ASRAM Medical College, Eluru, Andhra Pradesh - 534005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.102443

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  Abstract 

Benign fibrous histiocytoma is a rare tumor that most commonly involves the wing of ileum. Only a few cases have been reported in the literature. The olecranon process of the ulna is an uncommon site. We report a 35-yr-old female who presented with swelling in the elbow region including the forearm, a condition since two years. The radiological findings suggested a diagnosis of a giant cell tumor but the histological findings supported a diagnosis of benign fibrous histiocytoma. Resection of the tumor and reconstruction of the elbow was done with the fibula as a spacer due to wdisinclination of the patient for a custom-made prosthesis.

Keywords: Benign fibrous histiocytoma, fibula, spacer, giant cell, limb salvage, olecranon, tumor


How to cite this article:
Roy GK, Shaik RB. Benign fibrous histiocytoma of olecranon process of right ulna. J NTR Univ Health Sci 2012;1:168-71

How to cite this URL:
Roy GK, Shaik RB. Benign fibrous histiocytoma of olecranon process of right ulna. J NTR Univ Health Sci [serial online] 2012 [cited 2019 Nov 18];1:168-71. Available from: http://www.jdrntruhs.org/text.asp?2012/1/3/168/102443


  Introduction Top


Benign fibrous histiocytoma is a rare tumor characterized by aggressiveness with a potential of local spread and distant dissemination. Only a few cases have been reported till date in the available literature. Leading histological features do not appear to correlate with recurrence. The most common sites are the ileum followed by the femur, vertebrae, tibia, and ribs. [1] Exclusive involvement of the ulna is uncommon. We report a benign fibrous histiocytoma in a 35-year-old female who presented with a large swelling in the upper end of the forearm and right ulna region. We did not notice any congenital anamoly anywhere in her body.


  Case Report Top


A 35-year-old female presented with chief complaints of swelling in the right elbow including the forearm region since two years, which was progressively growing in size, associated with moderate pain. The patient had a history of trauma to the right elbow region four years before. There were no constitutional symptoms. General and systemic examination did not reveal any abnormality. On local examination, a swelling of size 15×8 cm was present in the posterior aspect of the right elbow arising from the olecranon and extending to the upper one-fourth of the ulna [Figure 1]. Engorged veins were present over the swelling. There was a mild local rise of temperature and no tenderness; it was hard to firm in consistency with no eggshell crackling. Blood investigations were within normal limits. Anteroposterior and lateral radiographs of the right elbow showed a well-defined oval expansile lesion rising from the olecranon process and upper shaft of the right ulna, giving a soap bubble appearance [Figure 2]. A fine needle aspiration cytology study of the swelling was done and a provisional diagnosis of a giant cell tumor was made. Magnetic resonance imaging (MRI) showed features suggestive of a giant cell tumor [Figure 3], [Figure 4], [Figure 5]. Tumor excision and reconstruction with a custom-made prosthesis was thought of as the best possible option of treatment. The condition, its prognosis, and various treatment modalities were discussed at length with the patient. She refused tumor excision and reconstruction of the ulna with a custom-made prosthesis. The patient was a manual laborer, and performing a simple excision and leaving the area as such would result in an unstable forearm. Therefore we chose the option of excision of the tumor and reconstruction of the elbow with autograft as a spacer. Tumor resection was done; along with a part of the healthy ulna and contralateral autologous fibula were used as a spacer, which was fixed with semitubular plate and aligned to the trochlea. Two Kirschner wires (K-wires) were used to keep the fibular graft in place, one in alignment with the trochlear surface of the humerus and the other to maintain relationship of the superior radioulnar joint. A check X-ray showed satisfactory alignment [Figure 6]. The excised tumor was of size 15×8 cm on the table. It was vertically split in two halves and the entire area was filled with slightly yellowish white dense tissue not yielding to pressure. The postoperative period was uneventful. Suture removal was done after 10 days. Histopathology report came as Benign fibrous histiocytoma of bone [Figure 7], [Figure 8]. The K-wires were removed after six weeks and the patient was discharged with an above-elbow plaster of Paris (POP) cast. First follow-up was at 10 weeks, and two successive follow-ups were made. On each occasion, the POP was removed and check X-ray taken. In the final follow-up, we found the alignment of bone graft against the lower end of the humerus a bit lax. The healing process at the junction of the graft with parent ulna was in progress but was very sluggish with meager evidence of new bone formation. Patient is at present being given guarded elbow movements including supination and pronation [Figure 9].
Figure 1: Preoperative picture of the swelling

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Figure 2: Preoperative radiograph showing soap bubble appearance

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Figure 3: MRI

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Figure 4: MRI

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Figure 5: MRI

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Figure 6: Postoperative radiograph

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Figure 7: Histopathology slide showing whorled pattern of histiocytes and giant cells

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Figure 8: Histopathology slide: magnified view

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Figure 9: Patient being given guarded movements

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  Discussion Top


Benign fibrous histiocytoma is a histopathological entity rather than a clinico-radiological one. [2] The present case was labeled as above after obtaining the histopathological opinion. Until then it was viewed as a giant cell tumor of the olecranon. Benign fibrous histiocytoma of the bone is relatively less frequently seen. Dahlin first described a benign and atypical lesion of malignant fibrous histiocytoma in 1978. Cellular, aneurysmal, and atypical variants in benign fibrous histiocytoma were also described. [3]

Microscopically, benign fibrous histiocytoma carries similar cellular fields as in nonossifying fibroma and fibrous cortical defect, which are common in younger age groups, whereas benign fibrous histiocytoma is common in elderly persons. The histopathological report in our case is similar to the description given in standard literature about the presence of spindle-shaped oval cells resembling fibroblasts intermixed with benign mononucleated and multinucleated cells akin to histiocytes. Storiform arrangement of cells was also identified.

The clinical features like painless, progressive growth of tumor with occasional constitutional symptoms were similar to the observations made by Dahlin, and the lesion was metaphyseal in nature. In spite of huge growth and the fact that the patient continued her daily routine activities, there was no pathological fracture. The overall diagnosis of benign fibrous histiocytoma should be made with a combination of clinico-radiological findings and histopathological features.

In spite of its huge growth, we did not find any malignant changes with clinical, radiological, and histopathological scrutiny. The available literature indicates that the tumor may sometimes be locally aggressive and lead to metastasis occasionally. The patient was followed three weeks ago when we found that the patient was able to utilize the reconstructed limb in her daily activities with reasonable satisfaction. There was no clinico-radiological evidence of recurrence or metastasis.

 
  References Top

1.Sanatkumar S, Rajagopalan N, Mallikarjunaswamy B, Srinivasalu S, Sudhir NP, Usha K. Benign fibrous histiocytoma of the distal radius with congenital dislocation of the radial head: A case report. J Orthop Surg (Hong Kong) 2005;13:83-7.  Back to cited text no. 1
[PUBMED]    
2.Dahlin DC. Benign and atypical fibrous histiocytoma. In: Dahlin DC, editor. Bone tumors. General aspects and data on 6,221 cases. 3rd ed. Springfield: Charles C Thomas; 1978. p. 116-36.  Back to cited text no. 2
    
3.Morphologically benign lesions of soft tissue and bone which metastasize - what can we do? In: Folpe AL, editor. ISBSTP Handout. Rochester, MN: Mayo Clinic; 2010.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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  Case Report
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   References
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