Post-traumatic fibro-osseous lesion of the rib

Post-traumatic fibro-osseous lesion of the rib (PTFOL) is a rare lesion that is most commonly noted incidentally. Ten incidence of PFOL is unknown but it is thought that it is underdiagnosed, as many of the cases are misdiagnosed as fibrous dysplasia. This could be attributed to the lack of familiarity of the lesion by radiologists, pathologists and orthopedic surgeons. PFOL is regarded as a reactive bony lesion which in most incidences is related to trivial trauma. However, in many of the reported cases similar to our case, no history of trauma is identified. It clinically, radiologically and sometimes histologically overlaps with some boney lesions including osteoid osteoma, fibrous dysplasia, Erdheim-Chester disease and eosinophilic granuloma (Table I). PFOL usually presents as well-defined nodule (Fig. 1) composed of intervening bland fibrous stroma and xanthomatous component (Fig. 2).
Our case interestingly showed significant xanthomatous component. The histological pattern of the lesion whether predominantly xanthomatous versus fibrotic has no clinical significance. The key histological feature of PFOL is transformation of anastomosing network of woven bony trabeculae (Fig. 3) noted centrally to mature lamellar bone noted peripherally which continue with the cortical bone (Fig. 4).
Most patients with PFOL show no recurrence and there is a controversy in the literature as regards their management, whether the lesion should be left and followed by imaging or it should be excised to rule out a more worrisome lesion, that may overlap clinically and on imaging. Our patient was well and did not show lesional recurrence, during the 7 years follow up period.

References

1. Smith SE, Keshavjee S. Primary chest wall tumors. Thorac Surg Clin 2010; 20: 495-507.
2. Hughes EK, James SL, Butt S, Davies AM, Saifuddin A. Benign primary tumors of the ribs. Clin Radiol 2006; 61: 314-322.
3. Sakellaridis T, Gaitanakis S, Piyis A. Rib tumors: a 15-year experience. Gen Thorac Cardiovasc Surg 2014; 62: 434-440.
4. Aubert S, Kerdraon O, Conti M, et al. Post-traumatic fibro-osseous lesion of the ribs: a relatively under-recognised entity. J Clin Pathol 2006; 59: 635-638.
5. Lichtenstein L, Jaffe HL. Fibrous dysplasia of bone. Arch Pathol 1942; 33: 777-816.
6. Johnson LC. Proceedings of Seminar of South-Eastern and South-Central Regions, College of American Pathologists; 1952 Nov. 12-13; Florida, United States.
7. Reed RJ. Fibrous dysplasia of the bone. A review of 25 cases. Arch Pathol 1963; 75: 480-495.
8. Kandel RA, Pritzker KP, Bedard YC. Symmetrical fibro-osseous dysplasia of rib – posttraumatic dysplasia? Histopathol 1981; 5: 651-658.
9. Blanco M, Cabello-Inchausti B, Cura M, Fernandes L. Post-traumatic fibro-osseous lesion of the ribs and scapula (sclerosing xanthofibroma). Ann Diagn Pathol 2001; 5: 343-349.
10. McDermott MB, Kyriakos M, Flanagan FL. Post-traumatic fibro-osseus lesion of the rib. Hum Pathol 1999; 30: 770-780.
11. Gouldesbrough DR. Symmetrical fibro-osseous dysplasia of rib - evidence for a traumatic aetiology. Histopathol 1990; 17: 267-270.
12. McCarthy EF, Moses DC, Zibreg JW, Dorfman HD. Painless fibro-osseous lesion of the rib resembling osteoid osteoma: a report of six cases. Skeletal Radiol 1985; 13: 263-266.
13. Kessler S, Mirra JM, Gordon P. Case report 823. Skeletal Radiol 1994; 23: 73-77.
14. Oechsli WR. Rib fracture from cough. Report of twelve cases. J Thorac Surg 1936; 5: 530-534.
15. Harvey RM. Rib fractures in atypical pneumonia. Am J Roent Rad Therapy 1944; 52: 487-493.
16. Bacha D, Ayadi-Kaddour A, Marghli A, et al. Post-traumatic fibro-osseous lesion of the rib. Ann Pathol 2009; 29: 36-38.
17. Sim FH, Wold LE. Fibrous tumor of bone. Instr Course Lect 1984; 33: 40-59.
18. Baer JW, Radkowski MA. Congenital multiple fibromatosis: A case report with review of world literature. Am J Roentgenol Radium Ther Nucl Med 1973; 118: 200-205.
19. Dorfman HD, Czerniak B. Bone tumors. Mosby Inc, St Louis 1998.
20. Huvos AG. Bone tumors, Diagnosis, Treatment and Prognosis. Saunders, Philadelphia 1991.
21. Reed RJ. Observations on bone maturation and fibrous dysplasia of bone. Bull Tulane M Fac 1959; 19: 45-53.
22. Ivan D, Neto A, Lemos L, Gupta A. Erdheim-Chester disease: a unique presentation with liver involvement and vertebral osteolytic lesions. Arch Pathol Lab Med 2003; 127: e337-e339.
23. Lantz B, Lange TA, Heiner J, Herring GF. Erdheim-Chester disease. A report of three cases. J Bone Joint Surg Am 1989; 71: 456-464.
24. Gürsoy S, Yaldiz S, Yuncu G, et al. Fibro-osseous lesion of rib. Acta Chir Hung 1999; 38: 249-252.
25. Dalinka MK, Turner ML, Thompson JJ, et al. Lipid granulomatosis of the ribs: Focal Erdheim-Chester disease. Radiology 1982; 142: 297-299.
26. Mirra JM. Bone Tumors. Clinical, Radiologic, and Pathologic Correlations. Lea and Febiger, Philadelphia 1989.

Address for correspondence

Dina El Demellawy
University of Ottawa
Children’s Hospital of Eastern Ontario
401 Smyth Road Ottawa, ON K1H 8L1
tel. (613) 737-7600 x3846
fax (613) 738-4837
e-mail: deldemellawy@cheo.on.ca