I Believe It Is Just A Strain - Page #4

Working Diagnosis:
Rectus femoris strain with hematoma formation in various stages of reabsorption

Ice, NSAIDs, physical therapy, activity as tolerated

Patient was seen and evaluated by the physical therapy department. After almost 6 weeks of treatment, she stated that she felt better while exercising and while getting the thigh massaged but otherwise felt worse. A decision was made to get an MRI of the right thigh.

Follow Up:
Patient returns to the clinic after she had the MRI.
The MRI showed a complex mass, 8 x 14 x 10 cm. No associated bony changes. Fluid level present within the mass. Likely Sarcoma but complex injury still possible. Case Photo #1
Follow Up:
Follow up MRI with contrast confirms the diagnosis of a Neoplasm. Case Photo #2 Case Photo #3 Case Photo #4
Patient was referred to a cancer specialty clinic but states that she has other things to do first. She states, "I believe it is just a strain. I believe in my faith.”
She does not present to the Oncology clinic.

Two months later, she is then seen by a different musculoskeletal oncologist. In the meantime, she had a biopsy that confirmed the diagnosis of a sarcoma.
A CT and PET scan completed at this time show metastases in the lungs. Patient again was not interested in a surgical solution and did not follow up with this oncologist either. Case Photo #5 Case Photo #6

Update: Almost one year after initial presentation, her small right lung metastasis have resolved but she developed a new large left sided metastasis. Case Photo #7 Case Photo #8 Case Photo #9

Author's Comments:
This is a case of what is commonly called a "sports tumor". While the presentation and reported history supported the initial diagnosis, the outcome was completely different from the typical quadriceps strains that we see in our clinic. The workup that was done and all attempts to get the patient to the definite treatment were futile in light of the patient's refusal to accept the diagnosis and necessary next steps. She believed that her faith would cure her.

Editor's Comments:
Teaching points:
1. Soft tissue masses in the buttock, groin, and thigh account for 46% of soft tissue sarcomas [1]
2. Red flags of soft tissue mass suggestive of cancer [1]:
a. diameter >5cm
b. increasing in size
c. deep to the fascia (mass moves with muscle contraction)
d. painful
3. Diagnostic imaging modality of choice: MRI [1]
4. Confirm diagnosis with core needle biopsy after imaging to avoid confusion from biopsy-related signal changes [1]

1. Bodington Richard, Stanley Paul R W. A man with a mass in the thighBMJ 2014; 348:g2483

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