Working Diagnosis:
Metastatic tumor of the humerus, primary esophageal squamous cell carcinoma origin

Treatment:
The patient underwent left humerus curettage, cementation, and prophylactic fixation. He then started palliative radiation to the humeral head and esophagus, alongside immunotherapy treatment (nivolumab).

Outcome:
Unfortunately his cancer progressed and treatment was discontinued. He pursued hospice care and ultimately succumbed to his disease in his home.

Author's Comments:
While ultrasound (US) is primarily used to evaluate soft tissue structures, this case serves to acknowledge the diagnostic value of US in detecting certain abnormalities of bone. Here, US played a pivotal role in diagnosing a metastatic bone tumor not seen on initial radiographs. Sonographic characteristics of bone tumors can vary depending on tumor type, location, and whether it is benign or malignant. Another key insight is the advantage of utilizing US-guidance with procedures, especially in cases of diagnostic uncertainty. Not only does US increase procedural accuracy, it may provide important anatomical considerations that would be otherwise overlooked if procedures were performed without US guidance.

Editor's Comments:
This is a very interesting case which demonstrates the importance and utility of musculoskeletal ultrasound in diagnosis. The case also highlights other conditions to consider on the differential diagnosis of chronic shoulder pain, such as neoplasia.

References:
Bianchi S. Ultrasound and bone: a pictorial review. J Ultrasound. 2020 Sep;23(3):227-257. doi: 10.1007/s40477-020-00477-4. Epub 2020 May 17. PMID: 32419074; PMCID: PMC7441135.
Madej T, Flak-Nurzyńska J, Dutkiewicz E, Ciechomska A, Kowalczyk J, Wieczorek AP. Ultrasound image of malignant bone tumors in children. An analysis of nine patients diagnosed in 2011-2016. J Ultrason.
2018;18(73):103-111. doi: 10.15557/JoU.2018.0015. PMID: 30335918; PMCID: PMC6440508.
Kabg B, Zeng H, Tang X, Xiong A, Ma Z, Liu G. Ultrasonographic evaluation of osteosarcomas. J Huazhong Univ Sci Technolog Med Sci. 2006;26(5):629-32. doi: 10.1007/s11596-006-0540-5. PMID: 17219988.
Zeng H, Kang B, Liu G, Tang X. Ultrasonographic diagnosis of bone tumor of the knee and its clinical implication. J Tongji Med Univ. 2001;21(3):236-7, 245. doi: 10.1007/BF02886440. PMID: 12539587.
Carra BJ, Bui-Mansfield LT, O'Brien SD, Chen DC. Sonography of musculoskeletal soft-tissue masses: techniques, pearls, and pitfalls. AJR Am J Roentgenol. 2014 Jun;202(6):1281-90. doi: 10.2214/AJR.13.11564. PMID: 24848826.
https://www.ultrasoundcases.info/cases/musculo-skeletal-bone-muscle-nerves-and-other-soft-tissues/bone/malignant-bone-tumors/

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