A 22-year-old male presented with one-and-half year history of painful, progressively increasing swelling around the right knee joint, which was insidious in onset. The swelling first appeared in the proximal tibia for which he took self medication for pain relief. After eight months he noticed another swelling in the distal femur which was progressing at a faster rate and was more painful. Subsequently, he developed a wound over the tibial swelling following a trivial fall, which progressively increased in size. There was no history of fever, cough, hemoptysis or weight loss.Physical examination revealed 15 x 8 cm circumferential swelling in proximal tibia with dilated veins and an exophytic growth anteriorly. The swelling was tender, hard in consistency, rough irregular surface with well defined borders. A 7x6 cm ulcer as present at the apex of this swelling anteriorly with everted edges, indurated base and covered with slough. Another well defined swelling of 18 x 10 cm was present circumferentially at the distal end of femur with local warmth, tenderness, hard in consistency, irregular rough surface and deep to the quadriceps muscle [Table/ Fig-1]. He had a fixed flexion deformity of 30 degrees at the knee with flexion up to 80 degrees possible. Wasting of thigh and calf muscles was evident. Two inguinal lymph nodes were palpable and tender but mobile. There was no distal neurovascular deficit.Radiograph of the right knee showed large expansile, osteolytic lesions with soap bubble appearance, no periosteal reaction and no matrix calcification in the distal femur, proximal tibia and proximal fibula with cortical breach at all sites. The lesion in the tibia was primarily metaphyseal [Table/ Fig-2]. Computed Tomography (CT) scan showed cortical breach in the tumours and the exophytic extent of tibial tumour [Table/ Fig-3]. Magnetic Resonance Imaging (MRI) of the lesion was hypointense on T1 weighted images and revealed the popliteal artery and tibial and common peroneal nerves to be pushed by the mass but not encased by it. CT scan of the chest and abdomen was done to look for any metastatic deposits but was normal. Fine needle aspiration cytology of inguinal nodes was suggestive of reactive lymphadenitis. Whole body Technetium 99m scan did not reveal any other site of involvement. Serum calcium, phosphorus, alkaline phosphatase and parathyroid hormone levels were normal. Core needle biopsy from femur and tibial lesions was performed which showed scattered osteoclastic giant cells and clusters of stromal cells suggestive of GCT.The patient subsequently underwent transfemoral amputation as the tumor was too extensive for curettage and resection with endoprosthetic reconstruction carried high risk of infection due to the presence of an ulcer [Table /Fig-4]. Histopathology examination of the tumours revealed features typical of GCT and no evidence of malignancy was seen . Bone margin was negative for tumour cells. The patient has no recurrence, new lesions or lung metastasis after three years. ABSTRACTGiant Cell ...

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Ewing's sarcoma is the second most common malignant primary bone tumor of childhood and adolescence affecting mainly the diaphysis of long bones and flat bones. This tumor is extraordinarily rare in small bones of the hand and presents as a swelling with atypical radiological features of cystic and lytic lesion with scant periosteal reaction. The common differential diagnosis include osteomyelitis, tuberculosis, enchondroma and benign tumors. Moreover, skip metastasis to adjacent bones is even rarer. The prognosis of this condition is greatly influenced by the presence of metastasis at presentation, further emphasizing the importance of early diagnosis. Multimodality treatment using surgery, radiotherapy and chemotherapy is currently recommended though no consensus exists. We report a case of Ewing's sarcoma of the little finger proximal phalanx which was initially missed and developed skip metastasis to several metacarpals within 4 months.

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A 15 year old male Arun Suresh Kammar patient presented with the chief complaints of right elbow swelling with discharging sinus since 5 years. Left elbow swelling and ulcer over left gluteal region since 3 years. Patient noticed gradually progressive, painless swelling over right elbow 5 years back and left gluteal region 3 years back for which he underwent surgery 4 and 3 years back respectively. One year latter patient developed gradually progressive diffuse swelling at left elbow with painful left elbow joint movement. Blood investigations were normal except raised phosphorus-6.8mg/dl(N-2.5-4.5mg/dl) and Alkaline phosphatase-52IU/L(N-20-40IU/L).Total excision was done for the left elbow and left gluteal region (periarticular) swelling and right elbow swelling subsided by itself.