Pediatric Tibial Tumors: Insights on Diagnosis and Symptoms

Pediatric tibial tumors

Hello Dr.
Chen,
My son (4 years and 6 months) has had a lump above the anterior aspect of his right tibia since he was two years old.
He feels hesitant to put weight on his right foot while walking, which makes his walking and running appear slightly limping.
Initially, I took him to the rehabilitation department at Chang Gung Memorial Hospital, where the physician arranged for X-rays and an ultrasound.
The X-ray revealed a mass, and the ultrasound showed vascular flow, leading the rehabilitation doctor to suspect a giant cell tumor (due to the blood flow response).
Additionally, the lump felt warmer to the touch compared to the surrounding skin, so he was promptly referred to an orthopedic surgeon at Chang Gung.
The orthopedic doctor later diagnosed it as a benign fibrous tumor, stating that a follow-up in a year would suffice.
When we returned for a follow-up at four years old, the X-ray showed that the tumor had grown larger.
The doctor explained that this was expected as he is still growing, and he maintained the original diagnosis of fibrous tumor.
However, I am confused because I found online articles stating that a bone tumor showing blood flow on ultrasound is indicative of a giant cell tumor.

I asked the orthopedic surgeon if the fibrous tumor could be compressing my son’s tibia, causing him to be hesitant to put weight on it.
The doctor replied that it should not be the case.
I also inquired whether this fibrous tumor could lead to future mobility issues, to which the doctor responded that it likely would not.
When I asked about the blood flow response observed during the ultrasound, the doctor reiterated his diagnosis of fibrous tumor.
He concluded that my son does not need to return annually, but rather every 2-3 years, expressing confidence in his diagnosis of a benign fibrous tumor.
However, I still have the following questions for you, Dr.
Chen:
1.
Can the presence of blood flow on ultrasound in a bone tumor be used to determine if it is a giant cell tumor?
2.
Is increased skin temperature over a bone tumor a normal symptom of fibrous tumor?
3.
Can a fibrous tumor of the tibia cause discomfort while walking or running, leading to hesitance in weight-bearing? (My son says he does not feel soreness while walking or running, but sometimes experiences discomfort during more vigorous activities.)
4.
Is it a normal response for a tibial fibrous tumor to be tender upon palpation? (When I pressed on the affected area, he said it did not hurt but he would retract his foot.)
Thank you!

Tim Wang, 40~49 year old female. Ask Date: 2016/05/16

Dr. Chen Yongxue reply Orthopedics

Hello, benign fibrous tumors are the most common benign tumors in children, with a higher prevalence in males, being twice as common as in females.
Since they are benign tumors, there are no reports of malignant transformation.
They typically occur in the distal femur or proximal tibia.
Most benign fibrous tumors are asymptomatic and are often discovered incidentally through X-rays; only a small number of patients experience symptoms.
However, the pain associated with these tumors is not related to the patient's activity; it occurs when the tumor is touched or when it becomes large enough to cause minor fractures.
Diagnosis is generally made using X-rays, and CT or MRI can be used if necessary.
A minority of patients may have tumors in more than one location, which may warrant a nuclear bone scan.
Benign fibrous tumors have the potential to disappear before the age of 20, and routine outpatient follow-up is usually sufficient.
Only a very small number of tumors become large enough to cause significant inconvenience in activities, which would then be considered for surgical treatment.
I believe you do not need to worry too much; regular outpatient follow-up is all that is required.
Thank you.

Reply Date: 2016/05/16

More Info

Dear [Name],
Thank you for your detailed inquiry regarding your son's condition. Understanding pediatric tibial tumors can be complex, especially when differentiating between various types of bone lesions. I will address your questions based on the information provided and current medical knowledge.

1. Ultrasound Blood Flow Reaction and Giant Cell Tumor: While it is true that giant cell tumors (GCT) of bone often exhibit increased vascularity, as indicated by blood flow on ultrasound, this finding is not exclusive to GCT. Other lesions, including benign tumors like fibrous dysplasia or even certain aggressive benign tumors, can also show increased blood flow. Therefore, while a blood flow reaction can suggest a more aggressive process, it cannot definitively diagnose a giant cell tumor without further histological examination.

2. Increased Skin Temperature Over the Tumor: The presence of increased skin temperature over a bone tumor can occur due to increased blood flow or inflammation associated with the tumor. In the case of a benign fibrous tumor, this may not be unusual, especially if there is some degree of irritation or inflammation. However, it is essential to monitor this symptom, as significant changes could warrant further investigation.

3. Discomfort While Walking or Running: Fibrous dysplasia, which is what your son's orthopedic surgeon has diagnosed, typically does not cause significant pain or discomfort unless there is a fracture or significant pressure on surrounding structures. If your son reports that he does not experience pain during regular activities but feels discomfort during more vigorous activities, this could be due to the tumor's presence affecting his gait or biomechanics. It is not uncommon for children to adjust their walking patterns to avoid discomfort, which can lead to a limp or altered gait.

4. Pain on Pressure: The reaction of your son to pressure on the fibrous tumor site can vary. If he does not report pain but exhibits a reflexive withdrawal (like pulling back his leg), this could be a normal response to pressure or discomfort. Children often have different pain thresholds, and their reactions can be influenced by many factors, including anxiety or anticipation of pain. If there is no significant pain or discomfort during normal activities, this is generally a positive sign.

In summary, while your son's diagnosis of a benign fibrous tumor seems to be well-supported by the clinical findings and imaging studies, it is crucial to maintain regular follow-ups as recommended by his orthopedic surgeon. Monitoring for any changes in size, symptoms, or function is essential. If you have concerns about his activity level or any new symptoms, do not hesitate to reach out to his healthcare provider for further evaluation.

Lastly, it is always beneficial to seek a second opinion if you feel uncertain about the diagnosis or treatment plan. Pediatric orthopedic specialists can provide further insights and reassurance regarding your son's condition.

Best wishes for your son's health and well-being.

Sincerely,
Doctor Q&A Teams

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