case_images: PMC11723737_01
case_images: Anteroposterior (a) and lateral (b) X-ray left thigh shows a relatively defined expansile of tissue opacity noted surrounding the meta-diaphyseal region of the left femur with sunburst type of periosteal reaction. Black arrow - lamellated (onion peel appearance) periosteal reaction, black arrowhead - sunburst type of periosteal reaction, yellow star - soft tissue lesion.
case_images: JOCR-15-171-g001.jpg
case_images: PMC11723737_01_JOCR-15-171-g001.jpg
case_images: F1
case_images: It revealed an ill-defined subtle expansile lytic lesion in the diaphysis and distal metaphysis region of the left femur with the suggestion of lamellated (onion peel) and sunburst (in a few areas) types of periosteal reaction (Fig. 1).
case_images: B mode ultrasound of the left thigh (a) shows continuous sunburst periosteal reaction with associated soft tissue. Significant vascularity is seen on color Doppler (b): Yellow star - soft tissue lesion, black arrow - periosteal reaction.
case_images: JOCR-15-171-g002.jpg
case_images: PMC11723737_01_JOCR-15-171-g002.jpg
case_images: F2
case_images: HRSG(High Resolution Sonography)left thigh was done, which revealed soft tissue showing significant vascularity on color Doppler with associated spiculated sunburst type of periosteal reaction (Fig. 2).
case_images: (a and b) B mode ultrasound of abdomen a heteroechoic lesion encasing and elevating the aorta. Yellow arrow - encased and elevated aorta, white arrow -calcific focus within mass casting post acoustic shadow, green arrow - multiple tiny calcific foci giving twinkling artifact.
case_images: JOCR-15-171-g003.jpg
case_images: PMC11723737_01_JOCR-15-171-g003.jpg
case_images: F3
case_images: Multiple enlarged pre/para-aortic lymph nodes and bilateral common, external, and internal iliac vessels were noted (Fig. 3).
case_images: (a) Large intra-abdominal mass with chunky calcification (yellow arrow) elevating and enhancing the aorta and its major branches (b). Another large heterogeneously enhancing soft tissue with periosteal reaction was noted in the left femur (c). Multiple metastatic lymph nodes are also seen in the bilateral paraaortic, bilateral common, and external iliac and popliteal regions..
case_images: JOCR-15-171-g004.jpg
case_images: PMC11723737_01_JOCR-15-171-g004.jpg
case_images: F4
case_images: Multiple enlarged heterogeneously enhancing retroperitoneal lymph nodes are seen along with bony metastatic lesions (Fig. 4).
case_images: (a, b, c) shows a significant reduction in size and lesion extension with internal calcification within the lesion after chemotherapy.
case_images: JOCR-15-171-g005.jpg
case_images: PMC11723737_01_JOCR-15-171-g005.jpg
case_images: F5
case_images: Follow-up CECT abdomen with the chest was done to assess chemotherapy response and for pre-operative planning which revealed a significant reduction in size and extent of the lesion with a significant reduction in number and size of retroperitoneal lymph nodes (Fig. 5,7).
case_images: (a) Gross photograph shows gray-white to yellowish well-circumscribed tumor (b) microphotograph shows tumor arranged in sheets. The tumor cells are round with a high N:C ratio, hyperchromatic nuclei, and scant amount of cytoplasm - small round blue cell tumor (H and E; x40) (c) Microphotograph shows immuno-histochemistry (IHC) negative for leukocyte common antigen (IHC; x40) (d) microphotograph shows IHC positive for synaptophysin (IHC; x10) (e) microphotograph shows IHC positive for chromogranin (IHC; x40).
case_images: JOCR-15-171-g006.jpg
case_images: PMC11723737_01_JOCR-15-171-g006.jpg
case_images: F6
case_images: These cells were positive for synaptophysin, chromogranin, and cluster of differentiation-99 and negative for leukocyte common antigen confirming the diagnosis of neuroblastoma (Fig. 6).