Case Study: Evaluation of a Painful Mass in the Thigh of a 52-Year-Old Female

Patient Profile:

• Name: Mrs. Susan Davis
• Age: 52 years
• Occupation: Office administrator
• Past Medical History: Hypertension, hypothyroidism
• Family History: No history of cancers or musculoskeletal disorders
• Medications: Levothyroxine 100 mcg daily, hydrochlorothiazide 25 mg daily
• Social History: Non-smoker, no alcohol use, sedentary lifestyle

Chief Complaint: Mrs. Davis presents with a painful mass in her left thigh that she noticed 3 months ago. The mass has grown in size and has recently started causing discomfort, particularly when walking or sitting for long periods. She denies any recent trauma, fever, or weight loss.

History of Present Illness:

• The mass is located on the anterior aspect of the left thigh and was initially painless but has become tender over the past few weeks.
• The size of the mass has noticeably increased since she first detected it.
• She denies any systemic symptoms such as night sweats, fever, or unexplained weight loss.
• No previous history of tumors or masses.

Physical Examination:

• BMI: 31 kg/m² (obese)
• Vital Signs: BP 136/84 mmHg, HR 76 bpm, RR 16/min
• Examination of the left thigh reveals:
  • A firm, immobile, palpable mass measuring approximately 7 cm in diameter on the anterior thigh.
  • The mass is not warm to the touch, but there is tenderness upon deep palpation.
  • No overlying skin changes or erythema.
  • Full range of motion in the hip and knee, but pain with deep flexion of the hip.

Initial Imaging: An ultrasound of the left thigh shows a solid mass with irregular borders. Further imaging is recommended for better characterization.

Questions for Case Assessment:

1. What are your initial differential diagnoses for a painful, growing mass in the thigh, and what key features in Mrs. Davis's presentation guide your thinking?

2. What imaging modality would you recommend next to further evaluate the mass, and what characteristics would you expect to see if the mass were benign versus malignant?

3. Discuss the role of biopsy in the evaluation of musculoskeletal tumors. Under what circumstances would you consider a biopsy in this case, and how would you decide on the type of biopsy to perform (e.g., fine-needle aspiration vs. core biopsy)?

4. What are the red flags for malignancy in musculoskeletal tumors, and how would those findings influence your management plan for Mrs. Davis?

5. At what point would you refer Mrs. Davis to a specialist, and which specialists should be involved in her care? How would imaging and biopsy results influence the urgency and type of referral?