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Paget Disease — SCE Rheumatology MCQ

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ModerateMetabolic Bone DiseasePaget DiseaseSCE Rheumatology

A 60-year-old man has Paget disease affecting the left tibia. Initial radiographs show cortical thickening, bony expansion and mixed lytic and sclerotic change. Serum alkaline phosphatase is 820 U/L, with normal calcium, phosphate and parathyroid hormone concentrations. During follow-up, he develops rapidly progressive focal pain and swelling at the affected site. Repeat imaging shows new cortical destruction and an extraosseous soft-tissue mass. Which complication should be suspected?

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Correct answer: C — Osteosarcoma

The correct answer is osteosarcoma. Sarcomatous transformation is rare in Paget disease but is a serious complication with a poor prognosis. New rapidly progressive pain, swelling, cortical destruction or an extraosseous mass at a previously pagetic site should prompt urgent investigation for malignancy. A pathological fracture generally presents with an acute mechanical event or fracture line rather than an enlarging soft-tissue mass. Secondary osteoarthritis occurs adjacent to affected bone and causes joint-localised mechanical pain and stiffness. High-output cardiac failure is associated with extensive, highly vascular polyostotic disease, not a focal destructive lesion. Nerve compression depends on involvement of anatomically confined sites such as the spine or skull and would produce neurological deficits.

Reference: NHS. Paget's disease of bone – Complications. Last reviewed 4 April 2023. https://www.nhs.uk/conditions/pagets-disease-bone/complications/