International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. (2010)

Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/oa.1165

SHORT REPORT

Differential Diagnosis of an Unusual

Tibial Pathology from Peru
S. S. PHILLIPS* AND J. W. VERANO
Department of Anthropology, Tulane University, 7041 Freret Steet, New Orleans, LA 70118, USA

ABSTRACT During an osteological analysis of human skeletal remains from the site of Punta Lobos (Huarmey Valley,
northern coastal Peru), an unusual erosive lesion of the cortex with periosteal reaction was observed on a right
tibia. The authors undertook a review of paleopathological and medical literature to arrive at a differential
diagnosis. The lesion is determined to be a non-malignant growth, possibly a large periosteal ganglion,
though a diagnosis of periosteal chondroma (a benign neoplasm) or other uncommon neoplasm could not be
definitively ruled out. Copyright 2010 John Wiley & Sons, Ltd.

Key words: neoplasm; Peru; tibia

Introduction Material
In 1998, a Peruvian archaeology team uncovered human The lesion was observed in Entierro (Burial) 77, which
remains at a site called Punta Lobos, a small spit of land at consisted of the incomplete remains of a single adult.
the edge of the Pacific Ocean near the mouth of the Missing elements were the right arm, left forearm, both
Huarmey River in northern Peru. Later osteological hands and the right os coxae and upper leg. Based on
analysis indicated a minimum number of individuals pelvic morphology and overall skeletal robustness, E77
(MNI) of 178 men and boys of various ages, from as young was a male individual. An age range of 4555 years was
as 8 to approximately 60 years at the age of death1. determined primarily by pubic symphyseal morphology
Calibrated radio-carbon dating places the remains at AD (Brooks & Suchey, 1990), which was supported by the
12501300. The context of the find and the presence of auricular surface morphology (Lovejoy et al., 1985). In
sharp force trauma in the neck region of many individuals addition to the tibial lesion, several pathologies, two of
indicate the site was the location of an ancient massacre which were traumatic in origin, were noted in E77: (1) a
(Phillips & Verano, 2005; Verano, 2007). Numerous healed fracture of the acromion process of the left
additional pathologies not related to the cause of death scapula with attendant arthritis of the left shoulder joint,
were noted among the skeletal remains, including a large (2) a healed fracture of the left femoral neck with some
lesion with periosteal bone growth located on the anterior displacement of the femoral head leading to moderate
of a right tibia. This paper discusses potential diagnoses of deformation of the both the head and the left
this unusual pathology. acetabulum and (3) a general inflammation of the
frontal bone.

* Correspondence to: Department of Anthropology, Tulane University,

7041 Freret Steet, New Orleans, LA 70118, USA. Description of the lesion
e-mail: [email protected]
1
A few juveniles had preserved hair, which was cut very short and others had The lesion was located on the medio-ventral aspect
preserved clothing in the form of loincloths. These two features, along with of the proximal diaphysis of the right tibia and
absence of any identifiably female remains led to the assumption that all appeared to mark the location of a large soft-tissue
Punta Lobos victims were male. This conclusion was later supported by an
analysis which found male DNA in all of the juvenile hair samples from mass lying between the external cortex and the
which DNA was successfully extracted (Scola, 2004). periosteum. The soft-tissue mass has since decayed,
Copyright # 2010 John Wiley & Sons, Ltd. Received 2 September 2009
Revised 28 January 2010
Accepted 18 February 2010
 S. S. Phillips and J. W. Verano

perpendicularly oriented new bone growth (indicative

of an osteosarcoma) and the tendency for malignant
periosteally-located chondroid tumours to invade the
cortex (Boriani et al., 1983; Brien et al., 1999; Robbin
& Murphey, 2000). Numerous conditions were
investigated as possible diagnoses, including ossified
subperiosteal hematoma, several kinds of bone cyst
and many varieties of benign neoplasm affecting the
periosteum. Two possible diagnoses for the tibial lesion
are suggested by the subperiosteal location, the
saucerisation of the external cortex and the nature of
the new bone growth: (1) periosteal chondroma and
(2) periosteal ganglion. Periosteal chondroma is a
rare, benign neoplasm that originates in the
Figure 1. Photo of the right Tibia of E77 (proximal is left). Note periosteum which has also been referred to as
periosteal bone growth is greatest on the distal and medial
margins of the lesion. Photo by JWV. parosteal and juxtacortical chondroma. It is a rare
condition, accounting for around only 1% of all
leaving a large (12 cm  3 cm) lesion characterised chondroid tumours (Brien et al., 1999). Periosteal
by saucerisation of the underlying cortex and chondromas produce saucerisation (pressure erosion)
periosteal reaction in the form of speculated bone of the cortex with a cuff or buttress of newly formed
growth forming a partial shell around the lesion, bone at one end, both features which are character-
predominantly at the medio-distal margin (Figures 1 istic of E77s lesion (Bauer et al., 1982; Brien et al.,
and 2). There appears to be a little thinning of 1999). Periosteal chondromas tend to occur in the
the tibial cortex in the area of the lesion, but there hands, feet and proximal metaphyses, although
is no perforation into the medullary cavity. they can also be found elsewhere in the body, and
Unfortunately, neither the degree of cortical they are more common in males. Arguing against a
thinning nor the presence of endosteal sclerosis diagnosis of periosteal chondroma is the age
could be determined because of a lack of access to distribution of the neoplasm; in modern times it
radiography at the field site where analysis was most commonly occurs in those under 30 years of
conducted. age, though older patients are reported. The small
size (<8 cm) of tumours reported in the literature
is also contradictory to the diagnosis of this lesion
Discussion as a periosteal chondroma (Boriani et al., 1983;
Nguyen & Burk, 1995; Robbin & Murphey, 2000).
Despite its large size, the lesion was determined to be E77s lesion is larger than the reported size ranges
benign based on the intact cortex, the lack of for either periosteal chondroma or periosteal
ganglion, but Ortner & Ragsdale (2005) point out
that medical literature records the appearance of
tumours and tumour-like growths of people who are
referred to treatment, while archaeologically derived
cases are commonly untreated cases. Thus, it is
possible that paleopathological examples will be of
greater size than clinically reported instances of
tumours.
Periosteal ganglia are thought to be caused by mucoid
degeneration of the periosteum, possibly as a secondary
reaction to trauma (Kobayashi et al., 1996; Valls et al.,
1997). Periosteal ganglia have a predilection for the
lower extremity, particularly the proximal shaft of the
tibia, and are more common in males and older
individuals (Abdelwahab et al., 1993; Okada et al., 1996;
Figure 2. Photo of right tibia (proximal is right) showing the intact Valls et al., 1997). Several authors have noted the
external cortex. Photo by JWV. proximity of many reported periosteal ganglia to the pes

Copyright # 2010 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. (2010)
Differential Diagnosis of an Unusual Tibial Pathology

anserinus and its bursa2 but did not find conclusive literature, much less in the literature of paleopathology.
evidence to link the condition with bursitis. A full No other clinical or paleopathological description of
understanding of the pathogenesis of periosteal any condition considered as a potential diagnosis fits
ganglion remains unclear, though the potential link the description of the lesion observed in E77s remains
between the lesion and trauma is intriguing, because of as well as periosteal ganglion and periosteal chon-
the presence of other traumatic injury in E77s skeletal droma. However, considering their rarity and given
remains. Like periosteal chondromas, periosteal ganglia the limitations of paleopathological diagnosis based
produce saucerisation of the external cortex without entirely on macroscopic examination, a diagnosis other
expansion into the medullary cavity (Benedetti et al., than these two conditions cannot be excluded. A
1996; Okada et al., 1996; Valls et al., 1997). Valls and review of the paleopathological literature found no
colleagues (1997) claim that thick spicules of periosteal case resembling the lesion in question. From a review of
bone formation arising from the cortex are common. the medical literature, it appears periosteal location is a
Again, this fits with the morphology of the lesion in rarely occurring variant for a variety of neoplasms and
question. As is the case with periosteal chondromas, so it may be that the lesion described here represents an
reported periosteal ganglia tend to be smaller than the uncommon variant of an otherwise more common
lesion observed in E77. tumour or tumour-like lesion.
A more secure diagnosis of the lesion in question is
difficult as much of the difference between periosteal
chondroma, periosteal ganglion and other neoplasms
lies in the histopathological features of the soft-tissue References
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2
The pes anserinus is the insertion of the combined tendon of sartorius,
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 S. S. Phillips and J. W. Verano

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Copyright # 2010 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. (2010)