Simple bone cyst

Changed by Calum Worsley, 13 Oct 2021

Updates to Article Attributes

Body was changed:

Show markup changes

Unicameral bone cysts (UBC), also known as simple bone cysts, are common benign non-neoplastic lucent bony lesions that are seen mainly in childhood and typically remain asymptomatic. They account for the S (simple bone cyst) in FEGNOMASHIC, the commonly used mnemonic for lytic bone lesions.

Epidemiology

They are usually found in children in the 1st and 2nd decades (65% in teenagers) and are more common in males (M:F ~ 2-3:1) ^2,6. Active unicameral bone cysts occur most frequently between the ages of 1 and 10 years.

Clinical presentation

These lesions are usually asymptomatic and found incidentally, although pain, swelling and stiffness of the adjacent joint also occur. The most frequent presentation is due to ~~complications by~~ pathological fracture. ^1,2,6.

Pathology

When uncomplicated by fracture the cysts contain clear serosanguineous fluid surrounded by a thin fibrous membranous lining. It is thought to arise as a defect during bone growth that fills with fluid, resulting in the expansion and thinning of the overlying bone.

During the active phase, the cyst remains adjacent to the growth plate. As the lesion becomes inactive it migrates away from the growth plate (normal bone is formed between it and the growth plate) and it gradually resolves ^3,5.

Location

They are typically intramedullary and active cysts are found in the metaphysis of long bones, abutting the growth plate ¹. Locations include ^1,2,5:

proximal humerus: most common 50-60%
proximal femur: 30%
other long bones
occurrence elsewhere is relatively uncommon, and usually occurs in adults
- spine: usually posterior elements
- pelvis: only 2% of UBC ¹
- calcaneus

As bone growth progresses the cyst loses its connection to the physis migrating into the diaphysis and subsequently healing. UBCs can be rarely seen in adults in unusual locations such as in the talus, calcaneus, or the iliac wing.

Radiographic features

Plain radiograph

Unicameral bone cysts are well defined geographic lucent lesions with a narrow zone of transition, mostly seen in skeletally immature patients, which are centrally located and show a thin sclerotic margin in the majority of cases with no periosteal reaction or soft tissue component. They sometimes expand the bone with thinning of the endosteum without any breach of the cortex unless there is a pathologic fracture. Prominent ridges of bone can appear as pseudotrabeculation on x-ray but in fact, UBC is usually unilocular. Rarely, they are truly multi-loculated ³.

If there is a fracture through this lesion a dependant bony fragment may be seen, and this is known as the fallen fragment sign.

CT and MRI

CT and MRI add little to the diagnosis, however, can be helpful in eliminating other entities that can potentially mimic a simple bone cyst (see differential diagnosis below).

MR signal characteristics for an uncomplicated lesion include:

T1: low signal
T2: high signal

Usually, there are no fluid-fluid levels unless there has been a complication with haemorrhage.

Scintigraphy

Unicameral bone cyst on bone scintigraphy tends to appear as foci of photopenia (cold spot). This is referred to as the doughnut sign which results in increased uptake peripherally and a photopenic centre. However, a pathological fracture would cause an increased radioisotope activity.

Treatment and prognosis

Intervention is usually not required for an asymptomatic lesion. If large and threatening to fracture, or causing deformity then an intralesional steroid injection can be performed ^3-5. If fractured the bone usually heals normally ⁵. In some instances, surgery with curettage and bone grafting is required.

History and etymology

Unicameral bone cysts were initially described by the German pathologist Rudolf Virchow in 1891 ^8,9.

Differential diagnosis

General imaging differential considerations include:

intraosseous lipoma
fibrous dysplasia
eosinophilic granuloma (EG)
giant cell tumour of bone: usually older, extending to the articular surface
non ossifying fibroma: eccentric, cortical base
haemophilic pseudotumour (intraosseous)
aneurysmal bone cyst (ABC): usually eccentric

-<p><strong>Unicameral bone cysts (UBC)</strong>, also known as <strong>simple bone cysts</strong>, are common benign non-neoplastic lucent bony lesions that are seen mainly in childhood and typically remain asymptomatic. They account for the <strong>S</strong> (simple bone cyst) in <a href="/articles/lucentlytic-bone-lesion-differential-diagnosis-mnemonic-1">FEGNOMASHIC</a>, the commonly used mnemonic for lytic bone lesions. </p><h4>Epidemiology</h4><p>They are usually found in children in the 1st and 2nd decades (65% in teenagers) and are more common in males (M:F ~ 2-3:1) <sup>2,6</sup>. Active unicameral bone cysts occur most frequently between the ages of 1 and 10 years.</p><h4>Clinical presentation</h4><p>These lesions are usually asymptomatic and found incidentally, although pain, swelling and stiffness of the adjacent joint also occur. The most frequent presentation is due to complications by <a href="/articles/pathological-fracture">pathological fracture</a>. <sup>1,2,6</sup>.</p><h4>Pathology</h4><p>When uncomplicated by fracture the cysts contain clear serosanguineous fluid surrounded by a thin fibrous membranous lining. It is thought to arise as a defect during bone growth that fills with fluid, resulting in the expansion and thinning of the overlying bone.</p><p>During the active phase, the cyst remains adjacent to the growth plate. As the lesion becomes inactive it migrates away from the growth plate (normal bone is formed between it and the growth plate) and it gradually resolves <sup>3,5</sup>.</p><h5>Location</h5><p>They are typically intramedullary and active cysts are found in the metaphysis of long bones, abutting the growth plate <sup>1</sup>. Locations include <sup>1,2,5</sup>:</p><ul>
+<p><strong>Unicameral bone cysts (UBC)</strong>, also known as <strong>simple bone cysts</strong>, are common benign non-neoplastic lucent bony lesions that are seen mainly in childhood and typically remain asymptomatic. They account for the <strong>S</strong> (simple bone cyst) in <a href="/articles/lucentlytic-bone-lesion-differential-diagnosis-mnemonic-1">FEGNOMASHIC</a>, the commonly used mnemonic for lytic bone lesions. </p><h4>Epidemiology</h4><p>They are usually found in children in the 1st and 2nd decades (65% in teenagers) and are more common in males (M:F ~ 2-3:1) <sup>2,6</sup>. Active unicameral bone cysts occur most frequently between the ages of 1 and 10 years.</p><h4>Clinical presentation</h4><p>These lesions are usually asymptomatic and found incidentally, although pain, swelling and stiffness of the adjacent joint also occur. The most frequent presentation is due to <a href="/articles/pathological-fracture">pathological fracture</a> <sup>1,2,6</sup>.</p><h4>Pathology</h4><p>When uncomplicated by fracture the cysts contain clear serosanguineous fluid surrounded by a thin fibrous membranous lining. It is thought to arise as a defect during bone growth that fills with fluid, resulting in the expansion and thinning of the overlying bone.</p><p>During the active phase, the cyst remains adjacent to the growth plate. As the lesion becomes inactive it migrates away from the growth plate (normal bone is formed between it and the growth plate) and it gradually resolves <sup>3,5</sup>.</p><h5>Location</h5><p>They are typically intramedullary and active cysts are found in the metaphysis of long bones, abutting the growth plate <sup>1</sup>. Locations include <sup>1,2,5</sup>:</p><ul>
~~-<li><a title="Calcaneus" href="/articles/calcaneus">calcaneus</a></li>~~
+<li><a href="/articles/calcaneus">calcaneus</a></li>

References changed:

1. Hammoud S, Weber K, McCarthy E. Unicameral Bone Cysts of the Pelvis: A Study of 16 Cases. Iowa Orthop J. 2005;25:69-74. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888766">PMC1888766</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16089077">Pubmed</a>
2. Coskun B, Akpek S, Dogulu F, Uluoglu O, Eken G. Simple Bone Cyst in Spinous Process of the C4 Vertebra. AJNR Am J Neuroradiol. 2004;25(7):1291-3. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7976534">PMC7976534</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15313727">Pubmed</a>
3. Felix S. Chew. Musculoskeletal Imaging. (2003) ISBN: 9780781737975 - <a href="http://books.google.com/books?vid=ISBN9780781737975">Google Books</a>
4. Wood W. Lovell, Robert B. Winter, Raymond T. Morrissy et al. Lovell and Winter's Pediatric Orthopaedics. (2006) ISBN: 9780781753586 - <a href="http://books.google.com/books?vid=ISBN9780781753586">Google Books</a>
5. Harry B. Skinner. Current Diagnosis & Treatment in Orthopedics. (2003) ISBN: 9780071387583 - <a href="http://books.google.com/books?vid=ISBN9780071387583">Google Books</a>
6. Adam Greenspan, Gernot Jundt, Wolfgang Remagen. Differential Diagnosis in Orthopaedic Oncology. (2007) ISBN: 9780781779302 - <a href="http://books.google.com/books?vid=ISBN9780781779302">Google Books</a>
7. Blumberg M. CT of Iliac Unicameral Bone Cysts. AJR Am J Roentgenol. 1981;136(6):1231-2. <a href="https://doi.org/10.2214/ajr.136.6.1231">doi:10.2214/ajr.136.6.1231</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/6786043">Pubmed</a>
8. Noordin S, Allana S, Umer M, Jamil M, Hilal K, Uddin N. Unicameral Bone Cysts: Current Concepts. Ann Med Surg (Lond). 2018;34:43-9. <a href="https://doi.org/10.1016/j.amsu.2018.06.005">doi:10.1016/j.amsu.2018.06.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30224948">Pubmed</a>
9. Wilkins R. Unicameral Bone Cysts. J Am Acad Orthop Surg. 2000;8(4):217-24. <a href="https://doi.org/10.5435/00124635-200007000-00002">doi:10.5435/00124635-200007000-00002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10951110">Pubmed</a>
1. Hammoud S, Weber K, Mccarthy EF. Unicameral bone cysts of the pelvis: a study of 16 cases. Iowa Orthop J. 2005;25 : 69-74. - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888766">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16089077">Pubmed citation</a><div class="ref_v2"></div>
2. Coskun B, Akpek S, Dogulu F et-al. Simple bone cyst in spinous process of the c4 vertebra. AJNR Am J Neuroradiol. 2004;25 (7): 1291-3. <a href="http://www.ajnr.org/cgi/content/full/25/7/1291">AJNR Am J Neuroradiol (full text)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15313727">Pubmed citation</a><div class="ref_v2"></div>
3. Chew FS, Bui-Mansfield LT, Kline MJ. Musculoskeletal imaging. Lippincott Williams & Wilkins. (2003) ISBN:0781737974. <a href="http://books.google.com/books?vid=ISBN0781737974">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0781737974?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0781737974">Find it at Amazon</a><div class="ref_v2"></div>
4. Lovell WW, Winter RB, Morrissy RT et-al. Lovell and Winter's pediatric orthopaedics. Lippincott Williams & Wilkins. (2006) ISBN:0781753589. <a href="http://books.google.com/books?vid=ISBN0781753589">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0781753589?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0781753589">Find it at Amazon</a><div class="ref_v2"></div>
5. Skinner HB. Current diagnosis & treatment in orthopedics. McGraw-Hill Medical. (2003) ISBN:0071387587. <a href="http://books.google.com/books?vid=ISBN0071387587">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0071387587?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0071387587">Find it at Amazon</a><div class="ref_v2"></div>
6. Greenspan A, Jundt G, Remagen W. Differential diagnosis in orthopaedic oncology. Lippincott Williams & Wilkins. (2006) ISBN:0781779308. <a href="http://books.google.com/books?vid=ISBN0781779308">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0781779308?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0781779308">Find it at Amazon</a><div class="ref_v2"></div>
7. Blumberg ML. CT of iliac unicameral bone cysts. AJR Am J Roentgenol. 1981;136 (6): 1231-2. <a href="http://dx.doi.org/10.2214/ajr.136.6.1231">doi:10.2214/ajr.136.6.1231</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/6786043">Pubmed citation</a><span class="auto"></span>
8. Noordin S, Allana S, Umer M, Jamil M, Hilal K, Uddin N. Unicameral bone cysts: Current concepts. (2018) Annals of medicine and surgery (2012). 34: 43-49. <a href="https://doi.org/10.1016/j.amsu.2018.06.005">doi:10.1016/j.amsu.2018.06.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30224948">Pubmed</a> <span class="ref_v4"></span>
9. Wilkins RM. Unicameral bone cysts. (2000) The Journal of the American Academy of Orthopaedic Surgeons. 8 (4): 217-24. <a href="https://doi.org/10.5435/00124635-200007000-00002">doi:10.5435/00124635-200007000-00002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10951110">Pubmed</a> <span class="ref_v4"></span>

ADVERTISEMENT: Supporters see fewer/no ads

{"current_user":null,"inclusions":[{"imageId":1676925,"studyId":16250,"caseSlug":"unicameral-bone-cyst-with-fracture-humerus-1","caption":"Figure 1: distribution of simple bone cysts","thumbnail":"https://prod-images-static.radiopaedia.org/images/1676925/2f13d4fbbc555864af1fe0984f1061_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":23906,"studyId":7499,"caseSlug":"unicameral-bone-cyst-with-a-fracture","caption":"Case 1: with fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/23906/20e2ec8ee8e14045a39000d5db6198_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":138173,"studyId":8420,"caseSlug":"unicameral-bone-cyst-femur-3","caption":"Case 2","thumbnail":"https://prod-images-static.radiopaedia.org/images/138173/4a7476e52d39c01e0e15626401abe7_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":155103,"studyId":8814,"caseSlug":"unicameral-bone-cyst-with-fracture-humerus","caption":"Case 3: with fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/155103/79fabc0ac74aa999b4c4351dc20a5b_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":155105,"studyId":8816,"caseSlug":"unicameral-bone-cyst-humerus","caption":"Case 4","thumbnail":"https://prod-images-static.radiopaedia.org/images/155105/e99d9f0ebf901c1be5cee4427f2f0b_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":7037362,"studyId":29704,"caseSlug":"unicameral-bone-cyst-8","caption":"Case 5: with fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/7037362/b2955794954285682320782429dd21_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":530303,"studyId":10883,"caseSlug":"unicameral-bone-cyst-femur-2","caption":"Case 6: probable UBC","thumbnail":"https://prod-images-static.radiopaedia.org/images/530303/07788c6c0c1804387a21b569cb7469_big_gallery.jpg","isStack":false,"diagnosticCertainty":"probable"},{"imageId":627335,"studyId":12769,"caseSlug":"unicameral-bone-cyst-with-fracture-humerus-1","caption":"Case 7: with classic \"fallen fragment\" sign","thumbnail":"https://prod-images-static.radiopaedia.org/images/627335/1734edaab232d7388758f69ff1906f_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":42134883,"studyId":71057,"caseSlug":"simple-bone-cyst-and-pathological-fracture","caption":"Case 8: with new bone formation","thumbnail":"https://prod-images-static.radiopaedia.org/images/42134883/f239b9a92d0650e0f380061be951f4_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":54378968,"studyId":103119,"caseSlug":"unicameral-bone-cyst-of-the-big-toe","caption":"Case 9: of big toe","thumbnail":"https://prod-images-static.radiopaedia.org/images/54378968/k_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":1421276,"studyId":15129,"caseSlug":"calcaneal-simple-bone-cyst","caption":"Case 10: calcaneal cyst","thumbnail":"https://prod-images-static.radiopaedia.org/images/1421276/05b1f38cb7ac8c312da9262c32b1e5_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":1806199,"studyId":16838,"caseSlug":"unicameral-bone-cyst-5","caption":"Case 11: with fallen fragment","thumbnail":"https://prod-images-static.radiopaedia.org/images/1806199/b54d7edff9ad637b5eeb543734d7ae_big_gallery.JPG","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":530301,"studyId":10882,"caseSlug":"unicameral-bone-cyst-9","caption":"Case 12: probable UBC","thumbnail":"https://prod-images-static.radiopaedia.org/images/530301/f5198dbbefb7eb4382acfff0f861fe_big_gallery.jpg","isStack":false,"diagnosticCertainty":"probable"},{"imageId":2333651,"studyId":20560,"caseSlug":"healed-unicameral-bone-cyst-following-fracture","caption":"Case 13: healed UBC following fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/2333651/934445d86d93012fddedd5eb55fc21_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":3012469,"studyId":22061,"caseSlug":"pathological-humeral-shaft-fracture-in-unicameral-bone-cyst","caption":"Case 14: with pathological humeral shaft fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/3012469/0184c980374df267dff9cd8ebcff163e6b18ad96a27026d97ec2bc53b3d97432_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":2606465,"studyId":20381,"caseSlug":"simple-bone-cyst-with-pathological-fracture","caption":"Case 15: with pathological fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/2606465/530080980fe7b8dc01182b0a815182_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":5199443,"studyId":26210,"caseSlug":"unicameral-bone-cyst-6","caption":"Case 16: with fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/5199443/d6003f67ecaf4b05383c68c3bac444_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":4984302,"studyId":25845,"caseSlug":"simple-bone-cyst-with-pathologic-fracture-1","caption":"Case 17: in an adult","thumbnail":"https://prod-images-static.radiopaedia.org/images/4984302/f8974d021bae90bbd759c19735ec8c_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":24892557,"studyId":52516,"caseSlug":"unicameral-bone-cyst-tibia-1","caption":"Case 18: tibia","thumbnail":"https://prod-images-static.radiopaedia.org/images/24892557/5ac42caa62b4b11670cb23d0662b7e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":44944234,"studyId":74138,"caseSlug":"unicameral-bone-cyst-10","caption":"Case 19","thumbnail":"https://prod-images-static.radiopaedia.org/images/44944234/abe6d3f6c1c61153438b3670e9127b_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52049108,"studyId":85236,"caseSlug":"radial-head-fracture-with-an-ulnar-unicameral-bone-cyst","caption":"Case 20","thumbnail":"https://prod-images-static.radiopaedia.org/images/52049108/9d12e500c6774deb46109e26993fad_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":53725636,"studyId":98502,"caseSlug":"unicameral-bone-cyst-11","caption":"Case 21","thumbnail":"https://prod-images-static.radiopaedia.org/images/53725636/IMG-0015-00011_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":59020314,"studyId":123557,"caseSlug":"unicameral-bone-cyst-14","caption":"Case 22","thumbnail":"https://prod-images-static.radiopaedia.org/images/59020314/f1f024f8f077d969257fe02dc624a9564c5fad94b2283d408a5a3aa13a98043b_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":61786139,"studyId":134476,"caseSlug":"unicameral-bone-cyst-with-fracture-femur","caption":"Case 23","thumbnail":"https://prod-images-static.radiopaedia.org/images/61786139/686d036e5d4753e98a5e1be2a1269880f994b9496e49007b02c58cfa0ed77b4d_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"}],"ddx_inclusions":[{"imageId":130247,"studyId":8253,"caseSlug":"giant-cell-tumor-16","caption":"Giant cell tumour of bone","thumbnail":"https://prod-images-static.radiopaedia.org/images/130247/501d480a68a8253a7ab9f9be756a6d_big_gallery.jpg","isStack":false,"diagnosticCertainty":"probable"},{"imageId":133349,"studyId":8318,"caseSlug":"aneurysmal-bony-cyst-humerus","caption":"Aneurysmal bone cyst","thumbnail":"https://prod-images-static.radiopaedia.org/images/133349/249949886f7487841053b7eff110cc_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":392052,"studyId":9976,"caseSlug":"intraosseous-lipoma-of-calcaneus","caption":"Intraosseous lipoma","thumbnail":"https://prod-images-static.radiopaedia.org/images/392052/c18e8381446e9a420e154c0aa5768f_big_gallery.jpg","isStack":false,"diagnosticCertainty":"probable"},{"imageId":5671965,"studyId":27335,"caseSlug":"intraosseous-haemophilic-pseudotumour","caption":"Haemophilic pseudotumour","thumbnail":"https://prod-images-static.radiopaedia.org/images/5671965/00330ff8767842834aeeacb767eb0e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"probable"},{"imageId":65142715,"studyId":147941,"caseSlug":"pseudotumour-of-the-calcaneus","caption":"Pseudotumour of the calcaneus","thumbnail":"https://prod-images-static.radiopaedia.org/images/65142715/ce3c4c72484e4d71efaaa12a4bef8aee4fc6199157b3a40615bba50b3b171638_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"}],"lang":"gb"}