Sclerotic bone metastases from sarcomatoid renal cell carcinoma

We present a case of sarcomatoid renal cell carcinoma with multiple sclerotic skeletal metastatic lesions. Renal cell carcinoma is frequently metastatic at presentation, with a high incidence of skeletal involvement, classically described as osteolytic. However, sclerotic or osteoblastic metastatic skeletal lesions from renal cell carcinoma are rare, with only two previous reports identified in the literature, neither of which involved the sarcomatoid variant of renal cell carcinoma. In our case the sclerotic metastases were characterized by bone scan, computed tomography (CT), magnetic resonance imaging (MRI), and histologic analysis. Received: 8 April 1999 Revision requested: 27 May 1999 Revision received: 24 June 1999 Accepted: 29 June 1999     

Bilateral ovarian metastasis of clear-cell renal cell carcinoma: A case report

Renal cell carcinoma (RCC) accounts for 2–3% of all adult malignancies. Clear-cell type RCC is the most common type, accounting for approximately 75% of all renal cancer cases. The most common sites of metastasis include the lung, bone, and liver. Ovarian metastasis of RCC is an exceptionally rare occurrence with only 41 cases reported in the literature with only 11 of these cases involving the bilateral ovaries. Here we present a case of clear-cell RCC arising from the left kidney with metastatic involvement of bilateral ovaries in a 48-year-old woman.     

FDG-avid sclerotic bone metastases in breast cancer patients: a PET/CT case series

Distant metastases from breast cancer most frequently occur in the skeleton. Although 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), with or without computed tomography (CT), is superior to bone scintigraphy for the detection of osteolytic bone metastases, it has been reported that sclerotic bone metastases frequently show no or only a low degree of FDG uptake on PET and PET/CT. Since both lytic and sclerotic metastases can occur in breast cancer patients, bone scintigraphy may remain of additional value in these patients. In this case series, we describe four breast cancer patients in whom FDG PET/CT has clearly visualized sclerotic bone metastases because of increased FDG uptake. Not so much the type of metastasis (sclerotic or lytic), but possibly the characteristics of the primary tumor or treatments prior to the FDG PET/CT scan might influence the degree of FDG uptake of bone metastases. The ability to detect sclerotic bone metastases based on increased FDG uptake supports the use of FDG PET/CT as a staging procedure in breast cancer patients, but knowledge of factors determining the visibility of bone metastases with FDG PET/CT is crucial.     

Distribution of metastases in breast carcinoma: CT evaluation of the abdomen

To determine the frequency and distribution of extrahepatic and extraskeletal metastases in patients with breast carcinoma, the abdominal CT scans of 260 consecutive patients were systematically evaluated. Extrahepatic and extraskeletal metastases were demonstrated in 26 patients (10%). Confirmation of findings was made by biopsy, autopsy, or by demonstration of progression or regression of disease. Twelve patients (4.6%) demonstrated metastases to the stomach, eleven of whom presented with a linitis plastica pattern. Retroperitoneal and/or mesenteric adenopathy was noted in 10 patients (3.8%), of whom three demonstrated associated hydronephrosis and one demonstrated associated biliary obstruction. Ascites was seen in 14 (5.4%) and peritoneal carcinomatosis in 7 (2.6%). Genitourinary involvement included metastases to the kidney (one case), ureter (one), and uterus (one). Direct invasion of the diaphragm by adjacent pleural metastases (two cases) as well as a soft tissue metastasis (one case) was also demonstrated. Metastases to the ovaries, adrenals, or pancreas could not be identified. Although lesions to the liver and skeleton account for the largest group of metastases from breast carcinoma seen in the abdomen, one should be aware of the potential for other locations of metastatic disease.     

Multiphase contrast-enhanced helical CT of liver metastases from renal cell carcinoma

The aim of this study was to evaluate whether in patients with metastatic renal cell carcinoma (RCC) multiphase liver studies would improve detection of metastatic liver disease. Forty-six consecutive patients with known metastatic RCC underwent standardized non-contrast and triphasic contrast enhanced hepatic CT examinations as part of their routine imaging studies. Once a liver abnormality was detected, it was characterized as metastatic by a panel of three radiologists who followed pre-set criteria. These criteria included change in size, biopsy results and lack of benign features. Presence and conspicuity of liver metastases were graded using a five-point scale by consensus of a panel of three radiologists. The highest number of lesions evaluated per patient was limited to ten. Seventy-two liver metastases were detected in 16 patients. Of these, 54 were seen on unenhanced scans; 47 in the hepatic arterial (HA) phase, at 25 s; 65 in the portal-venous (PV) phase, at 60 s; and 49 in delayed images, at 90 s. Scanning only during the PV phase would have missed seven lesions (10%), six of which were seen on unenhanced images and six were seen in HA phase. All patients with metastatic liver disease would have been identified by combination of unenhanced and PV phase or by HA and PV phase scanning. Forty-two lesions were graded more conspicuous on the PV phase, whereas 18 (25%) were more conspicuous on the HA phase. The combination of unenhanced, HA and PV scanning should be considered in the initial evaluation of patients with metastatic RCC for improved lesion detection and characterization. Subsequently, the combination of unenhanced and PV phase imaging is preferred.     

Computed tomography of cranial metastatic malignant melanoma: features, early detection and unusual cases

The cranial computed tomographic (CT) scans reported as showing metastatic disease in patients with malignant melanoma (MM) seen at the Westminster Hospital over a 5 year period were reviewed. Ninety-eight patients with intracranial metastatic MM were identified. Twelve had an initial scan which was reported as normal and particular attention was given to these to see if, in retrospect, any early features of metastatic disease were discernible. Fifty-eight cases showed the "typical" features of intracranial MM; the remainder were unusual in appearance, behavior, or site. Radiological regression was shown in only seven cases on follow-up scans; all but one of these patients had one or two large metastases. No significant lesion was thought to have been missed on a scan after the administration of intravenous contrast medium, but the lesions of three patients were difficult to discern on plain scans. Thus when MM metastasis is suspected, the use of the contrast-only scan is advocated.     

18F]fluorodeoxyglucose scintigraphy in diagnosis and follow up of treatment in advanced breast cancer

Seventeen patients with advanced breast cancer were imaged with a specially collimated gamma camera to study tumor uptake of 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) before and during therapy. Fourteen patients (82%) showed increased FDG accumulation in metastatic tumors, 6/8 (75%) of axillary, supra or infraclavicular metastatic lymph nodes were detectable. In one of these cases, FDG imaging was the first method to identify axillary metastasis causing nerve compression. Also, pulmonary and liver metastases could be imaged with FDG; both in two patients. The intra individual variability in uptake was considerable in bone metastases, and some lesions remained FDG negative: 99mTc-DPD was superior in detecting bone disease. Bone metastases of the osteolytic or mixed type were better visualized than sclerotic ones. Ten patients were reimaged later to assess the effect of therapy on FDG uptake. Increased uptake was associated with clinical progression, while unchanged or diminished uptake did not predict the course of disease as reliably. This study indicates that FDG can be used to image breast cancer metastases. FDG may be valuable in monitoring treatment response, but positron emission tomography (PET) would probably be more appropriate than planar imaging for this purpose.     

Prognosis of metastatic renal adenocarcinoma

The prognosis for metastatic renal adenocarcinoma is evaluated on the basis of a consecutive series of 99 initially metastatic patients and 79 patients who developed distant metastases after radical nephrectomy. Patients with only osseous metastases survived longer, but the differences in survival between these and patients with metastases at other sites were not statistically significant. The survival for patients who developed metastases after a disease-free interval of less than 6 months was significantly lower than for others. A solitary distant metastasis was removed from 7 patients and in 4 of these cases no recurrence has been observed during 1 to 9 years' follow-up. In 54% of patients with distant metastases cytostatic agents or hormones or both in combination were administered. Only two partial responses were demonstrated, both concerning pulmonary metastases. Radiation therapy had an appreciable effect in relieving pain resulting from osseous metastases.     

[18F]Fluorodeoxyglucose scintigraphy in diagnosis and follow up of treatment in advanced breast cancer

Seventeen patients with advanced breast cancer were imaged with a specially collimated gamma camera to study tumor uptake of 2-[¹⁸F]-fluoro-2-deoxy-D-glucose (FDG) before and during therapy. Fourteen patients (82%) showed increased FDG accumulation in metastatic tumors, 6/8 (75%) of axillary, supra or infraclavicular metastatic lymph nodes were detectable. In one of these cases, FDG imaging was the first method to identify axillary metastasis causing nerve compression. Also, pulmonary and liver metastases could be imaged with FDG; both in two patients. The intra individual variability in uptake was considerable in bone metastases, and some lesions remained FDG negative:^99mTc-DPD was superior in detecting bone disease. Bone metastases of the osteolytic or mixed type were better visualized than sclerotic ones. Ten patients were reimaged later to assess the effect of therapy on FDG uptake. Increased uptake was associated with clinical progression, while unchanged or diminished uptake did not predict the course of disease as reliably. This study indicates that FDG can be used to image breast cancer metastases. FDG may be valuable in monitoring treatment response, but positron emission tomography (PET) would probably be more appropriate than planar imaging for this purpose.     

Metastatic myxoid liposarcomas: imaging and histopathologic findings

Objective The objective was to describe the imaging and histopathologic characteristics of metastatic myxoid liposarcomas. Materials and methods This retrospective study was approved by the institutional review board and complied with HIPAA guidelines. The study group comprised 12 patients with metastatic myxoid liposarcoma who underwent MRI, CT, or FDG-PET. The location and imaging characteristics of the metastatic lesions were recorded, and the histopathology of all metastatic lesions was reviewed. Results There were 23 histologically proven metastases in 12 patients. Based on imaging criteria, there were 41 metastases. The mean time from the diagnosis of primary tumor to the first metastasis was 4.4 years. Sixty-seven percent of patients had bone and soft tissue metastases, 33% had pulmonary metastases, 33% had liver metastases, 25% had intra-abdominal, and 16% retroperitoneal metastases. CT demonstrated well-defined lobulated masses with soft tissue attenuation in all cases, without macroscopic fat component. In cases of osseous metastases, CT showed mixed lytic and sclerotic foci, with bone destruction in advanced cases. MRI demonstrated fluid-like signal intensity with mild heterogeneous enhancement in cases of soft tissue metastases. In osseous metastases, MRI showed avid heterogeneous enhancement. FDG-PET showed no significant FDG uptake for all metastases. MRI was the most useful imaging modality for osseous and soft tissue metastases. Conclusion Myxoid liposarcomas are soft tissue sarcomas, with a high prevalence of extrapulmonary metastases. The bones and soft tissues were the most common site of involvement, followed by the lungs and liver. MRI was the most sensitive modality in the detection of osseous and soft tissue metastases, and is the recommended modality for the diagnosis and follow-up of bone and soft tissue involvement.     

Long-term results in the treatment of 100 metastatic hypernephroid carcinomas

The success of renal cell carcinoma (RCC)-nephrectomy with radical lymph node dissection in stage I and II disease is undisputed. Through these measures 23% of metastases are controlled. The five-year survival time in stage III disease, however, stagnates at 35% +/- 14% despite radical surgery. Also, the additional tumor-vaccine-therapy of the Mainz-Joint-Study-Group was successful only in stage I and II disease, whereas stage III disease did not benefit from this therapy. As 50% of all radically operated patients developed metastases within three years after surgery, the call by radio-oncologists for supplementary radiotherapy beginning with stage III disease must be put foreward. The problems of therapy and chances of survival in generalized disease are demonstrated in 100 of our cases treated by surgery, radiotherapy and with MPA (medroxyprogesteroneacetate). Whereas Schmiedt et al. show a total survival time of 10,3 months after diagnosis of metastatic disease, the Offenbach patients achieved 16,5 months with a median survival time of 11,75 months. The necessity of therapeutic intervention is confirmed by the fact that the most favorable median survival time, 15,75 months, was achieved in metastatic disease involving three organs. We present here the special features of the individual organ manifestations and point out that not only the mean and median survival time, but also the very widely varying survival times in individual cases, make conscientious oncological post-treatment follow up and management a requirement.     

Physiologic subperiosteal new bone formation: prevalence,distribution, and thickness in neonates and infants

OBJECTIVE: Hematogenous metastases to skeletal muscles have been reported to be rare. We report eight biopsy-proven cases of skeletal metastases occurring in sites of previously documented skeletal muscle trauma. We retrospectively reviewed MR imaging examinations obtained at a large orthopedic surgical oncology service from January 1994 through December 2000 for biopsy-proven metastases to skeletal muscles. Our retrospective review revealed 28 patients with biopsy-proven skeletal muscle metastases. Of these 28 patients, eight had a documented clinical history of previous trauma at the site of skeletal metastasis. Five of these eight patients underwent MR imaging before the development of a metastasis. MR imaging revealed a hematoma in three of the five patients and a partial muscle tear in two of the five patients. The hematomas and partial muscle tears were in the same skeletal muscle location in which the metastatic disease subsequently developed. Metastatic disease was documented by MR imaging and subsequent biopsy. CONCLUSION: Skeletal muscle injury may alter muscle physiology and result in increased susceptibility to the development of metastatic disease at such sites.     

Can Initial 18F-FDG PET-CT Imaging Give Information on Metastasis in Patients with Primary Renal Cell Carcinoma?

Purpose

The aim of this study was to investigate the relationship between the maximum standardized uptake values (SUVmax) of primary renal cancers with and without metastatic lesions, if any. We also studied the relationship between the size of primary renal cancers and their SUVmax, and tried to find a clinical value of ¹⁸F-FDG PET-CT for the initial evaluation of renal cell carcinoma (RCC).

Methods

The cases of 23 patients, 16 men and 7 women, who underwent PET-CT examination before operation were retrospectively reviewed. We measured the SUVmax of the primary renal cancers and those of any existing metastatic lesions, and the size of the primary renal cancers. We compared the SUVmax of primary RCCs with metastases and those without metastases, SUVmax of primary RCC and those of metastases, and studied the correlation between the size and SUVmax of primary RCCs.

Results

The SUVmax of primary RCC of the 16 patients without metastasis ranged from 1.1 to 5.6 with a median value of 2.6. Those of the patients with metastasis ranged from 2.9 to 7.6 with a median of 5.0. The size of the all 23 primary renal cancers ranged from 1.7 cm to 13.5 cm, with a median of 4.5 cm, and their SUVmax ranged from 1.1 to 7.6, with a median of 2.9. There was a statistically significant difference between the SUVmax of the primary RCC with metastasis (5.3 ± 1.7) and those without metastasis (2.9 ± 1.0). There was a moderate positive correlation between the sizes and SUVmax of all 23 primary RCCs. However, there was no statistically significant correlation between the sizes and SUVmax of primary RCCs with metastatic lesions and the same for RCCs without metastasis. The cutoff value of SUVmax for predicting extra-renal lesion was 4.4 and that for size was 5.8 cm according to the receiver operating characteristic curves.

Conclusions

Those who have primary RCC with high SUVmax are suggested to have a likelihood of metastasis. Also, there was a moderate trend of increasing value of SUVmax of primary RCC as their size increases. Physicians should beware of missing extra-renal lesions elsewhere.     

Renal cell carcinoma presenting with diffuse peritoneal metastases: CT findings

Renal cell carcinoma (RCC) spreads predominantly by direct extension, lymphatic dissemination, or venous invasion. Intraperitoneal metastatic spread of RCC involving mesentery and omentum is very uncommon. We report three unusual cases of RCC in which widespread diffuse intraperitoneal metastases were present at the time of diagnosis. The CT findings in these cases included extensive ascites, widespread omental infiltration, and peritoneal implants, as well as retroperitoneal metastases.     

Colorectal breast metastases presenting with atypical imaging features

Breast metastases from non-breast primaries are rare in female patients and exceedingly rare in male patients, with only a handful of cases described. Lymphoma, metastatic melanoma and bronchial carcinoma are the primary sites for the majority of breast metastases. Breast metastases from colorectal carcinoma have been described previously in only a small number of cases in the literature. Here, we report a further two patients with biopsy-proven colorectal carcinoma metastases to both breasts, who demonstrate contrasting unusual and atypical imaging features that have not been reported previously. In one case, the imaging appearances mimic a multifocal primary breast carcinoma. Metastatic disease in the breast is a marker for disseminated metastatic spread, with a correspondingly poor prognosis. Therefore, we review the imaging features that differentiate metastatic breast disease from multifocal breast primaries, which are important to recognize because the management options for these patients differ greatly.     

Pitfalls in the radiographic diagnosis of Paget's disease of the pelvis

One hundred thirty six unselected cases, radiographically diagnosed as Paget's disease of the pelvis, were reviewed in a retrospective study. In three patients below the age of 40 years purely sclerotic lesions of Paget's disease mimicking iliitis condensans or sclerosing osteomyelitis were found progressing with time to the combined osteolytic and sclerotic stage. Neither a purely lytic stage nor progression from the combined to the sclerotic stage was ever observed. A case each of histiocytic lymphoma, histiocytosis X, osteomyelosclerosis, and prostatic carcinoma, all closely mimicking Paget's disease were found in this series. In three cases radiographically undiagnosed implants from carcinoma of the breast, prostate, and myeloma were found in the Paget bone. Limitations in the radiographic diagnosis of both uncomplicated and complicated Paget's disease of the pelvis are stressed.     

Epidural Metastasis in Nasopharyngeal Carcinoma

BACKGROUND: In nasopharyngeal carcinoma, both, a short metastasis-free interval after primary treatment and the occurrence of epidural metastasis have been associated with poor prognosis. We present the clinical course of a young patient with these two conditions and review the literature. PATIENT: A 26-year-old male with stage T2N3M0 non-keratinizing carcinoma (WHO type 2) of the nasopharynx was treated with induction chemotherapy and radical radiotherapy, 6 months after documentation of a clinical complete remission, the patient experienced metastatic disease to the C7-D1 vertebral bodies associated with an epidural soft tissue mass. Since no further metastatic lesions were detectable, the patient was treated with radiotherapy alone (3 960 cGy/22 fractions). RESULTS: Treatment resulted in compete resolution of neurological and radiological signs of the disease and the patient continues to be disease-free, 32 months after salvage treatment. In a literature search, we identified 54 reported cases with long-term survival after treatment for metastatic nasopharyngeal cancer. The vast majority of them had primary tumors with undifferentiated histology and was treated with combination chemotherapy. In 25 of them, radiotherapy was given as consolidation therapy (in 19 cases for bone and in six cases for mediastinal lymph node metastases). CONCLUSIONS: Epidural metastatic disease from a nasopharyngeal carcinoma is highly sensitive to moderate doses of fractionated radiotherapy. MR imaging is essential for the detection of relevant soft tissue disease extensions within the epidural space and proper selection of the radiation target volume in vertebral metastases. In patients with nasopharyngeal carcinoma, the occurrence of a solitary epidural metastasis after a short metastasis-free interval is not incompatible with long-term survival.     

Metastatic breast carcinoma to bone disguised by osteopoikilosis

A case of metastatic lobular carcinoma of the breast in conjunction with osteopoikilosis is described. Widespread diffuse sclerotic bone lesions were identified on radiographs in a patient with breast carcinoma. In addition computed tomography demonstrated discrete spherical areas of increased density throughout the skeleton manifest typically by osteopoikilosis. No systemic symptoms were evident, blood parameters were normal and the lesions did not demonstrate any increased uptake of technetium on bone scan. An iliac crest bone biopsy, however, revealed metastatic disease in addition to osteopoikilosis. Conventional radiological investigations may not delineate metastasis on a background of bone dysplasia.     

Uptake of cis-4-[18F]fluoro-L-proline in urologic tumors.

Tumor uptake of the amino acid cis-4-[18F]fluoro-L-proline (cis-FPro) was studied with PET in eight patients with urologic tumors. METHODS: Three patients had primary renal cell carcinomas (RCCs), one had a local recurrence of RCC, one had squamous RCC, one had an adrenal hemangioma, one had inguinal metastases of penile squamous carcinoma, and one had suspected metastatic disease from prostate cancer. PET scans of the trunk were acquired at 1 and 3-5 h after intravenous injection of 400 MBq cis-FPro and compared with 18F-FDG PET scans and CT. RESULTS: None of the tumors or metastases showed significant uptake of cis-FPro. FDG uptake was seen in one of the three primary RCCs, in the local recurrence of RCC, in the squamous RCC, and in the metastases of penile cancer. CONCLUSION: Cis-FPro appears not to be a promising PET tracer in oncology.     

Uveal melanoma: development of metastases after helium ion irradiation

Forty-two (16%) of 261 patients with ocular melanoma who were treated with helium ions between January 1978 and November 1986 have developed metastatic disease. The time between start of helium ion treatment and recognition of metastatic disease ranged from 3 to 67 months (median, 27 months). The mean pretreatment tumor height in the patients with metastases was 7.7 mm. All 42 patients who developed metastatic disease have died. The median survival after diagnosis of metastatic disease was 5 months; the longest survival was 49 months. The most common site of metastasis was the liver (n = 34). Four (10%) of the 42 patients with metastases also had local recurrence of the tumor. Multivariate analysis identified three variables that predicted independently the development of metastases and lack of survival. These variables are anterior location of tumor (P = .027), tumor height greater than 5 mm (P = .02), and tumor diameter greater than 10 mm (P = .0075).