Bone scan demonstrating metastasis to the breast from an ovarian carcinoma and a review of the literature

Breast metastasis from a primary ovarian neoplasm is very rare. We report a case of breast metastasis along with involvement of the liver, spleen, and pelvis from ovarian carcinoma in a 54-year-old woman demonstrated by whole-body bone scanning. Ovarian metastatic deposits frequently show calcification, and a Tc-99m MDP bone scan could be useful in determining the extent of calcified soft tissue metastatic spread in these patients. A review of the literature of breast metastases form ovarian carcinoma is discussed.     

99mTc pertechnetate thyroid scan leads to serendipitous detection of metastatic thyroid cancer

99mTc pertechnetate is considered insensitive in detecting thyroid carcinoma metastases. We report the case of a 71-year-old male patient, in whom metastasis of an unknown thyroid cancer was diagnosed incidentally on a routine 99mTc pertechnetate scan, performed for the assessment of nodular thyroid disease. Marked tracer accumulation was unexpectedly noted on the left frontal region, where a palpable, painless, soft tissue mass was present. Surgical excision of the mass revealed metastatic poorly differentiated thyroid carcinoma synchronous to soft tissue and adjacent bone.     

Osteoblastic metastases from breast carcinoma with false-negative bone scan

 The authors report a case of metastatic breast carcinoma that on investigation was shown to have a negative bone scan in spite of multiple densely sclerotic metastases on radiography and CT and a positive bone biopsy. The literature is reviewed with regard to the subject of negative bone scans in this situation.     

Detection by (18)F-FDG PET of unsuspected extensive bone marrow metastases in a case of basosquamous carcinoma of the cheek

Basosquamous carcinoma (BSC) is a rare type of malignancy with features of both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) with a potential for aggressive behaviour infiltration and destruction. First reported by MacCormac in 1910 in a series of rodent ulcers, this entity does have an increased risk of recurrence and metastases as well, which distinguish it from other forms of basal cell carcinoma. The overall incidence of basosquamous carcinoma ranges from 1.2% to 2.7%. An unusual case of basosquamous carcinoma (BSC) is presented where 18- fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scan diagnosed unsuspected extensive metastatic disease in the bone marrow, which was further proven histopathologically. The patient was a 32 years old man with history of recently diagnosed basosquamous carcinoma of left cheek involving left lower eyelid and left eyeball. Contrast enhanced computed tomography(ceCT) of the head and neck demonstrated involvement of the left cheek skin by the malignancy along with erosion of zygomatic bone and phthisis bulbi of the left eye. The serum alkaline phosphatase was elevated (255units, normal range 50-150units). The patient was referred for (18)F-FDG PET, for disease status evaluation. The scan showed intense tracer uptake in the left zygomatic region, the site of known primary disease. Intense tracer uptake was noted in the multiple lesions of bone marrow of axial as well as appendicular skeleton. The scan appearance was highly suggestive of metastatic bone marrow involvement. A bone marrow biopsy was performed to confirm the scan findings. Guided by the (18)F-FDG PET scan findings, bone marrow biopsy was performed and metastatic basosquamous carcinoma was diagnosed. We believe this is the first reported case of basosquamous carcinoma where extensive metastatic bone marrow disease was diagnosed with the aid of (18)F-FDG PET. At first diagnosis, an advanced stage of BSC is often present. Due to its metastatic potential, extensive primary surgical resection of BSC, possibly completed by radiation or photodynamic adjuvant treatment is recommended. Given the aggressive nature of basosquamous carcinoma, whole body (18)F-FDG PET is very useful in diagnosing metastatic BSC. In conclusion, this is the first reported case of the use of (18)F-FDG PET study for diagnosing metastatic bone marrow disease in a patient with basosquamous carcinoma.     

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.     

Bone and liver metastases in uterine, cervical and ovarian cancer

Examination for liver and bone metastases was performed in 30 women suffering from carcinoma of the uterus and in 27 with cervical and 37 with ovarian carcinoma. Scintigraphy was the examination method of choice in bone metastases and computed tomography in liver metastases. Bone metastases were not seen in any patient in the stages I to IV with carcinoma of the cervix and ovarian carcinoma. Bone metastases were found in one patient in stage III and in one in stage IV with carcinoma of the uterus. Liver metastases were found in four patients in stages III and IV with carcinoma of the uterus and in five patients with ovarian carcinoma.     

Association of prostate-specific antigen levels and patterns of benign and malignant uptake detected. on bone scintigraphy in patients with newly diagnosed prostate carcinoma

The bone scan patterns of benign and malignant uptake in 432 patients with newly diagnosed prostate carcinoma were reviewed in relation to prostate-specific antigen (PSA) levels determined within 4 months of scintigraphy. Scan results were categorized in terms of likelihood of metastatic disease and anatomical locations of benign and malignant lesions were tabulated. At least one suspect focus was identified in 138 scans (32%), and metastatic bone disease was present in 38 (9%). Metastatic disease prevalence increased from 1% for PSA <20 ng x ml(-1) to 58% for PSA>100 ng x ml(-1). Among patients with PSA>20 ng x ml(-1) (n = 157), 70 (45%) had at least one bone scan finding of concern for metastases and 35 (22%) proved to have metastatic disease. Almost all scans with metastases had either limited disease (< or = 5 suspicious lesions; n = 16; 42%) or extensive metastases (> 20 abnormalities; n = 19; 50%). The majority of patients with limited skeletal metastases had PSA < 100 ng x ml(-1) (11/16; 69%), while almost all patients with extensive skeletal involvement had PSA >100 ng x ml(-1) (17/19; 89%). Among those with limited metastatic disease, most (13/16; 81%) had at least one lesion in the pelvis or sacrum; the next most common sites were in the thoracic and lumbar spine (six each; 38%). In scans with a low to moderate suspicion for bone metastases, the only anatomical site with a significantly higher prevalence of malignant than benign lesions was the pelvis.     

Visualization of metastatic liver disease on technetium-99m bone scintigraphy

To determine the frequency with which liver metastases are visualized on bone scintigraphy, 425 pairs of liver and bone scans, performed within one month of each other, were reviewed. Sixty-three of the 425 liver scans showed metastases. Of these 63, five cases of carcinoma of the colon and six cases of carcinoma of the lung also visualized by Tc-99m MDP scintigraphy. This represented 46% of colon metastases and 15% of lung metastases detected on liver scan. Liver metastases from other primary tumors were not detected on bone scan, but the numbers for these tumors were small. The liver metastases which were detected on bone scan were significantly larger than those which were not. The literature was reviewed and the primary and secondary tumors of liver with uptake of Tc-99m phosphate compounds listed.     

Serum osteocalcin measurements in prostate carcinoma patients with skeletal deposits shown by bone scintigram: comparison with serum PSA/PAP measurements.

The correlation of technetium-99m-HMDP bone scintigraphic findings, serum osteocalcin as a measure of bone turnover and prostate-specific antigen (PSA) and/or prostate acid phosphatase (PAP) was determined in 19 men with bone metastasis due to prostatic carcinoma. Six of the 19 patients with metastases on bone scan showed elevation of osteocalcin. These patients had extensive metastatic disease. All 19 men with positive bone scans had high serum PSA and/or PAP levels. Serum osteocalcin measurement is less sensitive to detection of bone deposits than PSA/PAP measurements (p less than 0.0008).     

Absent Sternum as the First Manifestation of Bone Metastasis on Bone Scintigraphy

The sternum is known as a relatively common site for bone metastases by a variety of malignant neoplasms. The usual finding is increased radiotracer uptake on bone scintigraphy, and cold metastasis is distinctly unusual. In addition, total nonvisualization of the sternum presenting as bone metastasis is extremely rare. We describe two cases with similar findings (absent sternum showing no activity of the sternal segments on bone scintigraphy), which corresponded to metastatic involvement. These findings were shown to be the first manifestation of hepatocellular carcinoma in one patient and bone metastasis in another patient with ovarian cancer.     

Two unusual cases of metastatic osteosarcoma detected by Tc-99m MDP bone scintigraphy

Tc-99m MDP bone scintigraphy is widely used for initial staging and subsequent follow-up of patients with osteosarcoma. Two unusual cases are presented here, one with diffuse pleural metastases and one with diffuse peritoneal metastases. In one case, an abnormal bone scan was the first indication of metastatic disease. Both the metastatic pattern of osteosarcoma and the indications for bone scintigraphy are reviewed.     

Bone and Calcified Soft Tissue Metastases of Medullary Thyroid Carcinoma Better Characterized on <Superscript>18</Superscript>F-Fluoride PET/CT than on <Superscript>68</Superscript>Ga-Dotatate PET/CT

Herein, we report a case of a 19-year-old man with multiple endocrine neoplasia type 2B (MEN2B) and medullary thyroid carcinoma (MTC) diagnosed when he was 12 years of age. The patient had previously undergone total thyroidectomy, cervical radiotherapy, and chemotherapy. He progressed with known bone, pulmonary, and lymph node metastases and was scanned with ¹⁸F-fluoride (¹⁸F-NaF) and ⁶⁸Ga-dotatate whole-body positron emission tomography/computed tomography (PET/CT) for metastatic disease monitoring. We found that the MTC bone metastases and soft tissue calcified metastases were better characterized on ¹⁸F-NaF PET/CT than on ⁶⁸Ga-dotatate PET/CT. This case illustrates that the ¹⁸F-NaF PET/CT could be helpful not only to the detection of bone metastases but also to the detection of calcified soft tissue metastases in patients with MTC.     

Value of FDG PET in papillary thyroid carcinoma with negative 131I whole-body scan.

The management of metastatic thyroid carcinoma patients with a negative 131I scan presents considerable problems. Fifty-four athyrotic papillary thyroid carcinoma patients whose 1311 whole-body scans were negative underwent 18F-fluorodeoxyglucose (FDG) PET; the purpose was to determine whether this procedure could localize metastatic sites. We also assessed its usefulness in the management of these patients. METHODS: Whole-body emission scan was performed 60 min after the injection of 370-555 MBq 18F-FDG, and additional regional attenuation-corrected scans were obtained. Metastasis was pathologically confirmed in 12 patients and was confirmed in other patients by overall clinical evaluation of the findings of other imaging studies and of the subsequent clinical course. RESULTS: In 33 patients, tumor had metastasized, whereas 21 patients were in remission. FDG PET revealed metastases in 31 patients (sensitivity 93.9%), whereas thyroglobulin levels were elevated in 18 patients (sensitivity 54.5%). FDG PET was positive in 14 of 15 metastatic cancer patients with normal thyroglobulin levels. In 20 of 21 patients in remission, FDG PET was negative (specificity 95.2%), whereas thyroglobulin levels were normal in 16 patients (specificity 76.1%). The sensitivity and specificity of FDG PET were significantly higher than those of serum thyroglobulin. In patients with negative 1311 scans, FDG PET detected cervical lymph node metastasis in 87.9%, lung metastasis in 27.3%, mediastinal metastasis in 33.3% and bone metastasis in 9.1%. In contrast, among 117 patients with 131I scan-positive functional metastases, 131I scan detected cervical lymph node metastasis in 61.5%, lung metastasis in 56.4%, mediastinal metastasis in 22.2% and bone metastasis in 16.2%. In all 5 patients in whom thyroglobulin was false-negative with negative antithyroglobulin antibody, PET showed increased 18F-FDG uptake in cervical lymph nodes, mediastinal lymph nodes, or both. Among patients with increased 18F-FDG uptake only in the cervical lymph nodes, the nodes were dissected in 11. Metastasis was confirmed in all, even in normal-sized lymph nodes. CONCLUSION: FDG PET scan localized metastatic sites in 131I scan-negative thyroid carcinoma patients with high accuracy. In particular, it was superior to 131I whole-body scan and serum thyroglobulin measurement for detecting metastases to cervical lymph nodes. FDG PET was helpful for determining the surgical management of these patients.     

Sub-super bone scan caused by bone marrow involvement of prostate cancer

A 67-year-old man presented with malaise and marked anemia. A diagnostic workup revealed severe pancytopenia on a complete blood count and diffuse sclerotic change in the axial skeleton on a plain abdominal radiograph. Bone metastases being suspected from these findings, bone scintigraphy was performed. The bone scan demonstrated uniformly increased skeletal activity with faint soft-tissue activity. The findings of the bone scan, however, appeared atypical of the super scan caused by diffuse bone metastases, without any decrease in radioactivities of the appendicular skeleton and kidneys. Bone marrow scintigraphy with In-111 chloride demonstrated central marrow failure and peripheral expansion, which indicated the possibility of myelophthisis. The patient underwent bone marrow biopsy, which revealed replacement of the bone marrow by metastatic adenocarcinoma. Further examinations detected the primary lesion in the prostate. In this case, the findings of the bone scan were insufficient for the super scan, and might be categorized as a sub-super scan. It would be important to recognize this incomplete form of super scan as a rare scintigraphic pattern of diffuse bone marrow metastases.     

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     

Predictors of a positive baseline bone scan in breast cancer

The aim of this retrospective study was to determine the predictors of a positive bone scan in female patients with breast carcinoma. The participants were 126 females with newly diagnosed breast carcinoma and a baseline bone scan. Patients who had started treatment before their bone scan were excluded. Bone scans were assessed as "no metastases" or "definite skeletal metastases" without knowledge of the patient's predictor variables. Those with "possible metastases" were correlated with other available imaging and clinical information, and recategorized as "no metastases" or "definite skeletal metastases". Results were compared with predictor variables. Significant predictors were increasing age, a higher histopathological grading and positive progesterone receptor status following a forward-stepwise logistic regression analysis. Axillary nodal status, tumour size and oestrogen receptor status did not correlate with a positive bone scan. Not every patient needs a staging bone scan. This study is important because it predicts the need for baseline scintigraphy for specific patients in whom skeletal metastases are more likely to be present or to develop. The findings are particularly valuable in times of worldwide resource scarcity and evolving surgical practice.     

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.     

骨转移瘤漏误诊的影像学分析

目的借鉴漏误诊病例的经验教训,提高对本病的影像诊断水平。方法回顾性分析18例经手术病理证实的影像漏误诊骨转移瘤。结果骨转移瘤病例以多发,溶骨为主。影像检查漏误诊分别为：X线8例,CT2例。结论X线、CT是检查骨转移瘤重要手段,但有一定限度,条件许可时应尽早做MRI检查,并做必要的鉴别诊断。     

Metastatic transitional cell carcinoma from the bladder: radiographic manifestions.

Metastases from transitional cell carcinoma of the bladder are not widely appreciated radiographically, although they are commonly found at autopsy. Radiographic evidence of metastatic disease was reviewed in 51 patients. Sites included lung, 28; bone, 24; mediastinum, eight; liver, eight; brain, three; urethra, one; abdominal nodes, one; and extradural space, two. The patterns of lung metastases consisted of solitary nodules, multiple nodules, sigmental infiltrates, pulmonary edema, and a Pancoast tumor. A sarcoidlike pattern with hilar and interstitial disease was also seen. One patient had a malignant pleural effusion. Mediastinal lymph node enlargement was isolated or associated with lung involvement. Bone metastases demonstrated either an osteoblastic or a mixed osteolytic-osteoblastic pattern in 47% of the instances. Ivory vertebrae were identified in three patients. Because of the significance of identifying metastatic disease before any extensive curative bladder surgery, we recommend at least a preoperative chest radiograph, a bone scan, and a liver scan.     

Visualization of hepatic metastases of medullary thyroid carcinoma on Tc-99m MDP bone scintigraphy

A 35-year-old man with a history of medullary carcinoma of the thyroid underwent a whole-body bone scan for chest wall pain. Extensive irregular radionuclide uptake was observed in hepatic metastases in both lobes, later confirmed on CT scan. A case of technetium-99m MDP uptake in hepatic metastases from medullary carcinoma of the thyroid is presented and the literature is reviewed.