What is Your Diagnosis

Gwilym Lodwick is not really needed in this case—the combination of clinical symptoms and the radiograph points Giufeng the direction of malignancy, most likely metastatic disease:

Metastases: In elderly people metastases are the most frequent focal bone lesions. They can be osteolytic (for example, kidney, breast, thyroid cancer; Fig. 8.18a), mixed (breast), or osteoblastic (for example, prostate, breast; Fig. 8.18b). They tend to be rare in the peripheral skeleton. The lesions often have an ill-defined margin with irregular contours. They can also destroy the cortical bone. In tumor patients, a bone scan is a good test to assess for metastatic spread, although it may miss metastasis in very aggressive tumors where surrounding bone does not have sufficient time to produce a reactive osteoblastic response. Tumors that are predominantly osteolytic cause foci of decreased radiotracer activity on bone scan that are much more difficult for the radiologist to perceive than small focal areas of increased activity. There are now promising efforts

I The Case of Agatha Kristeeze

Fig. 8.17 You are looking at the pelvic radiograph of Agatha Kristeeze. Do you agree with Giufeng?

Fig. 8.17 You are looking at the pelvic radiograph of Agatha Kristeeze. Do you agree with Giufeng?

I Metastases a Osteolytic metastases b, c Osteoblastic metastases a Osteolytic metastases b, c Osteoblastic metastases

Osteoblastic Metastasis

Fig. 8.18a This osteolytic metastasis has led to a pathological very dense regions indicating osteoblastic metastases. This fracture of the ulna. The defect is very irregular in its margin man had a prostate carcinoma. Had the patient been a woman, and a large soft tissue component seems to be present as one would have had to consider primarily underlying breast well. The patient had a renal carcinoma of which this was a cancer. c The bone windows of the head CT in this same patient peripheral metastasis. b The lumbar vertebrae show multiple show the osteoblastic lesions in the skull.

Fig. 8.18a This osteolytic metastasis has led to a pathological very dense regions indicating osteoblastic metastases. This fracture of the ulna. The defect is very irregular in its margin man had a prostate carcinoma. Had the patient been a woman, and a large soft tissue component seems to be present as one would have had to consider primarily underlying breast well. The patient had a renal carcinoma of which this was a cancer. c The bone windows of the head CT in this same patient peripheral metastasis. b The lumbar vertebrae show multiple show the osteoblastic lesions in the skull.

I Multiple Myeloma

I Multiple Myeloma

Osteoblastic Skull Fractures

Fig. 8.19 a, b The radiograph of the skull (a) shows multiple patchy defects. An extensive infiltration of the cancellous bone with abnormal myeloic cells is likely. This historic specimen (b) emphasizes the degree of destruction that may be present in myeloma. (Thanks to the Berlin Museum of Medical History for permission to use this photograph.)

Fig. 8.19 a, b The radiograph of the skull (a) shows multiple patchy defects. An extensive infiltration of the cancellous bone with abnormal myeloic cells is likely. This historic specimen (b) emphasizes the degree of destruction that may be present in myeloma. (Thanks to the Berlin Museum of Medical History for permission to use this photograph.)

under way to use whole-body MRI to screen for metastases, which may be more sensitive overall. Targeted radiographs then exclude degenerative changes as a cause of the increased bone turnover and may help define the risk of fracture before radiation therapy or a surgical treatment is initiated.

Multiple myeloma: Multiple myeloma is a disease of the elderly. Typically, osteolytic lesions arise in the long tubular bones and the axial skeleton—osteoblastic lesions are rare. An early radiographic sign is erosion of the cortical

I Osteopoikilosis

Metastasis Sea Cadera
Fig. 8.20 The very rare osteopoikilosis features many small bone islands within the cancellous bone.

bone from the within the marrow space (Fig. 8.19). If the cortex is permeated by the tumor, a large soft tissue component may develop. In the axial skeleton the bone structure may turn very coarse in diffuse disease. Multiple myeloma is primarily diagnosed on the basis of laboratory parameters. Its extent and the course of the disease as well as the fracture risk are well documented in an elaborate series of radiographs of the axial skeleton and the proximal extremities. MR is more sensitive than radiography in detection of disseminated disease foci; its success is mostly based on the ability to image bone marrow displacement due to the disease and bone marrow edema. Bone scans are not indicated in myeloma because they may fail to demonstrate the sites of involvement in a large number of patients.

Some other, nonneoplastic diseases also have to be considered by Giufeng:

Osteopoikilosis: This is a benign, asymptomatic disease that features multiple small sclerotic bone lesions, mainly in the pelvis (Fig. 8.20) and the tubular bones. Bone scans show no abnormality in osteopoikilosis.

Paget disease: Paget disease (syn.: osteitis deformans) is a regional disease of the skeleton in the elderly. Its patho-genesis remains obscure. It is quite frequent in the British Isles, is seen in up to 10% of those above 80 years old in Central Europe and North America, and is almost unknown in China. The altered bone is enlarged; its texture becomes rather coarse and fibrous ("woven bone," Fig. 8.21). Cortical thickening is a prominent feature often associated with the sclerotic phase of the disease. Despite the apparent increase of cortical thickness, the overall stability of the bone decreases because the new bone is of

I Osteopoikilosis

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Responses

  • Sam
    What % does a bone scan miss osteolytic lesions?
    5 years ago

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