Case Report

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Radiological Category
Principal Modality (1) Principal Modality (2)
MRI
CT/ CXR/Nuclear
Case Report
Submitted by
Jason Pearce, MS IV
Faculty reviewer
Sandra. A. A. Oldham M.D.
Date accepted
August 30, 2007
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Case History

• Patient is a 49 year old hispanic woman
  presenting to the hospital with a 2 month history
  of headaches. Headaches were noted to be
  increasing in intensity. Over the same time
  period she has had episodes of blurred vision,
  hearing problems described as hearing waves,
  and sometimes feeling like she is in a tunnel.
  She denies any photophobia, N/V, rhinorrhea,
  tearing, fevers, neck pain or any additional
  stresses in her life. She also noted some lower
  back pain and hip pain. This pain has been
  present for a couple of months and hasnt really
  changed in intensity and is moderately controlled
  by Advil. She attributes this pain to getting
  older and being overweight.
• A significant piece of PMH is being withheld.

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T1 MRI w/o contrast

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T1 MRI w/contrast
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T2 MRI

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CXR

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CT w/contrast

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CT Abdomen

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CT Pelvis

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Bone Scan

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Test Your Diagnosis
Which one of the following is your choice for the
appropriate diagnosis?

• Primary Bone Tumor
• Multiple Myeloma
• Metastatic Cancer
• Fibrous Dysplasia

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CT Abdomen

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These images belong to two other patients. The
PMH not given earlier is this pt had hx of renal
cell carcinoma.

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Findings and Differentials
Findings MRI morphologically normal brain. No
intracranial mass lesions. There is a marrow
replacing expansile mass in bone posterior to
right occipital lobe measuring 2.4 x 1.4 x 2.9cm.
There is mild expansion of inner table of the
calvarium w/ extension into cranial vault. A
second marrow replacing mass in noted in left
parietal bone measuring 5mm in diameter. CT
Abd/Pel showed a 5.7 cm mass in right adrenal
gland, 7.8cm lytic lesion in right ilium at the
sacroiliac joint, a 3cm lytic lesion in left
acetabulum, all characteristic of metastatic
disease. Bone Scan There are hot lesions in
right iliac bone, a horizontal sacral fracture, a
focal area in left acetabulum, lytic lesion in
occipital bone on right side and a focal area on
left 6th rib. CXR bilateral pulmonary
metastases, surgical clips in abdomen.
Differentials

• Multiple Myeloma
• Metastatic Cancer
• Primary Bone Cancer
• Fibrous Dysplasia

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Discussion

• Multiple Myeloma
• Neoplastic proliferation of a single clone of
  plasma cells producing a monoclonal
• immunuglobulin found within the bone marrow.
  
• Median age of diagnosis is 66 years of age,
  w/ less than 10 prior to age of 50.
• Clinically presents as bone pain, unexplained
  anemia, symptoms of hypercalcemia,
• renal failure and recurrent infections.
• Lytic bone lesions caused by both rapid growth
  of myeloma cells inhibiting normal bone-
• forming cells, and production of substances
  that activate osteoclasts.
• Do not use bone scans to evaluate myeloma.
  Cytokines secreted by myeloma cells
• suppress osteoblast activity therefore,
  typically, no increased uptake is observed.
• Lesions are seen as focal or diffuse areas of
  hypointensity on T1-weighted images and
• as areas of intermediate or high signal
  intensity on T2-weighted images. Myeloma
• lesions tend to enhance somewhat with
  gadolinium.
• In our case it would be difficult to
  differentiate this from metastasis, but the
  degree of
• enhancement by gadolinium may be slightly
  less.

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Discussion

• Fibrous Dysplasia
• Fibrous dysplasia is a skeletal developmental
  anomaly of the bone-forming mesenchyme
• that manifests as a defect in osteoblastic
  differentiation and maturation. Virtually any
• bone in the body can be affected.
• Medullary bone is replaced by fibrous tissue,
  which appears radiolucent on radiographs,
• with the classically described ground-glass
  appearance.
• Most commonly found in persons aged 3-15
  years.
• 70-80 of fibrous dysplasias are monostotic
  present with pain or a pathologic fracture
• 20-30 of fibrous dysplasias are polyostotic
  often involving the facial bones and skull.
• It also occurs in an isolated craniofacial
  form. In the isolated variety, no extracranial
• lesions are present.
• On T1-weighted MRIs, the lesion has
  low-to-intermediate signal intensity equal to
  that of
• muscle. T2-weighted images also show low
  signal intensity owing to the high content of
• collagen and bone.

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Discussion

• Bone Metastases
• Metastases involve bone by means of 3 main
  mechanisms (1) direct extension, (2)
• retrograde venous flow, and (3) seeding with
  tumor emboli via the blood circulation.
• Seeding occurs initially in the red marrow
  this process accounts for the predominant
• distribution of metastatic lesions in the red
  marrowcontaining areas in adults.
• Bone metastasis can occur from almost any
  malignancy, but the most common are
• from the breast, kidney, lung, prostate, and
  thyroid.
• Lesions are lytic (bone loss), blastic
  (increased bone) or both.
• Lytic lesion lung, kidney, thyroid, and
  breast Blastic prostate treated breast ca
• Vascular metastasis include ovarian, renal,
  thyroid, and melanoma.
• Bone metastases usually affect axial
  skeleton, appendicular skeleton later (and
• much less frequently), and to the distal
  extremities is extremely rare.
• Diagnostic Imaging of suspected bone metastasis
  include
• Plain Films useful because most people present
  w/ pain to a particular bone,
• drawbacks are
  that the lytic bone metastases must be greater
  than
• 1 cm and have
  destroyed 30-50 of the bone density in order to
  be
• seen by
  x-ray.

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Discussion

• Bone Metastasis
• Bone Scan good for detecting lesions prior to
  evidence on plain film, and for
• ability to
  view all bones at one time, however bone scans
  are only
• specific for
  bone turnover, not malignancy.
• CT/MRI useful for equivocal changes on plain
  film. MRI can show bone changes
• even before
  metabolic abnormalities are seen on bone scans.
  Lesions
• are seen as focal
  or diffuse areas of hypointensity on T1-weighted
• images and as
  areas of intermediate or high signal intensity on
  T2-
• weighted images.

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Discussion

• Renal Cell Carcinoma (RCC)
• Epidemiology 50,000/13,000 diagnoses and deaths
  annually in U.S.
• No differences between race or gender.
  
• Predominately found in 6th 8th
  decade of life.
• 85 of primary renal cancers
  (Transitional cell carcinoma 8,
• Nephroblastoma Wilms Tumor among
  children 5-6)
• Risk Factors Smoking 2 fold increased risk,
  found in 1/3 of reported cases
• Obesity
• Dialysis increased, primarily after
  8-10 years of dialysis
• VonHippel-Lindau disease 40-60 will
  develop RCC
• Family History
• Symptoms completely asymptomatic (often pts
  present w/ metastatis)
• flank pain, abdominal mass, hematuria (all
  3 in only 8-10)
• anemia, HTN, fever of unknown origin
• paraneoplastic syndromes (erythrocytosis,
  PTHrp, renin, etc.)

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Discussion

• Renal Cell Carcinoma (RCC)
• Diagnosis
• 1. First choice is usually CT w/ contrast
• 95 of RCCs are hypervascular. 
  contrast enhancement is usually
• strong and
  heterogeneous due to areas or hemorrhage and
• necrosis
• 2. If CT inconclusive, get a Ultrasound to
  differentiate solid vs. cystic
• Most commonly is hyperechoic on
  sonography, but can also be
• hypo- and
  isoechoic
• 3. If still nondiagnostic or if pt cant receive
  IV contrast, consider MRI
• 4. When working up pt for possible metastasis,
  bone scans and PET
• scans are effective
  (however bone scan are only recommended for
• pts with bone pain or elevated serum
  alkaline phosphatase).

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Discussion

• Staging Robson Staging
• Stage 1 - Confined to the kidney
• Stage 2 - Involvement of perinephric fat but
  Gerota's fascia intact
• Stage 3 - Spread into renal vein
• Stage 4 - Spread into adjacent or distant
  organs
• I 90, II 75-90, III 50-70, IV
• Metastasize most commonly to these locations
  lung, lymph nodes, bone, liver, brain, and
  ipsilateral adrenal gland.
• Greatest risk for recurrence is within 5
  years, approximately 10 of
• pts present w/ metastasis 5 years post
  nephrectomy.
• Although recurrence of RCC has a poor prognosis,
  some studies are
• show longer survival w/ increased
  interval between nephrectomy and
• recurrence and also single foci
  of metastasis.
• Decreased survival is shown w/ serum LDH 1.5
  normal, serum
• Ca 10mg/dl, hemoglobin
  concentrations below normal, absence of
• disease free interval.

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Discussion

• Lung Mets 29-54 of pts w/ recurrence, 90
  diagnosed without
• symptoms,
  however f/u w/ CT vs CXR is still debated.
• Bone Mets 16-31 of pts w/ recurrence, however
  67-91 do present
• w/ localized pain.
  Usually only monitored by symptoms
• and
  serum alkaline phosphatase levels.
• Liver Mets 8-30 of pts w/ recurrence, 90 or
  more are detected by
• symptoms or abnormal lab values.
• Brain Mets 2-10 of pts w/ recurrence, greater
  than 80 have
• 
  symptoms, including headaches, altered
  behavior,
• 
  seizures or focal neurological signs.

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Renal Cell Carcinoma w/ distant metastases to
bone, lung and adrenal gland.
Diagnosis
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1.) Andreoli. Cecil Essentials of Medicine, 6th
Ed., 2004.2.) Atkins, Michael. Up To Date
Epidemiology, pathology, and pathogenesis of
renal cell carcinoma, 2007.3.) Peh,
Wilfred. eMedicine Bone Metastasis, 2007.4.)
Noveline, Robert A. Squires Fundamentals of
Radiology, 6th Ed., 2004.
References