Multiple Lytic Lesions Research Articles

Multiple Brown Tumors With Tc-99m MDP Superscan Appearance and Negative Tc-99m MIBI Uptake

A 20-year-old man presented with a spontaneous left humerus fracture after minimal loading. X-rays and a CT scan revealed multiple lytic lesions throughout the skeleton (humeri, ribs, spine, pelvic bones, femorals). Blood chemistries showed severe hypercalcemia of 15.7 mg/dL and hypophosphatemia, whereas the biopsy of a lytic lesion (right humerus) showed only a few macrophages and multinuclear giant cells. Tc-99m MDP and Tc-99m MIBI scans were performed. Neck surgery verified the presence of a parathyroid adenoma. The multiple lytic lesions that were seen are brown tumors (osteoclastomas) without focal Tc-99m MDP or Tc-99m MIBI uptake.

A newborn with multiple fractures as first presentation of infantile myofibromatosis

Pathological fractures occur in infancy from a variety of causes, but are a rare condition during neonatal period. We describe the case of a male newborn with a metaphyseal fracture of femur and multiple lytic lesions, diagnosed as infantile myofibromatosis.

LYTIC BONE LESIONS IN AN AUSTRALIAN POPULATION: THE RESULTS OF 100 CONSECUTIVE BIOPSIES

The identification of a lytic bone lesion is often perceived as a harbinger of malignancy, especially in an older patient. This study reviews the results of 100 consecutive biopsies of patients who presented with either a solitary lesion or multiple lytic bone lesions in the absence of a history of malignancy. Following preoperative planning, including plain radiographs, bone scan and computed tomography scanning, an open biopsy was carried out. The most common site affected was the pelvis (20 patients), followed by the femur (19) and tibia (15). The lesions were solitary in 88 patients and multiple in 12. The most common diagnosis was a secondary carcinoma presenting as a bone lesion, which was found in 25 patients. The carcinomas were a widely distributed group, but the most common among them were renal cell carcinoma (seven patients), breast carcinoma (five patients) and lung carcinoma (five patients). The most common primary bone tumour was a giant cell tumour (16) followed by myeloma (10). Multiple lesions were not universally an indication of a malignant process. In 14 patients the lesion was not a tumour. This study emphasizes the importance of obtaining a tissue diagnosis.

Magnetic resonance imaging of thickened pituitary stalk proceeding to Langerhans cell histiocytosis in a child

Magnetic resonance imaging has shown isolated pituitary stalk thickening in certain cases of idiopathic or secondary central diabetes insipidus (DI) due to infiltrative processes. We present a 4-year-old boy who was initially diagnosed as having central DI. The MRI showed isolated pituitary stalk thickening with prominent homogeneous contrast enhancement. The remaining findings on MRI were within normal limits. The patient's personal and family history and laboratory and clinical findings were unremarkable; therefore, he was initially diagnosed as having idiopathic DI. Since central DI and isolated pituitary stalk thickening may be considered to be the first manifestations of Langerhans cell histiocytosis, we decided to follow up the patient. After 5 months, following the initial diagnosis, on skeletal X-ray survey, the patient did indeed develop multiple lytic skull lesions which, on biopsy, were histologically typical bone lesions of Langerhans cell histiocytosis.

Active Pulmonary Tuberculosis with Vertebra and Rib Involvement: Case Report

Multifocal skeletal tuberculosis is defined as osteoarticular lesions that occur simultaneously at two or more locations and is generally associated with disseminated disease. Although involvement of bones accounts for 1 to 5% of all tuberculosis cases, multifocal involvement of the skeleton is extremely rare. We present a case of active pulmonary tuberculosis (TB) with vertebral and rib involvement and multiple hypodense lytic lesions accompanied by a paravertebral mass lesion. In the differential diagnosis, metastases, lymphoma, multiple myeloma, chordoma sarcoidosis and rare spinal infections such as brucellosis and fungal disease were considered. The diagnosis was established by surgical biopsy, taken by video-assisted thoracoscopic surgery. Especially for patients from TB-endemic areas, tuberculosis must be considered in the differential diagnosis and treatment should be started without delay.

Macrofocal multiple myeloma in young patients: A distinct entity with favorable prognosis

There are limited reports of young patients with multiple myeloma (MM) who presented with multiple lytic bone lesions but without intervening infiltration of bone marrow, a pattern consisting of macrofocal MM. In order to clearly define the clinical and laboratory features and outcome of such patients, a retrospective analysis was performed of symptomatic patients with MM ≤40 years of age at diagnosis who received primary treatment over a 20-year period. Ten of 51 patients fulfilled the criteria of macrofocal MM. When compared to patients with typical MM, patients with macrofocal pattern were less anemic, none had hypercalcemia, renal impairment, elevated serum LDH or stage 3 according to the International Staging System (ISS). Patients with macrofocal MM usually had preserved the uninvolved immunoglobulins. An objective response to primary treatment was noted in 55% of patients with macrofocal MM and in 50% of patients without this pattern. The median survival of patients with typical MM was 57 months and is projected to exceed 8 years in patients with macrofocal MM (p = 0.087). With macrofocal MM despite multiple lytic bone lesions, patients have features of low tumor burden and improved survival when compared with young patients with typical MM.

Lymphangiomatosis of Bone and Visceral Parenchyma: Report of Two Cases

Lymphangiomatosis is a rare disorder that occurs mainly in children or during the first two decades of life. It is characterized by a diffuse proliferation of lymphatic channels involving the bones, visceral parenchyma, and soft tissue. Most cases of lymphangiomatosis have bone and visceral involvement and usually present with chylothorax, chylous ascites, chylous pericardial effusion, or acute symptoms that are related to the affected organs. The authors experienced two cases that presented with chylothorax and multiple lytic bone lesions. Chest drainage and chemical pleurodesis were performed for treatment of the chylothorax. In one case, lytic bone lesions were found only in the right scapula and bone lengthening with an Ilizarov frame was performed for growth arrest in the right humerus. In the other case, lytic bone lesions were found in both femurs and both humeri, the right tibia, and the right scapula; and were particularly severe in the right tibia and femur. The lytic bone lesion, osteosclerosis, pathologic fracture, and pseudoarthrosis were so severe that weight-bearing was impossible. Internal fixation was performed with an intramedullary nail in the left femur.

Macrofocal Multiple Myeloma in Young Patients: A Distinct Entity with Favorable Prognosis.

Introduction: Most patients with multiple myeloma (MM) present with multiple lytic bone lesions, extensive marrow plasmacytosis and anemia. Furthermore in several of them hypercalcemia and renal impairment are evident at diagnosis. Over the years, we have seen occasional young patients with MM who presented with multiple lytic bone lesions but without intervening infiltration of bone marrow i.e. a pattern consisting of macrofocal MM.Patients and methods: In order to assess the clinical and laboratory features and the outcome of patients with macrofocal MM we performed a retrospective analysis of symptomatic patients with MM ≤40 years of age at diagnosis who received primary treatment over a 20 year period (from January 1, 1985 to December 31, 2004). The diagnosis of macrofocal MM required the presence of lytic bone lesions and the absence of obvious bone marrow plasmacytosis (BMPC<10%) on bone marrow aspirate and/or biopsy.Results: Among 51 patients ≤40 years at the time of initial treatment, 10 patients fulfilled the criteria of macrofocal MM. Patients' median age, gender, myeloma heavy and light chain were similar among patients of the 2 groups. When compared with patients with typical MM, patients with macrofocal pattern were less anemic (p=0.018), none had hypercalcemia (p=0.1), renal impairment (p=0.17), elevated serum LDH (p=0.14), or stage 3 according to the International Staging System (ISS) (p=0.13). Four of the 10 patients with macrofocal MM versus 0 of 41 patients with typical MM (p=<0.01) had a prior diagnosis of solitary bone plasmacytoma. Approximately 80% of patients in both groups received primary treatment based on high-dose dexamethasone regimens (VAD or VAD-like regimens). An objective response was noted in 55% of patients with macrofocal MM and in 50% of patients without this pattern. The median survival of patients with typical MM was 57 months and has not been reached in patients with macrofocal MM (p=0.087). In the latter group of patients, median survival is projected to exceed 8 years. The 10 year survival rate is 20% and 5% in patients with or without macrofocal myeloma respecrively.Conclusion: Our analysis indicates that macrofocal MM is a distinct entity in young patients with MM. Despite multiple lytic bone lesions, such patients have features of low tumor burden and an improved survival when compared with young patients with typical MM. Future studies including gene profiling may reveal potential biological differences among the two groups of patients.

Hypercalcemia in B-Cell Chronic Lymphocytic Leukemia: Report of a Case and Review of the Literature.

A 53 year old man with Rai stage IV CLL was being treated with R-HyperCVAD when he presented between cycles with fatigue, lethargy and pancytopenia. Clinical examination revealed diffuse adenopathy and splenomegaly. Serum calcium was 13.6 mg/dl, phosphorus level was 2.7 mg/dl, and alkaline phosphatase was 54 U/L. PTH was 4 Units/L (10–65), PTHrP < 0.2 pmole/L (0–1.9), 1–25 (OH) Vitamin D < 10pgm/ml (22–67). Quantitative immunglobulins: IgA 10 mg/dl, IgG 252 mg/dl, IgM 50 mg/dl. Immunofixation revealed a faint IgG lambda paraprotein. There were no lytic lesions on skeletal survey. Bone marrow biopsy revealed focal large cell transformation (Richter's syndrome). Cytogenetics revealed 3 metaphases with complex cytogenetic abnormalities, indicating clonal evolution. The hypercalcemia resolved with appropriate therapy, but despite subsequent treatment with CAMPATH, he died 2 weeks after diagnosis.A review of reported patients with CLL and hypercalcemia in the literature was performed from 1980 onwards using MEDLINE and PubMed; only those cases in which clinical aspects, biochemistry, PTH levels, imaging studies and concurrent pathology (if obtained) were documented, are summarized in this analysis (n=13).Rai stage: I n=1, II n=4, III n=3, IV n=5. Immunoreactive PTH levels were low or normal in 100% of patients. In 5 cases in which it was measured, 1–25 (OH) Vitamin D levels were not elevated. PTHrP was normal in 2 cases and elevated in 1. In nine patients, multiple lytic bone lesions were present on skeletal radiology. Two patients had osteopenia without lytic lesions. Two had no lytic lesions.Six of ten patients had evidence of transfomation on lymph node and/or bone marrow biopsy performed at the time of evaluation for hypercalcemia.Prognosis was poor (range 0.5–12 months) with only one patient surviving post allo-transplant.In conclusion, hypercalcemia in CLL is rare. Osteolytic lesions are present in the majority of cases. PTH levels are low, and thus this hormone is not mediating the hypercalcemia. The evidence is also against a role of elevated Vitamin D. Histological transformation is seen in half of the cases. Survival is poor after diagnosis of hypercalcemia. The mechanisms(s) of the osteolysis and hypercalcemia remain to be defined.

Afectación orbitaria como primera manifestación de la enfermedad de Hand-Schuller-Christian: Caso clínico

PURPOSE/MATERIAL AND METHOD: To describe the clinical case of a 20-month-old boy with Hand-Schuller-Christian disease. Exophthalmos was the only systemic manifestation evident over a period of at least 6 weeks, but later the triad of exophthalmos with multiple lytic lesions of the skull and diabetes insipidus were present. Histiocytosis X should be considered in the differential diagnosis of orbital tumors in children.

A case of multicentric reticulohistiocytosis with multiple lytic skull lesions

Multicentric reticulohistiocytosis (MR) is a rare multisystemic disorder of unknown aetiology characterized by cutaneous and joint manifestations. It is associated with malignancy in up to 31% of cases. Common radiological findings are peri-articular erosions and osteolytic punched-out areas. We present a case of MR with cutaneous nodules, joint pains, and multiple lytic skull lesions--a combination that has not been described before. Osteolytic activity of proinflammatory cytokines (tumour necrosis factor-alpha and interleukin-1) may explain the peri-articular erosions often seen in MR, and the multiple lytic skull lesions seen in our patient.

Multiple Lytic Bone Lesions in an 85-Year-Old Man

An 85-year-old, Russian-speaking man of Eastern European origin with a past medical history of Parkinson disease, hypothyroidism, and chronic anemia was evaluated for gradual increase in shortness of breath that worsened 2 days before admission. The patient did not complain of any chest pain, fever, cough, nausea, or vomiting. Physical examination showed an elderly man with shortness of breath during talking and at rest. His temperature was 36.18C; pulse, 100 beats per minute; respiratory rate, 30 to 40 breaths per minute; and blood pressure, 140/70 mm Hg. Examination of the cardiovascular system was unremarkable. Auscultation of the lungs revealed decreased breath sounds at the right base and bronchial breath sounds on the right side. No crackles, rhonchi, or wheezing were found. Physical examination of the patient’s abdomen showed splenomegaly, but no significant hepatomegaly. No lymphadenopathy was found. Examination of the nervous system showed no evidence of focal neurologic signs or evidence of any neuropathy. Examination of the neck showed deformities of the cervical spine, reportedly caused by fractures. The patient also complained of chronic bone pain for many years. Abnormal laboratory tests included serum sodium, 124 mEq/L; hemoglobin, 10.7 g/dL; hematocrit, 31.4%; and thyroid stimulating hormone, 3.2 mIU/mL. Both the white blood cell count and the platelet count were within normal limits. Total gamma globulins were slightly elevated (4.3

Vertebral and Spinal Cord Sarcoidosis

Campbell SE, Reed CM, Bui-Mansfield LT, Fillman E 64-year-old woman with a history of sarcoidosis presented with back and abdominal pain and was unresponsive to nonsteroidal antiinflammatory medications. In addition, the patient complained of weakness in her right arm. Physical examination of the abdomen was unremarkable, and examination of the spine revealed normal flexion and extension and no focal tenderness. Neurologic examination revealed slightly decreased strength in the right arm and hand. A posteroanterior chest radiograph showed a bilateral diffuse reticulonodular pulmonary parenchymal pattern, right paratracheal stripe thickening, and bilateral hilar lymphadenopathy (Fig. 1A). CT of the chest confirmed bilateral hilar, right paratracheal, and subcarinal lymphadenopathy and interstitial pulmonary disease. CT also revealed widespread retroperitoneal lymphadenopathy and multiple lytic lesions within the vertebral bodies and posterior elements of the thoracolumbar spine. Subsequent MRI of the spine revealed decreased T1 signal intensity and increased T2 signal intensity scattered throughout the spine (Fig. 1B). After IV sodium gadopentate was administered to the patient, multiple brightly enhancing lesions within the vertebral bodies, pedicles, laminae, and spinous processes were identified. Diffuse leptomeningeal and nerve root enhancement and an enhancing parenchymal spinal cord mass were also present (Fig. 1C). Biopsy of a vertebral lesion revealed noncaseating granuloma consistent with sarcoidosis without evidence of malignancy (Fig. 1D). Gram stains and cultures for fungi, aerobic and anaerobic organisms, and acid-fast bacilli were all negative. The differential diagnosis for diffuse marrow infiltration, enhancing intraaxial spinal cord mass, diffuse meningeal and nerve root enhancement, and mediastinal and retroperitoneal lymphadenopathy includes metastatic disease, lymphoma, leukemia, hematogenous osteomyelitis (tuberculous, fungal), and sarcoidosis [1]. Sarcoidosis is a systemic granulomatous disease of unknown etiology that has been shown to affect nearly every organ system. Osseous involvement occurs in 1–13% of cases, typically in the small tubular bones of the hands and feet [2, 3]. Sarcoidosis may affect either the vertebral column or the spinal cord. Typical vertebral column manifestations are lytic lesions with sclerotic borders that enhance on MRI and enhancement of the intervertebral disk [1, 3–5]. Typical spinal cord manifestations are leptomeningeal enhancement, enhancing spinal cord mass, nerve root “clumping,” and enhancing nerve root [4]. The most common spinal cord manifestation is leptomeningeal disease [4]. Given the variable manifestations of sarcoidosis within the spine, this disease should be considered in the differential diagnosis along with multiple sclerosis [4]; tuberculous meningitis [4]; and widespread vertebral involvement of metastatic disease, infection, or lymphoma [1]. Sarcoidosis is typically treated with corticosteroid therapy, after which clinical symptoms and even MRI findings may completely or partially resolve in 29% of the patients [6]. Prednisone

Case of the season: Kaposi sarcoma

49-year-old African male with a history of acquired immunodeficiency syndrome (AIDS) and Kaposi sarcoma(KS)presentedwithnonproductivecough,shortnessof breath, and exercise intolerance. He first came to the United States in 1995 for treatment of infectious retinitis thought due to cytomegalovirus, which resulted in blindness. The patient subsequently tested positive for human immunodeficiency virus (HIV). In 1998 an oral mucosal lesion was biopsied and found to be KS. Several skin lesions typical for KS were also discovered at that time. The patient denied pulmonary symptoms, and a chest radiograph obtained at that time was normal. Before his current presentation, the patient’s CD4 count was 54 (normal adult range 500 to 1500 cells/cubic mL of blood) and he had an HIV viral load of 5444 (normal is 0; treatment should be considered for HIV-infected people who have viral loads higher than 30,000 copies per mL of blood using a test known as a branched DNA test, or more than 55,000 copies using an RT-PCR test). A new HIV drug regimen was begun, and after several months, the patient’s skin lesions improved. The patient then returned to Africa and due to socioeconomic reasons was noncompliant with all medications. He was lost to follow-up for 2 years until he presented with his current complaint of nonproductive cough and shortness of breath. On his current admission a chest radiograph (Fig. 1A and B) revealed coarse, ill-defined opacities in the perihilar regions and lower lobes, with areas of nodularity. A small left pleural effusion and interlobular septal thickening (Kerley B lines) in the right lung base were also noted. A computed tomography (CT) scan of the chest (Fig. 1C and D) showed nodular thickening of the bronchovascular bundles, flameshaped opacities in a bronchovascular distribution, and confluence of nodular opacities in the lower lobes forming illdefinedmasses.Interlobularseptalthickening,smallbilateral pleural effusions, and axillary lymphadenopathy were also seen. Thepatientsubsequentlyunderwentbronchoscopywhich showed scattered, raised, erythematous, friable lesions throughout the tracheobronchial tree. Bronchoalveolar lavage was performed which revealed no infectious organisms on Gram stain or culture. A CT scan of the patient’s abdomen and pelvis (not shown) showed multiple lytic osseous lesions, which were proven to be Kaposi sarcoma by CTguided bone biopsy. An endoscopic examination performed because of upper gastrointestinal bleeding revealed Kaposi sarcoma involving the duodenum.

Clivus metastasis of squamous cell carcinoma: a rare location

Lung cancer is the most frequently encountered cancer in humans and commonly metastasizes to brain and bone. Metastasis to the clivus is very rare and there have been no previous reports. A 51-year-old woman was admitted to our hospital complaining of headache, and left shoulder, arm and back pain. The chest X-ray showed a left paracardiac mass measuring 4 × 4 cm in diameter and the thorax computed tomographic examination revealed a 4 × 4 cm mass in the left lower lobe, left hilar and mediastinal lyphadenopathy, and multiple lytic lesions in the thoracic vertebral bodies. Head magnetic resonance imaging showed a mass in the clivus with bony destruction. Bronchoscopic examination revealed an exophytic endobronchial lesion in the left lower bronchus lumen and a biopsy was taken from this lesion. The histopathological diagnosis was “poorly differentiated squamous cell carcinoma”. A punch biopsy was taken from the clivus via the transnasal–transphenoidal route. Histopathological findings of this biopsy were similar to the primary site tumor. We report a rare case of clivus metastasis from squamous cell lung cancer.

Multiple lytic bone lesions in an 85-year-old man: type 1 Gaucher disease, adult onset (nonneuronopathic form).

An 85-year-old, Russian-speaking man of Eastern European origin with a past medical history of Parkinson disease, hypothyroidism, and chronic anemia was evaluated for gradual increase in shortness of breath that worsened 2 days before admission. The patient did not complain of any chest pain, fever, cough, nausea, or vomiting. Physical examination showed an elderly man with shortness of breath during talking and at rest. His temperature was 36.18C; pulse, 100 beats per minute; respiratory rate, 30 to 40 breaths per minute; and blood pressure, 140/70 mm Hg. Examination of the cardiovascular system was unremarkable. Auscultation of the lungs revealed decreased breath sounds at the right base and bronchial breath sounds on the right side. No crackles, rhonchi, or wheezing were found. Physical examination of the patient’s abdomen showed splenomegaly, but no significant hepatomegaly. No lymphadenopathy was found. Examination of the nervous system showed no evidence of focal neurologic signs or evidence of any neuropathy. Examination of the neck showed deformities of the cervical spine, reportedly caused by fractures. The patient also complained of chronic bone pain for many years. Abnormal laboratory tests included serum sodium, 124 mEq/L; hemoglobin, 10.7 g/dL; hematocrit, 31.4%; and thyroid stimulating hormone, 3.2 mIU/mL. Both the white blood cell count and the platelet count were within normal limits. Total gamma globulins were slightly elevated (4.3

Lytic Lesions in Breast Cancer

A previously healthy 54-year-old woman presented with a two-week history of pelvic pain. On physical examination, she had limited movement, without tenderness in the bones. An initial radiographic survey of skeletal bone showed multiple lytic lesions in the axial skeleton (Panel A, arrow), the ribs, the skull (Panel B, arrow), bilaterally in the pelvis, both femurs (Panel C, arrow), and both humeri (Panel D, arrow). Blood tests showed normocytic normochromic anemia with a hematocrit of 24.9 percent, along with a sedimentation rate of 140 mm per hour. Calcium levels and the results of kidney-function and liver-function tests were normal. The . . .

Case 38-2004

A 40-year-old man noted a lump on the top of his head. Imaging studies showed a dural-based tumor invading bone and soft tissue. The lesion was excised and a diagnosis of plasmacytoma was made. Additional staging studies disclosed multiple lytic bone lesions, with no paraprotein and a negative bone marrow biopsy and aspirate. The discussants review recent advances in the management of multiple myeloma.

Cholestatic jaundice and bone lesions in an elderly woman

A 74-year-old Caucasian female presented with jaundice, clay-colored stools, diarrhea, and fatigue of 3 months' duration, accompanied by a weight loss of 6.8 kg. Physical examination demonstrated mild hepatomegaly. Initial blood work revealed abnormal liver biochemistries with a cholestatic pattern. An abdominal CT scan showed intrahepatic bile-duct dilatation without masses but with multiple lytic and blastic bone lesions. A sacral bone biopsy established the diagnosis. Endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, CT scan, bone biopsy and liver biopsy. Systemic mastocytosis affecting the biliary system resulting in a primary-sclerosing-cholangitis-like picture combined with diffuse blastic and lytic bone lesions. Biliary stenting, histamine 1- and 2-receptor blockers, and chemotherapy (cladribine).

Paracoccidioidomycosis in children: clinical presentation, follow-up and outcome.

From February, 1981 to May, 2001, 63 children under 15 y old (ages 2 - 15 y, median = 8 y, mean +/- 1 SD = 8 +/- 3 y) presenting 70 episodes of Paracoccidioidomycosis were admitted. The main clinical manifestations and laboratory features observed upon admission were: lymph node enlargement (87.1%), fever (75.7%), weakness (48.6%), pallor (41.4%), hepatomegaly (40%), splenomegaly (35.7%), anemia (90%), hypergammaglobulinemia (88.5%), eosinophilia (75.5%) and hypoalbuminemia (72.5%). Moderate to severe malnutrition was detected in 35.7% of the episodes (Gomez's criterion). Radiographic and technetium studies showed bone lesions in 20 of the episodes, most of them being multiple lytic lesions, involving both long (70%) and plain bones (30%). First line treatment consisted of an association of sulfametoxazole-trimethoprin, which was used, exclusively, in 50 episodes. Follow-up of hemoglobin levels, number of eosinophils in the peripheral blood, albumin and gammaglobulin serum levels revealed significant sequential improvement one and six months after hospital admission, being quite useful to evaluate treatment effectiveness. Six patients died (9.3%) and four developed sequelae (6.3%). In conclusion, the juvenile and disseminated forms can be observed in about 70% of the episodes of PCM occurring in children younger than 15 y old, most of them presenting with a febrile lymphoproliferative syndrome associated to anemia, eosinophilia and hypergammaglobulinemia.