Osteoblastic Lesions Research Articles

Die Wertigkeit digitaler Bildaufnahmeverfahren bei der Skelettdiagnostik

The clinical value and the imaging characteristics of digital radiography systems (image intensifier (I.I.) radiography: Polytron/Siemens, storage phosphor radiography: PCR/Philipps) in skeletal imaging were compared with film-screen radiography and 100 mm technique. The influence of spatial and contrast resolution, entrance dose and detectability of lytic, osteoblastic and cortical lesions were studied as well as the images of 25 parallel examined patients. Only with the small image intensifier (diameter 14 cm) the quality of 100 mm technique and digital I.I. radiography was equivalent to storage phosphor and film-screen radiography. Storage phosphor radiography seems to be better qualified than I.I. radiography to replace conventional techniques in skeletal imaging.

Ossifying Fibroma of the Cranial Vault

A 68-year-old female was admitted with mild headache in the right frontal region. Physical and neurological findings were normal. Plain X-rays revealed a poorly circumscribed, osteoblastic lesion in the right frontal bone. Computed tomography scan showed that the diploic space was destroyed but that the inner and outer tables were intact. On 99mTc bone scan, a hot lesion was visible in the same region. The lesion was expressed as a low-signal intensity area on T1-weighted magnetic resonance (MR) image and as a high-signal intensity area on T2-weighted MR image. The tumor was broadly resected together with peripheral normal bone, and cranioplasty using a resin plate was performed. The tumor was mainly composed of mature, regularly aligned bone (lamellar bone) and intermingled fibrous tissue. Ossifying fibroma is a rare, benign fibro-osseous tumor that mainly involves the craniofacial bone. A few cases involving the cranial vault alone have been reported. The relevant literature is reviewed, and discussion focuses on the differential diagnosis between ossifying fibroma and monostotic fibrous dysplasia.

Orbital Metastases From Prostate Carcinoma

Prostate carcinoma was previously thought to be a rare source of orbital metastasis. We studied a clinical series of eight cases of orbital metastases from prostate carcinoma. Presenting symptoms included proptosis, pain, diplopia, eyelid swelling, decreased vision, ptosis, and red eye. The mean age at onset was 72.1 years. In three of the eight patients, evaluation of the orbital masses led to the diagnosis of prostate carcinoma. Of the six patients in whom computed tomography was performed, four had predominantly osteoblastic lesions. In our experience, the rapid development of an osteoblastic orbital lesion in an elderly man is highly suggestive of metastatic prostate carcinoma.

Bone Metastases in Malignant Gastrinoma

Six patients (4 women, 2 men) with malignant gastrinoma developed multiple bone metastases; osteolytic as well as osteoblastic lesions occurred. All lesions involved the central skeleton, most caused symptoms, and, in 2 cases, there was associated hypercalcemia with normal serum parathormone levels. Poor responses were observed after treatment with cytotoxic drugs, but good symptomatic responses occurred after radiotherapy in 2 of the 4 patients in whom it was used. The peptic ulcer component of the disease was well controlled in all patients by cimetidine with or without anticholinergic supplements or by ranitidine alone in doses of 300-600 mg daily. Five of the 6 patients died with a mean survival after diagnosis of Zollinger-Ellison syndrome of 3.3 yr (range 1.0-7.0 yr), suggesting that bone metastases are associated with a poor prognosis in metastatic gastrinoma.

The relationship between natural killer cells and drugs that modify metastasis of PA-III cells

Rat prostate adenocarcinoma III (PA-III) cells produce in L-W rats local tumors at the implant site, osteolytic and osteoblastic lesions and metastatic tumors in the lungs. Treatment of rats with dichloromethylene diphosphonate (Cl 2MDP) prevented the osteolytic lesions, but the drug showed little beneficial effect on the local and/or metastatic spread of tumor cells. While treatment of rats with piroxicam inhibited PA-III cell metastasis, it manifested only moderate protection against the development of osteolytic lesions. Treatments with both Cl 2MDP and piroxicam resulted in smaller tumors, no osteolysis and significantly reduced metastasis. Comparisons of natural killer (NK) cell activities in normal and in tumor-bearing rats, with and without drug treatments, showed that NK cell activity was suppressed by Cl 2MDP, and enhanced by piroxicam. When treatments included both drugs, NK cell activity was enhanced. Thus, the suppression of NK cell activity resulting from treatment with Cl 2MDP was reversed by piroxicam with resultant benefits from both drugs.

Giant lymph node hyperplasia with osteoblastic bone lesions and the POEMS (takatsuki's) syndrome

A 38-year-old black man with giant lymph node hyperplasia (GLH), osteoblastic lesions, and the POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes) was treated at the University of Chicago Hospitals. The patient had hepatosplenomegaly and generalized peripheral lymphadenopathy. Endocrinologic abnormalities included decreased testosterone with elevated luteinizing hormone and follicle-stimulating hormone, as well as hyperprolactinemia and possible hypothyroidism. Biopsy of a right femoral lymph node revealed GLH, and an osteoblastic pelvic lesion showed a marked lymphoplasmacytic infiltrate. By immunohistochemical techniques, plasma cells in the lymph node and osteoblastic lesion were polyclonal. A polyclonal hypergammaglobulinemia was present. The lymph node T-lymphocyte population showed a decreased helper-to-suppressor cell ratio. Other findings included thickening of the skin, finger clubbing, and anasarca. A severe sensory-motor polyneuropathy was the major factor contributing to the patient's death. The association of GLH, osteoblastic bone lesions, and the POEMS syndrome has been noted previously in Japan; however, the authors are unaware of reports on Western patients who had this combination of clinical and laboratory findings.

The course of metastatic disease originating from carcinoma of the prostate.

The purpose of this work was to study the time sequence and the patterns of the multistep spread of metastases. Fifty-one patients with stage D carcinoma of the prostate, previously treated for their primary tumor by surgery or radiotherapy combined with hormonal manipulation and for metastases by hormones and chemotherapy, were included in the study. The metastatic dissemination, characterized primarily by the appearance of bone metastases, could follow two distinct patterns: The first, characterized by sequential appearance of osteoblastic metastases, followed by the development of osteolytic bone lesions, and the second pattern, characterized by the simultaneous appearance of osteoblastic and osteolytic bone lesions. In cases with solely osteoblastic bone metastases, the lesions are hormone sensitive and long-lasting remissions could be obtained. The development of osteolytic bone lesions is usually accompanied by the recurrence of the primary tumor and appearance of metastases in other sites, such as the lymph nodes and lungs. Bone metastases became resistant to hormonal manipulation and with chemotherapy short remissions were obtained. The course of the terminal period is faster, with shorter survival times. The determination of serum acid and alkaline phosphatase levels seems to reflect the course of the disease during the initial period of the disease only, i.e. when bone metastases are sensitive to hormonal treatment.

Crescent sign on radionuclide static brain imaging

A 58-YEAR-OLD MAN was admitted because of recent onset of ataxia, blurred vision, and headache. One year previously he had low back pain, and a radiograph was interpreted as showing an osteoblastic lesion in the lumbosacral region. He was referred to the urology clinic (Veterans Administration Medical Center, Lexington, Kentucky) because of the possibility of metastatic prostatic carcinoma. Laboratory and clinical findings were negative for prostate malignancy. Bone scintigraphy suggested Paget's disease of bone involving the skull, left clavicle, both humeri, and the thoracic and lumbar spine. Alkaline phosphatase was 379/a/mL (N = 30 to 110 #/mL). Bone radiographic surveys were consistent with Paget's disease of skull, spine, humeri, and clavicle. A myelogram showed high-grade partial impingement at the level of T-12 and L-3 to L-4, L-4 to L-5 posterior extradural defect. Physical examination on the current admission showed decreased corneal reflex on the left, and diminished hearing with air conduction greater than bone conduction bilaterally. Right lateral nystagmus with rotatory component was noted. Brain stem auditory-evoked responses showed a right-side defect consistent with a brain stem lesion. The left side could not be properly evaluated. Brain scintigraphy showed a crescentshaped area of increased radioactivity over the left convexity (Fig 1). The current skull radiograph showed thickened calvarium with extensive sclerotic, especially on the left side (Fig 2). Repeat bone scintigraphy (Fig 3) was essentially unchanged from the previous scan. A computed tomographic (CT) scan of the skull (Fig 4) showed asymmetric enlargement of the bony calvarium on the left side and no evidence of intracranial involvement. Usually a cresent sign on the anterior and/or posterior projection of the static brain image is considered to be characteristic of subdural hematoma; however, the sign is not pathognomic for dural fluid collection, and it may be encountered in many head conditions including lesions of the scalp, calvarium, meninges, and cerebrum. Subdural hematoma or subdural effusion usually shows a peripheral compression on the side of abnormality in the radionuclide cerebral angiogram. In the present case, the posterior cerebral radionuclide angiogram has no evidence of

Osteoblastic Lesions in a Patient with a Bladder Filling Defect

Osteoblastic Lesions in a Patient with a Bladder Filling Defect

Osteoblastic metastatic disease as a therapeutic response to adjuvant chemotherapy in breast cancer

Included in this study were 43 breast cancer patients treated with adjuvant chemotherapy who presented metastasis only in bone. Forty-two percent had metastasis during chemotherapy, and 58% had metastasis after the completion of chemotherapy. In 66% of the patients, the lesions were osteolytic. Twenty-nine percent had osteoblastic lesions, and 5% had mixed lesions. Of the patients with osteoblastic metastatic disease, five showed asymptomatic, osteoblastic disease; this response was considered to be a healing response to chemotherapy. These five patients were continued on the same therapy. The median duration of this response to the adjuvant chemotherapy was 29 months (range 6 to 62+). In one patient, osteoblastic disease gradually faded, and skeletal radiographs reverted to normal.

Early combined hormonal and chemotherapy for metastatic prostatic carcinoma

Twenty-four patients with confirmed Stage D carcinoma of the prostate were treated with a combination of bilateral orchiectomy, estrogens (diethylstilbestrol) and chemotherapy (5-fluorouracil), and cyclophosphamide soon after diagnosis was established. Patients were followed up between forty-two to seventy-two months. Seventy-five per cent of patients reported relief of bone pain after initiation of therapy, and 83.3 per cent reported relief of their urinary symptoms. The primary tumor shrank in all patients, and initial stabilization or partial disappearance of osteoblastic lesions on bone scans was noted in 79.1 per cent of patients. The cumulative survival rates at five and six years were 63.48 and 50.78 per cent, respectively. The combined therapy was well tolerated by the patients, and complications were not severe and of a transient nature.

Skeletal Manifestations in Cutaneous T-Cell Lymphomas

The clinical course of three patients with cutaneous T-cell lymphoma (CTCL) in whom skeletal disease developed is presented and the literature on skeletal involvement in these disorders is reviewed. Three separate types of skeletal manifestations occurred: (1) osteolytic lesions, (2) osteoblastic lesions, and (3) diffuse osteoporosis. Hypercalcemia was present in two cases. Tumor cells from two patients in short-term culture secreted osteoclast-activating factor(s). Both of these patients had pathologic evidence of osteoclast activation in bone sections. Thus, the tumor cells in certain patients with CTCL may derive from a monoclonal proliferation of a T-cell subset capable of producing humoral bone-resorbing factor(s) similar to those demonstrated in cultures of mitogen- and antigen-activated normal lymphocytes. Since skeletal lesions are unusual, it would follow that other T-cell subsets account for pathologic cell proliferation in most patients with CTCL.

Oophorectomy in advanced breast cancer: clinical radiologic correlations.

The radiograms of the chest and skeleton of 49 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance or progression of intrathoracic lesions, like the appearance or progression of osteolytic lesions, corresponded to a progression of the disease in other sites. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy. The response of chest and bone metastases is usually rather early, and the first radiographic survey should be performed about 3 months after ovariectomy.

The skeletal manifestations of chronic myelogenous leukemia

Skeletal lesions were radiographically apparent in 6 of 36 (16%) patients with chronic myelogenous leukemia. The spectrum of radiographic changes including diffuse osteoporosis, focal osteolytic and osteoblastic lesions, chloroma, and arthritis, and their clinical behavior is discussed.

Monostotic fibrous dysplasia in the temporal bone: a late prehistoric occurrence.

Fibrous dysplasia, characterized by benign osteolytic and osteoblastic lesions may involve one or several bones. Recent investigators have suggested that it may be merely a phase of what have previously been thought to be several different bone diseases. Isolated fibrous dysplasia in the temporal bone is infrequent. Several reports of this disease have appeared in the literature of paleopathology, but none involved only the temporal bone. Monostotic involvement of the right temporal bone was discovered in the skull of an adult male recovered from an archeological site dating from the Late Mississippian period (A.D. 1,350-A.D. 1,650). It will provide an opportunity for preliminary documentation of the antiquity of this disease in the southeastern portion of the United States.

The influence of bone pain on the results of bone scans.

The diagnostic value of bone pain in 227 consecutive patients with known primary tumor was investigated and bone scans were obtained. Eighty-two of 130 patients with bone pain had metastases with positive scans. In contrast, 80 of 97 patients without pain did not have metastases and the scans were negative; 13, however, did have metastases and positive scans, and in 10 of these the lesions were osteoblastic. Osteoblastic metastases may not produce pain. In a group of 70 patients with bone pain of unknown origin or elevated phosphatase levels, bone scans were also obtained and evaluated. Only one had metastatic disease, 40 were negative, and 29 had positive scans due to benign disease. It is concluded that in the assessment of malignancies, bone pain is a good indication for bone scintigraphy, except in those patients with osteoblastic lesions. However, when malignant disease has not yet been established, bone pain is not a reliable indication for scanning and radiographic examination is the initial examination of choice.

Soft tissue metastasis of a chemodectoma. A case report and review of the literature

A case of a single soft tissue metastases (abdominal wall) occurring 15 years after removal of chemodectoma of the right carotid bifurcation is described. The tumor had apparently been completely removed with excision of portions of the common, external and internal carotid arteries up to the base of the skull. Seven years later osteolytic and osteoblastic lesions were noted in the cervical and thoracic vertebrae which were radiated with 3500 rad. The 19 previously reported cases of chemodectomas with distant metastases are reviewed.

Symptomatic Osseous Sarcoidosis with Findings on Bone Scan

Twenty-one years after the onset of sarcoidosis, a 51-year-old woman experienced pain in the lower portion of her back, which proved to be the result of sarcoidosis involving the pelvis. The pelvic abnormality consisted of osteosclerotic and osteoblastic lesions. A bone scan showed several other areas of increased uptake, and the diagnosis was confirmed by bone biopsy. The patient improved with treatment with steroids, but the findings on the x-ray film and the bone scan did not change. Sarcoidosis may cause obscure, but symptomatic, osseous lesions.

Disappearance of Osteoblastic Metastases in Prostatic Carcinoma Following Estramustine Therapy

To the Editor.— Healing of osseous metastases is usually described as a recalcification process and is best seen in osteolytic lesions. 1 Osteoblastic lesions are more difficult to evaluate. Eighty percent of the skeletal metastases in prostatic carcinoma are purely osteoblastic in nature 2 ; thus, the evaluation of improvement is difficult. Endocrine therapy may bring about a dramatic clinical improvement associated with return of acid and alkaline phosphatase values to normal, but the roentgenographic appearance of the blastic lesions rarely changes. In an early report, Huggins and co-workers 3 claimed that all patients with prostatic carcinoma who underwent orchiectomy had increased osteosclerosis of the skeletal metastases. Others 2 have reported an occasional shrinkage of osteoblastic lesions, but complete disappearance of osteoblastic metastases has never, to our knowledge, been previously reported. Two patients treated with estramustine phosphate (Estracyt) who were observed for more than three years exhibited a gradual complete disappearance

Chemotherapy of skeletal metastases

INTRODUCTION Metastatic cancer to bone is the most common bone cancer,23 unlike primary bone tumors, occurs at multiple sites 90% of the time.13 The axial skeleton is most often affected; the extremities rarely. Neoplasms of the breast, lung, prostate, kidney and thyroid account for nearly 80% of bone metastases. Skeletal metastases from the colon, pancreas and stomach are uncommon, occurring in less than 10% of patients with these tumors.‘.‘333 Radiographic appearance of the bone metastases aids in the identification of the primary source. Osteoblastic lesions in males most frequently will be of prostatic origin, rarely from pancreas, colon, lung, carcinoid tumor, Hodgkin’s disease, or myeloma. _41though the majority of skeletal breast lesions are lytic, the most common source of blastic bony metastases in women is breast cancer. Lytic bone lesions generally are without characteristic identifying features which would help in the identification of the primary cancer, with the exception of kidney, which often presents as a solitary radiolucent expansile bone lesion. Radiotherapy is the treatment of choice for skeletal metastases which are painful and few in number or located in strategic areas of skeletal support. However, many bone lesions, can be expected to respond favorably to chemotherapy. The effectiveness of chemotherapy on various skeletal metastases is reviewed. THYROID Thyroid carcinomas characteristically have many long term survivors following surgical therapy, 80-90% live 10 years or greater. The small number that succumb to ‘their disease often have bone or pulmonary metastases or both.1%1834 Papillary carcinoma occurs in approximately 66% of patients and tends to metastasize to local lymph nodes. Follicular carcinoma occurs in 20% of patients with a predilection for vessel invasion and subsequent bone and lung metastases. Treatment other than surgery has resided consistently with oral 13’1 administration. The dose is generally lOO-300mCi given repeatedly over 2 years for a total dose of 500 mCi.” I31 I has been documented to accumulate in bone metastases and to have a favorable effect on survival. In one study, all of 10 patients lived 5 years, with 3 patients living 6, 15 and 25 years after ‘9 therapy.” There is even documentation of roentgenograms returning to normal in 5 of 30 patients, with total regression of pain in all patients.” Other chemotherapeutic agents used in metastatic thyroid cancer without success are 5-fluorouracil, methotrexate, actinomycin D, cyclophosphamide, phenylaline mustard, and others.” The use of bleomycin has had conflicting reports.‘6 Adriamycin (75 mglm’ q3 week) achieved 4 partial remissions in 12 patients with bone involvement, it was documented as 50% radiographic regression for 1 month. One patient had relief of pain.‘O 13’1 appears to be the agent of choice when metastases are small and capable of concentrating 1311. Thus far, adriamycin is the only chemotherapeutic agent shown to be effective in advanced bone metastases.