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Ddx please
30 yo woman with incidental finding on CT abd/pelvis for belly pain. Lytic lesion in iliac bone, hot on PET. A few smaller lytic lesions in sacrum. EXQUISITELY painful with biopsy. The bone around it was not painful at all. Path results here, and send out, are read as normal bone and hematopoietic cells. (I just realized I don’t know how to attach a photo, so a little help!)
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55 Replies
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nope that didn’t work either.
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MR appearance? Or did it go CT -> PET? Where in iliac and sacrum? Near SI joint? Seems like the PET tied your hands.
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CT–>PET well circumscribed lytic lesion right ilium near SI joint. Hot on PET. A few smaller lytic lesions in right sacral ala. too small for PET. Crazy sensitive when needle hit the soft part.
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Images would be great to see if you can somehow upload them
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Multiple myeloma would fit.
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Myeloma is and was my first choice, but they specifically state in the path that it doesn’t have the appearance of myeloma. Maybe very early? (ie still looks like normal bone).
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happy to share images if someone can tell me how to post them here
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Brown tumor might be worth consideration. Easy enough to look for hyperparathyroidism.
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Get the path reviewed.
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The path was done here, then sent out at my request due to discordant findings. Same result.
I put brown tumor in ddx also EG, but they did a PET and CT C/A/P and everything else was normal. Breast MRI as well. -
1)Without having images, if this case got referred in to our bone tumor board it would get a universal
“why isn’t there an MRI yet”
It can help characterize the lesion and, with discordant results can help to see if the first biopsy was somehow into a chunk of normal bone (… sometimes there are two lesions and the needle gets halfway in between etc)
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2) Sensitivity to bone biopsy, especially if you are using any suction/aspiration to your technique is highly idiosyncratic by patient. Pain does not narrow my differential (say in the way an exquisitely
painful St mass might make me think neurogenic tumor)
3) What does the cortex look like? Is it broken/thinned? Geographic 1a (sclerotic margin?) Is there a soft tissue component? What is the HU of the lesion? Any chance it’s just fat and *looks* lytic on the CT? Any chance you got in to a hunk of lytic phase Pagets?
4) When you say “hot” on PET… how hot? Lots and lots of benign stuff can be a bit warm. -
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Unfortunately the patient is not terribly interested in more imaging. She is of the mindset that the biopsy showed nothing so she is not going to do anything else. I doubt she will come in for an MRI.
I have performed my fair share of bone biopsies. Both marrow and hard bone. I understand patients have varying degrees or perception of pain. Honestly, this patient had an almost alarming degree of pain. I’m talking writhing around on table when the needle touched the lesion. I stopped, and she stopped complaining. As soon as I touched (literally touched, not advanced or moved) the needle, she started writhing in pain again. Keep in mind she had Fentanyl and Versed on board and was laying on her belly so she couldn’t see what I was doing. It was very surprising. I immediately thought, wait is this some weird nerve bundle or nerve tumor that I am touching? But it is sitting inside of the bone, with no connection to anything. So I did the biopsy thinking that at least she wouldn’t get a foot drop or something if it is nervous tissue.
There is a thin margin around the lytic lesion. Barely perceptible, but it is there. I wouldn’t call it sclerotic. PET max SUV 8.8 so it’s medium hot. No soft tissue component. It is well circumscribed inside of the otherwise normal appearing bone. Tiny similar lytic lesions in right sacral ala. Too small for PET.
I still think because of her age, its early myeloma. Unfortunately, I doubt she would go for a repeat biopsy, and two path depts say it doesn’t look like myeloma. Going back to my med school HemOnc days, bony mets are 99% “BLT with Kosher Pickle and Mayo”: Breast, Lung, Thyroid, Kidney, Prostate, Myeloma.
It wasn’t there 2 years ago, so it will present itself soon enough..unfortunately.
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Seems like a young patient ( 30 y/o). Also, female. Don’t discount sarcoidosis with hot PET lesion and lucent/ lytic appearance on CT that were not there before and a couple of other foci. If there is a chest CT, look for pulm. manifestation of the same.
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Hard to give too specific of a diagnosis without the images, but if it’s a new lytic bone lesion compared to 2 years ago and 8.8 SUV max it’s pretty unlikely to be “normal bone”.
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This is grossly discordant.
Again, if this was brought to our tumor board we would *strongly* advise the patient to continue the work up.
First have the path re-reviewed outside.
If it remains discordant (“normal bone”) then, given the lesion described and its interval development over a short time frame, then repeat biopsy is warranted.
At our place we would review the biopsy images to make sure that the biopsy was actually lesional tissue. If the biopsy was technically appropriate then surgical biopsy next. If it is possible that the biopsy missed the lesion, then repeat image guided.
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Agree 100% with above.
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Open bx.
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Hemipelvectomy
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If its a sarcoma; that is next.
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It was an incidentally noted lesion on AP CT for belly pain in 30 y/o female , that is hyper metabolic on PET. while I agree that repeat ( possibly Surgical biopsy) may be required for confirmation ; in my experience incidentally noted ( asymptomatic) FDG avid lesions on PET in young people tend to be non cancerous and sarcoid is in the Ddx.
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Unlikely to be sarcoid. She had a CT C/A/P that was negative. MRI breast was negative aslo. After the outside path report came back and after I did a second look at my biopsy images confirming needle in dead center of lesion, I recommended f/u with Ortho for their recommendations for biopsy. But like I said, the patient is a 30 year old who isn’t keen on additional imaging, much less procedures.
For me, 8.8 SUV is too hot for most noncancerous lesions.
I’ll post an update if and when we get more info. -
Quote from RADD2010
It was an incidentally noted lesion on AP CT for belly pain in 30 y/o female , that is hyper metabolic on PET. while I agree that repeat ( possibly Surgical biopsy) may be required for confirmation ; in my experience incidentally noted ( asymptomatic) FDG avid lesions on PET in young people tend to be non cancerous and sarcoid is in the Ddx.
You can put sarcoid in the differential if you want, though it’s not very common to see in bone. Maybe 5% of sarcoid cases. And that’s of course assuming the patient has sarcoid.
Aside from the SUV, the other critical factor is that it wasn’t there (apparently) 2 years ago. Have to be very suspicious in that case.
Either way, “normal bone, next case” likely ain’t gonna cut it for this one.-
Good discussion. Look forward to follow up.
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One other thing; and of course it won’t be this, but I have seen a similar case in almost every way that turned out to be a primitive liposarcoma. It took an open bx, and a lot of big shot pathologists to even give it a name.
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save image on phone as jpeg. Go to full version at bottom of screen.
Quick Reply: [link=https://www.auntminnie.com/Forum/tm.aspx?high=&m=643991&mpage=1](Open Full Version)[/link]
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I don’t have any icons (ie paperclip) when I click full version; just post, preview, cancel, and attach signature.
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Did you adequately sample the lesion?
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You can see my introducer needle in the lesion. I did a core bx, and an FNA with a Chiba. Local path and send out path reports say normal hematopoietic elements.
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Fibrous dysplasia should have been there 2 years ago. It wasn’t. (She previously had a CT through the ED for belly pain)
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Quote from 67ED5CC042435
Weird. I think you did your due diligence with your recs.
What about fibrous dysplasia?
Fibrous dysplasia should show up on path
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I still think 1)myeloma, 2)myeloma, 3)myeloma, 4)something weird.
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I don’t know if they have gone as far as serum electrophoresis. Like I said she is 30 and not too keen on much follow up. Denial is a strong defense mechanism.
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Quote from dysdiadochokinesia
You can see my introducer needle in the lesion. I did a core bx, and an FNA with a Chiba. Local path and send out path reports say normal hematopoietic elements.
[attachment=0]
What Kind of core did you do? 13 gauge Jamshedi core?
Normal hematopoetic elements doesn’t sound right when there is an obvious lytic lesion. -
May be a long shot with the metabolic update, but any chance this could just represent a geode? I found a random study with degenerative cysts showing up to 6 SUV max. Certainly something that could have developed in the short term, is close to joint and wouldn’t be too peculiar in this age group. May account for negative biopsy results if you just passed through some fluid and got into normal surrounding bone. Still hard to explain the pain described by the patient. Interesting case and I admire your persistence.
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Quote from rad567
May be a long shot with the metabolic update, but any chance this could just represent a geode? I found a random study with degenerative cysts showing up to 6 SUV max. Certainly something that could have developed in the short term, is close to joint and wouldn’t be too peculiar in this age group. May account for negative biopsy results if you just passed through some fluid and got into normal surrounding bone. Still hard to explain the pain described by the patient. Interesting case and I admire your persistence.
Schmorles node
[h2]Microscopic[/h2] Features:
[ul][*]Subchondral necrosis of bone – [b]key feature[/b]. [ul][*]Loss of osteocytes within the bony trabeculae. [/ul] [*]Reactive woven bone: [ul][*]Thickened trabeculae.[*]Increased numbers of osteoblasts and osteoclasts. [/ul] [*]Bone marrow cavity fibrosis with small blood vessels and loss of adipocytes (reactive process). [/ul] Note:
[ul][*]Histologically, [i]Schmorl’s node[/i] is considered a cousin of avascular necrosis of the femoral head. [/ul] -not normal hematopoetic elements -
Interesting, but I was not referring to schmorl’s nodes.
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Quote from rad567
Interesting, but I was not referring to schmorl’s nodes.
Schmorls node similar path as geode or subchondral cyst.
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I saw your images. Theres the lesion in the iliac bone thats hot on PET. Am I being fooled or is there a cluster of similar lesions on the same slice in the sacrum? The sclerotic rims and the presence of cold lesions on PET (and age 30) seems unusual for myeloma. Could be cancer sure but maybe granulomatous disease as possibility. Its been a while but Ive seen either active coccidio or histo lesions in the spine before.
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The lytic lesions in the sacrum are likely too small to be hot on PET. I have seen plenty of 30-somethings with myeloma unfortunately. That doesn’t mean it isn’t something inflammatory though.
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Wow !
Where do u practice ? I am in California and haven’t seen a single 30 year old patient with multiple myeloma in my 15 years of radiology practice !
“Less than 1% of multiple myeloma cases are diagnosed in people younger than 35. Most people diagnosed with this cancer are [b]at least 65 years old”[/b] -
I agree. I have seen it in this age but super rare, a definite zebra in this age group with what we’ve seen so far.
The best test for this patient hasn’t been done yet so need to do that before we can give a good Ddx.
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That lesion isnt much bigger than something I might easily blow past , kinda scary.
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Agree, The lesion has sclerotic margin ! Doesn’t matter if SUV is 6 or 8. Granulomatous disease more likely, not myeloma or cancer in a 30 year old female.
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I can’t think of a good reason this patient got a breast MRI but not a pelvic MRI (unless I skimmed over it in the thread). This case should be CT to MRI 100% of the time, +/- PET only if needed.
As far as the geode/subchondral inflammatory erosion, you should be able to connect it to the SI joint in those cases, even if its a small neck. Don’t see that here but it’s only 1 image, would need to scroll.
In my opinion I would strongly recommend an MRI. If its something suspicious there may be other scattered small lesions that PET wouldnt pick up as well.
At minimum, should get some sort of imaging in 3 months to follow up. May declare itself by then. -
yeah, f/u with MRI is the most reasonable thing to do.
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Laurane bone biopsy kit. Not sure of gauge but it ain’t small.[;)]
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Thanks for posting the images. Great thoughts in the thread. Myeloma definitely of concern.
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Quote from dysdiadochokinesia
Laurane bone biopsy kit. Not sure of gauge but it ain’t small.[;)]
Laurane bone biopsy kit. 11-13 gauge- I looked it up. Consider going over this case with the pathologist. The margin of the lesion as well as the center should be sampled.
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