Presentation on theme: "Case Report #  Submitted by: Jason Pearce, MS IV Faculty reviewer:"— Presentation transcript:
1 Case Report #  Submitted by: Jason Pearce, MS IV Faculty reviewer: Radiological Category:Principal Modality (1):Principal Modality (2):MRICT/ CXR/NuclearCase Report # Submitted by:Jason Pearce, MS IVFaculty reviewer:Sandra. A. A. Oldham M.D.Date accepted:August 30, 2007
2 Case HistoryPatient 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 hasn’t 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.
13 These images belong to two other patients. The PMH not given earlier is this pt had hx of renal cell carcinoma.
14 Findings and Differentials 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, 7.8cmlytic 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 MyelomaMetastatic CancerPrimary Bone CancerFibrous Dysplasia
15 Discussion Multiple Myeloma Neoplastic proliferation of a single clone of plasma cells producing a monoclonalimmunuglobulin 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 cellssuppress osteoblast activity; therefore, typically, no increased uptake is observed.Lesions are seen as focal or diffuse areas of hypointensity on T1-weighted images andas areas of intermediate or high signal intensity on T2-weighted images. Myelomalesions tend to enhance somewhat with gadolinium.In our case it would be difficult to differentiate this from metastasis, but the degree ofenhancement by gadolinium may be slightly less.
16 Discussion Fibrous Dysplasia Fibrous dysplasia is a skeletal developmental anomaly of the bone-forming mesenchymethat manifests as a defect in osteoblastic differentiation and maturation. Virtually anybone 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 fracture20-30% 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 extracraniallesions are present.On T1-weighted MRIs, the lesion has low-to-intermediate signal intensity equal to that ofmuscle. T2-weighted images also show low signal intensity owing to the high content ofcollagen and bone.
17 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 predominantdistribution of metastatic lesions in the red marrow–containing areas in adults.Bone metastasis can occur from almost any malignancy, but the most common arefrom 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 caVascular metastasis include: ovarian, renal, thyroid, and melanoma.Bone metastases usually affect axial skeleton, appendicular skeleton later (andmuch 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 than1 cm and have destroyed 30-50% of the bone density in order to beseen by x-ray.
18 Discussion Bone Metastasis Bone Scan: good for detecting lesions prior to evidence on plain film, and forability to view all bones at one time, however bone scans are onlyspecific for bone turnover, not malignancy.CT/MRI: useful for equivocal changes on plain film. MRI can show bone changeseven before metabolic abnormalities are seen on bone scans. Lesionsare seen as focal or diffuse areas of hypointensity on T1-weightedimages and as areas of intermediate or high signal intensity on T2-weighted images.
19 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 & Wilm’s Tumor among children 5-6%)Risk Factors: Smoking – 2 fold increased risk, found in 1/3 of reported casesObesityDialysis – increased, primarily after 8-10 years of dialysisVonHippel-Lindau disease – 40-60% will develop RCCFamily HistorySymptoms: completely asymptomatic (often pts present w/ metastatis)flank pain, abdominal mass, hematuria (all 3 in only 8-10%)anemia, HTN, fever of unknown originparaneoplastic syndromes (erythrocytosis, PTHrp, renin, etc.)
20 Discussion Renal Cell Carcinoma (RCC) Diagnosis: 1. First choice is usually CT w/ contrast*** 95% of RCCs are hypervascular. contrast enhancement is usuallystrong and heterogeneous due to areas or hemorrhage andnecrosis2. If CT inconclusive, get a Ultrasound to differentiate solid vs. cystic*** Most commonly is hyperechoic on sonography, but can also behypo- and isoechoic3. If still nondiagnostic or if pt can’t receive IV contrast, consider MRI4. When working up pt for possible metastasis, bone scans and PETscans are effective (however bone scan are only recommended forpts with bone pain or elevated serum alkaline phosphatase).
21 Discussion Staging: Robson Staging Stage 1 - Confined to the kidney Stage 2 - Involvement of perinephric fat but Gerota's fascia intactStage 3 - Spread into renal veinStage 4 - Spread into adjacent or distant organsI >90%, II 75-90%, III 50-70%, IV <10%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% ofpts present w/ metastasis 5 years post nephrectomy.Although recurrence of RCC has a poor prognosis, some studies areshow longer survival w/ increased interval between nephrectomy andrecurrence and also single foci of metastasis.Decreased survival is shown w/ serum LDH >1.5 normal, serumCa >10mg/dl, hemoglobin concentrations below normal, absence ofdisease free interval.
22 DiscussionLung Mets: 29-54% of pts w/ recurrence, 90% diagnosed withoutsymptoms, however f/u w/ CT vs CXR is still debated.Bone Mets: 16-31% of pts w/ recurrence, however 67-91% do presentw/ localized pain. Usually only monitored by symptomsand serum alkaline phosphatase levels.Liver Mets: 8-30% of pts w/ recurrence, 90% or more are detected bysymptoms or abnormal lab values.Brain Mets: 2-10% of pts w/ recurrence, greater than 80% havesymptoms, including; headaches, altered behavior,seizures or focal neurological signs.
23 DiagnosisRenal Cell Carcinoma w/ distant metastases to bone, lung and adrenal gland.
24 References1.) Andreoli. Cecil Essentials of Medicine, 6th Ed., ) Atkins, Michael. Up To Date; Epidemiology, pathology, and pathogenesis of renal cell carcinoma, ) Peh, Wilfred. eMedicine; Bone Metastasis, ) Noveline, Robert A. Squire’s Fundamentals of Radiology, 6th Ed., 2004.