INTERESTING IMAGE
Xanthogranulomatous Osteomyelitis of Rib Mimicking Malignant Lesions in 18F-FDG PET/CT Imaging A Report of Two Cases Yan-li Wang, MD,*Þ Hua Yu, MD,þ Hua Zhang, MD,§ Xin-jian Cui,Þ and Jian-kui Han, PhD* Abstract: Xanthogranulomatous osteomyelitis is a rare inflammatory process characterized histologically by collection of foamy macrophages admixed with mononuclear cells. We describe 2 cases with chest and back pain; radiography and CT scan identified expansile osteolytic rib destructive lesions with soft tissue mass. 18F-FDG PET/CT revealed accumulation of 18 F-FDG similar to malignancy. Xanthogranulomatous osteomyelitis was histologically confirmed with numerous foamy histiocytes admixed with inflammatory infiltrate. Key Words: xanthogranulomatous osteomyelitis, inflammatory false positive
18
F-FDG PET/CT,
(Clin Nucl Med 2014;39: e315Ye317)
Received for publication January 15, 2013; and revision accepted June 24, 2013. From the *Department of Nuclear Medicine, Qilu Hospital, Shandong University, Jinan; and Departments of †PET/CT, ‡Nuclear Medicine, and §Occupational Disease, Qingdao City Center Hospital, Qingdao, China. Conflicts of interest and sources of funding: none declared. Reprints: Jian-kui Han, PhD, Department of Nuclear Medicine, Qilu Hospital, Shandong University, Wenhua Xi Road, Jinan, Shandong 250012, China. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3905Ye315
Clinical Nuclear Medicine
& Volume 39, Number 5, May 2014
REFERENCES 1. Cuzzutto C. Xanthogranulomatous osteomyelitis. Arch Pathol Lab Med. 1984; 108:973Y976. 2. Franco V, Aragona F, Genova G, et al. Xanthogranulomatous cholecystitis histopathological study and classification. Pathol Res Pract. 1990;186:383Y390. 3. Singh SK, Khandelwal AK, Pawar DS, et al. Xanthogranulomatous cystitis: a rare clinical entity. Urol Ann. 2010;2:125Y126. 4. Vankalakuni M, Saikia UN, Mathew M, et al. Xanthogranulomatous osteomyelitis of ulna mimicking neoplasm. World J Surg Oncol. 2007;5:46. 5. Kamat G, Gramapurohit V, Myageri A, et al. Xanthogranulomatous osteomyelitis presenting as swelling in right tibia. Case Report Pathol. 2011;2011: 257458. 6. Borjian A, Rezaei F, Eshaghi MA, et al. Xanthogranulomatous osteomyelitis. J Orthop Traumatol. 2012;13:217Y220. 7. Zheng Z, Pan YM, Guo FW, et al. Multimodality FDG PET/CT appearance of pulmonary tuberculoma mimicking lung cancer and pathologic correlation in a tuberculosis-endemic country. South Med J. 2011;104:440Y445. 8. Atacrgin S, Arslan N, Ozet A, et al. Abnormal FDG uptake on 18Ffluorodeoxyglucose positron emission tomography in patients with cancer diagnosis: case reports of tuberculous lymphadenitis. Intern Med. 2009; 48:115Y119.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Clinical Nuclear Medicine
Wang et al
& Volume 39, Number 5, May 2014
FIGURE 1. A 45-year-old man presented with 2 months of increasing chest pain. Radiography and CT demonstrated third left rib expansile osteolytic destruction with soft tissue mass; 3D reconstruction (A). An 18F-FDG PET MIP (B) demonstrates activity in the left third rib and left thyroid. The left third rib lesion (C) and a left thyroid nodule (D) with high uptake of 18F-FDG were identified. The left third rib lesion was resected and a left thyroid lobectomy was performed. Microscopically, the rib lesion (E) showed a diffuse infiltrate, composed of numerous foamy histiocytes admixed with inflammatory infiltrate (hematoxylin-eosin, original magnification 10), and the thyroid nodule (F) showed intact capsule, folliculi, and uniform-sized follicle epithelial cells (hematoxylin-eosin, original magnification 10). The pathological diagnoses of xanthogranulomatous osteomyelitis and thyroid adenoma were made. Xanthogranulomatous osteomyelitis is a chronic inflammatory condition characterized histologically by foamy macrophages admixed with mononuclear cells.1 Xanthogranulomatous inflammation is more typically seen in kidney, gallbladder, colon, pancreas, and salivary gland.2,3 Lung, brain, and bone are rarely affected. Cozzutto reported the first 2 cases of xanthogranulomatous osteomyelitis in 1984, 1 involving the first rib and epiphysis of tibia, respectively. Xanthogranulomatous osteomyelitis typically extends to adjacent tissues and is commonly misdiagnosed as malignant neoplasm.4 Five cases of xanthogranulomatous osteomyelitis have been reported,1,4Y6 and there is little experience of xanthogranulomatous osteomyelitis in PET/CT imaging.
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* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 5, May 2014
Osteomyelitis of Rib in
18
F-FDG PET/CT
FIGURE 2. A 46-year-old man with prior history of trauma presented with chest and back pain increasing over 7 months. Physical examination revealed percussion chest and back pain. Radiography and CT demonstrated expansile osteolytic destruction in the eighth right rib and the fifth left rib; 3D reconstruction (A). 18F-FDG PET/CT MIP (B) shows that the eighth right rib lesion involves the T7 and T8 vertebra, SUVmax 7.57 (C). The fifth left rib SUVmax was 3.79 (D). Microscopically, diffuse inflammatory infiltration containing neutrophilic granulocytes and lymph-plasma cells admixed with foamy macrophages consistent with xanthogranulomatous osteomyelitis were demonstrated (hematoxylin-eosin, original magnification 20; E). 18F-FDG uptake is not specific for malignancy, and some benign abnormalities can demonstrate 18F-FDG accumulation as well.7 Additionally, inflammatory cells such as neutrophils, lymphocytes, and activated macrophages at the site of inflammation of infection show increased 18F-FDG accumulation.8
* 2013 Lippincott Williams & Wilkins
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Xanthogranulomatous Osteomyelitis of Rib Mimicking Malignant Lesions in 18F-FDG PET/CT Imaging A Report of Two Cases Yan-li Wang, MD,*Þ Hua Yu, MD,þ Hua Zhang, MD,§ Xin-jian Cui,Þ and Jian-kui Han, PhD* Abstract: Xanthogranulomatous osteomyelitis is a rare inflammatory process characterized histologically by collection of foamy macrophages admixed with mononuclear cells. We describe 2 cases with chest and back pain; radiography and CT scan identified expansile osteolytic rib destructive lesions with soft tissue mass. 18F-FDG PET/CT revealed accumulation of 18 F-FDG similar to malignancy. Xanthogranulomatous osteomyelitis was histologically confirmed with numerous foamy histiocytes admixed with inflammatory infiltrate. Key Words: xanthogranulomatous osteomyelitis, inflammatory false positive
18
F-FDG PET/CT,
(Clin Nucl Med 2014;39: e315Ye317)
Received for publication January 15, 2013; and revision accepted June 24, 2013. From the *Department of Nuclear Medicine, Qilu Hospital, Shandong University, Jinan; and Departments of †PET/CT, ‡Nuclear Medicine, and §Occupational Disease, Qingdao City Center Hospital, Qingdao, China. Conflicts of interest and sources of funding: none declared. Reprints: Jian-kui Han, PhD, Department of Nuclear Medicine, Qilu Hospital, Shandong University, Wenhua Xi Road, Jinan, Shandong 250012, China. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3905Ye315
Clinical Nuclear Medicine
& Volume 39, Number 5, May 2014
REFERENCES 1. Cuzzutto C. Xanthogranulomatous osteomyelitis. Arch Pathol Lab Med. 1984; 108:973Y976. 2. Franco V, Aragona F, Genova G, et al. Xanthogranulomatous cholecystitis histopathological study and classification. Pathol Res Pract. 1990;186:383Y390. 3. Singh SK, Khandelwal AK, Pawar DS, et al. Xanthogranulomatous cystitis: a rare clinical entity. Urol Ann. 2010;2:125Y126. 4. Vankalakuni M, Saikia UN, Mathew M, et al. Xanthogranulomatous osteomyelitis of ulna mimicking neoplasm. World J Surg Oncol. 2007;5:46. 5. Kamat G, Gramapurohit V, Myageri A, et al. Xanthogranulomatous osteomyelitis presenting as swelling in right tibia. Case Report Pathol. 2011;2011: 257458. 6. Borjian A, Rezaei F, Eshaghi MA, et al. Xanthogranulomatous osteomyelitis. J Orthop Traumatol. 2012;13:217Y220. 7. Zheng Z, Pan YM, Guo FW, et al. Multimodality FDG PET/CT appearance of pulmonary tuberculoma mimicking lung cancer and pathologic correlation in a tuberculosis-endemic country. South Med J. 2011;104:440Y445. 8. Atacrgin S, Arslan N, Ozet A, et al. Abnormal FDG uptake on 18Ffluorodeoxyglucose positron emission tomography in patients with cancer diagnosis: case reports of tuberculous lymphadenitis. Intern Med. 2009; 48:115Y119.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e315
Clinical Nuclear Medicine
Wang et al
& Volume 39, Number 5, May 2014
FIGURE 1. A 45-year-old man presented with 2 months of increasing chest pain. Radiography and CT demonstrated third left rib expansile osteolytic destruction with soft tissue mass; 3D reconstruction (A). An 18F-FDG PET MIP (B) demonstrates activity in the left third rib and left thyroid. The left third rib lesion (C) and a left thyroid nodule (D) with high uptake of 18F-FDG were identified. The left third rib lesion was resected and a left thyroid lobectomy was performed. Microscopically, the rib lesion (E) showed a diffuse infiltrate, composed of numerous foamy histiocytes admixed with inflammatory infiltrate (hematoxylin-eosin, original magnification 10), and the thyroid nodule (F) showed intact capsule, folliculi, and uniform-sized follicle epithelial cells (hematoxylin-eosin, original magnification 10). The pathological diagnoses of xanthogranulomatous osteomyelitis and thyroid adenoma were made. Xanthogranulomatous osteomyelitis is a chronic inflammatory condition characterized histologically by foamy macrophages admixed with mononuclear cells.1 Xanthogranulomatous inflammation is more typically seen in kidney, gallbladder, colon, pancreas, and salivary gland.2,3 Lung, brain, and bone are rarely affected. Cozzutto reported the first 2 cases of xanthogranulomatous osteomyelitis in 1984, 1 involving the first rib and epiphysis of tibia, respectively. Xanthogranulomatous osteomyelitis typically extends to adjacent tissues and is commonly misdiagnosed as malignant neoplasm.4 Five cases of xanthogranulomatous osteomyelitis have been reported,1,4Y6 and there is little experience of xanthogranulomatous osteomyelitis in PET/CT imaging.
e316
www.nuclearmed.com
* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 5, May 2014
Osteomyelitis of Rib in
18
F-FDG PET/CT
FIGURE 2. A 46-year-old man with prior history of trauma presented with chest and back pain increasing over 7 months. Physical examination revealed percussion chest and back pain. Radiography and CT demonstrated expansile osteolytic destruction in the eighth right rib and the fifth left rib; 3D reconstruction (A). 18F-FDG PET/CT MIP (B) shows that the eighth right rib lesion involves the T7 and T8 vertebra, SUVmax 7.57 (C). The fifth left rib SUVmax was 3.79 (D). Microscopically, diffuse inflammatory infiltration containing neutrophilic granulocytes and lymph-plasma cells admixed with foamy macrophages consistent with xanthogranulomatous osteomyelitis were demonstrated (hematoxylin-eosin, original magnification 20; E). 18F-FDG uptake is not specific for malignancy, and some benign abnormalities can demonstrate 18F-FDG accumulation as well.7 Additionally, inflammatory cells such as neutrophils, lymphocytes, and activated macrophages at the site of inflammation of infection show increased 18F-FDG accumulation.8
* 2013 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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