INTERESTING IMAGE
Marked Hematopoiesis Masquerading Multiple Bone Metastasis in a Lung Cancer Patient With Myelodysplastic Syndrome Osamu Imataki, MD,* Shumpei Uchida, MD,† Kohei Shiroshita, MD,† Jun-ichiro Kida, MD,* and Makiko Uemura, MD* Abstract: We diagnosed a 62-year-old man with lung cancer, well-differentiated squamous cell carcinoma, on the right upper lobe and left lower lobe. He had a history of myelodysplastic syndrome and refractory anemia with ringed sideroblasts diagnosed 5 years earlier. The patient's 18F-FDG PET/CT for the clinical staging of lung cancer revealed accumulations of FDG in multiple bones including the rib bones, which strongly suggested multiple bone metastases. He underwent lobectomies and excision of the right fourth and fifth rib bones. The pathological findings of resected rib bones exhibited hypercellular bone marrow without excess of blasts. Key Words: myelodysplastic syndrome, hypercellular marrow, lung cancer, multiple bone metastases, FDG PET (Clin Nucl Med 2015;40: 574–575)
Received for publication November 2, 2014; revision accepted November 17, 2014. From the *Division of Hematology and Stem Cell Transplantation, Department of Internal Medicine, and †Postgraduate Medical Training Center, Faculty of Medicine, Kagawa University, Kagawa, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Osamu Imataki, MD, Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kitagun, Kagawa, 761-0793, Japan. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4007–0574
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REFERENCES 1. Castello A, Coci A, Magrini U. Paraneoplastic marrow alterations in patients with cancer. Haematologica. 1992;77:392–397. 2. Chiang SB, Rebenstock A, Guan L, et al. Diffuse bone marrow involvement of Hodgkin lymphoma mimics hematopoietic cytokine-mediated FDG uptake on FDG PET imaging. Clin Nucl Med. 2003;28:674–676. 3. Blodgett TM, Ames JT, Torok FS, et al. Diffuse bone marrow uptake on wholebody F-18 fluorodeoxyglucose positron emission tomography in a patient taking recombinant erythropoietin. Clin Nucl Med. 2004;29:161–163. 4. Inoue K, Okada K, Harigae H, et al. Diffuse bone marrow uptake on F-18 FDG PET in patients with myelodysplastic syndromes. Clin Nucl Med. 2006;31: 721–723. 5. Teo BK, Badiee S, Hadi M, et al. Correcting tumour SUV for enhanced bone marrow uptake: retrospective 18F-FDG PET/CT studies. Nucl Med Commun. 2008;29: 359–366. 6. Hashimoto Y, Tsujikawa T, Kondo C, et al. Accuracy of PET for diagnosis of solid pulmonary lesions with 18F-FDG uptake below the standardized uptake value of 2.5. J Nucl Med. 2006;47:426–431. 7. Degirmenci B, Wilson D, Laymon CM, et al. Standardized uptake value-based evaluations of solitary pulmonary nodules using F-18 fluorodeoxyglucose-PET/ computed tomography. Nucl Med Commun. 2008;29:614–622. 8. Shin DS, Shon OJ, Han DS, et al. The clinical efficacy of (18)F-FDG-PET/CT in benign and malignant musculoskeletal tumors. Ann Nucl Med. 2008;22:603–609.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015
Myelodysplastic Syndrome Mimicking Metastasis
FIGURE 1. We diagnosed a 62-year-old man with lung cancer, well-differentiated squamous cell carcinoma, on the right upper lobe and left lower lobe. He had a history of myelodysplastic syndrome and refractory anemia with ringed sideroblasts diagnosed 5 years earlier. A chromosomal analysis of his bone marrow cells detected the normal karyotype. He subsequently underwent 18F-FDG PET/CT for the clinical staging of lung cancer to determine whether surgical treatment was indicated. The FDG PET/CT revealed accumulations of FDG in multiple bones, which strongly suggested multiple bone metastases (A). However, the SUVmax of the bone spots was lower (maximally 3.73) compared with that of the primary site (11.68) in the lung. A CT-guided bone biopsy failed to define malignancy in the hot spots of his bone lesions. He underwent lobectomies (right S1 and left S6) and excision of the right fourth and fifth rib bones. The pathological findings of resected lungs illustrated well-differentiated squamous cell carcinoma without local vascular or lymphatic invasions. The pathology of the resected bone lesions exhibited hypercellular bone marrow without excess of blasts (B). Dysfunction of hematopoiesis in bone marrow such as hyperplasia and aplasia has been found in patients with cancers even without marrow metastases.1 These abnormalities are seen as a paraneoplastic syndrome, which is an uncommon condition giving rise to a confusion of management in medical oncology. A diffuse bone marrow FDG uptake has been reported in some special clinical situations including myelodysplastic syndrome.2–4 Although diffuse uptake of FDG in bone marrow leads to a recommendation of correction of SUV,5 in a case of spotty enhanced uptake, the adjustment of SUV cannot been indicated routinely. Some retrospective cohort studies indicated a cutoff of FDG below a certain SUV might discriminate primary benign and malignant musculoskeletal tumors.6–8 As shown in the present case, we need to pay attention in a prediction of metastatic benign and malignant skeletal lesions.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
575
Marked Hematopoiesis Masquerading Multiple Bone Metastasis in a Lung Cancer Patient With Myelodysplastic Syndrome Osamu Imataki, MD,* Shumpei Uchida, MD,† Kohei Shiroshita, MD,† Jun-ichiro Kida, MD,* and Makiko Uemura, MD* Abstract: We diagnosed a 62-year-old man with lung cancer, well-differentiated squamous cell carcinoma, on the right upper lobe and left lower lobe. He had a history of myelodysplastic syndrome and refractory anemia with ringed sideroblasts diagnosed 5 years earlier. The patient's 18F-FDG PET/CT for the clinical staging of lung cancer revealed accumulations of FDG in multiple bones including the rib bones, which strongly suggested multiple bone metastases. He underwent lobectomies and excision of the right fourth and fifth rib bones. The pathological findings of resected rib bones exhibited hypercellular bone marrow without excess of blasts. Key Words: myelodysplastic syndrome, hypercellular marrow, lung cancer, multiple bone metastases, FDG PET (Clin Nucl Med 2015;40: 574–575)
Received for publication November 2, 2014; revision accepted November 17, 2014. From the *Division of Hematology and Stem Cell Transplantation, Department of Internal Medicine, and †Postgraduate Medical Training Center, Faculty of Medicine, Kagawa University, Kagawa, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Osamu Imataki, MD, Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kitagun, Kagawa, 761-0793, Japan. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4007–0574
574
www.nuclearmed.com
REFERENCES 1. Castello A, Coci A, Magrini U. Paraneoplastic marrow alterations in patients with cancer. Haematologica. 1992;77:392–397. 2. Chiang SB, Rebenstock A, Guan L, et al. Diffuse bone marrow involvement of Hodgkin lymphoma mimics hematopoietic cytokine-mediated FDG uptake on FDG PET imaging. Clin Nucl Med. 2003;28:674–676. 3. Blodgett TM, Ames JT, Torok FS, et al. Diffuse bone marrow uptake on wholebody F-18 fluorodeoxyglucose positron emission tomography in a patient taking recombinant erythropoietin. Clin Nucl Med. 2004;29:161–163. 4. Inoue K, Okada K, Harigae H, et al. Diffuse bone marrow uptake on F-18 FDG PET in patients with myelodysplastic syndromes. Clin Nucl Med. 2006;31: 721–723. 5. Teo BK, Badiee S, Hadi M, et al. Correcting tumour SUV for enhanced bone marrow uptake: retrospective 18F-FDG PET/CT studies. Nucl Med Commun. 2008;29: 359–366. 6. Hashimoto Y, Tsujikawa T, Kondo C, et al. Accuracy of PET for diagnosis of solid pulmonary lesions with 18F-FDG uptake below the standardized uptake value of 2.5. J Nucl Med. 2006;47:426–431. 7. Degirmenci B, Wilson D, Laymon CM, et al. Standardized uptake value-based evaluations of solitary pulmonary nodules using F-18 fluorodeoxyglucose-PET/ computed tomography. Nucl Med Commun. 2008;29:614–622. 8. Shin DS, Shon OJ, Han DS, et al. The clinical efficacy of (18)F-FDG-PET/CT in benign and malignant musculoskeletal tumors. Ann Nucl Med. 2008;22:603–609.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 7, July 2015
Myelodysplastic Syndrome Mimicking Metastasis
FIGURE 1. We diagnosed a 62-year-old man with lung cancer, well-differentiated squamous cell carcinoma, on the right upper lobe and left lower lobe. He had a history of myelodysplastic syndrome and refractory anemia with ringed sideroblasts diagnosed 5 years earlier. A chromosomal analysis of his bone marrow cells detected the normal karyotype. He subsequently underwent 18F-FDG PET/CT for the clinical staging of lung cancer to determine whether surgical treatment was indicated. The FDG PET/CT revealed accumulations of FDG in multiple bones, which strongly suggested multiple bone metastases (A). However, the SUVmax of the bone spots was lower (maximally 3.73) compared with that of the primary site (11.68) in the lung. A CT-guided bone biopsy failed to define malignancy in the hot spots of his bone lesions. He underwent lobectomies (right S1 and left S6) and excision of the right fourth and fifth rib bones. The pathological findings of resected lungs illustrated well-differentiated squamous cell carcinoma without local vascular or lymphatic invasions. The pathology of the resected bone lesions exhibited hypercellular bone marrow without excess of blasts (B). Dysfunction of hematopoiesis in bone marrow such as hyperplasia and aplasia has been found in patients with cancers even without marrow metastases.1 These abnormalities are seen as a paraneoplastic syndrome, which is an uncommon condition giving rise to a confusion of management in medical oncology. A diffuse bone marrow FDG uptake has been reported in some special clinical situations including myelodysplastic syndrome.2–4 Although diffuse uptake of FDG in bone marrow leads to a recommendation of correction of SUV,5 in a case of spotty enhanced uptake, the adjustment of SUV cannot been indicated routinely. Some retrospective cohort studies indicated a cutoff of FDG below a certain SUV might discriminate primary benign and malignant musculoskeletal tumors.6–8 As shown in the present case, we need to pay attention in a prediction of metastatic benign and malignant skeletal lesions.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
575
