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Diagnostic
Oncology
Case
Studies
,. .I
Solitary
Bone Scan Abnormality with Breast Carcinoma
in a Patient ..1*
A 42-year-old white female discovered a 1 .5 cm mass in her left breast; subsequent biopsy revealed a well differentiated adenocarcinoma. Because of a prior history of metastatic carcinoma to a cervical lymph node (subsequent review of submitted biopsy material showed no evidence of malignancy), a 9#{176}technetium diphosphonate whole body bone scan was performed as part of her preoperative evaluation. A single focus of increased nuclide activity was present in the distal left tibia (see above). The patient had no symptoms referable to this site, and no tenderness could be elicited. Corresponding radiographs (fig. 1) revealed a zone of medullary bone lysis containing multiple arclike calcifications. Portions of the periphery of the lesion were poorly delimited, with a small zone of endosteal scalloping present along the lateral tibial cortex. The radiologic picture was strongly suggestive of a cartilage-producing tumor (enchondroma or low grade chondrosarcoma); the lack of a circumscribed border and the pattern of calcification rendered a bone infarct on a metastasis unlikely. Following an inconclusive needle biopsy, the patient underwent a complete excision of the tibial lesion with freezing of the cavity with liquid nitrogen and
This
is one
of a bimonthly
and UCLA Comprehensive more common neoplasms. Medicine,
Los Angeles,
Am J Roentgenol © 1978 American
series
Cancer
Case California
130:353-355, Roentgen
of case
reports
edited
by A. Robert
packing with bone from the ilial crest. The final pathologic diagnosis from the excision was “atypical cartilage lesion,” possibly a low grade chondrosarcoma. Since the patient did not want a mastectomy, she and her surgeon agreed that preservation of the breast and avoidance of adjuvant chemotherapy would be considered if the axillary nodes were negative. She subsequently underwent axillary node dissection, and all 28 nodes removed were free of microscopic tumor. Radiotherapy to the breast was given.
Discussion
Future improvement in survival rates for carcinoma of the breast rests on the successful therapy of microscopic metastases which may be present at the time of initial medical evaluation [1 , 2]. The axial skeleton is the most frequent site of extranodal metastases from carcinoma of the breast [2]. Clinical parameters such as serum alkaline phosphatase levels and bone pain are poor indicators
of dissemination
to bone
[3, 4].
Radiography is, by virtue of its insensitivity, screening procedure for skeletal metastases.
Kagan
and
Richard
J. Steckel
(Southern
California
Permanente
a poor Consider-
Medical
Group
Center) to present and discuss contemporary problems and procedures in the identification and staging of the and discussion contributed by Jernold H. Mink and Marshall E. Bein, Department of Radiology, UCLA School of 90024.
February
Ray Society
1978
353
0361 -803X/78/0200
-
0353 $02.00
DIAGNOSTIC
Downloaded from www.ajronline.org by 117.253.99.235 on 10/23/15 from IP address 117.253.99.235. Copyright ARRS. For personal use only; all rights reserved
354
Fig.
1.-A,
Radiograph
lateral tibeal cortex.
of
lesion
Needle inserted
able bone mineral content before a lytic lesion becomes graph [5, 6]; in fact, premortem
in distal
diaphysis
under anesthesia
(30%-50%)
visible tomograms
on
ofleft
ONCOLOGY
tibia.
for localization
B, Localization of suspect
must be lost a plain radioof the
CASE
lumbar
spine could detect metastases in only 48% of cases in which they were proven to be present at autopsy [5]. A similar correlative study of nuclear scan sensitivity is not available yet, but numerous studies have cleanly mdicated that the 9Tc nuclide bone scan is an exquisitely more sensitive examination than plain radiography [4, 7-10]. It must be emphasized, however, that the scan is totally nonspecific: a variety of nonmalignant causes can produce a scan hot spot (table 1). To minimize the likelihood of error, we perform a combined nadiographic-nadionuclide bone examination on all individuals referred to our department for a bone scan. Immediately after the scan, nadiognaphs of all “hot spots” and symptomatic foci are made. In addition, an anteropostenion radiograph of the pelvis is obtained for every patient; instances of false negative scans in the presence of diffuse symmetrical disease or obscuration of a lesion by nuclide activity in the bladder are thus eliminated. The scan and radiognaphs are then reviewed together by one radiologist. A negative scan alone essentially precludes nad iographically evident metastases
needle
STUDIES
pointing
area immediately
toward
zone
ofendosteal
prior to excisionai
(prior to treatment) 12]. Thus extensive eliminated in many
thinning
or scailoping
in
biopsy.
from mammary carcinoma [7-9, 11, radiographic skeletal surveys can be instances, preventing needless radiation exposure and saving the patient both time and money. Obtaining bone scans and appropriate radiographs on the same day obviates the need for a return to the department. Furthermore, the clinician receives a single comprehensive opinion rather than two often equivocal, or even conflicting, reports. The practicality of bone scanning in the preoperative evaluation of patients with clinical stage I carcinoma of the breast has yet to be determined conclusively. Howeven, there is some evidence that even patients with “eanly” carcinoma may have disseminated disease diagnosable on scans [1 , 13, 14]. Our policy for patients with stage I breast cancer is to perform survey bone scans only if there are bone symptoms on evidence of another malignancy; in patients with clinical stage II (or higher) disease, however, bone scans are performed in all patients. Follow-up radiography and occasional biopsy of scan-positive, radiograph-negative bone foci are useful in defining further those patients who, before the advent of the radionuclide bone scan, might have been assumed to be free of tumor.
DIAGNOSTIC
ONCOLOGY TABLE
Nonmalignant
Downloaded from www.ajronline.org by 117.253.99.235 on 10/23/15 from IP address 117.253.99.235. Copyright ARRS. For personal use only; all rights reserved
Soft Tissue
Abnormalities
Myositis
ossificans
Injection
sites
Osseous
patient local
for
the
refused for
management
appear
Base of skull
Metabolic
bone
Inferior
metastatic
manly
by
present
axillary
surgery
patient
grade
chondrosarcoma,
bones
and
the
breast
scanning in osseous of the normal ‘Tc
was
with
cases.
autopsy
The the
is best
physicians
include
tibial
lesion
since skeleton
handled
the
as if it were
a low
enchondromas have
of
a definite
communication
and imaging lar attention
between
specialites to careful
ties with plain noma in whom
the
in staging correlation
clinical,
long
have
proved to have a second were potentially curable.
altered
prognosis
and
9. O’Mana JAMA
10.
pathologic,
management
primary
tumor;
Sue Boggan
for preparing
pro-
both
the manuscript.
.
Surg
56:757-764,
from Br
J
1969
2. Sklaroff cancer
OM, Charkes NO: Bone metastases from breast at the time of radical mastectomy. Surg Gynecol Obstet 127:763-768, 1968 3. Galasko CSB, Doyle FH: The detection of skeletal metastases
from
mammary
cancer.
A regional
comparison
be-
tween radiology and scintigraphy. C/in Radiol 23 : 295-297, 1972 4. Hopkins GB, Knistensen KAB: Whole body skeletal scintiphotography in the detection of occult metastatic breast
61 :73-75,
Bone
imaging
J Radiol
with
eaTc
NY
Electrol polyphos-
1974
RE: Bone scanning in osseous 229:1915-1917, 1974
Silberstein
EB, Saenger
EL, Tofe
HM: Imaging phosphonate),
of bone metastases ‘5F, and skeletal
107:551-555,
1973
metastatic
AJ, Alexander
disease. GW,
Park
with saTcSnEHDP (diradiography. Radiology
.
Lancet
REFERENCES 1 Galasko CSB: The detection of skeletal metastases mammary cancer by gamma camera scintigraphy.
PHS:
and
in the spine.
Osmond JO, Pendengrass HP, Potsaid JS: Accuracy of ““Tc-diphosphonate bone scans and roentgenognams in the detection of prostate, breast, and lung carcinoma metastases. Am J Roentgeno/ 125 :972-977, 1975 12. Desaulniers M, Lacourciere Y, Lisbona R, Rosenthal L: A detailed comparison of bone scanning with swTcpolyphos phate and radiographic skeletal surveys for neoplasm. J Can Assoc Radiol 24 : 340-343, 1973 13. Roberts JG, Gravelle IH, Baum M, Bligh AS, Leach KG, Hughes LE: Evaluation of radiography and isotopic scintigraphy for detecting skeletal metastases in breast cancer. 11
ACKNOWLEDGMENT We thank
JJ, Smith
J Surg
incidence
radiographs. A patient with breast carcithe presumption of disseminated disease
foundly, tumors
of radiographic
a comparison with ‘5F and skeletal radiography. Br J Radiol 47:387-392, 1974 8. Citnin DL, Greig WA, Calder JF, Bessent HC, Tuohy JB, Blumgart LH: Preliminary experience of bone scanning with saTclabeled polyphosphate in malignant disease. Br
tumors, with particuof all scan abnormali-
would
1973
phate:
of malignant degeneration [16-19]. The positive scan, indicating activity within the tumor, and the focus of cortical erosion on the radiograph further influenced their decision. This case emphasizes the need for close cooperation and
WestJ Med 119:10-13, Sproul EE: Correlation
findings
7. Barrett
pri-
attending
AL,
in suspected metastases Acad Med Bull 31 : 146-146, 1955 6. Babaintz L: Les osteopathies arthropiques. 29:333-362, 1948
radiation
These
tip of scapulae
Epiphyses of growing skeleton Stennoclavicular joints External occipital protuberance
carcinomas. 5. Bachman
Results
Structures
metastatic disease. JAMA 229:1915-1917, 1974; and Charkes polyphosphate rectilinear bone scan. Radiology 107:563-570.
treated
I disease.
cancer
adenopathy)
axial
disease
tumors are under 2 cm with nodes (stage I). In our opinion, (i.e., larger breast masses and!
[15].
treated
and
stage
for selected
primary lymph cancer
Normai
Abnormalities
in any stage of healing
surgery
proved
of
to be excellent
patients whose negative axillary more advanced or
breast
irradiation
1
of a Scan Hot Spot
Fractures
Note.Adapted from O’Mara RE: Bone ND, valentine G. Cravitz B: interpretation 1973.
This
355
STUDIES
Osteomyelitis Osteoarthnitis Postbiopsy sites Osteoid osteoma Hypertroph ic pulmonary osteoanthropathy Hyperostosis frontalis interna Melorheostosis Paget’s disease Degenerative disc disease Bone infarction (epiphyseal and metadiaphyseal)
Operative sites Calcific tendinitis
with
Causes
CASE
1 :237-239,
1976
14. Citrin DL, Bessent AG, Blumgart LH, Greig WA: Early detection of metastatic breast cancer using new bone scanning agents. Proc Roy Soc Med 68 :386-387, 1975 15. Mansfield CM: Early Breast Cancer: Its History and Results of Treatment. Basel, S. Karger, 1976 16. Edeiken J, Hodes PJ: Roentgen Diagnosis of Diseases of Bone, vol 2, 2d ed. Baltimore, Williams & Wilkins, 1973 17.
Lichtenstein L, Jafte HL: Patho/ 19:553-574, 1943
Chondnosarcoma
of bone.
Am
18. Aegerter E: Diagnostic radiology and the pathology of bone disease. Radio! Clin North Am 8 : 21 5-226, 1970 19. Hamlin JA, Adler L, Greenhaum El: Central enchondroma: a precursor to chondrosarcoma? J Can Assoc Radiol 22:206-209, 1971
J
Diagnostic
Oncology
Case
Studies
,. .I
Solitary
Bone Scan Abnormality with Breast Carcinoma
in a Patient ..1*
A 42-year-old white female discovered a 1 .5 cm mass in her left breast; subsequent biopsy revealed a well differentiated adenocarcinoma. Because of a prior history of metastatic carcinoma to a cervical lymph node (subsequent review of submitted biopsy material showed no evidence of malignancy), a 9#{176}technetium diphosphonate whole body bone scan was performed as part of her preoperative evaluation. A single focus of increased nuclide activity was present in the distal left tibia (see above). The patient had no symptoms referable to this site, and no tenderness could be elicited. Corresponding radiographs (fig. 1) revealed a zone of medullary bone lysis containing multiple arclike calcifications. Portions of the periphery of the lesion were poorly delimited, with a small zone of endosteal scalloping present along the lateral tibial cortex. The radiologic picture was strongly suggestive of a cartilage-producing tumor (enchondroma or low grade chondrosarcoma); the lack of a circumscribed border and the pattern of calcification rendered a bone infarct on a metastasis unlikely. Following an inconclusive needle biopsy, the patient underwent a complete excision of the tibial lesion with freezing of the cavity with liquid nitrogen and
This
is one
of a bimonthly
and UCLA Comprehensive more common neoplasms. Medicine,
Los Angeles,
Am J Roentgenol © 1978 American
series
Cancer
Case California
130:353-355, Roentgen
of case
reports
edited
by A. Robert
packing with bone from the ilial crest. The final pathologic diagnosis from the excision was “atypical cartilage lesion,” possibly a low grade chondrosarcoma. Since the patient did not want a mastectomy, she and her surgeon agreed that preservation of the breast and avoidance of adjuvant chemotherapy would be considered if the axillary nodes were negative. She subsequently underwent axillary node dissection, and all 28 nodes removed were free of microscopic tumor. Radiotherapy to the breast was given.
Discussion
Future improvement in survival rates for carcinoma of the breast rests on the successful therapy of microscopic metastases which may be present at the time of initial medical evaluation [1 , 2]. The axial skeleton is the most frequent site of extranodal metastases from carcinoma of the breast [2]. Clinical parameters such as serum alkaline phosphatase levels and bone pain are poor indicators
of dissemination
to bone
[3, 4].
Radiography is, by virtue of its insensitivity, screening procedure for skeletal metastases.
Kagan
and
Richard
J. Steckel
(Southern
California
Permanente
a poor Consider-
Medical
Group
Center) to present and discuss contemporary problems and procedures in the identification and staging of the and discussion contributed by Jernold H. Mink and Marshall E. Bein, Department of Radiology, UCLA School of 90024.
February
Ray Society
1978
353
0361 -803X/78/0200
-
0353 $02.00
DIAGNOSTIC
Downloaded from www.ajronline.org by 117.253.99.235 on 10/23/15 from IP address 117.253.99.235. Copyright ARRS. For personal use only; all rights reserved
354
Fig.
1.-A,
Radiograph
lateral tibeal cortex.
of
lesion
Needle inserted
able bone mineral content before a lytic lesion becomes graph [5, 6]; in fact, premortem
in distal
diaphysis
under anesthesia
(30%-50%)
visible tomograms
on
ofleft
ONCOLOGY
tibia.
for localization
B, Localization of suspect
must be lost a plain radioof the
CASE
lumbar
spine could detect metastases in only 48% of cases in which they were proven to be present at autopsy [5]. A similar correlative study of nuclear scan sensitivity is not available yet, but numerous studies have cleanly mdicated that the 9Tc nuclide bone scan is an exquisitely more sensitive examination than plain radiography [4, 7-10]. It must be emphasized, however, that the scan is totally nonspecific: a variety of nonmalignant causes can produce a scan hot spot (table 1). To minimize the likelihood of error, we perform a combined nadiographic-nadionuclide bone examination on all individuals referred to our department for a bone scan. Immediately after the scan, nadiognaphs of all “hot spots” and symptomatic foci are made. In addition, an anteropostenion radiograph of the pelvis is obtained for every patient; instances of false negative scans in the presence of diffuse symmetrical disease or obscuration of a lesion by nuclide activity in the bladder are thus eliminated. The scan and radiognaphs are then reviewed together by one radiologist. A negative scan alone essentially precludes nad iographically evident metastases
needle
STUDIES
pointing
area immediately
toward
zone
ofendosteal
prior to excisionai
(prior to treatment) 12]. Thus extensive eliminated in many
thinning
or scailoping
in
biopsy.
from mammary carcinoma [7-9, 11, radiographic skeletal surveys can be instances, preventing needless radiation exposure and saving the patient both time and money. Obtaining bone scans and appropriate radiographs on the same day obviates the need for a return to the department. Furthermore, the clinician receives a single comprehensive opinion rather than two often equivocal, or even conflicting, reports. The practicality of bone scanning in the preoperative evaluation of patients with clinical stage I carcinoma of the breast has yet to be determined conclusively. Howeven, there is some evidence that even patients with “eanly” carcinoma may have disseminated disease diagnosable on scans [1 , 13, 14]. Our policy for patients with stage I breast cancer is to perform survey bone scans only if there are bone symptoms on evidence of another malignancy; in patients with clinical stage II (or higher) disease, however, bone scans are performed in all patients. Follow-up radiography and occasional biopsy of scan-positive, radiograph-negative bone foci are useful in defining further those patients who, before the advent of the radionuclide bone scan, might have been assumed to be free of tumor.
DIAGNOSTIC
ONCOLOGY TABLE
Nonmalignant
Downloaded from www.ajronline.org by 117.253.99.235 on 10/23/15 from IP address 117.253.99.235. Copyright ARRS. For personal use only; all rights reserved
Soft Tissue
Abnormalities
Myositis
ossificans
Injection
sites
Osseous
patient local
for
the
refused for
management
appear
Base of skull
Metabolic
bone
Inferior
metastatic
manly
by
present
axillary
surgery
patient
grade
chondrosarcoma,
bones
and
the
breast
scanning in osseous of the normal ‘Tc
was
with
cases.
autopsy
The the
is best
physicians
include
tibial
lesion
since skeleton
handled
the
as if it were
a low
enchondromas have
of
a definite
communication
and imaging lar attention
between
specialites to careful
ties with plain noma in whom
the
in staging correlation
clinical,
long
have
proved to have a second were potentially curable.
altered
prognosis
and
9. O’Mana JAMA
10.
pathologic,
management
primary
tumor;
Sue Boggan
for preparing
pro-
both
the manuscript.
.
Surg
56:757-764,
from Br
J
1969
2. Sklaroff cancer
OM, Charkes NO: Bone metastases from breast at the time of radical mastectomy. Surg Gynecol Obstet 127:763-768, 1968 3. Galasko CSB, Doyle FH: The detection of skeletal metastases
from
mammary
cancer.
A regional
comparison
be-
tween radiology and scintigraphy. C/in Radiol 23 : 295-297, 1972 4. Hopkins GB, Knistensen KAB: Whole body skeletal scintiphotography in the detection of occult metastatic breast
61 :73-75,
Bone
imaging
J Radiol
with
eaTc
NY
Electrol polyphos-
1974
RE: Bone scanning in osseous 229:1915-1917, 1974
Silberstein
EB, Saenger
EL, Tofe
HM: Imaging phosphonate),
of bone metastases ‘5F, and skeletal
107:551-555,
1973
metastatic
AJ, Alexander
disease. GW,
Park
with saTcSnEHDP (diradiography. Radiology
.
Lancet
REFERENCES 1 Galasko CSB: The detection of skeletal metastases mammary cancer by gamma camera scintigraphy.
PHS:
and
in the spine.
Osmond JO, Pendengrass HP, Potsaid JS: Accuracy of ““Tc-diphosphonate bone scans and roentgenognams in the detection of prostate, breast, and lung carcinoma metastases. Am J Roentgeno/ 125 :972-977, 1975 12. Desaulniers M, Lacourciere Y, Lisbona R, Rosenthal L: A detailed comparison of bone scanning with swTcpolyphos phate and radiographic skeletal surveys for neoplasm. J Can Assoc Radiol 24 : 340-343, 1973 13. Roberts JG, Gravelle IH, Baum M, Bligh AS, Leach KG, Hughes LE: Evaluation of radiography and isotopic scintigraphy for detecting skeletal metastases in breast cancer. 11
ACKNOWLEDGMENT We thank
JJ, Smith
J Surg
incidence
radiographs. A patient with breast carcithe presumption of disseminated disease
foundly, tumors
of radiographic
a comparison with ‘5F and skeletal radiography. Br J Radiol 47:387-392, 1974 8. Citnin DL, Greig WA, Calder JF, Bessent HC, Tuohy JB, Blumgart LH: Preliminary experience of bone scanning with saTclabeled polyphosphate in malignant disease. Br
tumors, with particuof all scan abnormali-
would
1973
phate:
of malignant degeneration [16-19]. The positive scan, indicating activity within the tumor, and the focus of cortical erosion on the radiograph further influenced their decision. This case emphasizes the need for close cooperation and
WestJ Med 119:10-13, Sproul EE: Correlation
findings
7. Barrett
pri-
attending
AL,
in suspected metastases Acad Med Bull 31 : 146-146, 1955 6. Babaintz L: Les osteopathies arthropiques. 29:333-362, 1948
radiation
These
tip of scapulae
Epiphyses of growing skeleton Stennoclavicular joints External occipital protuberance
carcinomas. 5. Bachman
Results
Structures
metastatic disease. JAMA 229:1915-1917, 1974; and Charkes polyphosphate rectilinear bone scan. Radiology 107:563-570.
treated
I disease.
cancer
adenopathy)
axial
disease
tumors are under 2 cm with nodes (stage I). In our opinion, (i.e., larger breast masses and!
[15].
treated
and
stage
for selected
primary lymph cancer
Normai
Abnormalities
in any stage of healing
surgery
proved
of
to be excellent
patients whose negative axillary more advanced or
breast
irradiation
1
of a Scan Hot Spot
Fractures
Note.Adapted from O’Mara RE: Bone ND, valentine G. Cravitz B: interpretation 1973.
This
355
STUDIES
Osteomyelitis Osteoarthnitis Postbiopsy sites Osteoid osteoma Hypertroph ic pulmonary osteoanthropathy Hyperostosis frontalis interna Melorheostosis Paget’s disease Degenerative disc disease Bone infarction (epiphyseal and metadiaphyseal)
Operative sites Calcific tendinitis
with
Causes
CASE
1 :237-239,
1976
14. Citrin DL, Bessent AG, Blumgart LH, Greig WA: Early detection of metastatic breast cancer using new bone scanning agents. Proc Roy Soc Med 68 :386-387, 1975 15. Mansfield CM: Early Breast Cancer: Its History and Results of Treatment. Basel, S. Karger, 1976 16. Edeiken J, Hodes PJ: Roentgen Diagnosis of Diseases of Bone, vol 2, 2d ed. Baltimore, Williams & Wilkins, 1973 17.
Lichtenstein L, Jafte HL: Patho/ 19:553-574, 1943
Chondnosarcoma
of bone.
Am
18. Aegerter E: Diagnostic radiology and the pathology of bone disease. Radio! Clin North Am 8 : 21 5-226, 1970 19. Hamlin JA, Adler L, Greenhaum El: Central enchondroma: a precursor to chondrosarcoma? J Can Assoc Radiol 22:206-209, 1971
J
