Analyses of the clinical characteristics of 49 cases of malignancy with multiple bone lesions as the first manifestation

Objective To investigate the clinical features of several cases of malignancy with multiple bone lesions as the first manifestation.Methods Forty-nine cases of malignancy with multiple bone lesions as the first manifestation were retrospectively analyzed from May 2018 to July 2019.All patients complained of“pain at the site of bone lesion”upon admission.Baseline patient information,such as age,gender,location of bone lesions,etiology,diagnosis method,time of onset was collected.Results The median age of the patients was 56 years old,of which 83.7%(41/49)were aged≥50 years.The median time of onset was 2 months.Among the cases,40 were confirmed as solid tumor bone metastasis,whereas the remaining 9 cases as hematological system tumor.Lung cancer and multiple myeloma were the main tumor types,accounting for 40.8%(20/49)and 16.3%(8/49),respectively.Other common causes were seven cases of cancer affecting the digestive system(three cases of liver cancer,three cases of gastric cancer,and one case of esophageal cancer),as well as seven cases of unknown primary cancer.Half of the solid tumors had only multiple bone metastases but no other distant metastasis.Conclusion Multiple bone lesions accompanied by pain may be the first clinical manifestation in various malignant tumors.The common tumor types were lung cancer,multiple myeloma,and digestive system tumor.It is more common in people aged 50 years and older.Multiple bone lesions might be the only metastasis site of some solid tumors,and its mechanism needs further investigation.

Comparisons between glucose analogue 2-deoxy-2-(^(18)F)fluoro-D-glucose and ^(18)F-sodium fluoride positron emission tomography/computed tomography in breast cancer patients with bone lesions

AIM: To compare 2-deoxy-2-(18F)fluoro-D-glucose(18F-FDG) and 18F-sodium (18F-NaF) positron emission tomography/computed tomography (PET/CT) accuracy in breast cancer patients with clinically/radiologically suspected or known bone metastases.METHODS: A total of 45 consecutive patients with breast cancer and the presence or clinical/biochemical or radiological suspicion of bone metastatic disease underwent 18F-FDG and 18F-fluoride PET/CT. Imaging results were compared with histopathology when available, or clinical and radiological follow-up of at least 1 year. For each technique we calculated: Sensitivity (Se), specificity (Sp), overall accuracy, positive and negative predictive values, error rate, and Youden’s index. McNemar’s χ2 test was used to test the difference in sensitivity and specificity between the two diagnostic methods. All analyses were computed on a patient basis, and then on a lesion basis, with consideration ofthe density of independent lesions on the co-registered CT (sclerotic, lytic, mixed, no-lesions) and the divergent site of disease (skull, spine, ribs, extremities, pelvis). The impact of adding 18F-NaF PET/CT to the work-up of patients was also measured in terms of change in their management due to 18F-NaF PET/CT findings.RESULTS: The two imaging methods of 18F-FDG and 18F-fluoride PET/CT were significantly different at the patient-based analysis: Accuracy was 86.7% and 84.4%, respectively (McNemar’s χ2 = 6.23, df = 1, P = 0.01). Overall, 244 bone lesions were detected in our analysis. The overall accuracy of the two methods was significantly different at lesion-based analysis (McNemar’s χ2 = 93.4, df = 1, P < 0.0001). In the lesion density-based and site-based analysis, 18F-FDG PET/CT provided more accurate results in the detection of CT-negative metastasis (P < 0.002) and vertebral localizations (P < 0.002); 18F-NaF PET/CT was more accurate in detecting sclerotic (P < 0.005) and rib lesions (P < 0.04). 18F-NaF PET/CT led to a change of management in 3 of the 45 patients (6.6%) by revealing findings that were not detected at 18F-FDG PET/CT.CONCLUSION: 18F-FDG PET/CT is a reliable imaging tool in the detection of bone metastasis in most cases, with a diagnostic accuracy that is slightly, but significantly, superior to that of 18F-NaF PET/CT in the general population of breast cancer patients. However, the extremely high sensitivity of 18F-fluoride PET/CT can exploit its diagnostic potential in specific clinical settings (i.e., small CT-evident sclerotic lesions, high clinical suspicious of relapse, and negative 18F-FDG PET and conventional imaging).

Fracture risk assessment in children with benign bone lesions of long bones

BACKGROUND Fracture risk assessment in children with benign bone lesions of long bones remains poorly investigated.AIM To investigate the risk factors for pathological fracture in children with benign bone lesions and to propose a modified scoring system for quantitative analysis of the pathologic fracture risk.METHODS We retrospectively reviewed 96 pediatric patients with benign bone lesions.We compared radiographic and clinical features between 40 patients who had fractures through a benign bone lesion and 56 who had no fracture.Information including histological diagnosis,anatomical site,radiographic appearance,severity of pain,and lesion size was recorded for the patients.A modified scoring system was proposed to predict the risk of fracture.RESULTS The univariate comparisons showed a significant difference between the fracture and non-fracture groups in terms of lesion type,pain,lesion-to-bone width,and axial cortical involvement of the patients(P<0.05).Lesion type,pain,lesion-tobone width,and axial cortical involvement were independently correlated with an increased risk of fracture.The mean score of the fracture group was 7.89,whereas the mean score of the non-fracture group was 6.01.The optimum cut-off value of the score to predict pathological fracture was 7.The scoring system had a sensitivity of 70%and a specificity of 80%for detecting patients with fractures.The Youden index was 0.5,which was the maximum value.The area under the receiver operator characteristic was 0.814.CONCLUSION Lesion type,pain,lesion-to-bone width,and axial cortical involvement are risk factors for pathological fracture.The modified scoring system can provide evidence for clinical decision-making in children with benign bone lesions.A bone lesion with a total score>7 indicates a high risk of a pathologic fracture and is an indication for prophylactic internal fixation.

Skeletal cystic angiomatosis:A rare cause of unilateral lytic bone lesions

Cystic angiomatosis is a rare, benign, multifocal disorder of bone and viscera. Angiomatous deposits result in bone lysis and organ dysfunction. Bony cystic lesions occur in the axial and proximal appendicular skeleton. Lesions may cause bone pain or pathological fracture. Diagnosis is difficult, of exclusion and demands a biopsy. The prognosis varies upon whether the lesions are solely skeletal or there is visceral involvement. A 71-year-old man reports increasing symptoms of painful swelling in the right thoracic wall for over a month. The swelling was bony hard in consistency. Except for his bony swelling, the patient’s physical examination was within normal limits, as were all his laboratory studies. X-ray imagery showed multicystic expansive lytic areas involving the right ribs. Computerized tomography, magnetic resonance imagery and gallium bone scan revealed lytic lesions of multiple right ribs, and cervical, dorsal, lumbar and sacrum iliac spine. A right rib biopsy has shown a cystic formation with endothelial walls. Five years later, the patient remained stable, with no clinical, laboratory or imagilogic progression of disease and without visceral involvement. This case is presented in his rarity and differential diagnosis challenge.

Enchondromas of Long Bones and Other Skeletal Lesions Found Incidentally Need Critical Evaluation, But Rarely Systematic Follow-Up

Purpose: Incidental bone lesions are a challenge for the specialist, who has to give recommendations for further management. This review of our cases will assist in the decision whether the lesion can be “neglected”, needs further active follow-up or direct initiation of treatment. Patients and Methods: 153 cases of incidental bone findings were presented to our musculoskeletal tumor service for evaluation from July 2008 through June 2021. 73 of them were cartilaginous tumors and 63 of these were diagnosed as enchondroma of a long bone based on X-Ray and MRI. Results: Follow-up imaging of the enchondroma patients was available for 35 patients at 1 to 13 years (mean 4.3 y), with no change in size except for one femoral diaphyseal enchondroma with increasing diameter from age 18 to 20 years. 14 additional patients answered written contact stating that they remained asymptomatic at 2 to 12 years (mean 5.6 y). None of the patients has been reported to the Swiss Confoederation Cancer Registry to have developed malignancy. Among the 10 other cartilaginous tumors were one chondrosarcoma grade II exhibiting different imaging, 3 non-long-bone localizations (pelvis, scapula and rib), 2 Ollier-type enchondromas, and 2 osteochondromas. Incidental findings other than cartilaginous tumors were fibrous dysplasia (n = 31), non-ossifying fibroma (n = 31) and 18 other “sporadic” entities. Conclusions: Incidentally found enchondromas not exhibiting aggressive features need no systematic follow-up and patients can be “discharged” with the advice to present, if symptoms would develop. This also applies to fibrous dysplasia and the other sporadic lesions. 6 cases with other diagnoses needed specific treatment.

Reliability and sensitivity to change of IW-TSE versus DESS magnetic resonance imaging sequences in the assessment of bone marrow lesions in knee osteoarthritis patients: Longitudinal data from the Osteoarthritis Initiative (OAI) cohort

Background: Bone marrow lesions (BMLs) are associated with osteoarthritis (OA). We assessed the performance of two commonly used MRI sequences, IW-TSE and DESS, for reliability in the detection of BMLs and sensitivity to estimate change over time. We suggested that the IW-TSE would demonstrate higher sensitivity to change than DESS in the assessment of BML prevalence and change over time. This study was performed using a subset of the Osteoarthritis Initiative (OAI) cohort. Methods: A sub-group of 144 patients was selected from the OAI progression cohort who all had IW-TSE and DESS MRI acquisitions at baseline and 24 months. BMLs were assessed using a semi-quantitative scale in the global knee, medial and lateral compartments, and subregions. Intra-reader reliability was assessed on a subset of 51 patients. Results: Intra-reader reliability was substantial for the global knee ≥ 0.64, medial ≥ 0.70, and lateral ≥ 0.63 compartments for IW-TSE and DESS. The prevalence of BML detected at baseline was only slightly greater for IW-TSE compared to DESS. The mean BML score at baseline was significantly higher (p ≤ 0.006) for the IW-TSE than the DESS. However, mean change at 24 months was similar for both sequences for all regions except the medial compartment (p = 0.034) and medial femur (p = 0.015) where they were significantly higher for DESS than IW-TSE. Moreover, the prevalence of BML change at 24 months was similar in all regions except the global knee (p = 0.047) and the lateral tibial plateau (p = 0.031). Conclusion: This study does not suggest superior sensitivity to change of one sequence over the other for almost all the regions. The only difference is a higher BML mean change over time detected by the DESS sequence in the medial compartment and femur. These data bring into perspective that both sequences seem equivalent regarding their use for the assessment of BML in clinical trials.

Expect the unexpected:Brown tumor of the mandible as the first manifestation of primary hyperparathyroidism

Hyperparathyroidism(HPT)is a condition in which one or more parathyroid glands produce increased levels of parathyroid hormone(PTH),causing disturbances in calcium homeostasis.Most commonly HPT presents with asymptomatic hypercalcemia but the clinical spectrum may include disturbances reflecting the combined effects of increased PTH secretion and hypercalcemia.Brown tumors are rare,benign,tumor-like bone lesions,occurring in 1.5%to 4.5%of patients with HPT,as a complication of an uncontrolled disease pathway,and are nowadays rarely seen in clinical practice.The tumor can appear either as a solitary or multifocal lesion and usually presents as an asymptomatic swelling or a painful exophytic mass.Furthermore,it can cause a pathological fracture or skeletal pain and be radiologically described as a lytic bone lesion.The diagnosis of a brown tumor in HPT is typically confirmed by assessing the levels of serum calcium,phosphorus,and PTH.Although when present,brown tumor is quite pathognomonic for HPT,the histologic finding often suggests a giant cell tumor,while clinical presentation might suggest other more frequent pathologies such as metastatic tumors.Treatment of brown tumors frequently focuses on managing the underlying HPT,which can often lead to regression and resolution of the lesion,without the need for surgical intervention.However,in refractory cases or when dealing with large symptomatic lesions,surgical treatment may be necessary.

Compressive Myeloradiculopathies in Multiple Myeloma: Clinical and Radiological Characteristics of a Series of 29 Patients

Introduction: Patients with multiple myeloma (MM) develop neurological complications such as root and/or spinal cord compression in at least 5% of cases. The aim of this work is to describe the clinical and radiological features of root and/or spinal cord compression occurring during multiple myeloma. Patients and Methods: We conducted a retrospective study in the Clinical Haematology Department of Dalal Jamm Hospital and the National Blood Transfusion Centre, the Neurological Clinic of Fann Hospital Centre and the Internal Medicine Department of Aristide Le Dantec Hospital in Dakar between January 2016 and December 2019. All patients whose multiple myeloma diagnosis was established according to the International Myeloma Working Group’s 2014 and who had root, spinal or myeloradicular compression, were included in our study. Results: A total of 29 patients were included. The average age was 54.31 years [32 - 76 years]. The sex ratio (M/F) was 1.6. Motor deficits were the reason for consultation in 68% of the patients and spinal pains were reported by 93% of the patients. Neurological signs revealed multiple myeloma in all our patients. 25 patients (86.2%) had paraplegia and 1 patient had tetraparesis. Hypoesthesia to a defined sensory level was noted in 8 patients (28%). 5 patients (17.24%) had sphincter disorders. The types of lesions showed by imaging were vertebral lysis in 100% of cases, vertebral compression in 37% of cases, and epidural infiltration in 34% of cases. 12 patients (41.37%) had spinal compression, 14 patients (48.27%) had root compression, and 3 patients (10.34%) had myeloradicular compression. Spinal cord compression was most often at the dorsolumbar level (91.3% of cases) and root compression was mainly located in the lumbar spine (76.47% of cases). Conclusion: Spinal and root compressions are common complications of multiple myeloma, often revealing the disease in our context. The dorsolumbar level was most often of interest in our study.

Non-secretory multiple myeloma expressed as multiple extramedullary plasmacytoma with an endobronchial lesion mimicking metastatic cancer:A case report

BACKGROUND Non-secretory multiple myeloma(MM)is a rare condition that accounts for only 3%of MM cases and is defined by normal serum and urine immunofixation and a normal serum free light chain ratio.Non-secretory MM with multiple extramedullary plasmacytomas derived from endobronchial lesions is extremely rare and can be misdiagnosed as metastasis of solid cancer.CASE SUMMARY A 36-year-old man presented with progressive facial swelling and nasal congestion with cough.Various imaging studies revealed an endobronchial mass in the left bronchus and a large left maxillary mass with multiple destructive bone metastatic lesions.He initially presented with lung cancer and multiple metastases.However,pathologic reports showed multiple extramedullary plasmacytomas in the left maxilla and the left bronchus.There was no change in the serum and urine monoclonal protein levels,and no abnormalities were observed in laboratory examinations,including hemoglobin,calcium,and creatinine levels.The bone marrow was hypercellular,with 13.49%plasma cells.The patient was diagnosed with non-secretory MM expressed as multiple extramedullary plasmacytomas with endobronchial lesions in a rare location.Radiation therapy for symptomatic lesions with high-dose dexamethasone was started,and the size of the left maxillary sinus lesion dramatically decreased.In the future,chemotherapy will be administered to control lesions in other areas.CONCLUSION We present a rare case of non-secretory MM with multiple extramedullary plasmacytoma with an endobronchial lesion.