METASTATIC EXTRAOSSEOUS ACCUMULATION OF 99MTC-MDP IN A PATIENT WITH GIANT CELL TUMOR OF THE HUMERUS – A CASE REPORT
Keywords:
bone tumor, bone scan, giant cell tumor, extraosseous 99mTc-MDP uptake, metastatic calcificationAbstract
Introduction: Proposed mechanisms for extraosseous 99mTc - MDP uptake are extracellular fluid expansion, enhanced regional vascularity and permeability, and elevated tissue calcium concentration. It can be due to nonmalignant causes, such as parathyroid adenoma, vitamin D intoxication or Paget disease or can be of malignant origin. Malignant conditions are sometimes associated with a life-threatening hypercalcemia and metastatic calcifications.
Case report: We report a case of a 50-year-old female complaining of back pain and pain in the right leg. CT and MRI scan of the thorax showed a soft tissue mass at the level of the proximal metadiaphysis of the left humerus, with osteolysis of the bone, as well as a penetration of the cortex in multiple spots. Giant cell tumor of the humerus was confirmed by core biopsy. Bone scan showed increased uptake of the tracer in facial bones and mandibula, in the head of the left humerus, both iliac bones and the right acetabulum. Also, extraosseous accumulation of the tracer was found in both lungs, in the heart, and in the stomach, consistent with metastatic calcifications. The patient was diagnosed with a multicentric giant cell tumor, and was treated with monoclonal antibody therapy with Denosumab for two months. Six months later, he passed away. There are many differential diagnoses regarding extraooseous tracer uptake on bone scintigraphy. Careful work-up is necessary because the treatment planning might be completely different once the etiology is elucidated.
References
Okamoto Y. Accumulation of technetium-99m methylene diphosphonate. Conditions affecting adsorption to hydroxyapatite. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80(1): 115-119. doi: 10.1016/s1079-2104(95)80027-1.
Xu YH, Song HJ, Qiu ZL, Luo QY. Multiple extraosseous accumulation of 99mTc-MDP in acute lymphocytic leukemia and reference to literature. Hell J Nucl Med 2010; 13: 273-276. PMID: 21193884.
Hwang GJ, Lee JD, Park CY, Lim SK. Reversible extraskeletal uptake of bone scanning in primary hyperparathyroidism. J Nucl Med 1996; 37: 469-471. PMID: 8772648. quiz 154-6. PMID: 12968045.
Elgazzar A.H. Diagnosis of Soft Tissue Calcification. In: Orthopedic Nuclear Medicine. Springer, Berlin, Heidelberg 2004.
Seifert G. Heterotope (extraossäre) Verkalkung (Kalzinose). Atiologie, Pathogenese und klinische Bedeutung [Heterotopic (extraosseous) calcification (calcinosis). Etiology, pathogenesis and clinical importance]. Pathologe 1997; 18(6): 430-438. doi: 10.1007/s002920050238.
Duvvuri B, Lood C. Mitochondrial Calcification. Immunometabolism 2021; 3(1): e210008. doi: 10.20900/immunometab20210008.
Wale DJ, Wong KK, Savas H, Kandathil A, Piert M, Brown RK. Extraosseous findings on bone scintigraphy using fusion SPECT/CT and correlative imaging. AJR Am J Roentgenol 2015; 205(1): 160-172. doi: 10.2214/AJR.14.13914.
Majeed Y, Riaz S, Hassan A. Appearances of soft tissue calcification on Tc99m MDP bone scan. J Pak Med Assoc 2019; 69(4): 600. PMID: 31000873.
Kempter H, Hagner G, Savaser AN, Huben H, Minguillon C. Metastatic pulmonary calcification in a patient with multiple myeloma nonsecretory. Respiration 1986; 49: 77-80. doi: 10.1159/000194863.
Meyer MA, Mc Claughry P. Reversible Tc-99m diphosphonate uptake in gastric tissue related hypercalcemia associated with malignancy: A comparative study using FDG PET whole body imaging. Clin Nucl Med 1995; 20(9): 767-769. doi: 10.1097/00003072-199509000-00002.
Yasuo M, Tanabe T, Komatsu Y, Tsushima K, Kubo K, Takahashi K, et al. Progressive pulmonary calcification after successful renal transplantation. Intern Med 2008; 47(3): 161-164. doi: 10.2169/internalmedicine.47.0442
Ghostine B, Sebaaly A, Ghanem I. Multifocal metachronous giant cell tumor: case report and review of the literature. Case Rep Med 2014; 2014: 678035. doi: 10.1155/2014/678035.
Turcotte RE, Wunder JS, Isler MH, Bell RS, Schachar N, Masri BA, et al. Giant cell tumor of long bone: A Canadian sarcoma group study. Clin Orthop Relat Res 2002; 397: 248-258. doi: 10.1097/00003086-200204000-00029.
Akaike G, Ueno T, Matsumoto S, Motoi N, Matsueda K. Rapidly growing giant cell tumor of bone in a skeletally immature girl. Skeletal Radiol (2016); 45(4): 567-573. doi: 10.1007/s00256-015-2276-4.
Ignac Fogelman, Susan Clarke, Gary Cook, Gopinath Gnanasegaran. Atlas of Clinical Nuclear Medicine, Third Edition.Copyright year 2014. ISBN 9781841846538.
Mundy GR, Guise TA. Hypercalcemia of malignancy. Am J Med 1997; 103(2): 134-145. doi: 10.1016/s0002-9343(97)80047-2.
Palaniswamy SS, Padma S, Harish V, Rai JK. Hypercalcemia with extraosseous MDP uptake in a bone scan as initial presentation in a case of cutaneous T-cell lymphoma. Journal of Cancer Research and Therapeutics 2011; 7(1): 72-74. doi: 10.4103/0973-1482.80474.
Zaman M, Riffat Hussain R, Sajjad Z, Mansoor Naqvi M, Khan K, Khan G, et al. Concomitant gastric and lung uptake of 99mTc - MDP on bone scan in a patient with diffuse large B-cell Non-Hodgkin’s lymphoma. Pakistan Journal of Radiology 2010; 20(4): 171-173. https:// ecommons.aku.edu/pakistan_fhs_mc_radiol.
Majeed Y, Riaz S, Hassan A. Appearances of soft tissue calcification on Tc99m MDP bone scan. J Pak Med Assoc 2019; 69(4): 600. PMID: 31000873.
Liu S, Xie J, Yu F, Cai H, Wu F, Zheng H, Ma C, et al. 99mTc-Methylene Diphosphonate Uptake in Soft Tissue Tumors on Bone Scintigraphy Differs Between Pediatric and Adult Patients and Is Correlated with Tumor Differentiation. Cancer Manag Res 2020; 12:2449-2457. doi: 10.2147/CMAR.S241636.
Chawla S, Henshaw R, Seeger L, Choy E, Blay JY, Ferrari S, et al. Safety and efficacy of denosumab for adults and skeletally mature adolescents with giant cell tumour of bone: interim analysis of an open-label, parallel-group, phase 2 study. Lancet Oncol 2013; 14(9): 901-908. doi: 10.1016/S1470-2045(13)70277-8.
Borkowska A, Goryń T, Pieńkowski A, Wągrodzki M, Jagiełło-Wieczorek E, Rogala P, et al. Denosumab treatment of inoperable or locally advanced giant cell tumor of bone. Oncol Lett 2016; 12(6): 4312-4318. doi: 10.3892/ol.2016.5246.
Thomas D, Henshaw R, Skubitz K, Chawla S, Staddon A, Blay JY, et al. Denosumab in patients with giant-cell tumour of bone: an open-label, phase 2 study. Lancet Oncol 2010; 11(3): 275-280. doi: 10.1016/S1470-2045(10)70010-3.
