Metástase óssea como forma de apresentação de carcinoma hepatocelular / Bone metastasis as the presenting symptom of hepatocellular carcinoma

O carcinoma hepatocelular (CHC) é o tumor maligno primário do fígado mais frequente, apresentando na maioria das vezes em doentes cirróticos. O espectro de apresentação é muito variado e as manifestações clínicas dependem da fase evolutiva da doença. A progressão local e sistémica do carcinoma hepatocelular é frequente e as metástases ósseas não são incomuns. Apesar de as metástases ósseas serem uma forma de apresentação rara de carcinoma hepatocelular, por vezes estas precedem as manifestações hepáticas pelo que o carcinoma hepatocelular deve ser incluído no diagnóstico diferencial de lesões ósseas osteolíticas. Os autores apresentam um caso clínico e uma breve revisão teórica, pela sua raridade e importância clínica, sublinhando a importância do diagnóstico diferencial de carcinoma hepatocelular um doente previamente assintomático, sem doença hepática conhecida anteriormente, com um fractura patológica...

Hepatocellular carcinoma (HCC) is the most frequent primary malignancy of the liver, presenting most often in cirrhotic patients. The spectrum of presentation is very varied and clinical manifestations depend on the phase of the disease. The local and systemic progression of hepatocellular carcinoma is frequent and bone metastases are not uncommon. Although bone metastases are a rare form of presentation of hepatocellular carcinoma, sometimes they precede hepatic manifestations and that's way hepatocellular carcinoma should be included in the differential diagnosis of osteolytic bone lesions. The authors present a case report and a brief literature review, due to its rarity and clinical importance, stressing the importance of the differential diagnosis of hepatocellular carcinoma in a previously healthy patient without previously known liver disease, with a pathological fracture...

Metastatic Bone Tumors with Sunburst Periosteal Reaction

PURPOSE: The purpose of this study was to describe the clinical and imaging features of metastatic bone tumors with sunburst periosteal reaction and to define the characteristic findings which would be helpful for differentiating metastatic bone tumors from primary malignant bone tumors. MATERIALS AND METHODS: The authors retrospectively reviewed the cases of nine patients with pathologically confirmed metastatic bone tumors with sunburst periosteal reaction, for which imaging studies (plain radiographs [n=9], radioisotope [RI] scans [n=4], magnetic resonance [MR] images [n=6], and computed tomographic [CT] scans [n=4]) were performed. The imaging studies of each lesion were analyzed by two musculoskeletal radiologists focusing on the metastatic site, patterns of bone response, signal intensity characteristics and pattern of contrast enhancement on MR. The clinical records of the patients were reviewed with regard to the age and sex of the subjects, the clinical presentation, and the origin of the primary tumors. RESULTS: The cases consisted of six men and three women, whose mean age was 62 years (age range, 50-88 years). The primary tumors were adenocarcinoma of the stomach [n=4], adenocarcinoma of the lung [n=2], adenocarcinoma of the prostate [n=1], hepatocellular carcinoma of the liver [n=1], and adenocarcinoma of unknown origin [n=1]. The sites of metastatic involvement exhibiting sunburst periosteal reaction were the scapula [n=2], proximal humerus [n=2], rib [n=1], iliac bone [n=1], tibia [n=1], spine [n=1], and proximal phalanx [n=1]. In all patients, the imaging findings showed osteolytic [n=3] or osteoblastic [n=6] lesions with sunburst periosteal reaction. In six cases, the lesions were iso-intense on the T1-weighted images and heterogeneously hyperintense on the T2-weighted images. The gadolinium-enhanced T1-weighted images showed a nearly homogenous enhancement of the lesions without any central necrotic portion. CONCLUSION: Although metastatic bone tumor exhibiting sunburst periosteal reaction is rare, it should be included along with primary malignant bone tumors in the differential diagnosis of bone lesions with sunburst periosteal reaction, especially in older patients with or without a known primary malignancy.

Multiple Bone Metastases on Radionuclide Bone Scans Distributed to Batson's Plexus

PURPOSE: Multiple bone metastases that appear on 99mTc-MDP bone scans tend to be distributed in the axialskeleton, including the proximal humeri and femora;this is similar to the distribution seen in Batson'sparavertebral plexus. The purpose of this study was, therefore, to evaluate- by examining the anatomicdistribution of metastases- the metastatic mechanism of cancer cells of various primary tumors in Batson's plexus. MATERIALS AND METHODS: Three hundred and forth-five known cases of primary tumors and multiple bone metastaseswere confirmed by bone scan imaging. The axial skeleton was divided into seven parts: skull, ribs, scapulas,spine, pelvis, proximal humeri, and proximal femora. In addition, the spine was divided into cervical, thoracicand lumbar areas. RESULTS: Among the 345 cases, bony metastases were distributed as follows: ribs, 186 (53.9%);spinal areas, 172 (49.9%); pelvis, 94 (27.2%); proximal femora, 85 (24.6%); skull, 63 (18.3%); proximal humeri, 45(13%); and scapulas, 31 (9%). Among the 243 primarily thoracic cancer cases (e.g. lung, breast or esophagus),distribution was as follows: ribs, 142 (58.4%); spinal areas 111 (45.7%); and pelvis, 54 (22.2%). Among the 69cancers which were primarily of the upper abdomen (e.g. stomach or liver), distribution spinal areas, 44 (63.8%);ribs, 33 (47.8%); and pelvis, 26 (37.7%). While the 33 primarily pelvic cancers (e.g. prostate, uterine cervix orbladder), were distributed between spinal areas (17, 51.5%), the pelvis (13, 39.4%), and the ribs (11, 33.3%).There were no statistically significant differences in the distribution of bony metastases according to primarycancers. CONCLUSION: Multiple bone metastases, as seen on bone scan images, coincided with the distribution ofBatson's plexus. We therefore conclude that although pelvic tumors can metastasize to the axial skeleton bydirectly anastomosing into Batson's plexus, other primary tumors metastasize from systemic veins to Batson'splexus as a result of the occurrence of venous reflux when intrathoracic or intra-abdominal pressure is increased.

Phalangeal and Metacarpal Metastases from Clear Cell Sarcoma of the Kidney: A Case Report

Clear cell sarcoma of the kidney(CCSK) is rare, and was previously thought to be a variant of Wilms' tumor. Incontrast to patients with Wilms' tumor, bone metastasis is common in patients with CCSK, in which because of itsskeletal metastasis, prognosis is worse. We describe the radiographic, MR imaging, and bone scintigraphy findings,and include a review of the literature.

Multiple Bone Metastasis of Medulloblastoma: A Case Report

Medulloblastoma is one of the most undifferentiated primitive neuroectodermal tumors and represents about 30% of all posterior fossa tumors in children. Disseminated medulloblastoma, mainly involving cerebral surfaces, ventricles and the subarachnoid space can, in 50% of patients, be identified on intial imaging studies. One thirdof these lesions metastasize to an extracranial site, primarily to bone. Osseous metastases, which occur mainly after craniectomy are typically lytic, but osteoblastic lesions also may occur. We experienced the case of a 14year-old female patient with multiple bone metastases of medulloblastoma after craniectomy. Bone metastaticlesions were present in the right femur and thoracic spine and were osteoblastic or osteolytic