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CASE REPORT
Year : 2020  |  Volume : 19  |  Issue : 3  |  Page : 310-312

Diffuse pleural metastases of osteosarcoma detected by bone scan


Department of Nuclear Medicine, A. C. Camargo Cancer Center, Liberdade, São Paulo, Brazil

Date of Submission23-Apr-2020
Date of Decision01-Jun-2020
Date of Acceptance26-Jun-2020
Date of Web Publication22-Aug-2020

Correspondence Address:
Dr. André Marcondes Braga Ribeiro
Department of Nuclear Medicine, A. C. Camargo Cancer Center, Rua Professor Antônio Prudente, 211, 01509-010, Liberdade, São Paulo
Brazil
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DOI: 10.4103/wjnm.WJNM_59_20

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   Abstract 

Osteosarcoma (OS) is a fast-growing tumor, with a high risk of local recurrence and distant metastases, with the lung and bone being the most common sites of dissemination occurring in approximately 80% of cases. Pleural metastases rarely occurs and the appearance of diffuse pleural thickening with ossification is not usual, with few such cases reported due to the current state-of-art treatment protocols. A 29-year-old woman, diagnosed with a proximal left tibial OS underwent planar and single-photon emission computed tomography/computed tomography bone scan scintigraphy with99mtechnetium methylene diphosphonate showing bilateral pleural uptake, corresponding to multiple calcified foci of thickening and nodules.

Keywords: Bone scan, osteosarcoma, pleural metastases


How to cite this article:
Ribeiro AM, Lima EN, Lima DH. Diffuse pleural metastases of osteosarcoma detected by bone scan. World J Nucl Med 2020;19:310-2

How to cite this URL:
Ribeiro AM, Lima EN, Lima DH. Diffuse pleural metastases of osteosarcoma detected by bone scan. World J Nucl Med [serial online] 2020 [cited 2020 Sep 21];19:310-2. Available from: http://www.wjnm.org/text.asp?2020/19/3/310/292983


   Introduction Top


Osteosarcoma (OS), the most common primary malignant neoplasm of the bone, has the second-highest mortality rate among pediatric cancers, and is most commonly diagnosed in patients in the second and third decades of life.[1] It is a fast-growing tumor, with a high risk of local recurrence and distant metastases, with the lung and bone being the most common sites of dissemination, occurring in approximately 80% of cases,[2] but metastases to other sites are uncommon and occur in fewer than 10% of cases.[3]

Bone scan scintigraphy (BS) with99m technetium methylene diphosphonate (99m Tc-MDP) is useful for the detection of distant bone disease, which is the second most likely location for metastatic spread. Positive findings on the bone scan may warrant additional imaging of the area of concern and ultimately, a biopsy may be necessary to prove the definitive presence of distant bone disease.[4]

Pleural metastases rarely occurs and the appearance of diffuse pleural thickening with ossification is not usual, with few such cases reported currently reported due to the state-of-art treatment protocols.[5],[6] Most of the reported cases occurred after the initial treatment and isolated pleural metastases without lung metastases are unusual.[7]

Histologically, this tumor is composed of a sarcomatous fibroblastic stroma in which osteoblastic activity induces the formation of tumor osteoid and bone. Uptake of bone-seeking radionuclides in OS metastases have been described and the mechanism of uptake is believed to be direct incorporation in the osteoid deposited by the tumor, including pleural metastases.[8]

Herein, we report an interesting case of OS with bilateral pleural and lung metastases, without bone involvement detected by BS.


   Case Report Top


A 29-year-old woman was diagnosed with high-grade fibroblastic OS in the proximal left tibia. She was initially treated with chemotherapy, followed by amputation of the left lower limb. Thirteen months later, she complained of dyspnea and chest pain. A computed tomography (CT) scan of the chest was performed and showed multiple pulmonary and pleural nodules suggestive of involvement secondary to the OS. In addition, a planar and single-photon emission computed tomography/CT, BS with99m Tc-MDP was also requested and demonstrated bilateral diffuse pleural plaques, which corresponded to multiple calcified foci of thickening and nodules [Figure 1] and [Figure 2]. BS did not show signs of bone metastases.
Figure 1: Planar images of the bone scan showing diffuse areas of99mtechnetium methylene diphosphonate uptake in the pleura projection bilaterally

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Figure 2: Coronal computed tomography image showing multiple calcified foci of thickening and nodules in both pleura (left) and the single-photon emission computed tomography/computed tomography fusion showing the99mtechnetium methylene diphosphonate uptake correspondence in these areas (right)

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After restaging examinations, systemic palliative treatment for the patient was started.


   Discussion Top


OS is an aggressive primary bone tumor arising from primitive bone-forming cells.[6] The metastases of OS are typically hematogenous and the most common sites are lungs and bone.[2] Pleural metastases of OS are exceedingly rare[6] and the appearance of diffuse pleural thickening with ossification is also unusual, and few such cases have been reported.[3] A study that included 134 patients diagnosed with OS showed that 13 of them had extrapulmonary metastases, and only two of them presented pleural metastases.[3]

Pleural metastases in OS can occur by two mechanisms: Direct contact of pleura with the lung metastases and hematogenous spread of OS.[7]

Conventional imaging features of extraskeletal OSs are largely nonspecific.[9] It is a fact that this kind of tumor can produce bone and osteoid,[10] BS can help to show these lesions, including pleural metastases.

BS is often used in conjunction with CT to identify metastases, and the presence or absence of metastatic disease remains one of the most important predictors of patient outcome.[4]

Although CT had already shown lung and pleural lesions, our intention was to demonstrate a rare presentation of OS and an unusual image of pleural metastases detected by BS, and its diffuse pattern of distribution compared to the anatomical diagnostic method.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot bechrological order guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Pochanugool L, Subhadharaphandou T, Dhanachai M, Hathirat P, Sangthawan D, Pirabul R, et al. Prognostic factors among 130 patients with osteosarcoma. Clin Orthop Relat Res 1997;345:206-14.  Back to cited text no. 1
    
2.
Lindsey BA, Markel JE, Kleinerman ES. Osteosarcoma overview. Rheumatol Ther 2017;4:25-43.  Back to cited text no. 2
    
3.
Rastogi R, Garg R, Thulkar S, Bakhshi S, Gupta A. Unusual thoracic CT manifestations of osteosarcoma: Review of 16 cases. Pediatr Radiol 2008;38:551-8.  Back to cited text no. 3
    
4.
Geller DS, Gorlick R. Osteosarcoma: A review of diagnosis, management, and treatment strategies. Clin Adv Hematol Oncol 2010;8:705-18.  Back to cited text no. 4
    
5.
Marchiori E, Menna Barreto M, Zanetti G. Pleural metastases of osteosarcoma. Ann Thorac Surg 2018;105:e87-e88.  Back to cited text no. 5
    
6.
Krishnamurthy K, Alghamdi S, Kochiyil J, Bruney GF, Poppiti RJ. Osteosarcoma presenting with malignant pleural effusion in a 55 year old. Respir Med Case Rep 2018;25:314-7.  Back to cited text no. 6
    
7.
Sukumaran R, Nayak N, Mony R, Kaur J, Nair S: Osteosarcoma presenting with massive malignant pleural effusion. Oncol J India 2019;3:20.  Back to cited text no. 7
    
8.
Palestro CJ, Styles ST, Kim CK, Goldsmith SJ. Bone scintigraphy in pleural metastases of osteogenic sarcoma. Clin Nucl Med 1990;15:346-7.  Back to cited text no. 8
    
9.
Roller LA, Chebib I, Bredella MA, Chang CY. Clinical, radiological, and pathological features of extraskeletal osteosarcoma. Skeletal Radiol 2018;47:1213-20.  Back to cited text no. 9
    
10.
Murphey MD, Robbin MR, McRae GA, Flemming DJ, Temple HT, Kransdorf MJ. The many faces of osteosarcoma. Radiographics 1997;17:1205-31.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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