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CASE REPORT
Year : 2020  |  Volume : 19  |  Issue : 2  |  Page : 144-146

Synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease in a case of newly diagnosed prostatic carcinoma


Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

Date of Submission07-Aug-2019
Date of Acceptance10-Jan-2019
Date of Web Publication17-Jan-2020

Correspondence Address:
Dr. Kaushik Chagarlamudi
Department of Radiology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106
USA
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DOI: 10.4103/wjnm.WJNM_63_19

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   Abstract 


Tc-99m methylene diphosphonate bone scintigraphy (bone scan) is a highly sensitive technique for the evaluation of osseous pathology. However, the nonspecificity of the method can present diagnostic challenges in differentiating benign from malignant processes. Often, Paget's disease and osseous metastasis can coexist in elderly patients. Therefore, it is important to accurately distinguish the two pathologies, as each has a different prognosis and impacts clinical management. Obtaining the appropriate clinical diagnosis often involves a combination of laboratory, radiographic, and clinical data. We present a case of newly diagnosed prostatic carcinoma presenting with synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease.

Keywords: Bone scintigraphy, osseous metastasis, Paget's disease, prostate carcinoma


How to cite this article:
Devita R, Chagarlamudi K, Kardan A. Synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease in a case of newly diagnosed prostatic carcinoma. World J Nucl Med 2020;19:144-6

How to cite this URL:
Devita R, Chagarlamudi K, Kardan A. Synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease in a case of newly diagnosed prostatic carcinoma. World J Nucl Med [serial online] 2020 [cited 2020 Nov 26];19:144-6. Available from: http://www.wjnm.org/text.asp?2020/19/2/144/275846




   Introduction Top


An 87-year-old male with prostate cancer and a prostate-specific antigen (PSA) of 21 was evaluated for osseous metastasis with bone scintigraphy. Bone scintigraphy demonstrated multiple areas of focal increased uptake, including the mid-cervical spine, T7-T8 vertebral bodies, left posterior 6th rib, and right iliac wing, concerning for osseous metastatic disease [Figure 1]. In addition, there was focal increased radiotracer uptake within the medial portion of the right clavicle, T11 vertebral body, medial compartment of the left knee, and the calvarium sparing the mandible, secondary to Paget's disease [Figure 2] and [Figure 3]. Of note, the image demonstrates the “Mickey Mouse sign” of the T11 vertebral body [Figure 2]. There was also mild increased heterogeneity throughout the thoracolumbar spine, secondary to degenerative changes.
Figure 1: Diffuse areas of increased uptake including mid cervical spine, T7-T8 vertebral bodies, left posterior 6th rib and right iliac wing concerning for osseous metastatic disease

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Figure 2: Increased radiotracer uptake in T11 vertebral body demonstrates Mickey Mouse sign

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Figure 3: Uptake in calvarium sparing the mandible secondary to Paget's disease

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   Case Report Top


An 87-year-old male was referred to urology after complaining of urinary incontinence with a PSA value of 14 that subsequently rose to 21. The patient underwent magnetic resonance imaging which revealed findings concerning for malignancy. Biopsy revealed prostate cancer w/Gleason score of eight. To evaluate for metastatic disease, both computed tomography (CT) chest/abdomen/pelvis and bone scintigraphy were ordered. The CT report commented on a bony lesion in the right ileum with no lymphadenopathy. Bone scan showed diffuse uptake consistent with osseous metastatic disease, Paget's disease, and degenerative disease. Due to the increased sensitivity of the bone scan, the patient was able to be started on the appropriate medications and has responded well to therapy.


   Discussion Top


Both Paget's disease and skeletal metastases affect similar areas of the body and can present similarly on imaging. Bone scintigraphy has been shown to be the most sensitive method of detecting osseous metastases from prostate adenocarcinoma as well as detecting the increased vascularity and osteoblastic activity of Paget's disease.[1],[2] The lack of specificity in this modality often leaves room for radiologic interpretation. The differentiation between the two processes remains an important task to help guide clinical management, as up to 27% of bone scan abnormalities in patients with known cancer are due to benign causes.[3] Correlation with radiography can help differentiate between metastases and Paget's disease as the latter demonstrates pathognomonic signs on CT.[4] Classically, the lysis and sclerosis of bone in Paget's disease result in osteoporosis circumscripta and the cotton-wool sign of the skull.[5] On scintigraphy, preferential tracer accumulation in certain areas such as inner table and diploe of the frontoparietal bones of the skull have been noted to resemble these radiographic signs.[6] Another differentiating factor suggestive of Paget's disease is the presence of the “Mickey Mouse sign.” This describes uptake in the vertebral body, posterior elements, and spinous processes and is more suggestive of Paget's than metastases, even in patients with cancer.[7] In this case, CT scan was used to corroborate the changes consistent with the Mickey Mouse sign were secondary to Paget's disease. On CT, mixed lytic and sclerotic changes along with enlargement of the posterior processes of the T11 vertebral body favor Paget's disease over metastasis [Figure 4], [Figure 5], [Figure 6]. Another way to differentiate between the two conditions is the evaluation of the intensity of tracer uptake. Paget's disease often demonstrates intense, well-demarcated, and evenly distributed uptake. Osseous metastatic disease, on the other hand, tends to present with random, amorphic lesions or patchy tracer uptake with effacement of the normal bone outlines.[3] Paget's disease also tends to preserve anatomic details while metastatic disease tends to obscure anatomy.[8]
Figure 4: Axial computed tomography image of the T11 vertebral body demonstrating a mixed appearance of lytic and sclerotic regions

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Figure 5: Sagittal compuetd tomography image of the T11 vertebral body demonstrating enlargement of the posterior processes

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Figure 6: Coronal compuetd tomography image of the T11 vertebral body demonstrating changes consistent with Paget's disease

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In this case, the findings of osseous metastases and Paget's disease were confounded by underlying degenerative changes, which have classically been characterized as radiotracer uptake in weight-bearing regions, such as the thoracic and lumbar spine. This is a significant distinction as metastases have been found in 11% of areas with radiotracer uptake consistent with degenerative arthritis, per a case series of 579 scans of patients with known metastatic disease.[3] In conclusion, bone scintigraphy is a sensitive, but nonspecific, method for detecting osseous metastatic disease. In the presented case, bone scan was an invaluable resource in identifying key imaging features that elucidated differences between etiologies and directly impacted clinical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Schaffer DL, Pendergrass HP. Comparison of enzyme, clinical, radiographic, and radionuclide methods of detecting bone metastases from carcinoma of the prostate. Radiology 1976;121:431-4.  Back to cited text no. 1
    
2.
Kumar AA, Kumar P, Prakash M, Tewari V, Sahni H, Dash A. Paget's disease diagnosed on bone scintigraphy: Case report and literature review. Indian J Nucl Med 2013;28:121-3.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Corcoran RJ, Thrall JH, Kyle RW, Kaminski RJ, Johnson MC. Solitary abnormalities in bone scans of patients with extraosseous malignancies. Radiology 1976;121:663-7.  Back to cited text no. 3
    
4.
Shih WJ, Riley C, Magoun S, Ryo UY. Paget's disease mimicing skeletal metastases in a patient with coexisting prostatic carcinoma. Eur J Nucl Med 1988;14:422-3.  Back to cited text no. 4
    
5.
Cushing FR, Bone HG. Radiographic diagnosis and laboratory evaluation of Paget's disease of bone. Clin Rev Bone Miner Metab 2002;1:115-34.  Back to cited text no. 5
    
6.
Bahk YW, Park YH, Chung SK, Chi JG. Bone pathologic correlation of multimodality imaging in paget's disease. J Nucl Med 1995;36:1421-6.  Back to cited text no. 6
    
7.
Kim CK, Estrada WN, Lorberboym M, Pandit N, Religioso DG, Alavi A. The 'mouse face' appearance of the vertebrae in paget's disease. Clin Nucl Med 1997;22:104-8.  Back to cited text no. 7
    
8.
Sonoda LI, Balan KK. Co-existent paget's disease of the bone, prostate carcinoma skeletal metastases and fracture on skeletal scintigraphy-lessons to be learned. Mol Imaging Radionucl Ther 2013;22:63-5.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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