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Age / Sex : 65 / M
Age / Sex : 65/M
Chief complaint : General check up
for lung cancer (Small cell lung cancer)
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of
this case.
* Send Application Answers to In Sook Lee, MD (lis@pusan.ac.kr)
Courtesy : Han Jong-Kyu, Soonchunhyang Unversity Cheonan Hospital
Diagnosis: Bone metastasis (mimicking vertebral hemangioma)
Discussion
Findings:
MRI: L3 vertebral mass shows low SI on T1WI,
intermediate SI on T2WI and high SI on fat suppressed T2WI with vertical
striations, and well enhancement on Gd-T1WI.
Bone scan: No abnormal uptake.
PET/CT: FDG hot uptake in L3, suggestive of
osteolytic bone metastasis.
Differential Diagnosis:
Vertebral hemangioma
Diagnosis:
Bone metastasis
(mimicking vertebral hemangioma)
Discussion:
Vertebral hemangioma is a common vertebral lesion with a
frequency of 12% in women and 9% in men. They are generally asymptomatic. Histologically, they
correspond to cavernous hemangiomas and contain dilated, blood-filled, vascular
spaces lined by flat endothelial cells, set in a stroma containing large mounts
of adipose tissue and no hematopoietic cells.
On T1-weighted SE images, signal intensity of
asymptomatic vertebral hemangioma is higher to that of adjacent marrow,
although it can also be equivalent and not visible on T1-weighted images. On
T2-weighted SE images, its signal is consistently high. Presence of fat cells and
dilated vessels with interstitial edema most likely accounts for its high
signal intensity on T1- and T2-weighted images, respectively. Frequently, punctuated
or linear areas of low signal intensity are also seen on T1- and T2-weighted
images, probably caused by the presence of thickened trabeculae. Signal
enhancement of hemangioma after gadolinium injection is variable, depending on
its appearance on T1-weighted images and the type of sequence that is obtained
after contrast injection. Enhancement pattern
can be homogeneous or peripheral.
Occasionally, asymptomatic vertebral hemangioma shows low
signal intensity on T1-weighted images, with marked enhancement on postcontrast
T1-weighted SE images. These hemangiomas can be confused with significant
marrow lesions. The
symptomatic vertebral hemangioma generally demonstrates low signal intensity on
T1-weighted images with extraosseous component.
The FDG-PET
scan findings are similar to the reduced uptake typically seen with bone
scintigraphy and helps to differentiate metastatic disease from the more benign
hemangioma.
References:
1.
Vande Berg BC, Lecouvet FE, Galant C, Maldague
BE, Malghem J. Normal variants and frequent marrow alterations that simulate
bone marrow lesions at MR imaging. Radiol Clin North Am.
005 Jul;43(4):761-70, ix. Review.
2. Laguna R, Silva F, Vazquez-Sellés J, Orduña E,
Flores C. Vertebral hemangioma mimicking a metastatic bone lesion in
well-differentiated thyroid carcinoma. Clin Nucl Med.
2000 Aug;25(8):611-3.
3. Basu S, Nair N.J. “Cold”
vertebrae on F-18 FDG PET: Causes and Characteristics. Neurooncol. 2006
Oct;80(1):91-5. Epub 2006 Jul 19.
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