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Age / Sex : 45 / F
Chief complaint: follow-up study after concurrent chemoradiation therapy for cervical cancer
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case.
(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)
Courtesy: 이영환(Lee Young-Hwan), 대구가톨릭대학교병원(Daegu
Catholic university Medical Center)
Diagnosis: Diffuse hematopoietic marrow hyperplasia
Discussion
Findings:
T1-weighted
MR image shows homogeneous decrease in signal intensity of vertebral marrow,
lower than that of the intervertebral disc (complete fatty marrow is seen in
the irradiated lower lumbar and sacral area). T2- and fat-saturated T2-weighted
images show low signal intensity of vertebral marrow. No significant
enhancement is seen. CT shows no evidence of bony destruction or sclerotic
change. Bone scan and PET-CT show normal finding.
Differential Diagnosis:
Diffuse
hematopoietic marrow hyperplasia
Bone
metastasis
Marrow
infiltrative disease
Diagnosis: Diffuse hematopoietic
marrow hyperplasia
Discussion:
Diffuse hematopoietic marrow
hyperplasia is defined by the presence of hypercellular hematopoietic marrow in
the axial skeleton. It occurs in response to numerous stimuli that trigger
production of red marrow cells, such as administration of hematopoietic growth
factors during chemotherapy. Several chronic disorders that are associated with
anemia including hereditary hemoglobinopathies and chronic infection also cause
red marrow expansion. Diffuse red marrow hyperplasia is also observed in
middle-aged obese women, in heavy smokers, and in people who engage in
intensive sports activities such as long-distance running.
On T1-weighted images, hematopoietic
marrow hyperplasia is associated with a marked decrease in signal intensity of
vertebral marrow that becomes similar or lower than that of the adjacent disc.
On T2-weighted images, vertebral signal intensity is intermediate or low
probably because red marrow hyperplasia is associated with an increase in the
intracellular amount of iron. After intravenous gadolinium injection, signal
intensity enhancement is variable based on the cellularity of marrow.
Diffuse hematopoietic marrow
hyperplasia can be confused with diffuse marrow infiltration in the spine. As a
rule, marrow hyperplasia shows a signal similar to that of red marrow. The
signal intensity pattern of diffuse marrow infiltration by neoplastic cells can
differ from that of red marrow. However, they are cases in which confusion is
possible.
Dynamic contrast MR studies, and
diffusion-weighted images have all shown to be of some help, but none has
demonstrated definite conclusive results. FDG-PET imaging has also shown a
limitation in this setting because diffuse increased uptake can be observed in
red marrow hyperplasia as in neoplastic medullary infiltration. Therefore,
obtaining a blind iliac crest biopsy may remain the more accurate technique to
address this occasionally difficult problem definitively.
References:
1. Vande Berg BC, Lecouvet FE,
Galant C, Simoni P, Malghem J. Normal variants of the bone marrow at
MR imaging of the spine. Semin Musculoskelet Radiol.
2009;13(2):87-96
* Cervical cacner의 radiation therapy history가 있고, quiz에 제시된 image에서 sacral area 의 bone marrow fat signal intensity 뚜렷하므로, 관리자 직권으로 이 부위의 irradiation-related fatty marrow change는 semi-correct answer로 처리하였음을 알립니다.
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