Unusual cause of generalized osteolytic vertebral lesions: a case report

Evaluation of sarcoidosis with multiple bone lesions using both bone scintigraphy and FDG-PET/CT: A case report

Sarcoidosis is a systemic granulomatous disease; however, the incidence of bone sarcoidosis is relatively rare. The short tubular bones of the hands and feet are most frequently affected, while the vertebrae and the pelvic bones are rarely involved. We hereby report a rare case of multiple bone sarcoidosis involving the vertebrae and pelvic bones, evaluated before and after steroid therapy using two different imaging modalities: bone scintigraphy and A 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT). FDG-PET/CT is effective for detecting bone lesions; however, whole-body imaging is recommended to detect the short tubular bones of the hands and feet, which are most frequently affected.

Expert review for clinical and translational imaging actionable imaging findings in the daily PET/CT scenario

Background and aim

The American College of Radiology (ACR) defines "actionable findings" the ones requiring a special communication between radiologists and referring clinicians, suggesting to organize their categorization in a three-degree scale on the basis of the risk for the patient to develop complications. These cases may fall in a grey-zone communication between different care figures with the risk of being underestimated or even not being considered at all. In this paper, our aim is to adapt the ACR categorization to the most frequent actionable findings encountered when reporting PET/CT images in a Nuclear Medicine Department, describing the most frequent and relevant imaging features and presenting the modalities of communication and the related clinical interventions that can be modulated by the prognostic severity of the clinical cases.

Materials and methods

We performed a descriptive, observational and critical analysis of the most relevant literature on the topic of "actionable findings", in particular, starting from the reports of the ACR Actionable Reporting Work Group, we categorised and described, in a narrative review, the most relevant "actionable findings" encountered in the Nuclear Medicine PET/CT daily practice.

Results

To the best of our knowledge, to date there are no clear indications on this selective PET/CT topic, considering that the current recommendations target mainly radiologists and assume a certain level of radiological expertise. We resumed and classified the main imaging conditions under the term of "actionable findings" according to the corresponding anatomical districts, and we described their most relevant imaging features (independently of PET avidity or not). Furthermore, a different communication timing and strategy was suggested on the basis of the findings' urgency.

Conclusion

A systematic categorization of the actionable imaging findings according to their prognostic severity may help the reporting physician to choose how and when to communicate with the referring clinician or to identify cases requiring a prompt clinical evaluation. Effective communication is a critical component of diagnostic imaging: timely receipt of the information is more important than the method of delivery.

Complete paraplegia with diffuse osteolytic skeletal metastases: an uncommon presentation of carcinoma of the prostate

INTRODUCTION

Skeletal metastases of advanced prostatic cancer are usually osteoblastic in appearance. Osteolytic secondaries are an uncommon entity. In such scenarios, it is important to differentiate prostatic metastases from other pathologies which give an identical radiological appearance, such as multiple myeloma. Another important point to remember is that neurological complications secondary to prostatic metastases are quite uncommon.

CASE PRESENTATION

We describe a man with advanced prostatic carcinoma who presented to us with an uncommon combination of sudden onset complete paraplegia associated with diminished sensation in the lower half of the body and diffuse osteolytic lesions in the entire skeletal system. On detailed workup, it was found that his prostatic specific antigen (PSA) was grossly elevated. Markers for multiple myeloma were negative. Accordingly, computerized tomography of the abdomen was performed. The latter revealed an enlarged prostate gland infiltrating into the bladder base. Histopathological analysis from the prostate as well as the bone marrow showed an identical picture thereby confirming our diagnosis. The individual underwent palliative spinal canal decompression following which he was put on anti-androgenic treatment. At one year follow up, he was ambulatory and able to walk with use of crutches.

DISCUSSION

To the best of our knowledge, this is the first reported case of osteolytic prostatic metastases presenting as complete paraplegia. In this situation, in addition to evaluation for prostate CA, we also recommend screening for multiple myeloma as the clinico-radiological profile of the two diseases are similar but their management is very different.

Osseous sarcoidosis: clinical characteristics, treatment, and outcomes--experience from a large, academic hospital

OBJECTIVE

Osseous sarcoidosis has been infrequently reported. We aimed to characterize the distribution of lesions, clinical presentation, treatment, and outcomes for osseous sarcoidosis.

METHODS

Cases of osseous sarcoidosis were identified by directed inquiry to clinicians and electronic query. Cases were defined as having pathologic evidence of non-caseating granulomas on bone biopsy or evidence of osseous lesions on imaging attributable to sarcoidosis in patients with known sarcoidosis. Detailed characteristics were obtained by medical record review.

RESULTS

We identified a total of 20 cases of osseous sarcoidosis. Osseous lesions were detected by imaging during the initial sarcoidosis presentation in 60% of cases. In those who had a prior diagnosis of sarcoidosis, the median duration of sarcoidosis before detection of osseous involvement was 4.3 years. Symptoms were present in 50% of cases. All cases had more than one bone involved. The axial skeleton was involved in the majority of cases (90%), primarily the pelvis and the lumbar spine. Most cases required no treatment (55%); a minority of cases (45%) were treated, most often with prednisone, methotrexate, or hydroxychloroquine. Two cases required multiple immunosuppressants, including tumor necrosis factor inhibitors, for refractory symptomatic osseous sarcoidosis. Treated cases were younger than those who were untreated. At last follow-up, most cases (85%) were asymptomatic from osseous lesions.

CONCLUSIONS

In this case series of osseous sarcoidosis from a single center, most patients had multiple bones affected and had other systemic manifestations of sarcoidosis. A minority required treatment for relief of symptoms, and most cases were asymptomatic at last follow-up.