1 of 6

Man with melanoma and lung metastases.

Our appreciation is extended to Dr. Lauren Ladd,
Indiana University Department of Radiology,
for contributing this case.

History:  Man with melanoma and lung metastases.
Click these images to enlarge them.

Click for galleryClick for galleryClick for gallery

Can you select the choice that depicts the patient's chief complaint?

Paralysis.Chest wall pain.Hypotension.Hemoptysis.Dysphagia.
1 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
2 of 6

Man with melanoma and lung metastases.

Here now are 2 pairs of matched images, each pair showing the same chest wall anatomy. The left image in each pair is current, the right image is from 18 months ago. Click to enlarge.

Click for galleryClick for gallery
Click for galleryClick for gallery

Why does the patient have chest wall pain?

Expansile rib lesion.Periosteal reaction.Pleural-based mass.Rib fractures.Soft-tissue abscess.
2 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
3 of 6

Man with melanoma and lung metastases.


The patient has no history of trauma, and no known bone metastases. However, as the images show, the patient does have a RLL lung lesion. This lesion has been treated.


Below are the same four images. Can you determine why the patient has developed rib fractures? (Revealed on next page of the case).

Click for galleryClick for galleryClick for galleryClick for gallery
3 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
4 of 6

Man with melanoma and lung metastases.

Click for galleryClick for galleryClick for galleryClick for gallery
Findings:  Development of right lateral 7th and 8th rib fractures with surrounding mottled sclerosis and bony irregularity


Differential diagnosis:

  • Metastatic disease
  • Primary bone tumor (sarcoma, fibrosarcoma)
  • Chronic fracture
  • Osteomyelitis
  • Radiation damage (osteitis, osteonecrosis)
Diagnosis:  Radiation osteonecrosis
4 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
5 of 6

Man with melanoma and lung metastases.


Key points:
 

  • Radiation consequences on bone depend on the type and location of bone irradiated, radiation dose / fractionation, and age of the patient
    • Diaphyses are relatively resistant compared to epiphyses (most sensitive)
    • Superficial bones (i.e., mandible) are more affected due to increased dose
    • Microscopic bone changes begin at 3 Gy, osteoblast function hindered at 4 Gy, and chondrocytes damaged at 12 Gy
  • Radiation osteitis is less severe and debatably reversible bone change, including osteopenia secondary to osteoblast malfunctioning and secondary resorption of bone
  • Radiation osteonecrosis is more severe and nonreversible bone change, including bone progenitor cell damage as well as vascular compromise from endarteritis
  • Presentation:
    • Most often asymptomatic and discovered incidentally on imaging for known malignancy
    • May present with pain if insufficiency fracture of the damaged bone
    • Earliest bone changes are seen 6 – 12 months after radiation treatment
    • Common locations: pelvis, scapula
  • Imaging findings:
    • Mixed lytic and sclerotic appearance, possibly mimicking permeative pattern
    • Osteopenia with course and irregular trabeculae
    • Sometimes described as Paget-like appearance but without bony expansion
    • Cortical thinning in long bones
    • No associated soft tissue masses
    • Localized to radiation field, often abrupt change between abnormal and normal bone (corresponds to radiation port)
    • Cold on nuclear medicine bone scan when true osteonecrosis is present
    • Consider MR to evaluate for associated soft tissue mass and/or extent
  • Consequences of radiation osteonecrosis:
    • Fractures (insufficiency), bone infarcts (long bones), osteomyelitis
    • Secondary malignancy (uncommon, late consequence): osteosarcoma, ~4-40 years after exposure, histologically different from primary tumor
    • Secondary bone tumors more likely benign (osteochondroma) if <2 years old at time of radiation

References: 

  1. Bluemke DA, Fishman EK, and Scott WW. Skeletal Complications of Radiation Therapy. RadioGraphics. 1994; 14:111-121.
5 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
6 of 6

Man with melanoma and lung metastases.


Congratulations!

You have completed AuntMinnie's Case of the Day(SM)!

We hope your experience has been fun and educational. Please view more at:
Case of the Day(SM) Home Page
Show / Update Score
6 of 6
Case of the Day(SM) Copyright
AuntMinnie.com AuntMinnie.com Back To Top
Copyright © 2014 AuntMinnie.com. All Rights Reserved.
Back To Case

Gallery

swipe or use buttons at the bottom
Back To Case

Gallery

swipe or use buttons at the bottom
All content on this Website is licensed to, or Copyright © 2011, AuntMinnie.com. All Rights Reserved. Images and text may be reused by permission only. All copyright watermarks must be left intact.

Powered by EDACTICTM Invented & Developed by Mark S. Frank, M.D.
Back