The patient is a 33y/o Hispanic woman who presented to a local hospital with complaints of generalized body aches for months, vomiting 4-5 times/day for 3 weeks with progressively worsening symptoms. She was recently diagnosed with Bell’s Palsy. She also complained of 25 pound weight loss in last 2 months. CT found a mass in the brain.

She was transferred to UAMS for workup and evaluation of brain mass. MRI and CT of the brain confirmed “TUMORAL PROCESS SUCH AS A LYMPHOMA, CHORDOMA, OR ARISING FROM THE NASOPHARYNX SUCH AS A NASOPHARYNGEAL CARCINOMA.” This was not believed to be the primary site. Mammogram and following ultrasound and biopsy confirmed bilateral breast cancer (three lesions in right breast and two in the left). A whole body bone scan was performed to determine the extent of metastatic disease…

BONE SCAN
CLINICAL INDICATION: Patient with suspected metastatic disease and an unknown primary carcinoma.

PROCEDURE:
The patient was injected with 25 mCi of Technetium-99m MDP. Full body delayed images in both the anterior and posterior projections were obtained as per protocol.
 

FINDINGS:
Multiple focal areas of increased uptake is noted throughout the patient's skeletal system. This includes the skull, manubrium, lesions in the sternum, multiple bilateral rib lesions, thoracic and lumbar spine areas, the whole pelvis, both SI joints, both humeri, and the bilateral femurs.

Physiological activity is noted in the kidneys and bladder.

IMPRESSION: WIDESPREAD METASTATIC DISEASE INVOLVING BOTH THE AXIAL AND APPENDICULAR SKELETON.

A/P:
Metastatic Breast Cancer: On weekly taxol + XRT… could get herceptin depending on FISH result which is still pending.
Brain Metasteses: on dexamethasone and XRT
Bone lesions: no intervention at this time
Pain: Oxycontin 30mg BID + Oxycodone 10mg q4 prn.

Teaching Note:  FISH (Fluorescence In Situ Hybridization)

The FISH test looks for the HER2 gene abnormality. This test is the most accurate, but less available, way to find out if a breast tumor is likely to respond to Herceptin. The FISH test shows how many copies of the HER2 gene are in tumor cells. This gene directs cells to make the HER2 protein. The more copies of the gene, the more HER2 receptors the cells have.

With the FISH test, you get a score of either "positive" or "negative" (some hospitals call a negative test "zero"). If the tumor is "FISH positive," it will probably respond well to Herceptin.
 

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© 2007 Nuclear Education Online

Case study contributed by Jason Luper, PharmD candidate, UAMS

Images courtesy of University of Arkansas for Medical Sciences Dept of Nuclear Medicine.