|
History: The patient is a 66 year-old
female with a significant history of metastatic breast cancer.
She was first diagnosed eight years ago and received a lumpectomy,
radiation therapy, and Tamoxifen. Metastatic disease was found
in the pelvis five years after breast cancer was treated, which was
about 2003, and was treated at that time with Arimidex and Zometa.
It is noted that she has healing pelvic fractures. She was
previously taking medication for osteoporosis (drug name unknown.) She is in clinic today for a submental (under the
chin) mass that she noted about a month ago. It was thought to have
been an infection and was given antibiotics. This mass never caused
her any discomfort, never had any purulence or erythema.
A follow-up evaluation with a PET scan and bone
scan revealed intense uptake of the radiopharmaceuticals in the
mandible. Both of the mentioned studies
demonstrated some increased activity and possible metastasis to the
anterior mandible. Other possible diagnosis are reactive lymph node,
or
associated with osteonecrosis of the mandible due to the prior
bisphosphonate usage.
Physical Examination:
General: Well-nourished female in a wheelchair in no acute distress.
HEENT: Oral cavity demonstrates edentulous on
the mandible. Upper teeth are intact at present. Lower dentures were
removed, and oral cavity was found to have no lesions or fullness.
The submentum was palpated, finding about a 1.5 to 2 cm firm nodule
that is slightly mobile, though appears to be attached to the
mandible. This did not appear to be salivary in nature.
MDP Bone Scan |
FINDINGS: There are numerous foci of increased activity
throughout the axial skeleton consistent with metastatic
disease. These include the anterior mandible, the left side
of T11, the left side of L1, the left side of L4, right side
of L5. There is also increased activity in both posterior
ilia, but the left is significantly worse than the right.
There is also increased activity in both pubic bodies. Most
of the left iliac crest is not visualized and appears to be
photopenic defect that extends into the wing from there.
IMPRESSION:
1. WIDE SPREAD METASTATIC DISEASE WITH INCREASED ACTIVITY OF
FOCI DESCRIBED ABOVE AND POSSIBLE LARGE COLD, LYTIC LESION
IN THE LEFT ILIAC WING. SOME OF THESE CHANGES, ESPECIALLY
THE CHANGES IN THE MID SPINE, MAY BE DEGENERATIVE IN NATURE.
ADDENDUM: Multiple foci of increased activity noted along
the costochondral junctions on the right side of the chest
most consistent with traumatic changes. |
Excerpt from PET Scan Report:
UPTAKE IN THE ANTERIOR MANDIBLE WHICH MAY REPRESENT INFECTION/OSTEONECROSIS
FROM BISPHOPHONATE ADMINISTRATION AND LESS LIKELY A METASTATIC
LESION.
|
Teaching Note:
An article in the July Pharmacy Today titled "Jaw
Necrosis Linked to Bisphosphonate Use" reported "osteonecrosis
of the jaw, a recently recognized adverse effect of biphosphonates,
is a particularly difficult problem to manage. According to a
systematic review published recently in the Annals of Internal
Medicine (www.annals.org),
nearly all reported cases have involved patients with multiple
myeloma or metastatic carcinoma who have received intravenous,
nitrogen-containing bisphosphonates, chiefly pamidronate and
zoledronic acid."
"Bisphosphonates can produce microdamage because they alter the
bone deposition and repair processes. Prolonged use of
bisphosphonates may suppress bone turnover to the point that such
microdamage persists and accumulates" "Twice as many patients
had problems with the mandible than the maxilla, and 60% of patients
had a dental surgical procedure before developing osteonecrosis"
(Note the patient above had lower dentures).
Sook-Bin Woo, John W. Hellstein, and John R. Kalmar
Systematic Review: Bisphosphonates and Osteonecrosis of the Jaws
Ann Intern Med, May 2006; 144: 753 - 761.
Back to
Newsletter
© 2006 Nuclear Education Online
- Images courtesy of UAMS Dept of
Nuclear Medicine.
|
