Case Author(s): Thomas Vreeland MD, John Larhorra, MD, Tom R.Miller, MD, PhD , 11/19/94 . Rating: #D2, #Q4

Diagnosis: Radiation Nephritis

Brief history:

Four year-old boy with stage IV neuroblastoma undergoing evaluation for osseous metastatic disease.

Images:

Anterior and posterior whole-body images from bone scintigraphy

View main image(bs) in a separate image viewer

View second image(mr). MRI images of the abdomen.

View third image(xr). Abdominal plain film showing the radiation port.

Full history/Diagnosis is available below

Diagnosis: Radiation Nephritis

Full history:

This patient is a four year-old boy with stage IV neuroblastoma originally diagnosed two years ago. He underwent surgical resection, high-dose chemotherapy and bone marrow transplantion. He developed leg pain six months ago and was subsequently found to have recurrence involving the pedicles of L3. He received several radiation treatments and is referred for this study to rule-out osseous metastatic disease.

Radiopharmaceutical:

Tc-99m MDP

Findings:

Bone Scintigraphy:

(1) Persistent, mildly increased activity is seen involving the pedicles of L3, without interval change compared to a prior bone scintigraphy performed at the time of development of pain (not included in this teaching file). No new foci of abnormally increased activity to otherwise suggest osseous metastatic disease are seen.

(2) Moderately increased activity is seen along the medial border of the right kidney representing an interval change compared to the prior examination. Therefore, in this patient with a history of recent radiation treatments, radiation nephritis is the most likely etiology.

MRI Examination:

(1) Enhancing, epidural mass extending from L2 - L4.

(2) Blastic involvement of the L3 verterbral body is unchanged.

Abdominal X-ray:

The radiation port is seen.

Discussion:

Radiation Nephritis:

(1) The threshold dose for development of nephritis is 2,300 rads

(2) May occur up to two years after treatment

(3) Clinically, the nephritis resembles a chronic glomerulonephritis with normal-to-small kidney(s) in the field of radiation. Parenchymal thickness in involved areas is also diminished.

(4) Associated with hypertension

(5) Histologically, one sees interstitial fibrosis, tubular atrophy, glomerular and arteriolar sclerosis.

Followup:

MRI examination performed six months after this study and the course of radiation demonstrated no new focal lesions to suggest metastatic disease. Also, the epidural mass extending from L2 - L4 and the pedicles of L3 remained unchanged.

View followup image(bs). Bone scintigraphy six months after radiation treatment shows resolution of the renal finding.

Major teaching point(s):

This is an unusual case demonstrating radiation nephritis.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Genitourinary System, Category:Inflammation,Infection)

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Case number: bs015

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