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PAGET'S DISEASE AND BREAST CANCER METASTASES
Authored By: Joanna Fair and Henry Royal.
Patient: 70 year old
History: 70 year old patient: Additional history withheld.
Image Size:[small][as-submitted]

Fig. 1
Whole body bone scan

Fig. 2
Whole body bone scan with spot images

Fig. 3
Post-void images

Fig. 4
Whole body bone scan performed ~1 1/2 years previously

Fig. 5
Frontal skull radiograph

Fig. 6
Lateral skull radiograph
Image Size:[small][as-submitted]

Findings: Radiopharmaceutical:  19.8 mCi Tc-99m MDP i.v.

Whole-body images, spot views, and post-void images were obtained. (Fig. 1, Fig. 2, and Fig. 3).

These images demonstrate intense calvarial and facial bone uptake.

There are also multifocal areas of abnormal uptake in the thoracic and lumbar spine, the left ilium/sacrum, bilateral scapulae, the right greater trochanter, and at least one right posterior rib.


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A bone scan obtained 1.5 years previously (Fig. 4) demonstrated even more intense calvarial and facial bone uptake, with multifocal abnormal uptake elsewhere in the skeleton.

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Frontal and lateral skull radiographs demonstrate a 'cotton-wool' appearance to the calvarium with expansion of the mandible, right greater than left.

DDx: Multifocal metastatic disease versus Paget's disease plus multifocal metastatic disease.
Diagnosis: Paget's disease plus multifocal metastatic disease from breast cancer.
General Discussion: Full patient history:

69-year-old woman with longstanding history of Paget's disease, seen on a bone scan six years previously (images not available).  The patient presented with an 8-cm breast mass, found to be a primary breast malignancy.  The initial bone scan findings, correlated with a CT showing liver and osseus metastases, were thought to be most consistent with known Paget's disease and superimposed osseus metastases from breast cancer.  The patient was initially treated with Xeloda and Zometa (a bisphosphonate used for metastatic bone lesions and for Paget's disease) for approximately 3 months; she was subsequently changed to Avastin plus Abraxane for approximately 10 months.  The patient had not been on any therapy for several months prior to the most recent bone scan.

Discussion:

Paget's disease is a common disorder; its prevalence in the United Kingdom is ~5% in people greater than 60 years old.  On bone scintigraphy, Paget's disease typically involves the majority or entirety of affected bones, with marked increased uptake and an expansile appearance.  Bone scintigraphy is more sensitive than plain radiography for detecting involved bones.  Paget's disease can be treated with bisphosphonates; during therapy, uptake in an affected bone may decrease and become more focal. 

In this patient with newly diagnosed metastatic breast cancer, the diffuse calvarial uptake would be atypical for breast cancer metastases and was most consistent with her known diagnosis of Paget's disease.
References: Ryan, PJ and Fogelman, I.  "Bone Scintigraphy in Metabolic Bone Disease."  Semin Nucl Med. 1997 Jul;27(3):291-305.
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Additional Details:

Case Number: 148550Owner(s): Joanna Fair and Henry RoyalLast Updated: 02-07-2013
Anatomy: Skeletal System   Pathology: Metabolic
Modality: Conventional Radiograph, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: bsnm, pagets disease, breast cancer, metastatic disease, bone scintigraphyACR: 40000.84000, 40000.33000

Case has been viewed 40 times.
Certified by Henry Royal on 10-15-2010

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