Bone metastasis from squamous cell carcinoma

Case contributed by Jack Ren

Presentation

Deformed R shoulder following fall 5/7 ago with pain. Hx oropharyngeal squamous cell carcinoma.

Patient Data

Age: 65
Gender: Male
Modality: X-ray

Fracture lines are seen through the blade and spine of the right scapula.  A destructive lytic lesion of the spine of scapula is best seen on the lateral projection but the length of the spine is also absent on the AP film. Appearance is suspicious for a pathological fracture.

Surgical clips are noted in the right base of neck/thoracic apex.

Old right-sided rib fractures.

Modality: CT

A large ( 89 x 110 x 79 mm ) soft tissue mass replaces most of the superior right scapula with a pathological fracture through the base of the acromium and a further fracture through the body of the scapula. Mass extends to the margin of the glenohumeral joint but not into it.There is no involvement of the adjacent ribs or right humeral head. The mass does not encase the adjacent axillary artery or vein. 

Surgical staples along the right side of the neck and an absent right sternocleidomastoid in keeping with the history of previous oropharyngeal cancer.

A 59 x 66 x 95 mm hypodense lesion in segment VI of the liver has multiple small satellite nodules  and there is stranding in the surrounding fat. There is a linear hypodensity extending from the lesion to the posterior division of the right portal vein that is suspicious for thrombus in the segmental portal vein. There are multiple enlarged porta hepatis lymph nodes measuring up to 17 x 26 mm.

Multiple calcified gallstones are noted. The spleen, pancreas, kidneys and adrenals are unremarkable. The prostate is enlarged ( 59 x 47 x 30 mm ). There is moderate atheroma in the abdominal aorta.

Conclusion

Large right scapula destructive lesion with an associated soft tissue mass. In this setting the lesion likely represents a metastatic deposit. Possible further lesion in the right ilium.

Large liver lesion with surrounding satellite lesions and possible portal segmental vein thrombosis and associated lymphadenopathy.

Modality: Nuclear medicine

Focal intense tracer uptake in the right scapula involving the acromial/coracoid process, spine, and upper third of the medial border of scapula) is consistent with known scapula lesion on diagnostic imaging.

Linear tracer uptake involving the posterior right 8th, 9th and 10th ribs may represent previous rib fractures.

Tracer uptake best seen anteriorly in the L2 vertebral body probably represent anterior osteophytes.

There is no abnormal tracer uptake seen in the right ilium as noted on CT to suggest bony metastasis. No other significant abnormalities are seen. Normal renal and soft tissue outlines.

OVERALL IMPRESSION

Scintigraphic appearances are consistent with osteoblastic bony metastasis involving the right scapula . Linear uptake in the right posterior 8-10th ribs is likely due to previous fracture.

Modality: Ultrasound

ULTRASOUND GUIDED BIOPSY

Large scapular mass.

Posterolateral approach, 13/14G coaxial technique, single pass, 3 core samples.

Tract lies along the scapular spine line.

Tract not marked.

 

Pathology report of right shoulder mass:

MACROSCOPIC DESCRIPTION: "(R) shoulder": Multiple pale tan tissue fragments up to 20mm. A1. (KAL)

MICROSCOPIC DESCRIPTION: Sections show multiple cores of tissue which is largely replaced by tumour. The tumour consists of sheets of malignant basaloid epithelial cells which have prominent areas of necrosis.

DIAGNOSIS: Right shoulder: Malignant. Features in keeping with a metastatic basaloid squamous cell carcinoma. The previous diagnosis of a basaloid squamous cell carcinoma has been noted.

Case Discussion

Given the history of oropharyngeal SCC and multiple lesions the lesion easiest to biopsy (the shoulder mass) was sampled.

Importance of this case is to recognize the features of pathological fracture on the initial plain film. Initial report (not given here) identified the fractures only.

Ultrasound was used to guide biopsy rather than as a diagnostic tool. If there was a change that the lesion was a primary bone tumour the biopsy tract would have been marked with carbon.

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Case Information

rID: 30133
Case created: 21st Jul 2014
Last edited: 4th Oct 2015
Inclusion in quiz mode: Included

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