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Bone Case 12 Answers

1) Describe any abnormal areas of uptake

There is an area of decreased uptake in the 7th and 8th ribs of the right posterior chest with subtle raised uptake in the surrounding ribs.

2) What does this tell you about the underlying pathological process?

This area of relative photopaenia ("cold" lesion) tells us that either

(i) the underlying process is osteolytic (e.g. Benign conditions such as myelofibrosis, haemangiomas or brown tumors; Primary bone malignancies include multiple myeloma, osteosarcoma and fibrosarcoma or Metastatic lesions from breast, lung, kidney or thyroid)

(ii) there is artefactual shielding of the area (e.g. barium, jewelry, coins, pacemakers and orthopedic, breast or dental prostheses)

(iii) there is congenital absence or has been surgical resection +/- prosthesis

(iv) there is ischaemia of the area (e.g. due to avascular necrosis, acute osteomyelitis, vasculitis, connective tissue disorders, pancreatitis, radiotherapy, high-dose steroids, Caisson's disease, frostbite, electrical burns, haemophilia, Gaucher's, thalaessaemia or sickle cell disease )

3) Given the clinical history, what possible diagnoses cross your mind?

Patients with coeliac disease are at increased risk of tumours. They are at 2X risk of gastrointestinal and lymphatic tumours but specifically 70-80X risk of T-cell non-Hodgkin lymphoma. Although still very rare, this represents an overall 7% lifetime risk. The risk of developing these tumours is probably decreased to normal with a strict gluten-free diet.

This patient had a biopsy-proven extranodal T-cell NHL, affecting the R posterolateral chest wall.

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