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Bone Case 4 Answers

1) Are there any abnormal areas of uptake?
2) If so, where?

There is an isolated area of uptake over the midline vertex of the skull. This was identical to the site of the clinically apparent mass and the aggressive lesion

3) List some possible causes

The causes of an isolated focal area of raised uptake in the skull is as follows

Eosinophilic granuloma, Ivory osteoma, Chronic osteomyelitis, Asymmetric hyperostosis frontalis interna, Isolated metastatic disease, Early Paget's disease Chondrosarcoma or Underlying meningioma

4) Do you think it is related to his previous lymphoma?

There is a raised incidence of secondary tumours after chemotherapy and radiotherapy in survivors some 10-20 years after successful treatment. This usually takes the form of tumours in the radiation field, particularly sarcomas, further lymphomas and leukaemia. However, the skull was not irradiated in this patient and they had no known secondary primary tumour

Cranial MRI demonstrated that this was hyperostosis secondary to a 5cm parasagital meningioma. Meningiomas themselves can take up MDP and this is related to intratumoural calcification. The hyperostosis associated with a meningioma is much more intense than intratumoural uptake, probably as it is due to new bone formation. Hyperostosis is seen in around 50% of cases and it is due to tumour invasion combined with tumour that secretes both oestrogen and alkaline phosphatase.

Of note, there is a link with breast cancer and meningiomas. It seems to be related to oestrogen levels and meningiomas often bear oestrogen receptors. However, this patient is male and his meningioma is probably sporadic in nature.

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The text is entirely the opinion of the author and does not necessarily reflect that of RUH NHS Trust or the Bristol Radiology Training Scheme. Website content devised by Paul McCoubrie.