|Year : 2002 | Volume
| Issue : 2 | Page : 179-181
Abnormal bone scan : Importance of clinical correlation
Dharm Raj Singh, K Gaitonde, N Santoshi, N Patil, V Srinivas
Department of Urology & Uro-Oncology, PD Hinduja National Hospital, Mumbai, India
P.D. Hinduja National Hospital & Medical Research Centre, V.S. Marg, Mahim, Mumbai - 400 016
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A case of renal cell carcinoma which was diagnosed to have metastatic disease on the basis of two hot spots in ribs on bone scan, is presented. After careful and thorough history, it turned out to be fracture ribs which occurred due to bad positioning during radical nephrectoiny. This case highlights the importance of clinical judgement especially in the modern era of sophisticated investigations.
Keywords: Renal Cell Carcinoma; Bone Scan; Metastasis
|How to cite this article:|
Singh DR, Gaitonde K, Santoshi N, Patil N, Srinivas V. Abnormal bone scan : Importance of clinical correlation. Indian J Urol 2002;18:179-81
| Case Report|| |
A 45-year-old male patient underwent a right radical nephrectomy in November 2000 at an outside hospital. The histology showed an encapsulated renal cell carcinoma which was moderately differentiated with negative hilar nodes. A preoperative bone scan had not been done as the alkaline phosphatase was normal and the patient did not have bone pain.
The patient developed pain over the left lower ribs, postoperatively. It was severe in intensity and required analgesics for control. His repeat alkaline phosphatase was normal and a bone scan done showed two hot spots over the left 10 th and 11 th ribs [Figure - 1]. A diagnosis of metastatic renal cell carcinoma was made and he was referred to us for further management.
The patient came to see us one month after his radical nephrectomy to discuss the treatment options for metastatic renal cell carcinoma. On reviewing the bone scan [Figure - 1], the two distinct hot spots were well seen and the physical examination was unremarkable except for tenderness over these two areas.
However on close questioning it was apparent that the patient became aware of acute, severe pain in this area immediately after the anesthesia wore off and this pain was more intense than that of the surgical wound.
A working diagnosis of fracture ribs was made and this was confirmed by plain X-ray [Figure - 2] and CT scan [Figure - 3] which showed a fracture with callus surrounding it.
A rib biopsy was not done to definitely exclude malignancy. However the patient responded well to conservative treatment and became asymptomatic in one month's time. Follow-up X-ray 3 months later showed a well-healed fracture.
| Discussion|| |
The visualization of a hot spot even in an individual with a known carcinoma, is not specific for metastatic disease although the probability is very high especially when multiple lesions are noted. The shape of the abnormality may be valuable since a metastatic deposit invading along a rib becomes elongated while a rib fracture tends to be significantly more focal. Overall 55% of solitary bone scan abnormalities are caused by neoplastic disease and 25% by trauma. Among patients with known primary tumors, 70% rib lesions are malignant. 
Our case is interesting since the hot spots in the ribs were initially thought to be metastatic and the patient had been advised chemotherapy. It is difficult to categorically rule out a malignancy unless a bone biopsy is done, but this has added complications.  However by obtaining a thorough history, the possibility of a rib fracture occuring while positioning the patient for a flank incision became apparent. This enabled us to avoid a rib biopsy and treat him conservatively with a successful outcome.
This case highlights the importance of taking a good clinical history even in this modern era of sophisticated investigations, as occasionally an unusual pathology will emerge and a patient need not be labeled as having incurable metastatic disease.
| References|| |
|1.||Vander Wall H. Evaluation of Malignancy : Metastatic bone disease. In : Murray IPC. Ell PJ (eds.). Nuclear medicine in clinical diagnosis and treatment. Churchill Livingstone. 2: 1171-1172. |
|2.||Kattapuram SV. Rosenthal DI. Percutaneous biopsy of skeletal lesions. Am J Roentgenol 1991; 157: 935-942. |
[Figure - 1], [Figure - 2], [Figure - 3]