AJR 2003; 180:669-671
© American Roentgen Ray Society
Focal Nodular Hyperplasia of the Hematopoietic Marrow Simulating Vertebral Metastasis on FDG Positron Emission Tomography
Marcelo Bordalo-Rodrigues1,2,
Christine Galant3,
Max Lonneux4,
Didier Clause4 and
Bruno C. Vande Berg1
1 Department of Radiology, Cliniques Universitaires St. Luc, Université
Catholique de Louvain, 10 Ave. Hippocrate, 1200 Brussels, Belgium.
2 Present address: Department of Radiology, Hospital das Clinicas-Universidade
de Sao Paulo, Ave. Dr. Eneas de Carvalho Aguiar, 255, 05403-001 Sao Paulo,
Brazil.
3 Department of Pathology, Cliniques Universitaires St. Luc, Université
Catholique de Louvain, 1200 Brussels, Belgium.
4 Department of Internal Medicine, Cliniques Universitaires St. Luc,
Université Catholique de Louvain, 1200 Brussels, Belgium.
Received March 11, 2002;
accepted after revision July 30, 2002.
Address correspondence to B. C. Vande Berg.
Introduction
We report the case of a patient with bronchioloalveolar carcinoma with
focal nodular hyperplasia of the hematopoietic marrow in dorsal vertebral
bodies revealed on FDG positron emission tomography (PET) and MR imaging.
Differentiation with metastatic disease is discussed.
Case Report
A 77-year-old man presented with a 1-month history of intermittent episodes
of cough. The patient was a former smoker (60 packs per year; stopped 10 years
before) with diabetes mellitus controlled by diet, and he had systolic
hypertension controlled by the use of captopril (75 mg/day). He used no other
drugs. Hematologic test results were unremarkable. A chest radiograph revealed
a spiculated pulmonary nodule in the right upper lobe. A CT-guided
transthoracic biopsy of the lesion revealed bronchioloalveolar cell
carcinoma.
Whole-body PET using the glucose analogue FDG was performed as a
pretherapeutic staging procedure for the lung carcinoma. High uptake of the
radiotracer was noted in the right upper lobe, corresponding to the primary
tumor, as well as in the vertebral body of T8 (Fig.
1A,
1B,
1C,
1D,
1E,
1F). Radiographic findings of
the thoracic spine were normal. T1-weighted (TR/TE, 400/16) spin-echo MR
images of the spine showed a 2 x 2 cm focus of decreased signal
intensity in the lateral aspect of the T8 vertebral body and a 1 x 1 cm
focus of decreased signal intensity in the lateral aspect of the T11 vertebral
body (Fig. 1A,
1B,
1C,
1D,
1E,
1F). Signal intensity of the
two lesions was moderately lower than that of adjacent vertebral marrow and
higher than that of the adjacent disk on T1-weighted spin-echo images. On
fat-saturated T2-weighted (2250/50) fast spin-echo images, lesions were not
seen because their signal was equivalent to that of adjacent marrow. The
vertebral cortex and adjacent soft tissues were preserved. MR imaging of the
pelvic girdle showed a normal red marrow appearance and distribution. The two
vertebral lesions observed on MR imaging were considered to be secondary
deposits from the lung cancer. A biopsy of the T8 vertebral body lesion was
planned because bone metastasis of a bronchioloalveolar carcinoma is unusual
at diagnosis and because the definite depiction of bone metastasis would
exclude the patient from surgery.
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Fig. 1A. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. Posterior coronal FDG positron emission tomography (PET)
image obtained 60 min after injection of 370 MBq of FDG reveals hot spot
(arrow) in lateral aspect of one vertebral body. Normal tracer uptake
is seen in kidneys, liver, and spleen.
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Fig. 1B. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. Sagittal T1-weighted spin-echo MR image of thoracic
spine shows area of moderately decreased signal intensity (arrow) in
vertebral body of T8.
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Fig. 1C. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. On sagittal fat-saturated T2-weighted MR image
(corresponding to B), abnormality seen on T1-weighted image is not
visible (arrow). Area of decreased signal intensity is artifact.
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Fig. 1D. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. Left parasagittal T1-weighted spin-echo MR image shows
round area (arrow) of moderately decreased signal intensity in
vertebral body of T11.
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Fig. 1E. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. On fat-saturated T2-weighted MR image, abnormality seen
on T1-weighted image is not visible. This area was normal on FDG PET image
(A).
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Fig. 1F. —77-year-old man with focal nodular hyperplasia of
hematopoietic marrow. Low-power magnification photograph of biopsy specimen (H
and E, x80) of T8 abnormality shows hypercellular marrow with reduced
proportion of adipocytes. At higher power magnification (not shown), normal
hematopoietic marrow devoid of neoplastic cells was found.
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For the CT-guided biopsy, a lateral scout image was obtained from S3 to T5
to provide a lateral image of the spine, with which the MR images of the
thoracolumbar spine could be compared. Axial CT images, 2.5 mm thick, were
obtained of the T7-T9 vertebral bodies and showed no bone abnormality. A
percutaneous biopsy of the T8 vertebral body was performed by using a coaxial
penetration and biopsy set (Bonopty penetration and biopsy set; RADI Medical
System, Uppsala, Sweden) through a transpedicular approach. A 10-mm-long bone
marrow specimen was obtained.
Histologic examination showed hyperplastic hematopoietic bone marrow
without neoplastic proliferation. Numerous islets of the different stem cell
lines including erythroid, myeloid, and lymphoid cells were present, as well
as megakaryocytes. The proportion of fat cells was markedly decreased with
respect to the expected proportion in normal bone marrow of a vertebral body
(Fig. 1A,
1B,
1C,
1D,
1E,
1F). Normal immunohistochemical
analysis with monoclonal antibodies raised against cytokeratins of low
molecular weight revealed no carcinomatous cells and excluded the possibility
of a metastasis of the lung carcinoma. Anti-CD3, -CD15, and -CD20 antibodies
showed the polyclonality of the lymphoid cells.
Because the T8 vertebral lesion was shown to be a focal nodular hyperplasia
of hematopoietic marrow, the pulmonary lesion was resected.
Discussion
Hyperplasia of the hematopoietic marrow is a deviation from the accepted
adult pattern of red-yellow marrow distribution, with an augmentation of the
red components. A benign form of hematopoietic hyperplasia is associated with
heavy smoking, long distance running, and obesity
[1,
2,
3]. A more significant form of
hematopoietic hyperplasia is observed in association with malignancies and
chronic anemia [4]. In patients
with cancer, hyperplasia of the hematopoietic marrow can be encountered after
the administration of granulocyte-colony-stimulating factors
[5,
6], used as an adjunct to
radiation or chemotherapy to decrease the myelosuppression associated with
these treatments.
In all reported cases of hyperplasia of the hematopoietic marrow, marrow
changes were diffuse with a marked decrease in signal intensity of the spinal
and pelvic bone marrow on T1-weighted MR imaging. In our patient, the normal
red-yellow marrow distribution pattern in the pelvic girdle and the normal
marrow-disk signal intensity ratio in the spine eliminated the possibility of
diffuse hypercellular hematopoietic marrow. The patient had not received any
drug known to interfere with the hematopoietic system, and findings of blood
tests were normal.
The current observation highlights one feature that has not been addressed
in the literature. It shows that a biopsy-proven focal area of normal but
hypercellular red marrow may show increased uptake on FDG PET and therefore
may be confused with other causes of increased uptake including neoplasm or
infection. This observation is well in line with reports of diffuse increased
uptake of FDG in patients undergoing treatment with
granulocyte-colony-stimulating factor that promotes the growth and
differentiation of hematopoietic stem cells
[5,
6]. The increased uptake and
accumulation of FDG in normal but stimulated cells is explained by the
upregulation of glucose transport and metabolism in these cells. It is likely,
but not proven because of the lack of biopsy specimen from the T11 lesion,
that some areas of hypercellular red marrow may remain occult on FDG PET
images.
In the current observation, the areas of decreased signal intensity on
T1-weighted images were considered to indicate metastatic disease. In
retrospect, the signal intensity on T1-weighted images of both lesions was
higher than that of adjacent disks, a feature that would suggest normal marrow
[7]. However, additional
features suggestive of benign marrow including symmetric distribution in the
bone and the presence of central high-signal-intensity areas on T1-weighted
images were absent [8]. On
T2-weighted fat-saturated images, the signal of the lesions was equivalent to
that of normal adjacent marrow, a feature consistent with but not specific to
normal red marrow. An optimal MR imaging technique was not used for the
assessment of the bone marrow, and IV contrast studies could have been used to
increase specificity of MR imaging findings.
In conclusion, we illustrate a case of focal nodular hyperplasia of
hematopoietic marrow in dorsal vertebral bodies in a patient with
bronchioloalveoloar carcinoma, with FDG PET and MR imaging findings that may
mimic bone metastases.
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Introduction
Case Report
