DOI:10.2214/AJR.06.0150
AJR 2007; 188:S7-S9
© American Roentgen Ray Society
AJR Teaching File: Cavitated Mass with Hypertrophic Osteoarthropathy
Dean A. McNaughton1,2 and
Ba D. Nguyen1
1 Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd.,
Scottsdale, AZ 85259.
2 Present address: Department of Radiology, The University of Iowa Hospitals and
Clinics, Iowa City, IA 52242.
Received January 27, 2006;
accepted after revision April 10, 2006.
Address correspondence to B. D. Nguyen
(Nguyen.Ba{at}mayo.edu).
Keywords: chest • hypertrophic osteoarthropathy • infectious disease • lung • PET
Clinical History
A 62-year-old man presents with several months' history of chronic dry
cough, recent onset of hemoptysis, and a right upper lung mass. The patient's
clinical history is remarkable for a cigarette smoking habit of 56 pack-years.
He denies any fever or night sweating. All cultures and serology tests have
negative results.
Radiologic Description
The initial chest radiograph (Fig.
1A) shows a large right upper lobe mass. Subsequent chest CT
(Fig. 1B) shows a cavitated
right upper lobe lesion measuring 4.5 x 8 x 4 cm and having
thickened walls. The same CT examination raises the possibility of osseous
lytic lesions, which prompts bone scintigraphy. The whole-body
99mTc MDP (methylene diphosphate) bone scan
(Fig. 1C) does not detect any
osseous metastasis but shows activity suggesting hypertrophic osteoarthropathy
of the lower extremities, predominantly on the right side. Fluorine-18 FDG PET
is performed to evaluate the right lung mass and to aid in staging metastatic
disease. PET maximum-intensity-projection images
(Fig. 1D) show abnormal
radiotracer accumulation in the walls of the cavitated right lung lesion but
no evidence of locoregional or distant dissemination. A CT-guided biopsy of
the right lung lesion is proposed to the patient, in addition to other
alternative therapeutic options. The patient chooses the surgical
procedure.
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Fig. 1B —62-year-old man with several-month history of coughing and right
lung mass. Chest CT scan shows large cavitated mass with thickened walls in
posterolateral aspect of right upper lobe (arrow).
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Fig. 1c —62-year-old man with several-month history of coughing and right
lung mass. Whole-body bone scintigraphy with 99mTc MDP (methylene
diphosphate) shows hypertrophic osteoarthropathy of lower extremities,
predominantly on right side (arrows). No evidence of osseous
metastasis is seen.
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Fig. 1D —62-year-old man with several-month history of coughing and right
lung mass. PET volumetric images show abnormal FDG uptake in right lung lesion
(arrow) but no evidence of locoregional or distant dissemination.
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Differential Diagnosis
The differential diagnosis in this patient includes lung abscess, lung
metastasis, lung adenocarcinoma, and Marie-Bamberger disease (hypertrophic
osteoarthropathy).
Diagnosis
The diagnosis in this patient is lung abscess caused by Streptococcus
viridans.
Commentary
Fluorine-18 FDG PET is a sensitive functional imaging technique for lung
oncologic evaluation and staging because of the high glucose metabolism of
malignant neoplasms. Pulmonary PET scans may be falsely positive for
malignancy in inflammatory, infectious, or other nonneoplastic processes. Our
patient presented with a lung abscess due to Streptococcus viridans
that showed hypertrophic osteoarthropathy on bone scintigraphy and features
mimicking malignancy on PET.
The patient underwent right thoracotomy with upper lobectomy, superior
segmentectomy of the right lower lobe, and mediastinal nodal resection.
Pathology diagnosed a large abscess caused by Streptococcus viridans.
No histologic evidence of pulmonary or nodal malignancy was seen. This
false-positive case of pulmonary malignancy presented two interesting points
for discussion: hypertrophic osteoarthropathy and the positive FDG PET
findings in lung abscess.
Hypertrophic osteoarthropathy, also known as Marie-Bamberger disease, is a
syndrome first described by Eugen von Bamberger
[1] and Pierre Marie
[2] in 1889 and 1890,
respectively. It is characterized by periostosis involving the diaphyses of
tubular bones, arthritislike symptoms, and vasomotor disturbances involving
the hands and feet
[1-3].
In hypertrophic osteoarthropathy, digital clubbing (also known as Hippocratic
digits) is commonly present but not inevitable. Hypertrophic osteoarthropathy
is associated with malignancy in up to 90% of cases, most commonly non-small
cell lung cancer. However, the syndrome was originally described in
association with bronchiectasis, and it may also be seen with lung abscesses
or empyemas [1,
4]. The pathogenesis of
hypertrophic osteoarthropathy is not well known. However, the final common
pathway is theorized to involve the release of platelet-derived growth factor
(PDGF) by megakaryocytes deposited in peripheral tissues as a consequence of
the inability of the lungs to filter these cells. Alternatively, biochemical
explanations have been proposed
[5].
Pulmonary lesions with elevated FDG activity on PET are malignant in most
cases. However, FDG may accumulate at sites of infection and inflammation
[6]. In some cases, the
pulmonary FDG uptake may suggest nonneoplastic processes. In other instances,
the FDG accumulation pattern may be nodular and masslike, thus mimicking
neoplasm [7].
The presumed diagnosis in this patient was lung malignancy because of its
appearance on CT, PET, and bone scintigraphy. The diagnosis of lung abscess
(option A) was confirmed by pathology. Lung metastasis (option B) and lung
adenocarcinoma (option C) with necrosis and cavitation may have similar
appearances; however, those possibilities were not supported by the final
pathology. Marie-Bamberger disease (option D) is a syndrome associated with
many benign and malignant causes and represents only one facet of this case
presentation.
Objective
This case emphasizes that positive FDG PET findings may be due to
hypermetabolic inflammatory and infectious processes, and histologic proof is
required for the diagnosis of cancer.
Conclusion
Lung abscess and empyema, although less common than cancer, may present
with hypertrophic osteoarthropathy and FDG uptake simulating lung malignancy.
Tissue sampling is necessary to identify the lesion.
References
- von Bamberger E. Veranderungen der Rohrrenknochen bei
Bronchiektasie. Wien Klin Wochenschr1889; 2:226
- Marie P. De l'osteo-arthropathie hypertrophiante pneumique.
Rev Med Paris 1890;10
: 1
- Hansen-Flaschen J, Nordberg J. Clubbing and hypertrophic
osteoarthropathy. Clin Chest Med 1987;8
: 287-298[Medline]
- Abdelkafi S, Dubail D, Bosschaerts T, et al. Superior vena cava
syndrome associated with Nocardia farcinica infection.
Thorax 1997; 52:492
-493[Abstract]
- Clarke S, Barnsley L, Peters M, Morgan L, Van der Wall H.
Hypertrophic pulmonary osteoarthropathy without clubbing of the digits.
Skeletal Radiol 2001;30
: 652-655[CrossRef][Medline]
- Truong MT, Erasmus JJ, Macapinlac HA, et al. Integrated positron
emission tomography/computed tomography in patients with non-small cell lung
cancer: normal variants and pitfalls. J Comput Assist
Tomogr 2005; 29:205
-209[CrossRef][Medline]
- Ichiya Y, Kuwabara Y, Sasaki M, et al. FDG-PET in infectious
lesions: the detection and assessment of lesion activity. Ann Nucl
Med 1996; 10:185
-191[Medline]
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