Necrotizing granulomatous inflammation mimicking skeletal metastasis: a possible differential diagnosis
European Journal of Hybrid Imaging volume 6, Article number: 30 (2022)
Tuberculosis is an endemic disease in India for decades, and its coexistence in the patients with malignancy cannot be ignored. The non-specific uptake of 2-deoxy-2-[fluorine-18] fluoro-d-glucose in active infection and malignancy can affect the diagnosis and management of patients. However, characteristic anatomical features of the lesion aid not only in its localization but also in diagnosis. We share an interesting case of necrotizing granulomatous inflammation of dorsal spine mimicking skeletal metastases in a treated case of carcinoma cervix.
An important indication of the 2-deoxy-2-[fluorine-18] fluoro-d-glucose positron emission tomography integrated with computed tomography (F-18 FDG PET/CT) is the localization and characterization of a pathological lesion suspicious of malignant potential. The major advantage of hybrid imaging is the concurrent availability of functional and anatomical details of the lesions. Due to non-specific uptake of F-18 FDG in active infection, inflammation and neoplastic process PET has limited specificity in differentiating infection from malignancy. However, the pattern and sites of FDG uptake along with diagnostic CT help in anatomical localization of the disease and also in characterization of the lesion based on typical radiological features. We highlight the utility of F-18 FDG PET/CT in the accurate diagnosis of Pott’s spine mimicking skeletal metastasis in a treated case of carcinoma cervix.
A 77-year-old female was a known case of carcinoma cervix and completed chemo-radiotherapy 5 years ago (records unavailable) and had recent onset of bilateral lower limb weakness. F-18 FDG PET/CT (Fig. 1) showed hypermetabolic contiguous lytic lesions in D8-10 vertebrae with paradiscal cortical erosions, paravertebral soft tissue component, adjacent spinal canal extension and partial collapse of D9 vertebrae. This lesion was solitary, and there was no other imaging evidence of abnormality noted elsewhere, especially in pelvis, lung, liver and lymph nodes. Thus, loco-regional recurrence and distant metastases were ruled out. The radiological findings were typical for Pott’s spine. Paravertebral biopsy was advised and histopathology confirmed necrotizing granulomatous inflammation (Fig. 2).
Bone is the third most common distant metastases in cervical cancer after lungs and liver and can be found in any stage (Thanapprapasr et al. 2010; Hacker et al. 2005; Hage et al. 2000). The spine is the most common site of skeletal metastases (Thanapprapasr et al. 2010). According to an overview, up to 25% of tuberculosis cases are extra-pulmonary, and among them around 50% are Pott’s spines (Falagas et al. 2010). As per the Global Tuberculosis Report of WHO 2021, India is unfortunately among the 8 countries that account for the two-thirds of the global burden with high prevalence of multi-drug resistance and under-reporting of cases (Global Tuberculosis Report 2021). Tuberculosis and malignancy are risk factors for each other, and coexistence of tuberculosis in such cases cannot be ignored (Chen et al. 2021; Nanthanangkul et al. 2020). Also, the radiological appearances of tuberculosis and malignancy are very similar, thus increasing the confusion for diagnosis (Xiang et al. 2021). Pott’s spine is a known common differential for lytic skeletal metastases (Liu et al. 2017; Ye et al. 2016; Go et al. 2012), and non-specific uptake of F-18 FDG in active infection and inflammation reduces its specificity. The typical radiological features of Pott’s spine include anterior destruction of vertebral body, end plate erosions, loss of disc height, paravertebral masses and contiguous multi-vertebral involvement (Rivas-Garcia et al. 2013). However, the atypical findings are also increasingly observed like non-contiguous vertebral involvement and disc sparing (Go et al. 2012; Rivas-Garcia et al. 2013; Polley and Dunn 2009; Moore and Rafii 2001; Babhulkar et al. 1984; Yalniz et al. 2000). In this case, a latency of 5 years in emergence of symptoms with compressive neuropathy as the first symptom, and the solitary lesion with characteristic contiguous involvement of vertebrae and paradiscal lesions were supportive of granulomatous aetiology than metastases.
Though FDG is not specific in differentiating infection from malignancy, it helps in localization of the active disease process. And typical appearance of the lesion on CT can aid in its characterization. Thus, the hybrid imaging with FDG PET/CT is preferred in characterization of a lesion, especially in equivocal or discordant lesions.
Availability of data and materials
Babhulkar SS, Tayade WB, Babhulkar SK (1984) Atypical spinal tuberculosis. J Bone Joint Surg Br 66:239–242
Chen GL, Guo L, Yang S et al (2021) Cancer risk in tuberculosis patients in a high endemic area. BMC Cancer 21:679
Falagas ME, Kouranos VD, Athanassa Z et al (2010) Tuberculosis and malignancy. QJM 103:461–487
Global Tuberculosis Report 2021. World Health Organization. who.int/publications/i/item/9789240037021.
Go SW, Lee HY, Lim CH et al (2012) Atypical disseminated skeletal tuberculosis mimicking metastasis on PET-CT and MRI. Intern Med 51:2961–2965
Hacker NF (2005) Cervical cancer. In: Berek JS, Hacker NF (eds) Practical gynecologic oncology, 4th edn. Lippincott Williams & Wilkins, Philadelphia, PA, pp p265-336
Hage WD, Aboulafia AJ, Aboulafia DM (2000) Incidence, location, and diagnostic evaluation of metastatic bone disease. OrthopClin North Am 31:515–528
Liu B, Dong L, Wang X et al (2017) Tuberculosis mimicking metastases by malignancy in FDG PET/CT. QJM 110:173–174
Moore SL, Rafii M (2001) Imaging of musculoskeletal and spinal tuberculosis. Radiol Clin North Am 39:329–342
Nanthanangkul S, Promthet S, Suwanrungruang K, Santong C, Vatanasapt P (2020) Incidence of and risk factors for tuberculosis among cancer patients in endemic area: a regional cohort study. Asian Pac J Cancer Prev 21:2715–2721
Polley P, Dunn R (2009) Noncontiguous spinal tuberculosis: incidence and management. Eur Spine J 18:1096–1101
Rivas-Garcia A, Sarria-Estrada S, Torrents-Odin C et al (2013) Imaging findings of Pott’s disease. Eur Spine J 22(Suppl 4):567–578
Thanapprapasr D, Nartthanarung A, Likittanasombut P et al (2010) Bone metastasis in cervical cancer patients over a 10-year period. Int J Gynecol Cancer 20:373–378
Xiang Y, Huang C, He Y, Zhang Q (2021) Cancer or tuberculosis: a comprehensive review of the clinical and imaging features in diagnosis of the confusing mass. Front Oncol 11:644150
Yalniz E, Pekindil G, Aktas S (2000) Atypical tuberculosis of the spine. Yonsei Med J 41:657–661
Ye M, Huang J, Wang J et al (2016) Multifocal musculoskeletal tuberculosis mimicking multiple bone metastases: a case report. BMC Infect Dis 16:34
The authors thank Dr. Sameer Taywade (Associate Professor, Department of Nuclear Medicine, All India Institute of Medical Sciences, Jodhpur) for his support and guidance.
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Datta, D., Ravichandran, T., Kumar, R. et al. Necrotizing granulomatous inflammation mimicking skeletal metastasis: a possible differential diagnosis. European J Hybrid Imaging 6, 30 (2022). https://doi.org/10.1186/s41824-022-00151-4
- Necrotizing granulomatous inflammation
- Pott’s spine
- Carcinoma cervix
- F-18 FDG PET/CT