DX: 1. Ivory vertebrae due to osteoblastic breast cancer metastasis. 2. Pleural effusion (malignant ethiology?)

Well, this case got several comments on my Facebook account but yesterday the webpage had inconvenients on PC's worlwide; a "preventive" solution to a virus spread..anyways, here is the conclusion:

Here is a spot image on the finding:

According to history, patient was on Stage II breast cancer and was given surgical and quemotherapy treatment. We had no information on when was the last qxtx cycle. The indication of the screening was to search metastasis. Patient was clinicaly well but had worsening dispnea since the past week. Radiological findings are suggestive of right pleural effusion and osteoblastic metastasic disease on D11 that is visualized as sclerotic radiopaque vertebral body compared to the rest of vertebrae (ivory sign). This is imperative, the reason? it changes the TNM criteria and elevates the cancer staging from II to IV. This means failure to treatment and now has a sistemic disease with low prognosis.

Breast cancer stage (AJCC 5th edition)	5-year overall survival of over 50,000 patients from 1989[26]
Stage 0	92%
Stage I	87%
Stage II	75%
Stage III	46%
Stage IV	13%

The ivory vertebra sign has numerous causes. While clinical settings will vary, and a list of causes is available, most causes of the ivory vertebra sign are rare. In adults, three conditions should generally be considered: metastatic cancer, Paget disease, and lymphoma. In this case, metastatic disease is more likely.


It´s a worldwide protocol on oncological patients to do several screening tests in every stage of their disease. One of those is Chest X-Ray (CXR) wich is our first-step diagnostic tool to determine complications of the disease itself or consecuences of treatment. Most hospitals and private practice consultants skip the CXR and go directly to CT mailny because of high false negatives rates?. There is some controversy on this subject.

The ACR (American College of Radiology) appropriateness criteria has this recomendation in order to search lung metastasic disease:

Interventions and Practices Considered

1. X-ray, chest 
2. Computed tomography (CT), chest, without contrast 
3. Fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), whole body 
4. Magnetic resonance imaging (MRI), chest, with or without contrast 

So, there is no need to extract CXR in screening of metastasic disease but one has to be very carefull in looking for extrapulmonary signs of mets.




All comments are welcome!



http://radiology.rsna.org/content/235/2/614.full

http://emedicine.medscape.com/article/1157987-overview

http://www.guideline.gov/content.aspx?id=32638

http://en.wikipedia.org/wiki/Breast_cancer_classification