SUPER BONE SCAN due to Bone Marrow Metastases Appearing 19 Years after Surgery for Early Gastric Cancer – A Case Report

Abstract

A 54-year-old man presenting a so-called super bone scan is reported. The patient had a past history of subtotal gastrectomy due to early gastric cancer 19 years previously. Laboratory data indicated microcytic anemia and high serum alkaline phosphatase. Both the serum calcium and phosphate levels were within normal ranges. In spite of extensive examination for a primary malignant lesion in the organs including the remaining stomach, no solid tumors were identified. Pathological examinations revealed that the tumor cells in the biopsy specimen from the lumbar spine were almost identical to those in the gastric cancer excised 19 years previously. We considered that micrometastases in the bone marrow existed at the time of the initial surgery for gastric cancer and reappeared 19 years later showing super bone scan.

Overt bone metastasis and bone marrow micrometastasis of early gastric cancer

“…The most common diagnostic procedure for diagnosing bone metastasis was bone scintigraphy, but recently MRI or FDG-PET have gradually come into common use, and serum ALP offers helpful supplementary data for these imaging diagnoses. 10,12,17 Our patient base is extremely small, so our data may not be of great value; however, there are fi ndings in Table 1 that are notable, namely, the long intervals from gastrectomy to overt bone metastasis (average: 8 years 5 months, when the synchronous case is excluded) and the short survival time after the diagnosis of bone metastasis (average: 11.9 months).…”

“…We searched for articles using the key words "bone metastasis" and "early gastric cancer (carcinoma)" on Medline, and found that only 10 case reports ) existed in the English literature [9][10][11][12][13][14][15] (Table 1). The characteristics of EGC patients with overt bone metastasis, including our two cases, are presented in Table 1.…”

Multiple bone lesions resembling a metastatic origin. An unexpected diagnosis

“…Most tumours produce both kinds of substances and generate both kinds of bone lesions: osteolytic and osteoblastic metastasis (mixed pattern). There are a lot of non-tumoral pathologies that can also originate a mixed pattern (Ta T T ble 1) [3][4][5][6][7][8][9][10][11][12]. Screening fo f f r all these pathologies were done in this patient.…”

“…Diff f f e f f rential diagnosis of a mixed radiological pattern [3][4][5][6][7][8][9][10][11][12] Oncologic origin Non-tumoral pathologies Breast cancer [3] Sarcoidosis [8] Prostate cancer [4] Erdheim-Chester disease and other histiocytoses [9] Gastric cancer [5] Rosai-Dorfm f f an disease [10] POEMS syndrome [6] Paget's disease [11] Some lymphomas [7] Gaucher disease [12] …”

Differential Diagnosis of Rare Diseases Involving Bilateral Lower Extremities with Similar 99mTc-MDP Bone Scan Patterns: Analysis of a Case Series

“…Therefore, combination of laboratory tests, 99m Tc-MIBI planar or SPECT/CT fusion images and 99m Tc-MDP bone scintigraphy is of great value to make a differential diagnosis. In addition, super-bone-scans are observed in tumorous diseases such as agnogenic myeloid metaplasia [46], gastric cancer [47][48][49], intracranial glioma [50], prostate cancer [51,52], breast cancer [49] and even recurrent syncope [53]. In some of these cases, superscans on bone scintigraphy were caused by concomitant metastatic and metabolic bone diseases.…”