Dr. Pepe’s Diploma Casebook: Case 5 – SOLVED!

Dear friends

Today, I want to show you a classic case of vertebral affectation. I’m hoping for 100% correct answers.

59-year-old female with lumbar pain.

Fig 1

Fig 2

Most likely diagnosis:

1. Metastases
2. Lymphoma
3. Paget’s disease
4. All of the above

Click here for the answer

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    15 Responses to : Dr. Pepe’s Diploma Casebook: Case 5 – SOLVED!

    1. Vishal kalia says:

      The plain x-rays of lumbar spine and CT shows solitary dense vertebra with permeative destruction involving the body and pedicles. No expansion or soft tissue component is seen. No prominent vertical striations are seen. End plates are normal with preserved disc space. No lymphnodes are seen in visualised images with no anterior scalloping of the vertebra. The differential diagnosis of ivory vertebra in an adult – metastasis, lymphoma, paget´s, hemangioma, infection and mastocytosis. The most likely diagnosis in this patient will be metastasis from breast(female patient).

    2. Albert says:

      Totally agree. I also go with breast mets.

    3. Jess says:

      DDx is that of an IVORY VERTEBRA in an adult patient i.e All of the Above can present as such…

      …osteoblastic metastasis (breast ca in females and prostatic secondaries in males)can definitely look like this

      Paget’s – would also tend to expand the vertebral body (and with a relatively radiolucent center give the characteristic “picture-frame”

      Most likely out of the available options – I say,
      A. metastases

    4. Dr. F says:

      Imaging reveals expansion and sclerosis along with patchy intervening lucencies of the L 5 vertebral body and its posterior elements. In a female patient, the diagnosis of breast carcinoma with bone metastasis comes to mind.

    5. Agata Malkiewicz says:

      All of answers belong to differential diagnosis. But nonetheless visible paraspinal mass makes diagnosis of lymphoma more likely.

    6. DrAlfetiani says:

      Mostly mets

    7. Genchi Bari Italia says:

      Non sono d’accordo con la probabile diagnosi dei miei colleghi, per 2 cmotivi. 1 -la diagnosi di metastasi da cr mammario, dovrebbe presupporre appunto un CR mammario , che non è riportato, a meno che non sia occulto o misconosciuto. 2- è facile escludere il Paget sul modello di “riduzione” di volume del corpo vertebrale a differenza del Paget ove il volume “aumenta”.restano due condizioni patologiche, entrambe tumorali, per la componente litica; tuttavia il modello patogenetico della metastasi è differente da quello del linfoma,per la differente vascolarizzaione del corpo vertebrale rispetto all’arco.In questo caso è convolto anche l’arco indicando una crescita multifocale della neoplasia come si ha nel linfoma primitivo vertebrale che è la mia diagnosi.

    8. LL says:

      Ivory Vertebra Sign – D

    9. maka says:

      I think, it is the damage of metastases.

    10. daca says:

      4. Ivory vertebra.

    11. Ricardo Macareno says:

      Radiodense solitary lesion is identified, homogeneous, of a vertebral body keeping the size and contour, and without affecting adjacent vertebral discs. Most cases of ivory vertebra are secondary to other entities.In this case the absence of additional radiological findings, suggest metastatic disease.

    12. Dr. Pepe says:

      Of eleven answers, nine were right. Good show!

    13. Vincenzo Genchi says:

      Chiedo se nel linfoma PRIMITIVO, vertebrale, ci deve essere necessariamente una massa (adenopatica?), paravertebrale ovvero se questa ultima è prerogativa solo del linfoma nodale?Inoltre come stabilire la DD tra i vari modelli litici?Non penso possa essere un criterio oggettivo e riproducibile.

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    15. maged says:

      “The most reliable finding is the presence of soft tissue mass.”the most reliable sign for what ? for infection ??