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.
1. Metastases
2. Lymphoma
3. Paget’s disease
4. All of the above
Fig 3
Findings:
Increased density of the L5 vertebral body, without loss of volume. There is no disc involvement.
Neither CT nor MRI show a soft tissue mass. Given the homogeneity and the absence of soft tissue mass, the most likely diagnosis is metastases.
Final diagnosis: metastases from breast carcinoma
Fig 4
The solitary dense vertebra (ivory vertebrae) is a finding relatively easy to detect due to the increased opacity compared to other vertebrae. The differential diagnosis is relatively simple and includes metastases (prostate in the male and breast in the female), Paget’s disease, lymphoma, and reactive sclerosis.
In Paget’s disease, the vertebra shows a picture frame appearance, caused by cortical thickening and coarse trabeculation. There is usually an increase in the size of the vertebra, highly suggestive of Paget’s disease (Fig. 5).
Fig. 5. Paget’s disease. Note the picture-frame aspect of L-3 and the increase in size compared to the vertebras above and below.
Fig. 6
Unlike the low signal intensity of metastatic vertebrae in T1W images, the vertebra of Paget’s disease contain large areas of fat tissue.
Lymphoma causes increased bone density of the affected vertebrae, but it is usually accompanied by a destructive pattern and large soft tissue mass (Fig. 7).
Fig. 7. Lymphoma of L3. Note the destructive pattern of the bone and the soft tissue mass on CT (arrow).
The lack of fragments protruding anteriorly or posteriorly usually rules out posttraumatic lesions. The absence of disc involvement would go against infectious involvement.
The most reliable finding is the presence of soft tissue mass. Bone involvement can be both homogeneous and heterogeneous.
Reactive sclerosis may be due to inflammatory, traumatic or degenerative disease. Rarely involves a single vertebra and the disc is usually narrowed (Fig. 8).
Fig. 8. 52-year-old male with lumbar pain lasting 6 months. Note the sclerosis of L3-L4 and the narrowing of the disc space (arrow) secondary to Brucella infection.
Follow Dr. Pepe’s advice
Follow Dr. Pepe’s advice:
- Increased density of a vertebral body (ivory vertebra) can be detected easily on plain films.
- It is important to determine the homogeneity of the damage, the trabecular pattern, the existence of soft tissue mass or disc affectation to reach an appropriate diagnosis.
- TC and MRI are very useful for detecting these alterations.
Recommended reading: TS Graham. The Ivory Vertebra Sign. Radiology 2005; 235:614–615
Case prepared by Dámaso Aquerreta MD
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).
Totally agree. I also go with breast mets.
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
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.
iHola!
All of answers belong to differential diagnosis. But nonetheless visible paraspinal mass makes diagnosis of lymphoma more likely.
Mostly mets
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.
Ivory Vertebra Sign – D
I think, it is the damage of metastases.
4. Ivory vertebra.
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.
Of eleven answers, nine were right. Good show!
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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“The most reliable finding is the presence of soft tissue mass.”the most reliable sign for what ? for infection ??