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LETTER TO EDITOR
Year : 2014  |  Volume : 29  |  Issue : 1  |  Page : 60-61  

Rare splenic metastasis of renal cell carcinoma detected on 99m Tc-MDP bone scan


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication24-Jan-2014

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, E Borges Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.125784

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How to cite this article:
Agrawal A, Jatale P, Purandare N, Shah S, Rangarajan V. Rare splenic metastasis of renal cell carcinoma detected on 99m Tc-MDP bone scan. Indian J Nucl Med 2014;29:60-1

How to cite this URL:
Agrawal A, Jatale P, Purandare N, Shah S, Rangarajan V. Rare splenic metastasis of renal cell carcinoma detected on 99m Tc-MDP bone scan. Indian J Nucl Med [serial online] 2014 [cited 2019 Dec 8];29:60-1. Available from: http://www.ijnm.in/text.asp?2014/29/1/60/125784

Sir,

99m Tc-methylene diphosphonate (MDP) uptake in soft tissues like primary breast mass, liver metastases, ascites, and pleural effusion are well-known entities. We here in report a rare case of splenic metastasis from renal cell carcinoma (RCC) which was detected on 99m Tc-MDP bone scan. A 52-year-old male was a diagnosed case of clear cell carcinoma of the left kidney and had undergone nephrectomy 3 years ago. The patient was on regular follow-up and was disease free. However, a few months back he complained of severe backache. A bone scan done was done for evaluation of the bone pain. The 99m Tc-MDP scan did not reveal any abnormally increased activity in the axial and appendicular skeleton. The left kidney was not visualized; post nephrectomy status. But, an area of soft tissue uptake of tracer was seen in the left hypochondrium [Figure 1]. A contrast-enhanced computed tomography (CECT) abdomen was done which revealed a large hypodense inhomogenously enhancing mass (arrow) in the spleen. In addition to the splenic metastasis, metastatic lesions are also seen in the liver with recurrence in the left renal bed [Figure 2].
Figure 1: Anterior (a) and posterior (b) planar images of 99mTc-methylene diphosphonate (MDP) bone scan. No abnormally increased activity is noted in the bones suggesting no osteoblastic metastasis. A focal area of increased uptake is noted in the left hypochondrium (arrow). The left kidney is not visualized; post nephrectomy status

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Figure 2: Contrast enhanced computed tomography (CECT) scan; axial (a) sagittal (b) and coronal (c) images reveal a large hypodense inhomogenously enhancing mass (arrow) in the spleen. In addition to the splenic metastasis, metastatic lesions are also seen in the liver with recurrence in the left renal bed (c)

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Extraosseous uptake of MDP is not an unusual finding. Published reports have depicted MDP accumulation in liver metastases, [1],[2] pericardial metastasis, [3] and even metastasis from malignant peripheral nerve sheath tumor. [4] In lesions with calcifications seen on morphologic imaging, it is understood that the uptake of MDP is because of its affinity to bind to calcium. But soft tissue uptake in tissues which lack morphologic calcifications have also been documented. A proposed mechanism for MDP accumulation in soft tissue is cellular alterations in calcium metabolism. It is postulated that there is disruption of the cellular membrane through which the bone-seeking radiopharmaceutical gains entry into the cell and is deposited with calcium on the mitochondria or attaches to calcium by displacing other anions. [5]

Metastatic involvement of spleen is uncommon. The incidence of isolated metastasis is less than 1%. [6] Metastasis to the spleen from malignant neoplasms is a rare phenomenon and is usually found at autopsy. [7] Lung, bones, liver, and brain are the commonest sites of metastatic spread in renal cell cancer. [8],[9] Splenic metastases are usually asymptomatic. Sometimes the patient may present with abdominal mass or pain, fatigue, and weight loss. [10] Many theories have been postulated regarding the rarity of finding metastases to the spleen. It is suggested that it is due to the constant flow of blood through the spleen, the sharp angulation between the splenic and coeliac arteries prevent large tumor cells from passing through it. Also the lack of afferent lymphatic vessels prevents the spread via the lymphogenic route. [11],[12] Splenic metastases from RCC is quiet rare and only a few cases have been reported. To our knowledge this is the first case being reported, in which MDP has shown accumulation in a rare case of splenic metastasis from RCC.

 
   References Top

1.Romyn AM, Bushnell DL, Freeman ML, Kaplan E. Visualization of metastatic liver disease on technetium-99m bone scintigraphy. Clin Nucl Med 1987;11:264-7.  Back to cited text no. 1
    
2.Senda M, Tamak N, Torizuka K, Fujiwara Y, Kudo M, Tochio H, et al. Accumulation of Tc-99m methylene diphosphonate in calcified metastatic lesions of the liver from colonic carcinoma. Comparison with calcification on X-ray computed tomogram. Clin Nucl Med 1985;10:9-12.  Back to cited text no. 2
    
3.Kawase T, Fujii H, Nakahara T, Shigematsu N, Kubo A, Kosuda S. Intense accumulation of Tc-99m MDP in pericardial metastasis from breast cancer. Clin Nucl Med 2009;34:173-4.  Back to cited text no. 3
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4.Li L, Kuang A, Sheng S. Tc-99m MDP uptake in retroperitoneal malignant peripheral nerve sheath tumor and its metastases. Clin Nucl Med 2006;31:44-5.  Back to cited text no. 4
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5.Rasmussen H, Chance B, Ogata E. A mechanism for the reactions of calcium with mitochondria. Proc Natl Acad Sci USA 1965;52:1069-76.  Back to cited text no. 5
    
6.Nunes TF, Szejnfeld D, Miiji LN, Goldman SM. Isolated metachronous splenic metastasis from renal cell carcinoma after 5 years. BMJ Case Rep. 2012;2012.  Back to cited text no. 6
    
7.Tatsuta M, Shiozaki K, Masutani S, Hashimoto K, Imamura H, Ikeda M, et al. Splenic and pulmonary metastases from renal cell carcinoma: Report of a case. Surg Today 2001;31:463-5.  Back to cited text no. 7
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8.Ritchie AW, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983;10:390-400.  Back to cited text no. 8
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9.Garza CV, Perez-Alvarez SI, Gonzalez-Espinoza IR, Leon-Rodriguez E. Unusual metastases in renal cell carcinoma: A single institution experience and review of literature. World J Oncol 2010;1:149-57.  Back to cited text no. 9
    
10.Lam KY, Tang V. Metastatic tumors to the spleen: A 25-year clinicopathologic study. Arch Pathol Lab Med 2000;124:526-30.  Back to cited text no. 10
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11.Berge T. Splenic metastases. Frequencies and patterns. Acta Pathol Microbiol Scand 1974;82:499-506.  Back to cited text no. 11
    
12.Comperat E, Bardier-Dupas A, Camparo P, Capron F, Charlotte F. Splenic metastases: Clinicopathological presentation, differential diagnosis, and pathogenesis. Arch Pathol Lab Med 2007;131:965-9.  Back to cited text no. 12
    


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