NeuroRounds Dec 6, 2022 - Multiple Meningiomas Case Discussion
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The Video Transcript:
"So he's got multiple hemangiomas in the bone at different levels and the reason that's important is because this vertebral body was read as one gigantic L3 Hemangioma which is actually expanding into the spinal canal…, and the reason it helps you as you can see here that he's got he's got one here he's got one here if we scroll a little bit more over you can see some smaller ones boom, boom.
If he didn't have all these other lesions I might say well that's not really the case…, secondly you know this these could be metastatic lesions of some sort but he has no back pain. He looks healthy. He hasn't lost any weight he has no history of cancer um so it really does look and the signal characteristics of this appear to be hemangioma but it's expansile.
Hemangiomas typically aren’t expansile, so I'm going to turn this over to Dr Tydings now. John have you ever seen an expansile hemangioma and the guy's asymptomatic right now. What would you do how would you manage this?
I mean obviously that's a problem and I would also tell them to hold off on golf because even though we can surmise it's this or that we really have no idea what this is so I think we obviously need a lot of information. The chances of this being a primary bone lesion in an 82 year old guy is slight, so you got to assume the worst case scenario which is that this is metastatic cancer from somewhere else, so this guy needs a workup at the least.
You know…, the usual chemical stuff while the blood test's looking for everything.
I would probably also get a bone scan…, see what other areas in his skeleton are affected and specifically for the lumbar spine, I'd want a CT scan to get a better idea of the architecture and that'll also give you some of the typical findings of Hemangioma versus uh metastatic renal cancer versus any other type of thing that may give similar answers.
But I think in this case, it doesn't look like a simple Hemangioma we need to establish a diagnosis and then you can figure out what needs to be done from there.
Anybody know what the lab tests are that Dr Tydings is referring to that we typically want to get to work up? Bony lesions particularly in an elderly person…, there's a common disease that they can get that you can simply do a blood test and a urine test and you can you can make the diagnosis. It's called the serum protein electrophoresis and a urine protein electrophoresis, because a person with myeloma will have these proteins that are so prominent in their blood and in their urine that it just pops right up and it's a diagnosis of multiple myeloma.
M Fitzpatrick - I was just going to make a comment…, just like a teaching point. Typically multiple myeloma the patient would have back pain.
What would the bone look like?
Wouldn't it have like lytic lesions?
They'd be totally black. It'd be almost like the bone disappear in those areas right because it's lytic. It would be completely…, it would like be almost like it disappeared if this was a multiple myeloma this vertebral body would be basically dark on a on an X-ray.
It'd be pretty surprising that he would have multiple myeloma because it would be quite advanced at this time but as Dr Tydings points out, you’ve got to think about the worst and then work backwards and Radiologists can be wrong too.
They don't always make the right call on this and you know…, in this particular reading was “you know this is what it is”, and it really should have been like “this is what the differential diagnosis of this is”.
Remember don't just jump to a conclusion ask yourself what are three or four other things that this could be that I'm not thinking of? That's a lateral thinking technique that you need to use when you're thinking of diagnoses. So his CAT scan is cooking and you know also…, anytime you see a lesion in the bone your worst case scenario is some type of metastatic cancer. You always have to think…, could this just be some traumatic? Where there's some expansion of a fracture? Unlikely with that appearance, but you’ve got to think about that and another whole area you have to think about is some type of infection whether it's bacterial fungal or other.
I mean lots of things…, even TB can mimic these types of pictures, so it's something to always keep in the back your mind and when you have someone. You have no idea. You just shotgun all the tests basically at one time to make sure you don't miss everything."
Pardon the Interruption!
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