Vanishing bone metastasis: pictorial essay

Vanishing bone metastasis (pseudopathological vertebral body enhancement) is a pitfall in the interpretation of contrast-enhanced computed tomography (CT) scans of patients with thoracic vein obstruction, mainly in the superior vena cava and brachiocephalic veins, typically being related to thrombosis due to malignant tumors. On the basis of the CT findings, pseudopathological vertebral body enhancement can be misdiagnosed as sclerotic bone metastasis, leading to unnecessary treatment. Although not rare, pseudopathological vertebral body enhancement is usually underdiagnosed by radiologists. The aim of this study is to review the pathophysiology of this phenomenon, illustrating the most common collateral venous pathways in thoracic vein obstruction and making the correlation with the CT findings.

Keywords:
Neoplasm metastasis/physiopathology; Bone and bones/diagnostic imaging; Tomography, X-ray computed; Diagnostic errors; Venous thrombosis; Collateral circulation

Authorship

Erina Megumi Nagaya Fukamizu Correspondence: Dra. Erina Megumi Nagaya Fukamizu. Instituto do Câncer do Estado de São Paulo (Icesp). Avenida Doutor Arnaldo, 251, Cerqueira César. São Paulo, SP, Brazil, 01246-000. Email: erina@nagaya.com.br.

Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.Universidade de São PauloBrazilSão Paulo, SP, BrazilFaculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.

https://orcid.org/0000-0002-1172-5467

Adriano Seabra

https://orcid.org/0000-0002-8110-4869

Deborah Yukiko Otto

https://orcid.org/0000-0002-6851-7845

Marcio Valente Yamada Sawamura

https://orcid.org/0000-0002-9424-9776

Marcelo Bordalo-Rodrigues

https://orcid.org/0000-0003-4747-5081

Paulo Victor Partezani Helito

https://orcid.org/0000-0002-5709-6029

Correspondence: Dra. Erina Megumi Nagaya Fukamizu. Instituto do Câncer do Estado de São Paulo (Icesp). Avenida Doutor Arnaldo, 251, Cerqueira César. São Paulo, SP, Brazil, 01246-000. Email: erina@nagaya.com.br.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (9)

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Figure 1.
Diagram illustrating the vertebral venous plexus, highlighting the basivertebral vein (BV), external vertebral venous plexus (EVVP), and internal vertebral venous plexus (IVVP).

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Figure 2.
Diagram illustrating the vertebral venous plexus in the sagittal plane.

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Figure 3.
Superior vena cava obstruction, with consequent prominence of the azygos-hemiazygos system (arrows). Observe the external paravertebral venous plexuses (arrowheads) and the intercostal collateral veins (dotted arrows).

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Figure 4.
Patient with superior vena cava thrombosis and subscapular collateral vascular system ectasia to the left (arrows).

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Figure 5.
The mediastinal, pericardial, and pericardiophrenic collateral veins drain into the inferior vena cava via the inferior phrenic and transhepatic collateral veins. Arrows: pericardiophrenic collateral veins. Dotted arrow: pericardial collateral veins.

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Figure 6.
Superficial thoracoabdominal plexus collateral venous pathway (arrows).

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Figure 7.
The collateral thoracic veins drain into the left hepatic portal vein to reach the inferior vena cava, resulting in an area of increased contrast in the left hepatic lobe. Arrows: hepatic “hot spot” sign. Dotted arrows: superficial thoracic collateral veins.

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Figure 8.
A: Chest CT with intravenous contrast in a 50-year-old male patient diagnosed with small cell carcinoma evolving to superior vena cava thrombosis (arrow). B,C: Unenhanced and contrast-enhanced CT images, respectively. The unenhanced image shows preserved vertebral bodies, and the contrast-enhanced image shows enhancement of the upper thoracic vertebral bodies, due to reflux of contrast medium by the vertebral venous plexus (arrows).

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Figure 9.
A 34-year-old female patient who was receiving peripheral parenteral nutrition after massive enterectomy, because of mesenteric ischemia three years prior, and evolved to mild pain in the cervical and right supraclavicular regions. A: CT angiography showing thrombosis of the superior vena cava (SVC). B,C: In the images that include the thoracic spine, hyperdense areas can be seen in the vertebral bodies of the upper thoracic segment. D: On an unenhanced follow-up CT angiography image, no such hyperdense areas were seen. RIJV, right internal jugular vein; RSCV, right subclavian vein; RBCV, right brachiocephalic vein.

Figure 1. Diagram illustrating the vertebral venous plexus, highlighting the basivertebral vein (BV), external vertebral venous plexus (EVVP), and internal vertebral venous plexus (IVVP).

Figure 2. Diagram illustrating the vertebral venous plexus in the sagittal plane.

Figure 3. Superior vena cava obstruction, with consequent prominence of the azygos-hemiazygos system (arrows). Observe the external paravertebral venous plexuses (arrowheads) and the intercostal collateral veins (dotted arrows).

Figure 4. Patient with superior vena cava thrombosis and subscapular collateral vascular system ectasia to the left (arrows).

Figure 5. The mediastinal, pericardial, and pericardiophrenic collateral veins drain into the inferior vena cava via the inferior phrenic and transhepatic collateral veins. Arrows: pericardiophrenic collateral veins. Dotted arrow: pericardial collateral veins.

Figure 6. Superficial thoracoabdominal plexus collateral venous pathway (arrows).

Figure 7. The collateral thoracic veins drain into the left hepatic portal vein to reach the inferior vena cava, resulting in an area of increased contrast in the left hepatic lobe. Arrows: hepatic “hot spot” sign. Dotted arrows: superficial thoracic collateral veins.

Figure 8. A: Chest CT with intravenous contrast in a 50-year-old male patient diagnosed with small cell carcinoma evolving to superior vena cava thrombosis (arrow). B,C: Unenhanced and contrast-enhanced CT images, respectively. The unenhanced image shows preserved vertebral bodies, and the contrast-enhanced image shows enhancement of the upper thoracic vertebral bodies, due to reflux of contrast medium by the vertebral venous plexus (arrows).

Figure 9. A 34-year-old female patient who was receiving peripheral parenteral nutrition after massive enterectomy, because of mesenteric ischemia three years prior, and evolved to mild pain in the cervical and right supraclavicular regions. A: CT angiography showing thrombosis of the superior vena cava (SVC). B,C: In the images that include the thoracic spine, hyperdense areas can be seen in the vertebral bodies of the upper thoracic segment. D: On an unenhanced follow-up CT angiography image, no such hyperdense areas were seen. RIJV, right internal jugular vein; RSCV, right subclavian vein; RBCV, right brachiocephalic vein.

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Vanishing bone metastasis: pictorial essay

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[1] Correspondence: Dra. Erina Megumi Nagaya Fukamizu. Instituto do Câncer do Estado de São Paulo (Icesp). Avenida Doutor Arnaldo, 251, Cerqueira César. São Paulo, SP, Brazil, 01246-000. Email: erina@nagaya.com.br.