Presentation
3 months of intermittent arm/shoulder pain.
Patient Data
Frontal and lateral views of the right humerus show a long aggressive lesion involving the proximal metaphysis and proximal-to-mid diaphysis. The lesion is sclerotic with extensive periosteal changes. There is a spiculated (sunburst) periosteal reaction proximally and a more lamellated (onion skin) reaction at the mid diaphysis.
CT better demonstrates the x-ray findings of an aggressive sclerotic lesion of the right humerus with areas spiculated and lamellated periosteal reaction
Coronal T1 weighted image shows the typical low-to-intermediate signal intensity.
Axial T2 weighted image with fat saturation demonstrates high signal intensity as well as both the spiculated (proximal) and laminated (distal) periosteal reaction.
Coronal T1 weighted image post-contrast with fat saturation demonstrates avid enhancement.
A whole-body bone scan was performed as part of the initial work-up. Additional blood pool images of the lesion were obtained.
The right humerus lesion shows increased radiotracer accumulation on the blood pool phase and intense uptake on the delayed phase consistent with a hypervascular malignancy.
An additional site of abnormal, mild radiotracer uptake was present in the high right posterior calvarium and was later proven to be a metastatic lesion.
The patient was referred to a specialty center where they underwent further testing to confirm Ewing sarcoma in the right humerus with solitary calvarial metastasis.
Case Discussion
Ewing sarcoma is an aggressive small round blue cell malignancy.
Approximately 25% of patients with ES have metastases at diagnosis, most commonly to the lung or bones.
FDG PET-CT can be optimal for staging of Ewing sarcoma, however, a bone scan can occasionally aid in the detection of sclerotic osseous metastases as in this case.
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