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British Journal of Radiology (2004) 77, 869-870
© 2004 British Institute of Radiology
doi: 10.1259/bjr/14405146
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Short communication

Extraosseous uptake of metastatic lymph nodes of ureteral cancer on 99Tcm hydroxymethylene diphosphonate bone scintigraphy

H Kaida, MD 1 M Ishibashi, MD 1 K Baba, MD 1 H Nishida, MD 2 K Matsuoka, MD 3 and N Hayabuchi, MD 1

1 Division of Nuclear Medicine and Department of Radiology, 2 Department of Nephrology and Dialysis Unit and 3 Department of Urology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume City, Fukuoka, 830-0011, Japan

We describe a case of extraosseous uptake of 99Tcm diphosphonate in metastatic lymph nodes in a patient with a carcinoma of the ureter. A 70-year-old man with transitional cell carcinoma of the ureter had a total nephroureterectomy and a partial resection of the bladder. CT showed lymph node enlargement in both the left cervical and right common iliac artery regions and outside the iliopsoas muscle, with calcification (Figure 1Go). A biopsy confirmed transitional cell carcinoma, and metastases regressed following MVAC chemotherapy (Methotrexate, Vinblastine, Adriamycin and Cisplatin). When the metastases increased in size again, chemotherapy was given for a second time. Bone scintigraphy was performed to look for bone metastases. Extraosseous uptake in the lymph node metastases was noted in both the left cervical and right common iliac artery regions and outside the right iliopsoas muscle (Figure 2Go). The extraosseous uptake of 99Tcm diphosphonate compounds has been reported [1, 2], but the mechanism by which it occurs has not yet been explained. It has been suggested that there may be ionic exchange at the crystalline surface of an area of calcification [2, 3]. As there are some cases in which extraosseous uptake is noted without calcification, other mechanisms have been suggested, such as acceleration of calcium metabolism in tissues and tumours [2], vascularity and capillary permeability [2–5], and an increase in the calcium level in ischaemic cellular tissues [2, 3, 6]. It has also been suggested that 99Tcm diphosphonate compounds may deposit on the surface of the hydroxyapatite of intracellular mitochondria [2, 5, 7] and may combine with denatured protein [2], hormone and enzymatic receptors [2], and that both iron and immature collagen are deposited in the soft tissues [2, 8]. In this case, since calcification was seen in two areas of metastatic lymph nodes, we suggest that the mechanism of concentration of 99Tcm may have been ionic exchange on the crystalline surface of areas of calcification.



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  		Figure 1. Enhanced CT of abdominal region showing lymph node metastases, including calcification outside the right iliopsoas muscle.

 


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  		Figure 2. Bone scintigraphy, performed to look for bone metastases, showing an extraosseous uptake in the lymph metastases in both the left cervical and right common iliac artery regions and outside the right iliopsoas muscle.

 
It is well known that extraosseous uptake of 99Tcm diphosphonate compounds can occur in tumours. Extraosseous uptake of 99Tcm has been reported in malignant tumours, such as lung cancer, neuroblastoma [5, 9], breast cancer [5], metastatic liver tumours [2, 5, 9], osteosarcoma and ganglioneuroblastoma [5] and in benign tumours, such as lipomas [5], neurofibromas [5], angiomyolipomas [10] and haemangiomas [11], and especially in metastases of liver tumours [5, 12], osteosarcomas [2, 5], seminomas [5], tumours of the spleen [5] and pleural metastases [2]. However, to our knowledge, there have been no reports of extraosseous uptake of metastatic lymph nodes from ureteric cancer. Where there are metastases, bone scintigraphy may pick up metastatic lesions in the soft tissues as well as in the skeleton.

Received for publication July 28, 2003. Revision received January 5, 2004. Accepted for publication June 8, 2004.


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