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case_images: Timeline from the first surgery to the most recent onset of new symptoms. After undergoing a total of four surgeries over 6 years, the patient did well for 9 years without recurrence of metastasis and then visited our hospital again with new symptoms.
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case_images: In February 2022, 9 years later, the patient visited our hospital again with worsening general aches and multiple bone pain ( Figure 1 ). Eventually, bone pain improved ( Supplementary Figure 1 ).
case_images: Bone scan images were performed to evaluate the cause of worsening general pain and multiple bone pain that occurred 9 years after the last surgery. These images showed multiple hot-uptake lesions suggesting bone metastases or multiple traumatic fractures in the spine, pelvis, and ribs.
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case_images: A bone scan showed multiple hot-uptake lesions on the rib and sternum, suggesting osteoporotic fractures or bone metastases ( Figure 2 ).
case_images: (A, B) Chest MRI scans. Red arrows indicate high-signal-intensity lesions at the sternum and right third rib. (C, D) PET-CT scans. Yellow arrows indicate multiple FDG uptakes in the sternum and ribs. High-signal-intensity lesions on MRI were consistent with lesions with FDG uptake on PET-CT. MRI, magnetic resonance imaging; PET-CT, positron emission tomography-computed tomography; FDG, fluorodeoxyglucose.
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case_images: PET-CT confirmed FDG uptake similar to the bone scan ( Figure 3 ).
case_images: In the bone mineral density test, T-scores of the L spine and femur were less than -2.5, corresponding to osteoporosis. The total T-scores of L spine and femur were -5.1 and -3.8, respectively.
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case_images: Additional sternal magnetic resonance imaging (MRI) revealed a focal enhancing lesion on the right third rib, suggesting bone metastasis ( Figure 4 ).