case_images: PMC4695657_01
case_images: Anteroposterior radiographs of both femurs. (a) Mixed lytic-sclerotic lesions on the right femur. (b) Mixed lytic-sclerotic lesions on the left femur and a lytic destructive process with eccentric localization and a narrow zone of transition at diaphysis of the left femur extending to the left subtrochanteric region.
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case_images: PMC4695657_01_CRIHEM2015-803921.001.jpg
case_images: fig1
case_images: Anteroposterior radiographs of both femurs revealed mixed lytic-sclerotic lesions (Figures 1(a) and 1(b)) and a lytic destructive process with eccentric localization and a narrow zone of transition at diaphysis of left femur extending to left subtrochanteric region (Figure 1(b)).
case_images: MRI scan of pelvis and both femurs showed multiple metastatic bone lesions dominantly located in both femoral heads, necks, and trochanters with a largest of diameter 2 cm. (a) Multiple hypointense metastatic bone lesions on T1-weighted coronal imaging. (b) Multiple hyperintense metastatic bone lesions on T2-weighted coronal imaging.
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case_images: PMC4695657_01_CRIHEM2015-803921.002.jpg
case_images: fig2
case_images: On MRI scan, multiple hypointense metastatic bone lesions on T1-weighted coronal imaging and hyperintense metastatic lesions on T2-weighted coronal imaging dominantly located in both femoral heads, necks, and trochanters with largest of diameter 2 cm were present (Figures 2(a) and 2(b)).
case_images: Abdominal MRI on T1-weighted axial imaging revealed a 1 cm wide heterogeneous metastatic lesion at the left side of posterior L2 and L3 vertebrae corpus.
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case_images: fig3
case_images: Abdominal MRI on T1-weighted axial imaging revealed a 1 cm wide heterogeneous metastatic lesion at left side of posterior L2 and L3 vertebrae corpus (Figure 3).
case_images: The biopsy specimen of the right femoral lesion showed diffuse neoplastic infiltration consisting of cells with round, oval, regular nuclei, and medium-sized, clear cytoplasm (H&E, x400).
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case_images: fig4
case_images: Histopathological examination of the biopsy from right femoral lesion showed diffuse neoplastic infiltration consisting of cells with round, oval, regular nuclei, and medium-sized, clear cytoplasm (Figure 4).
case_images: Immunohistochemical features of the infiltrated cells in the right femur expressed CD20 ((a) x200), TRAP ((b) x200), CD11c ((c) x400), and annexin ((d) x400).
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case_images: fig5
case_images: Neoplastic cells expressed CD20, LCA, CD79 alpha, tartrate-resistant acid phosphatase (TRAP), CD11c, CD68, and annexin (Figure 5).
case_images: PET scan at diagnosis and 8 weeks after chemotherapy. (a) There was increased FDG uptake on axial skeleton, pelvis, and both femurs at diagnosis. (b) Follow-up PET scan demonstrated marked metabolic response with decrease in uptake of multiple metastatic lesions on both proximal humeri, the right lamina of C6 vertebra, and both first ribs.
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case_images: PMC4695657_01_CRIHEM2015-803921.006.jpg
case_images: fig6
case_images: FDG uptake on lateral sides of right 2nd and 3rd ribs, posterior sides of right 9th and 10th ribs, lateral sides of left 2nd, 5th, 6th, and 7th ribs, corpus sterni, corpus of D1, D5, D6, L1, and L2 vertebrae, spinous processes of D12, L3, and L4 vertebrae, right pedicle of C6 and D11 vertebrae, both femoral heads, necks and diaphyseal regions, sacrum, and pelvic bones (Figure 6(a)). Patient underwent radiotherapy to bilateral proximal femur at a dose of 20 Gy and obtained a complete clinical response with resolution of pain. Four weeks after completion of radiotherapy, a 7-day course of 0.1 mg/kg/day cladribine was administered. Follow-up PET scan performed 8 weeks after chemotherapy showed marked metabolic response with decrease in uptake of multiple metastatic lesions on both proximal humeri, right lamina of C6 vertebrae, and both first ribs (Figure 6(b)).