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case_images: X-ray, CT, and MRI images. Panel (A) displays the flattening of the L4 left vertebral body height. Panel (B) displays the bone destruction of L4 before chemotherapy, with a moderately circular low-density shadow with a range of 3.4 cm x 2.0 cm x 2.2 cm. Panel (C) displays a decrease in lytic bone destruction and an increase in the cortical bone density in posterior L4 after six cycles of chemotherapy. Panel (D) displays obvious calcification in the bone destruction area of the L4 vertebra at the last review. Panel (E) displays that the left side of the L4 vertebra is slightly flattened, with patchy long T1 equal length T2 signals and high T2 pressure lipid images.
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case_images: Subsequent lumbar spine X-ray depicted slight flattening of the lumbar vertebra 4 (L4) vertebral body ( Figure 1A ). Computed tomographic (CT) imaging of the lumbar spine revealed flattening of the L4 vertebral body, thin and discontinuous bone cortex, and osteolytic bone destruction on the left side of the vertebra, measuring approximately 3.0 cm x 2.0 cm x 2.2 cm ( Figure 1B ). Lumbar magnetic resonance imaging (MRI) displayed an uneven bone damage signal in the L4 vertebral body ( Figure 1E ). Following the completion of six cycles of chemotherapy, pulmonary CT scans evidenced a gradual reduction in the maximum diameter of the irregular soft tissue mass under the right axilla ( Figure 2C ), while lumbar spine CT exhibited thickening and densification of the bone cortex surrounding the L4 vertebral body, accompanied by evident bone formation and scattered calcification shadows in the area of osteolytic bone destruction ( Figure 1C ). On 20 February 2024, a re-examination CT revealed prominent calcification in the area of bone destruction in the L4 vertebral body ( Figure 1D ), with no significant alteration in the maximum diameter of the axillary mass compared to the previous scan ( Figure 2D ).
case_images: Axillary ultrasound and lung CT. Panel (A) shows the right axillary probe and irregularly shaped hypoechoic mass, measuring approximately 32 mm x 26 mm. Panel (B) shows the maximum axillary mass diameter at the time of initial admission. Panel (C) shows a significant reduction in the maximum diameter of the irregular soft tissue mass under the right axilla at the end of the entire chemotherapy cycle. Panel (D) displays the result of the February 2024 review, which indicated a decrease of approximately 2 cm in the maximum tumor diameter from the previous review.
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case_images: Lung CT revealed distinctive insect-like patterns of local bone destruction affecting thoracic vertebra 4 (T4) and the right first rib, with irregular soft tissue density shadows observed in the right armpit ( Figure 2B ). Ultrasonography detected a low-echo mass measuring approximately 32 mm x 26 mm, featuring clear boundaries and an irregular shape, exhibiting uneven internal echoes and the characteristic "rat tail sign" at both ends in the right axilla ( Figure 2A ). Following the completion of six cycles of chemotherapy, pulmonary CT scans evidenced a gradual reduction in the maximum diameter of the irregular soft tissue mass under the right axilla ( Figure 2C ), while lumbar spine CT exhibited thickening and densification of the bone cortex surrounding the L4 vertebral body, accompanied by evident bone formation and scattered calcification shadows in the area of osteolytic bone destruction ( Figure 1C ). On 20 February 2024, a re-examination CT revealed prominent calcification in the area of bone destruction in the L4 vertebral body ( Figure 1D ), with no significant alteration in the maximum diameter of the axillary mass compared to the previous scan ( Figure 2D ).
case_images: Bone scan nuclide concentration results. ECT revealed sparse radioactivity on the left side of the T4 and multiple abnormal focal nuclide concentrations on the right first rib, the L4, and the right iliac bone.
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case_images: Emission computed tomography (ECT) scans revealed multiple abnormal focal nuclide concentrations in the right first rib, L4 vertebral body, and right iliac bone, consistent with bone metastases ( Figure 3 ).
case_images: Pathology images. Panel (A) displays the pathological image of the right iliac bone tumor taken by a light microscope at x200 magnification, wherein some heterotypic cell components were detected. Panel (B) is a pathological image of an axillary puncture captured by light microscopy under a x200 magnifying glass. Malignant tumor cells were detected in the image.
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case_images: To determine the nature and origin of the tumors, a CT-guided puncture biopsy of the right iliac bone tumor was conducted on 29 May 2023, revealing a short spindle-cell malignant mesenchymal tumor suggestive of MPNST upon immunohistochemistry and staining ( Figure 4A ). Subsequently, on 6 June 2023, an ultrasound-guided puncture biopsy of the right axillary soft tissue tumor confirmed MPNST ( Figure 4B ).