J Korean Soc Radiol.  2018 Jan;78(1):30-34. 10.3348/jksr.2018.78.1.30.

Necrotic Bone Involvement in an Adult Afflicted with B-Cell Precursor Acute Lymphoblastic Leukemia Mimicking Osteomyelitis: A Case Report

• Kim HW
• Kwon SY
• Chong Y
• Park J

• KMID: 2399303
• DOI: http://doi.org/10.3348/jksr.2018.78.1.30

Abstract

A 41-year-old female presented with complaint of left hip and buttock pain. Magnetic resonance imaging (MRI) showed multi-focal bone marrow signal intensity changes in left iliac bone, sacrum and femur with an area of necrosis. The primary radiological differential diagnosis was multi-focal tuberculous osteomyelitis. Subsequent pelvic bone biopsy and bone marrow biopsy confirmed the diagnosis of B-cell precursor acute lymphoblastic leukemia with extensive necrosis, which is infrequent in leukemia. When musculoskeletal symptoms precede peripheral blood abnormalities and MRI scanning reveals multi-focal necrotic lesions rather than diffuse signal change, it can be difficult to identify and/or advance leukemia as differential diagnosis.

MeSH Terms

Adult*
B-Lymphocytes*
Biopsy
Bone Marrow
Buttocks
Diagnosis
Diagnosis, Differential
Female
Femur
Hip
Humans
Leukemia
Magnetic Resonance Imaging
Necrosis
Osteomyelitis*
Pelvic Bones
Precursor B-Cell Lymphoblastic Leukemia-Lymphoma
Precursor Cell Lymphoblastic Leukemia-Lymphoma*
Sacrum

Figure

• 

  Fig. 1 A 41-year-old woman with necrotic bone involvement on hip magnetic resonance imaging. A. T1-weighted coronal image (left upper panel) shows a patchy area of low signal intensity at the left iliac wing (arrows). The T2-weighted coronal image (right upper panel) with fat suppression shows intermediate to high signal intensity with serpentine hyper-intense rim (arrows). Note that the adjacent gluteus musculature also shows high signal intensity (arrowhead). The gadolinium-based contrast enhanced T1-weighted coronal (left lower panel) and axial images (right lower panel) reveal evidence of rim enhancement at left iliac wing (arrows) and sacrum (arrowhead), thought to be most consistent with necrosis. The adjacent gluteus muscle also shows patchy enhancement. B. A total body F-18-fluorodeoxy glucose positron emission tomography scan shows intense hypermetabolic lesions at T10, T12, L1 vertebral bodies, bilateral sacral alae and left iliac wing (arrows). C. Photomicrograph of pelvic bone biopsy specimen (upper panel, H&E × 400) shows lymphoblastic cell infiltration, while the other area (under panel, H&E × 100) shows extensive necrosis (arrowheads). Note that bone trabeculae (arrows) are preserved, suggesting bone marrow necrosis. H&E = hematoxylin and eosin stain

Reference

1. Moulopoulos LA, Koutoulidis V. MRI of the abnormal bone marrow: diffuse pattern. In : Moulopoulos LA, Koutoulidis V, editors. Bone Marrow MRI: a pattern-based approach. Milano: Springer;2014. p. 101–114.

2. Yoshikawa T, Tanizawa A, Suzuki K, Tanaka N, Hayashi T, Tsuda M, et al. The usefulness of T1-weighted magnetic resonance images for diagnosis of acute leukemia manifesting musculoskeletal symptoms prior to appearance of peripheral blood abnormalities. Case Rep Pediatr. 2016; 2016:2802596.

3. Kan JH, Hernanz-Schulman M, Frangoul HA, Connolly SA. MRI diagnosis of bone marrow relapse in children with ALL. Pediatr Radiol. 2008; 38:76–81.

4. Navarro SM, Matcuk GR, Patel DB, Skalski M, White EA, Tomasian A, et al. Musculoskeletal imaging findings of hematologic malignancies. Radiographics. 2017; 37:881–900.

5. Borowitz MJ, Chan JKC. B lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities. In : Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW, editors. WHO classification of tumours of haematopoietic and lymphoid tissues. 4th ed. Springer;2008. p. 171–175.

6. Kaygusuz I, Toptas T, Guven A, Firatli-Tuglular T, Tecimer T, Bayik M. Precursor B cell lymphoblastic lymphoma presenting as a solitary bone tumor: a case report and review of the literature. Int J Hematol. 2010; 92:757–761.

7. Mika J, Schleicher I, Gerlach U, Adler CP, Uhl M, Knoeller SM. Primary bone lymphomas thought to be osteomyelitis urgently demand a rapid diagnosis in bone pathology. Anticancer Res. 2012; 32:4905–4912.

8. Tang YM, Jeavons S, Stuckey S, Middleton H, Gill D. MRI features of bone marrow necrosis. AJR Am J Roentgenol. 2007; 188:509–514.

9. Hwang S, Panicek DM. Magnetic resonance imaging of bone marrow in oncology, part 2. Skeletal Radiol. 2007; 36:1017–1027.

10. Badar T, Shetty A, Bueso-Ramos C, Cortes J, Konopleva M, Borthakur G, et al. Bone marrow necrosis in acute leukemia: clinical characteristic and outcome. Am J Hematol. 2015; 90:769–773.