Late widespread skeletal metastases from myxoid liposarcoma detected by MRI only
© Hanna et al; licensee BioMed Central Ltd. 2008
Received: 17 January 2008
Accepted: 18 June 2008
Published: 18 June 2008
Myxoid liposarcoma is the second most commonly occurring sub-type of liposarcomas. In contrast to other soft tissue sarcomas, it is known to have a tendency to spread toward extrapulmonary sites, such as soft tissues, retroperitoneum, and the peritoneal surface. Bony spread, however, is not as common.
We report an unusual case of diffuse skeletal metastases from myxoid liposarcoma occurring 13 years after treatment of the primary tumour in the left lower limb. The skeletal spread of the disease was demonstrated on MRI only after other imaging modalities (plain radiography, CT and TC99 bone scans) had failed to detect these metastases.
MRI is an extremely sensitive and specific screening tool in the detection of skeletal involvement in these types of sarcomas, and therefore, should be a part of the staging process.
Classification of Liposarcomas
Well differentiated Lipoma like Sclerosing Inflammatory
Dedifferentiated Round cell Pleomorphic
Our case demonstrates the possibility of diffuse bone involvement with myxoid liposarcoma, even late in the course of the disease. This uncommon pattern of spread should certainly be taken into account when staging patients and determining their prognosis. It also shows the value of MRI in the detection of these metastases. Other methods for assessing skeletal metastases, including plain radiography, CT scanning and Tc 99m isotope scanning, would appear on the evidence of this, and other cases [6–9], to be insensitive to myxoid liposarcoma. Schwab et al.  have shown that even PET scans lack sufficient sensitivity to detect spinal involvement in this disease and recommended the use of total spine MRI when screening for metastases in MLS patients. Because bone secondaries are not common in soft tissue sarcomas, skeletal staging would not be routinely performed in many centres. Furthermore, relying solely on CT as a staging tool in these cancers might result in a significant number of metastases being missed. MRI, on the other hand, is an extremely sensitive tool to bone marrow replacement by abnormal tissue, as the high contrast between fat (marrow) and water (tumour) demonstrates metastatic lesions at an early stage . We believe that whole-body MRI may be a more appropriate staging investigation of this particular tumour with unique clinical features. Because our patient was initially asymptomatic, there was no way to detect the metastatic bone lesions and no reason to suspect they were present, and this may explain the late diagnosis. We do not know when skeletal lesions first occurred, as no spinal MRI was obtained between initial diagnosis and 2005. In addition, all other surveillance imaging investigations were negative. Ishii et al.  have reported two cases of relatively early bone metastases (2 and 4 years latency) not detected by bone scans. They attributed the normal accumulation of radiotracers to the likely diminished metabolic bone activity. Other authors have suggested that the myxoid stroma may prevent labelled glucose from reaching cells in sufficient quantity to be detected by the scanner .
By reporting this case, we emphasise two important points; diffuse skeletal metastases can occur late in the course of MLS (13 years latency in this case), and MRI appears to be more sensitive than any other imaging modality in detecting bone marrow involvement in this disease. It is therefore essential to consider the value of whole-body MRI in the management of patients with intermediate (myxoid) to high grade liposarcomas. We recommend this be used in the initial staging process, and whenever local recurrence/metastases are suspected.
Written informed consent was obtained from the patient's family for publication of this case report and any accompanying images.
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