Clinical Image Description We present a clinical image of a 72-year-old female patient with a history of pulmonary embolism, giant cell arteritis, hypertension, and Barrett’s esophagus. The patient underwent video-assisted thoracoscopic upper lobectomy with lymph node dissection for adenocarcinoma, followed by adjuvant chemotherapy and radiotherapy. Despite initial treatment, imaging revealed progressive disease with intraspinal metastasis. The clinical image demonstrates a Positron Emission Tomography - Computed Tomography (PET–CT) scan performed in November 2023, showing intraspinal metastasis along with other notable findings. Multiple Fluorodeoxyglucose (FDG) avid bone metastases are visible, involving the right 8th rib; left inferior iliac bone; and T2, T5, and L3 vertebrae. Intraspinal and dural metastases are also evident at various levels of the spine. Additionally, there is focal tracer uptake in the pituitary fossa, likely benign. This clinical image highlights the crucial role of imaging in the detection and characterization of metastatic disease progression. It showcases a challenging clinical scenario involving progressive lung cancer with intraspinal metastasis, which requires appropriate management strategies and supportive care for the patient. Despite a comprehensive workup, including a detailed history and physical examination, blood tests (including autoimmune disease serology to rule out paraneoplastic syndrome), Computed Tomography (CT), Magnetic Resonance Imaging (MRI) scans of the head and spine, and a lumbar puncture (which showed no metastasis), the administration of steroids and Intravenous Immunoglobulin (IVIG) as empirical treatment, which did not yield any clinical benefit, left the underlying cause of the patient’s symptoms unclear.1,2 In an unexpected turn of events, the rheumatologist made a remarkable decision to request a PET scan as part of a giant cell investigation when the patient presented with a sudden onset of blurred vision in the right eye. This decision proved to be instrumental, as the PET scan ultimately led to a definitive diagnosis. (Figure 1, 2)Figure 1: Fused Axial PET/CT image showed a focal tracer uptake within intraspinal metastasis.Figure 2: A coronal slice of fused PET/CT image showed focal tracer uptake within multiple dural/intraspinal metastases including lesions in the central canal.The utilization of a PET scan in the context of investigating giant cell-related conditions, such as giant cell arteritis, is not a common practice.3 However, in this particular case, it proved to be a pivotal step in unraveling the underlying cause of the patient’s symptoms. The PET scan likely revealed abnormal metabolic activity in the affected region, providing crucial evidence for the diagnosis.4 It is important to note that the significance of this decision lies in its unusual nature, as it deviates from the typical diagnostic approach for giant cell-related conditions. This unexpected utilization of a PET scan highlights the importance of considering alternative diagnostic methods and thinking outside the box when presented with challenging clinical scenarios. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Zamel et al. (Tue,) studied this question.