Sclerotic bone metastasis in pulmonary adenocarcinoma
Metastasis to the bone is not uncommon in lung cancer; however, osteoblastic bone metastasis is very rare. Published in the journal Case Reports in Medicine, the authors present a case of a 30-year-old female diagnosed to have pulmonary adenocarcinoma with multiple sclerotic bony lesions in the vertebra.

A 30-year-old female patient, was admitted with low back pain and generalized body ache for 2 months prior to presentation; it was excruciating pain especially during nighttime and not much relieved by simple analgesics. The patient has a history of poor appetite with weight loss of about 4-5 kg in a span of 3 months, otherwise had no pulmonary symptoms. She is a nonsmoker and has no past medical illnesses. Upon physical examination, the patient had bilateral discrete small cervical and axillary lymphadenopathy.

During routine workup in emergency, a chest X-ray was done, which was suggestive of bilateral fluffy hilar opacities and a CT thorax was done, which was suggestive of scattered areas of multifocal consolidation noted in the left lung and areas of scattered mosaic perfusion noted in the subpleural region, small nodules are also noted in the right lung, and both hila are prominent.

The bone window revealed multiple sclerotic bony lesions in the vertebra of variable sizes. US neck revealed bilateral cervical lymphadenopathy; right-side nodes are noted, the largest of which measures 21 × 10 mm in size. Left-side nodes are noted, the largest of which measures 12 × 9 mm in size. US breast examination was normal.

Whole-body PET scan revealed progressing pulmonary consolidations and nodules compared to the CT, multiple osseous involvements, generalized, metabolically active lymphadenopathy involving supra- and infradiaphragmatic regions, and hepatomegaly with solitary hepatic lesion.

Histopathology was most consistent with metastatic lung adenocarcinoma. The immunohistochemical (IHC) profile is most consistent with lung primary. Breast, ovary, and biliary tract are excluded by additional IHC with appropriate controls, which is positive for Napsin A and is negative for GATA-3.

Patient was referred to Cancer Centre for further plan of management. Patient started on chemotherapy with crizotinib 200 mg BID and denosumab 120 mg·q 4 weekly subcutaneous with good response according to the new PET scan. As compared to the previous PET scan 7 months before, there is favorable treatment response, metabolic resolution of previously seen left lung uptakes and lymph nodes above and below the diaphragm and metabolic resolution of bone metastases with increasing sclerosis also denoting favorable response.

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