PMC3884210_01
a The cervical spine CT scan showed osteolytic changes with bony fragmentations in the C3, C5 and C6 transverse processes and vertebral bodies. b A bone scan showed multiple rib fractures, but otherwise no remarkable uptake. c A PET-CT scan showed a multifocal, disseminated hypermetabolic lesion (maxSUV = 7.4) in the axial skeleton with metabolic lesions in the left axillary lymph node (maxSUV = 2.3) and both lungs (maxSUV = 2.6). d A PET-CT scan showed a left-breast mass with small daughter nodules (in the white circle) (maxSUV = 1.9).
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F1
These findings are suggestive of pathological fracture related to the presence of a tumor, such as metastatic carcinoma or multiple myeloma, rather than trauma (fig. 1a). Therefore, we strongly suspected the presence of multiple myeloma (fig. 1b). A PET-CT scan showed a disseminated hypermetabolic lesion (maxSUV = 7.4) in the axial skeleton, multiple, small-sized lung nodules and a multifocal hypermetabolic lung lesion (maxSUV = 2.6) as well as focal hypermetabolic lesions in the left axillary lymph nodes (maxSUV = 2.3) (fig. 1c). This revealed palpable and movable small nodular lesions in the periareolar area of the left breast, which had escaped interpretation on the PET-CT scan because the lesion was obscured (fig. 1d).
A bone marrow aspiration and biopsy showed neoplastic cell clusters. a BM touch print. Wright. x400. b BM aspiration. Wright. x400. c BM biopsy. HE. x100. d BM biopsy. HE. x400. e BM biopsy. Cytokeratin. x400. f BM biopsy. CD45. x400. Histopathology of metastatic ACC in the left axillary lymph node (g: HE, x100) and (h: HE, x400). Histopathology of adenoid cystic carcinoma in the left breast (i: HE, x100) and (j: HE, x400).
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F2
Neoplastic cells were stained with CK PAN (AE1/AE3) and were positive (fig. 2a-f). The result of core biopsy was ACC (fig. 2g, h). A core biopsy was performed and the pathology result was ACC, the same as that of the auxiliary lymph node biopsy (fig. 2i, j).