Images in Clinical Rheumatology
Multiple Vertebral Metastases With Fluid–Fluid Levels
Metástasis vertebrales múltiples con niveles líquido-líquido
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La biopsia ósea (C) reveló que dichas lesiones correspondían a metástasis de un adenocarcinoma pobremente diferenciado con células en anillo de sello (cabezas de flechas), rodeando un contenido hemorrágico (flechas) (hematoxilina-eosina 10×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Walter Alberto Sifuentes Giraldo, Vanessa Pachón Olmos, José Ignacio Gallego Rivera, Mónica Vázquez Díaz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes Giraldo" ] 1 => array:2 [ "nombre" => "Vanessa" "apellidos" => "Pachón Olmos" ] 2 => array:2 [ "nombre" => "José Ignacio" "apellidos" => "Gallego Rivera" ] 3 => array:2 [ "nombre" => "Mónica" "apellidos" => "Vázquez Díaz" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574314000264" "doi" => "10.1016/j.reumae.2013.10.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574314000264?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X13002118?idApp=UINPBA00004M" "url" => "/1699258X/0000001000000005/v1_201408240347/S1699258X13002118/v1_201408240347/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173574314001105" "issn" => "21735743" "doi" => "10.1016/j.reumae.2013.10.010" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "613" "copyright" => "Elsevier España, S.L.U." 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Ignacio Gallego Rivera, Mónica Vázquez Díaz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes Giraldo" "email" => array:1 [ 0 => "albertosifuentesg@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Vanessa" "apellidos" => "Pachón Olmos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "José Ignacio" "apellidos" => "Gallego Rivera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Mónica" "apellidos" => "Vázquez Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oncología Médica, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis vertebrales múltiples con niveles líquido-líquido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1300 "Ancho" => 1300 "Tamanyo" => 363475 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dorsolumbar spine magnetic resonance showing, in sagital (A) and axial (B) projections of a T2 potentiated sequence, the presence of multiple vertebral lesions with typical fluid–fluid levels, hyperintense superiorly and hypointense inferiorly. A bone biopsy (C) revealed that these lesions corresponded to metastasis of a poorly differentiated adenocarcinoma with signet ring cells (arrowheads), surrounding a hemorrhagic content (arrows) (hematoxilin-eosin 10×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 76-year-old female patient came to the clinic due to lumbar spine pain and weight loss, which had progressed over the past 6 months. She had been diagnosed with systemic sclerosis (SS) and interstitial lung disease 5 years prior and had been treated with cyclophosphamide induction therapy for 18 months (6 monthly cycles and 4 trimestral ones), followed by azathioprine and low dose steroid as maintenance treatment. Upon examination, the patient presented cachexia and diffuse pain on spinous process palpation. Spinal X-rays showed anterior vertebral body collapse at D8 and a magnetic resonance (MR) revealed multiple round lesions with a fluid-fluid level, with a hyperintense signal on the superior level potentiated sequence on T2 and an intermediate signal on T1, with hypointense signal on the inferior level of both sequences (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). A bone biopsy revealed that the lesions were metastasis from a poorly differentiated signet ring cell adenocarcinoma, surrounding hemorrhagic content (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). From an immunohistochemical point of view, the tumor cells expressed cytokeratin 7 and protein 15 of cystic disease liquid, indicating a likely breast cancer origin. However, no primary tumor was found in follow-up, which included a bilateral mastorgraphy, a craneo-cervical and thoraco-abdomino-pelvic computed tomography, a complete radionucleide bone scan, an endoscopy and a colonoscopy. The patient was treated with paclitaxel plus carboplatin, third level analgesia, zolendronate and palliative radiotherapy, remaining stable for 6 months afterward.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Fluid–fluid levels may appear when substances with different densities are contained within a cystic or compartmentalized structure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The presence of these levels in a bone lesion suggests internal bleeding, followed by stratification of the blood components in relation to their density.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> These levels may be seen on X-rays or tomography, but the best detection method is MR.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The superior level is usually hyperintense in relation to the inferior one in the T2 potentiated sequence because the latter may contain cellular components. However, in the T1 potentiated sequence the aspect varies depending on the stage of the lesion, showing an increased signal in the superior level when the hemorrhage is subacute, presumably due to the presence of extracellular metahemoglobin.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Fluid–fluid levels have been detected in various benign bone lesions, oncluding aneurysmatic bone cysts, simple bone cysts, giant cell tumors, chondroblastoma, osteoblastoma, brown tumors, fibrous dysplasia, Langerhans’ hystiocytosis, intraosseous ganglions and hemangiomas, but also in malignant lesions such as telangiectasic osteosarcoma, the malignant fibrous hystiocytoma, fibrosarcoma, and plasmocytoma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> However, these levels appear rarely in bone metastasis, with only 6 cases published up to date.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,5–8</span></a> In 3 of them there was a past history of cancer, breast<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> and bladder.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, in the rest of the cases, the detection of fluid-fluid levels revealed the presence of neoplasia, 2 of them respiratory in origin<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> and one unknown,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> as our patient's case. The lesions were multiple in 3 cases, all of them affecting the spine.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,7</span></a> Although the history of SS probably had no influence on the type of metastasis, these patients have an increased risk of neoplasia, especially lung, hematological, bladder and hepatocellular,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> with diagnosis not always easy in early stages. Another factor that must be taken into account in this case is treatment with cyclophosphamide because this drug may be associated with neoplasias such as leukemia, lymphoma, non-melanoma skin cancer and bladder neoplasia.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In conclusion, although fluid-fluid levels are not specific, when faced with the presence of multiple vertebral lesions of this kind, it is important to consider bone metastasis among the differential diagnosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Responsibilities</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of persons and animals</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors state that no experiments were performed on persons or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data confidentiality</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors state that they have followed their workplace protocols regarding the publication of patient data and all patients included in the study have received enough information and have given their written informed consent to participate in the study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors state that they have obtained informed consent from patients and/or subjects referred to in this article. This document is in the possession of the corresponding author.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors deny any conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of persons and animals" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sifuentes Giraldo WA, Pachón Olmos V, Gallego Rivera JI, Vázquez Díaz M. Metástasis vertebrales múltiples con niveles líquido-líquido. Reumatol Clin. 2013;10:338–339.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1300 "Ancho" => 1300 "Tamanyo" => 363475 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dorsolumbar spine magnetic resonance showing, in sagital (A) and axial (B) projections of a T2 potentiated sequence, the presence of multiple vertebral lesions with typical fluid–fluid levels, hyperintense superiorly and hypointense inferiorly. A bone biopsy (C) revealed that these lesions corresponded to metastasis of a poorly differentiated adenocarcinoma with signet ring cells (arrowheads), surrounding a hemorrhagic content (arrows) (hematoxilin-eosin 10×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fluid–fluid level: a nonspecific finding in tumors of bone and soft tissue" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.C. Tsai" 1 => "M.K. Dalinka" 2 => "M.D. Fallon" 3 => "M.B. Zlatkin" 4 => "H.Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 3 | 5 |
| 2024 October | 95 | 36 | 131 |
| 2024 September | 104 | 15 | 119 |
| 2024 August | 97 | 29 | 126 |
| 2024 July | 125 | 38 | 163 |
| 2024 June | 87 | 35 | 122 |
| 2024 May | 119 | 40 | 159 |
| 2024 April | 92 | 23 | 115 |
| 2024 March | 111 | 30 | 141 |
| 2024 February | 81 | 23 | 104 |
| 2024 January | 89 | 20 | 109 |
| 2023 December | 102 | 34 | 136 |
| 2023 November | 135 | 25 | 160 |
| 2023 October | 130 | 30 | 160 |
| 2023 September | 113 | 30 | 143 |
| 2023 August | 88 | 20 | 108 |
| 2023 July | 84 | 30 | 114 |
| 2023 June | 98 | 24 | 122 |
| 2023 May | 99 | 26 | 125 |
| 2023 April | 114 | 10 | 124 |
| 2023 March | 124 | 40 | 164 |
| 2023 February | 142 | 26 | 168 |
| 2023 January | 88 | 19 | 107 |
| 2022 December | 127 | 45 | 172 |
| 2022 November | 115 | 22 | 137 |
| 2022 October | 121 | 32 | 153 |
| 2022 September | 104 | 41 | 145 |
| 2022 August | 106 | 65 | 171 |
| 2022 July | 100 | 45 | 145 |
| 2022 June | 127 | 32 | 159 |
| 2022 May | 107 | 40 | 147 |
| 2022 April | 125 | 46 | 171 |
| 2022 March | 119 | 42 | 161 |
| 2022 February | 73 | 22 | 95 |
| 2022 January | 107 | 45 | 152 |
| 2021 December | 65 | 43 | 108 |
| 2021 November | 71 | 39 | 110 |
| 2021 October | 88 | 54 | 142 |
| 2021 September | 66 | 34 | 100 |
| 2021 August | 51 | 50 | 101 |
| 2021 July | 48 | 27 | 75 |
| 2021 June | 63 | 38 | 101 |
| 2021 May | 63 | 37 | 100 |
| 2021 April | 163 | 69 | 232 |
| 2021 March | 95 | 26 | 121 |
| 2021 February | 51 | 19 | 70 |
| 2021 January | 39 | 12 | 51 |
| 2020 December | 24 | 23 | 47 |
| 2020 November | 29 | 19 | 48 |
| 2020 October | 24 | 15 | 39 |
| 2020 September | 25 | 26 | 51 |
| 2020 August | 20 | 21 | 41 |
| 2020 July | 31 | 11 | 42 |
| 2020 June | 38 | 28 | 66 |
| 2020 May | 58 | 18 | 76 |
| 2020 April | 44 | 15 | 59 |
| 2020 March | 9 | 13 | 22 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 87 | 4 | 91 |
| 2018 March | 127 | 8 | 135 |
| 2018 February | 55 | 2 | 57 |
| 2018 January | 42 | 2 | 44 |
| 2017 December | 54 | 4 | 58 |
| 2017 November | 46 | 4 | 50 |
| 2017 October | 36 | 2 | 38 |
| 2017 September | 66 | 5 | 71 |
| 2017 August | 69 | 7 | 76 |
| 2017 July | 56 | 5 | 61 |
| 2017 June | 81 | 10 | 91 |
| 2017 May | 92 | 6 | 98 |
| 2017 April | 69 | 10 | 79 |
| 2017 March | 77 | 1 | 78 |
| 2017 February | 135 | 3 | 138 |
| 2017 January | 39 | 7 | 46 |
| 2016 December | 82 | 19 | 101 |
| 2016 November | 73 | 7 | 80 |
| 2016 October | 108 | 10 | 118 |
| 2016 September | 156 | 6 | 162 |
| 2016 August | 92 | 3 | 95 |
| 2016 July | 32 | 8 | 40 |
| 2016 April | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 31 | 7 | 38 |
| 2015 June | 46 | 12 | 58 |
| 2015 May | 51 | 18 | 69 |
| 2015 April | 27 | 13 | 40 |
| 2015 March | 44 | 4 | 48 |
| 2015 February | 47 | 5 | 52 |
| 2015 January | 49 | 14 | 63 |
| 2014 December | 40 | 10 | 50 |
| 2014 November | 34 | 7 | 41 |
| 2014 October | 66 | 24 | 90 |
| 2014 September | 25 | 12 | 37 |
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