SAPHO Syndrome in the Differential Diagnosis of Metastasis

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"referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Lafaurie Acevedo" ] 2 => array:2 [ "nombre" => "Vicente" "apellidos" => "Tormo Ferrero" ] 3 => array:2 [ "nombre" => "Rafael" "apellidos" => "Cardenal Macia" ] 4 => array:2 [ "nombre" => "Francisco José" "apellidos" => "Andreu Martínez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oncología Radioterápica, Hospital Universitari Sant Joan d’Alacant, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de SAPHO como diagnóstico diferencial de metástasis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => 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Sclerosis in sternal manubrium." ] ] ] "textoCompleto" => "IntroductionSAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis)<a class="elsevierStyleCrossRef" href="#bib0085">1</a> was proposed toward the end of the 1980s by Chamot et al.<a class="elsevierStyleCrossRef" href="#bib0090">2</a> to group a number of osteoarticular manifestations with common radiological features, like hyperostosis of anterior chest wall. These signs are often, although not necessarily, associated with dermatological conditions such as acne conglobata, palmoplantar pustulosis and/or psoriasis. The presence of the bone lesions may be unrelated to the development of the skin lesions. The cause of SAPHO syndrome is unknown, although different theories propose the presence of a certain genetic predisposition, infectious causes and the association of immune disorders.<a class="elsevierStyleCrossRef" href="#bib0095">3</a> The prevalence is unknown, although some authors report that it is 1 per 10,000 population in Caucasians and lower in Asian populations.<a class="elsevierStyleCrossRef" href="#bib0100">4</a> The diagnosis is based mainly on the clinical signs, indicated by the presence of at least one of the inclusion criteria and none of the exclusion criteria, as described by Benhamou et al.<a class="elsevierStyleCrossRef" href="#bib0105">5</a> The study includes ancillary diagnostic tests such as the specific bone scintigraphic image<a class="elsevierStyleCrossRef" href="#bib0110">6</a> of the “bull's head” sign in the sternoclavicular joint. The laboratory findings are also nonspecific, with the exception of an increase in acute-phase reactants.<a class="elsevierStyleCrossRef" href="#bib0115">7</a> The disease prognosis is usually benign, although, in certain cases, the pain produced by joint inflammation can be quite severe.<a class="elsevierStyleCrossRef" href="#bib0120">8</a> The treatment of this condition includes nonsteroidal anti-inflammatory drugs, intravenous bisphosphonates or biological therapies.<a class="elsevierStyleCrossRef" href="#bib0095">3</a> The response to a treatment is assessed in terms of pain relief, according to the visual analog scale, or using imaging techniques like bone scintigraphy (BS), computed tomography (CT) or positron emission tomography with CT (PET-CT).<a class="elsevierStyleCrossRefs" href="#bib0125">9,10</a>Case ReportWe present the case of a 64-year-old woman who was diagnosed with stage T1cN0 Mx invasive ductal carcinoma of right breast. After undergoing segmental mastectomy of right breast and selective biopsy of the sentinel lymph node, she was referred to our department by the Breast Disease Committee to receive adjuvant radiation therapy. The patient had a history of hypertension, dyslipidemia and intermittent low back pain, that she had had since her youth and associated with her job as a salesclerk. She had had no previous visits to any specialist and did not require medication on a regular basis.In the physical examination, there was no evidence of infection or inflammation of the mastectomy scar. However, the third proximal to the clavicle was enlarged and the patient perceived mild selective pain on palpation of the sternoclavicular joint. On examination of the abdomen, no masses or enlargement of organs was detected. The patient reported that she had never had clinical signs of skin conditions (palmoplantar pustulosis or acne).The study of the extension of the disease included BS, which revealed the presence of a diffuse blastic lesion in the sternal manubrium, suggestive of Paget's disease or a metastatic lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The study was completed with radiographs of chest, lumbosacral spine and pelvis (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>), in which the only finding was increased density in L4-L5 facet joints. Chest CT, recommended by the professionals in nuclear medicine, revealed sclerosis in the sternal manubrium, suggestive of metastasis (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Laboratory findings included normal values for alkaline phosphatase (95IU/L), calcium (9.57mg/dL), lactate dehydrogenase (161IU/L) and erythrocyte sedimentation rate (6mm). Only a slight increase in C-reactive protein (0.60mg/dL) was observed. A test for HLA-B27 was not requested because of the negative results in the laboratory tests and the limited relationship to SAPHO syndrome reported in some case series.<a class="elsevierStyleCrossRef" href="#bib0125">9</a>Given the difficulty of the case, a clinical discussion session was held, with the participation of the departments of radiation oncology, rheumatology, radiodiagnostics and nuclear medicine, to review the findings. The outcome was a definitive diagnosis of SAPHO syndrome, as the patient met one of the inclusion criteria described by Benhamou et al.,<a class="elsevierStyleCrossRef" href="#bib0105">5</a> hyperostosis of anterior chest wall, with or without dermal involvement, and none of the exclusion criteria (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A biopsy of the lesion was ruled out at that time, pending the radiographic evolution. The decision was made to perform BS and osteoarticular CT<a class="elsevierStyleCrossRef" href="#bib0135">11</a> 6 months later, at which time, no noteworthy changes were observed, and a biopsy of the affected area was definitively ruled out, as the images showed no signs of aggressive disease. During treatment, the patient required no analgesic medication of any type. We excluded the affected area from the field of treatment to avoid provoking modifications secondary to the radiotherapy that could lead to confusion when assessing the changes in the lesion. After 18 months of follow-up, the complete response of the tumor persists and the patient is disease-free.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiscussionSAPHO syndrome is a rare clinical condition of benign nature that usually presents in young individuals, a circumstance that makes it difficult to detect complications in the patients with this disease. The problem arises when it is diagnosed in a cancer patient, as none of the imaging techniques help to definitively rule out metastasis.<a class="elsevierStyleCrossRef" href="#bib0135">11</a> In the literature (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>),<a class="elsevierStyleCrossRefs" href="#bib0140">12–16</a> there are few cases in which SAPHO syndrome was diagnosed on the basis of an image suspected of depicting a metastasis that, after further study, was found to show no evidence of aggressive disease. Of these cases, only one was identified as breast cancer; in addition to the sternoclavicular involvement, there were dermatological signs that could have pointed to the diagnosis. In none of these cases was the biopsy of the region being studied (sternal manubrium) of any help in reaching the definitive diagnosis.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In our patient, the stage of her tumor (IA) and the phenotypic characteristics indicated that the result of the study of its extension, which was interpreted as a possible sternal metastasis of the breast carcinoma, could be questioned. Therefore, we considered possible diagnostic alternatives that could explain these findings. Although SAPHO syndrome is a clinical condition with a low incidence, knowledge of it can avoid a diagnosis of metastasis in patients found to have the characteristic image of the “bull's head” on BS. If this image had been seen in a patient with factors indicative of a poor prognosis, we probably would not have questioned the possibility of a metastatic lesion. As a result, the patient would have undergone chemotherapy (vinorelbine or taxanes) and more aggressive radiotherapy, and would have been exposed to the complications associated with these strategies.ConclusionsSAPHO syndrome has different clinical manifestations that, together with the osteitis that is characteristic of this entity, can result in different differential diagnoses. Thus, this syndrome should be taken into account in the context of the neoplastic disease, in order to avoid erroneous diagnoses that require aggressive treatments in a disease that usually has a benign course.Ethical DisclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of InterestThe authors declare they have no conflicts of interest." 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Prevalence, etiology and pathogenesis of the disease are unknown, while diagnosis is made both clinically and by the specific gammagraphic image of “bull horn” in the sternoclavicular joint.The following case of a 64-year-old woman diagnosed with infiltrating ductal carcinoma of the right breast pT1N0 Mx is reported. When studying the extent of the disease, a gammagraphic image of diffuse blast injury in the sterna manubrium was evidenced, which allowed the suspicion of Paget's disease or metastatic injury. Study was completed with a chest CT in which manubrium sclerosis was evidenced, suggesting metástasis.Results of the studies pointed out SAPHO syndrome as the most likely diagnostic option. The low tumor stage of the patient prompted the idea of possible alternative diagnoses. A deeper knowledge of this clinical condition may be crucial to avoid mistakes when classifying a subject in more advanced tumor stages, and consequently, to prevent the use of more aggressive chemotherapy and radiotherapy treatments." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El síndrome de SAPHO fue propuesto a finales de los años 80 para agrupar diversas manifestaciones osteoarticulares con hallazgos radiológicos propios como la hiperostosis de la pared anterior del tórax. La prevalencia, la causa y la patogénesis de la enfermedad son desconocidas. El diagnóstico se realiza tanto por la clínica como por la imagen específica gammagráfica de «asta de toro» en la articulación esternoclavicular.Se presenta el caso de una mujer de 64 años diagnosticada de carcinoma ductal infiltrante de mama derecha pT1N0 Mx. En el estudio de extensión de la enfermedad se evidenció imagen gammagráfica de lesión blástica, difusa, en manubrio esternal, sospechosa de enfermedad de Paget o lesión metastásica. Se completó el estudio con TC torácica en la que se evidenció esclerosis del manubrio esternal, sugerente de metástasis.Por el resultado de los estudios se pensó en el síndrome de SAPHO como opción diagnóstica más probable. El bajo estadio tumoral de la paciente hizo pensar en posibles alternativas diagnósticas. Conocer esta entidad clínica puede evitar errores a la hora de clasificar en estadios tumorales más avanzados a un sujeto y, por tanto, evitar tratamientos quimioterápicos y radioterápico más agresivos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Berenguer Francés MÁ, Lafaurie Acevedo A, Tormo Ferrero V, Cardenal Macia R, Andreu Martínez FJ. Síndrome de SAPHO como diagnóstico diferencial de metástasis. Reumatol Clin. 2016;12:288–291." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1415 "Ancho" => 1800 "Tamanyo" => 182266 ] ] "descripcion" => array:1 [ "en" => "Bone scintigraphy. Diffuse blastic lesion in sternal manubrium." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1053 "Ancho" => 995 "Tamanyo" => 126576 ] ] "descripcion" => array:1 [ "en" => "Chest radiograph. Rib cage." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 784 "Ancho" => 995 "Tamanyo" => 95920 ] ] "descripcion" => array:1 [ "en" => "Radiograph of the hip." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1320 "Ancho" => 984 "Tamanyo" => 122114 ] ] "descripcion" => array:1 [ "en" => "Chest computed tomography. Sclerosis in sternal manubrium." ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: modification of Benhamou et al.<a class="elsevierStyleCrossRef" href="#bib0105">5</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inclusion criteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Acne \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteomyelitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis involving chest wall \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hyperostosis with or without dermal involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis triggered by infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Chronic osteomyelitis in axial or peripheral skeleton with or without dermal involvement</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar keratoderma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diffuse idiopathic hyperostosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Osteoarticular manifestations triggered by retinoids \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1384927.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inclusion and Exclusion Criteria in SAPHO Syndrome." ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BS, bone scan; CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PET, positron emission tomography; SAPHO, synovitis, acne, pustulosis, hyperostosis and osteitis." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Present case report \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shibakuki et al.<a class="elsevierStyleCrossRef" href="#bib0140">12</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Abuhid et al.<a class="elsevierStyleCrossRef" href="#bib0145">13</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patel et al.<a class="elsevierStyleCrossRef" href="#bib0150">14</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inoue et al.<a class="elsevierStyleCrossRef" href="#bib0155">15</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Theuman et al.<a class="elsevierStyleCrossRef" href="#bib0160">16</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor site \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Breast \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bone involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular, sacroiliac and thoracic vertebral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular and lumbar vertebral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sternoclavicular, sacroiliac and thoracic vertebral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cutaneous involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palmoplantar pustulosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Imaging studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X-ray, CT, BS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MRI, CT, PET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X-ray, PET-CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT, BS, PET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X-ray, MRI, BS, PET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X-ray, CT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes Nonspecific inflammation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes Nonspecific fibrosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Laboratory tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elevated CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elevated ESR and CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1384928.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Review of Case Reports With a Diagnosis of SAPHO Syndrome Based on Images Suggestive of Metastasis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => 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Case Report

SAPHO Syndrome in the Differential Diagnosis of Metastasis

Síndrome de SAPHO como diagnóstico diferencial de metástasis

Miguel Ángel Berenguer Francés

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migberenguer@hotmail.com

Corresponding author.

, Alejandro Lafaurie Acevedo, Vicente Tormo Ferrero, Rafael Cardenal Macia, Francisco José Andreu Martínez

Servicio de Oncología Radioterápica, Hospital Universitari Sant Joan d’Alacant, Alicante, Spain

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        "titulo" => "S&#237;ndrome de SAPHO como diagn&#243;stico diferencial de met&#225;stasis"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography&#46; Sclerosis in sternal manubrium&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">SAPHO syndrome &#40;synovitis&#44; acne&#44; pustulosis&#44; hyperostosis and osteitis&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> was proposed toward the end of the 1980s by Chamot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> to group a number of osteoarticular manifestations with common radiological features&#44; like hyperostosis of anterior chest wall&#46; These signs are often&#44; although not necessarily&#44; associated with dermatological conditions such as acne conglobata&#44; palmoplantar pustulosis and&#47;or psoriasis&#46; The presence of the bone lesions may be unrelated to the development of the skin lesions&#46; The cause of SAPHO syndrome is unknown&#44; although different theories propose the presence of a certain genetic predisposition&#44; infectious causes and the association of immune disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> The prevalence is unknown&#44; although some authors report that it is 1 per 10&#44;000 population in Caucasians and lower in Asian populations&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The diagnosis is based mainly on the clinical signs&#44; indicated by the presence of at least one of the inclusion criteria and none of the exclusion criteria&#44; as described by Benhamou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> The study includes ancillary diagnostic tests such as the specific bone scintigraphic image<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> of the &#8220;bull&#39;s head&#8221; sign in the sternoclavicular joint&#46; The laboratory findings are also nonspecific&#44; with the exception of an increase in acute-phase reactants&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> The disease prognosis is usually benign&#44; although&#44; in certain cases&#44; the pain produced by joint inflammation can be quite severe&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> The treatment of this condition includes nonsteroidal anti-inflammatory drugs&#44; intravenous bisphosphonates or biological therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> The response to a treatment is assessed in terms of pain relief&#44; according to the visual analog scale&#44; or using imaging techniques like bone scintigraphy &#40;BS&#41;&#44; computed tomography &#40;CT&#41; or positron emission tomography with CT &#40;PET-CT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 64-year-old woman who was diagnosed with stage T1cN0 Mx invasive ductal carcinoma of right breast&#46; After undergoing segmental mastectomy of right breast and selective biopsy of the sentinel lymph node&#44; she was referred to our department by the Breast Disease Committee to receive adjuvant radiation therapy&#46; The patient had a history of hypertension&#44; dyslipidemia and intermittent low back pain&#44; that she had had since her youth and associated with her job as a salesclerk&#46; She had had no previous visits to any specialist and did not require medication on a regular basis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the physical examination&#44; there was no evidence of infection or inflammation of the mastectomy scar&#46; However&#44; the third proximal to the clavicle was enlarged and the patient perceived mild selective pain on palpation of the sternoclavicular joint&#46; On examination of the abdomen&#44; no masses or enlargement of organs was detected&#46; The patient reported that she had never had clinical signs of skin conditions &#40;palmoplantar pustulosis or acne&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study of the extension of the disease included BS&#44; which revealed the presence of a diffuse blastic lesion in the sternal manubrium&#44; suggestive of Paget&#39;s disease or a metastatic lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The study was completed with radiographs of chest&#44; lumbosacral spine and pelvis &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#44; in which the only finding was increased density in L4-L5 facet joints&#46; Chest CT&#44; recommended by the professionals in nuclear medicine&#44; revealed sclerosis in the sternal manubrium&#44; suggestive of metastasis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory findings included normal values for alkaline phosphatase &#40;95<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#41;&#44; calcium &#40;9&#46;57<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; lactate dehydrogenase &#40;161<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#41; and erythrocyte sedimentation rate &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; Only a slight increase in C-reactive protein &#40;0&#46;60<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; was observed&#46; A test for HLA-B27 was not requested because of the negative results in the laboratory tests and the limited relationship to SAPHO syndrome reported in some case series&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the difficulty of the case&#44; a clinical discussion session was held&#44; with the participation of the departments of radiation oncology&#44; rheumatology&#44; radiodiagnostics and nuclear medicine&#44; to review the findings&#46; The outcome was a definitive diagnosis of SAPHO syndrome&#44; as the patient met one of the inclusion criteria described by Benhamou et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> hyperostosis of anterior chest wall&#44; with or without dermal involvement&#44; and none of the exclusion criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A biopsy of the lesion was ruled out at that time&#44; pending the radiographic evolution&#46; The decision was made to perform BS and osteoarticular CT<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> 6 months later&#44; at which time&#44; no noteworthy changes were observed&#44; and a biopsy of the affected area was definitively ruled out&#44; as the images showed no signs of aggressive disease&#46; During treatment&#44; the patient required no analgesic medication of any type&#46; We excluded the affected area from the field of treatment to avoid provoking modifications secondary to the radiotherapy that could lead to confusion when assessing the changes in the lesion&#46; After 18 months of follow-up&#44; the complete response of the tumor persists and the patient is disease-free&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">SAPHO syndrome is a rare clinical condition of benign nature that usually presents in young individuals&#44; a circumstance that makes it difficult to detect complications in the patients with this disease&#46; The problem arises when it is diagnosed in a cancer patient&#44; as none of the imaging techniques help to definitively rule out metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12&#8211;16</span></a> there are few cases in which SAPHO syndrome was diagnosed on the basis of an image suspected of depicting a metastasis that&#44; after further study&#44; was found to show no evidence of aggressive disease&#46; Of these cases&#44; only one was identified as breast cancer&#59; in addition to the sternoclavicular involvement&#44; there were dermatological signs that could have pointed to the diagnosis&#46; In none of these cases was the biopsy of the region being studied &#40;sternal manubrium&#41; of any help in reaching the definitive diagnosis&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In our patient&#44; the stage of her tumor &#40;IA&#41; and the phenotypic characteristics indicated that the result of the study of its extension&#44; which was interpreted as a possible sternal metastasis of the breast carcinoma&#44; could be questioned&#46; Therefore&#44; we considered possible diagnostic alternatives that could explain these findings&#46; Although SAPHO syndrome is a clinical condition with a low incidence&#44; knowledge of it can avoid a diagnosis of metastasis in patients found to have the characteristic image of the &#8220;bull&#39;s head&#8221; on BS&#46; If this image had been seen in a patient with factors indicative of a poor prognosis&#44; we probably would not have questioned the possibility of a metastatic lesion&#46; As a result&#44; the patient would have undergone chemotherapy &#40;vinorelbine or taxanes&#41; and more aggressive radiotherapy&#44; and would have been exposed to the complications associated with these strategies&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">SAPHO syndrome has different clinical manifestations that&#44; together with the osteitis that is characteristic of this entity&#44; can result in different differential diagnoses&#46; Thus&#44; this syndrome should be taken into account in the context of the neoplastic disease&#44; in order to avoid erroneous diagnoses that require aggressive treatments in a disease that usually has a benign course&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SAPHO syndrome was proposed in the late 80s in order to group different osteoarticular manifestations with specific radiological findings such as the hyperostosis of the front part of the chest wall&#46; Prevalence&#44; etiology and pathogenesis of the disease are unknown&#44; while diagnosis is made both clinically and by the specific gammagraphic image of &#8220;bull horn&#8221; in the sternoclavicular joint&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The following case of a 64-year-old woman diagnosed with infiltrating ductal carcinoma of the right breast pT1N0 Mx is reported&#46; When studying the extent of the disease&#44; a gammagraphic image of diffuse blast injury in the sterna manubrium was evidenced&#44; which allowed the suspicion of Paget&#39;s disease or metastatic injury&#46; Study was completed with a chest CT in which manubrium sclerosis was evidenced&#44; suggesting met&#225;stasis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Results of the studies pointed out SAPHO syndrome as the most likely diagnostic option&#46; The low tumor stage of the patient prompted the idea of possible alternative diagnoses&#46; A deeper knowledge of this clinical condition may be crucial to avoid mistakes when classifying a subject in more advanced tumor stages&#44; and consequently&#44; to prevent the use of more aggressive chemotherapy and radiotherapy treatments&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de SAPHO fue propuesto a finales de los a&#241;os 80 para agrupar diversas manifestaciones osteoarticulares con hallazgos radiol&#243;gicos propios como la hiperostosis de la pared anterior del t&#243;rax&#46; La prevalencia&#44; la causa y la patog&#233;nesis de la enfermedad son desconocidas&#46; El diagn&#243;stico se realiza tanto por la cl&#237;nica como por la imagen espec&#237;fica gammagr&#225;fica de &#171;asta de toro&#187; en la articulaci&#243;n esternoclavicular&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso de una mujer de 64 a&#241;os diagnosticada de carcinoma ductal infiltrante de mama derecha pT1N0 Mx&#46; En el estudio de extensi&#243;n de la enfermedad se evidenci&#243; imagen gammagr&#225;fica de lesi&#243;n bl&#225;stica&#44; difusa&#44; en manubrio esternal&#44; sospechosa de enfermedad de Paget o lesi&#243;n metast&#225;sica&#46; Se complet&#243; el estudio con TC tor&#225;cica en la que se evidenci&#243; esclerosis del manubrio esternal&#44; sugerente de met&#225;stasis&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Por el resultado de los estudios se pens&#243; en el s&#237;ndrome de SAPHO como opci&#243;n diagn&#243;stica m&#225;s probable&#46; El bajo estadio tumoral de la paciente hizo pensar en posibles alternativas diagn&#243;sticas&#46; Conocer esta entidad cl&#237;nica puede evitar errores a la hora de clasificar en estadios tumorales m&#225;s avanzados a un sujeto y&#44; por tanto&#44; evitar tratamientos quimioter&#225;picos y radioter&#225;pico m&#225;s agresivos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Berenguer Franc&#233;s M&#193;&#44; Lafaurie Acevedo A&#44; Tormo Ferrero V&#44; Cardenal Macia R&#44; Andreu Mart&#237;nez FJ&#46; S&#237;ndrome de SAPHO como diagn&#243;stico diferencial de met&#225;stasis&#46; Reumatol Clin&#46; 2016&#59;12&#58;288&#8211;291&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acne&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arthritis involving chest wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hyperostosis with or without dermal involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis triggered by infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Chronic osteomyelitis in axial or peripheral skeleton with or without dermal involvement</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar keratoderma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diffuse idiopathic hyperostosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Osteoarticular manifestations triggered by retinoids&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">BS&#44; bone scan&#59; CRP&#44; C-reactive protein&#59; CT&#44; computed tomography&#59; ESR&#44; erythrocyte sedimentation rate&#59; MRI&#44; magnetic resonance imaging&#59; PET&#44; positron emission tomography&#59; SAPHO&#44; synovitis&#44; acne&#44; pustulosis&#44; hyperostosis and osteitis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Present case report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shibakuki et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Abuhid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inoue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Theuman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tumor site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Primary unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Primary unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Primary unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bone involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular&#44; sacroiliac and thoracic vertebral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular and lumbar vertebral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sternoclavicular&#44; sacroiliac and thoracic vertebral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cutaneous involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palmoplantar pustulosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Imaging studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X-ray&#44; CT&#44; BS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MRI&#44; CT&#44; PET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X-ray&#44; PET-CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&#44; BS&#44; PET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X-ray&#44; MRI&#44; BS&#44; PET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">X-ray&#44; CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<br>Nonspecific inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<br>Nonspecific fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Laboratory tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated CRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated ESR and CRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Review of Case Reports With a Diagnosis of SAPHO Syndrome Based on Images Suggestive of Metastasis&#46;</p>"
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      "titulo" => "References"
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            3 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                        0 => array:2 [
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                            0 => "Y&#46; Suei"
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                  "contribucion" => array:1 [
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                          "etal" => true
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              "identificador" => "bib0130"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "pii&#58;bcr2015209394&#59; doi&#58;10&#46;1136&#47;bcr-2015-209394"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnostic usefulness of 18F-fluorodoxyglucosa-positron emission tomography&#47;CT in SAPHO syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Namkoong"
                            1 => "M&#46; Ishii"
                            2 => "S&#46; Tasaka"
                            3 => "T&#46; Betsuyaku"
                          ]
                        ]
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Article information

ISSN: 21735743
Original language: English

DOI:10.1016/j.reumae.2015.08.004

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Year/Month	Html	Pdf	Total

2024 November	8	10	18
2024 October	51	35	86
2024 September	56	11	67
2024 August	95	35	130
2024 July	81	35	116
2024 June	125	37	162
2024 May	71	57	128
2024 April	81	25	106
2024 March	79	56	135
2024 February	51	26	77
2024 January	45	17	62
2023 December	44	37	81
2023 November	45	36	81
2023 October	43	32	75
2023 September	82	38	120
2023 August	42	18	60
2023 July	65	26	91
2023 June	59	23	82
2023 May	64	35	99
2023 April	42	10	52
2023 March	81	33	114
2023 February	73	28	101
2023 January	71	38	109
2022 December	73	31	104
2022 November	73	32	105
2022 October	89	27	116
2022 September	60	31	91
2022 August	57	46	103
2022 July	47	44	91
2022 June	59	34	93
2022 May	55	29	84
2022 April	47	40	87
2022 March	45	53	98
2022 February	81	37	118
2022 January	92	33	125
2021 December	50	47	97
2021 November	54	54	108
2021 October	74	46	120
2021 September	56	33	89
2021 August	61	49	110
2021 July	59	41	100
2021 June	57	45	102
2021 May	84	47	131
2021 April	171	91	262
2021 March	82	34	116
2021 February	62	28	90
2021 January	62	21	83
2020 December	61	22	83
2020 November	78	18	96
2020 October	71	21	92
2020 September	56	24	80
2020 August	44	30	74
2020 July	27	24	51
2020 June	48	17	65
2020 May	43	10	53
2020 April	33	23	56
2020 March	21	5	26
2020 February	2	0	2
2018 December	2	0	2
2018 May	6	2	8
2018 April	56	12	68
2018 March	64	8	72
2018 February	34	14	48
2018 January	33	4	37
2017 December	47	15	62
2017 November	45	21	66
2017 October	47	9	56
2017 September	45	12	57
2017 August	41	17	58
2017 July	43	24	67
2017 June	53	30	83
2017 May	65	27	92
2017 April	48	23	71
2017 March	50	53	103
2017 February	59	21	80
2017 January	24	23	47
2016 December	73	25	98
2016 November	66	38	104
2016 October	127	48	175
2016 September	152	44	196
2016 August	26	7	33
2016 July	16	6	22

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