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Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 346-347  

Unusual case of neuroblastoma with only growth plate metastasis in bilateral lower limbs on metaiodobenzylguanidine scintigraphy

Department of Nuclear Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission20-Feb-2021
Date of Decision14-Mar-2021
Date of Acceptance24-Mar-2021
Date of Web Publication23-Sep-2021

Correspondence Address:
Dr. Sameer Taywade
Department of Nuclear Medicine, All India Institute of Medical Sciences, Basni Phase II, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnm.ijnm_24_21

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Neuroblastoma is the most common extracranial solid tumor in childhood developing from primitive neural crest cells. I-131-metaiodobenzylguanidine (MIBG) a norepinephrine analog is highly sensitive and specific to identify primary and distant metastatic sites. We report the case of a 2-year-old female child with progressively increasing abdominal distention. Computed tomography (CT) revealed a large mass lesion involving the right suprarenal region with no hepatic or lymph node metastasis. No obvious skeletal abnormality was detected on the whole-body skeletal survey and Tc-99 m-methylene diphosphonate bone scan to suggest metastasis. I-131-MIBG scintigraphy with single-photon emission computerized tomography-CT showed MIBG-avid primary tumor in a suprarenal location with bilateral lower limbs growth plate as the only site of metastasis.

Keywords: Growth plate metastasis, I-131-metaiodobenzylguanidine, neuroblastoma, Tc-99 m-methylene diphosphonate bone scan

How to cite this article:
Yadav N, Taywade S, Kumar R, Prashanth A. Unusual case of neuroblastoma with only growth plate metastasis in bilateral lower limbs on metaiodobenzylguanidine scintigraphy. Indian J Nucl Med 2021;36:346-7

How to cite this URL:
Yadav N, Taywade S, Kumar R, Prashanth A. Unusual case of neuroblastoma with only growth plate metastasis in bilateral lower limbs on metaiodobenzylguanidine scintigraphy. Indian J Nucl Med [serial online] 2021 [cited 2021 Dec 8];36:346-7. Available from:

Neuroblastoma is a third common pediatric tumor arising from primitive neural crest cells of the sympathetic ganglion.[1],[2] It is an aggressive tumor with the propensity to metastasize to lymph nodes, bone marrow, cortical bone, and liver.[3],[4] Tc-99 m-methylene diphosphonate (MDP) bone scan is not routinely advised in the evaluation of neuroblastoma.[5] It can be useful in patients with nonmetaiodobenzylguanidine (MIBG) avid primary tumor and in patients for whom the primary tumor has been excised. One of the common pitfalls described in neuroblastoma on Tc-99 m-MDP bone scan is the blurring of growth plates with the extension of radiotracer uptake in the metaphyseal region in growing bones. In the pediatric age group, this can obscure the underlying skeletal metastasis.[6],[7] On the other hand, radioiodine-labeled MIBG imaging is considered as the mainstay in the management of neuroblastoma because of its high sensitivity and specificity.[7],[8],[9],[10] It is useful in detecting primary as well as metastatic sites. Although bone marrow/skeletal metastasis is common in neuroblastoma, the involvement of only lower limb growth plates without any other sites of metastases is unusual. In our case, there was no definite skeletal involvement on the Tc-99 m-MDP bone scan, whereas the I-131-MIBG scan showed metastases only to the bilateral lower limb growth plates without other metastatic sites [Figure 1]. To the best of our knowledge, not much data are available in the literature with only growth plate metastasis in neuroblastoma. This unusual presentation of neuroblastoma emphasizes the importance of critical evaluation of Tc-99 m-MDP bone scan in the pediatric population with asymmetrical radiotracer uptake at growing bones and it also reiterates the undisputed role of I-131-MIBG scan in the evaluation of neuroblastoma.
Figure 1: (a) Anterior view of whole-body Tc-99 m-methylene diphosphonate bone scan showed no skeletal metastasis. However, there was asymmetrical uptake in growth plates in the bilateral tibia with no significant metaphyseal extension (b). The patient subsequently underwent I-131-metaiodobenzylguanidine scan. (c) Anterior view images of whole-body I-131-metaiodobenzylguanidine scan demonstrated heterogeneous radiotracer uptake in the abdomen predominantly on the right side and crossing the midline (thick red arrow). Faint radiotracer accumulation also noted in the lower end of the left femur (blue arrow) and upper end of the right tibia (thin red arrow). (e) Abdomen single-photon emission computerized tomography-computed tomography images revealed large metaiodobenzylguanidine avid heterogeneous mass lesion (thick red arrow) with areas of calcification in the right suprarenal location crossing the midline, closely abutting and compressing the liver and infiltrating the right kidney. The right suprarenal gland was not seen separately from the mass. I-131-metaiodobenzylguanidine lower limbs spot view (d) and single-photon emission computerized tomography-computed tomography (f) showed heterogeneous metaiodobenzylguanidine concentration in the lower end of the bilateral femur (blue arrow), upper end of the bilateral tibia (right >left, shown by thin red arrow), and lower end of left tibia (green arrow) at growth plate regions. Corresponding computed tomography images revealed subtle intramedullary sclerosis at the lower end of the left femur and lower end of the left tibia involving growth plates. No metaiodobenzylguanidine avid metastatic sites were noted elsewhere in the body

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   References Top

American Cancer Society. Cancer Facts & Figures 2014. Atlanta, Ga: American Cancer Society; 2014.  Back to cited text no. 1
Goodman MT, Gurney JG, Smith MA, Olshan AF. Sympathetic nervous system tumors. In: Editors: Ries LA, Smith MA, Gurney JG, Linet M, Tamra T, Young JL. Cancer Incidence and Survival Among Children and Adolescents: United States SEER Program 1975–1995. Bethesda, MD: National Cancer Institute; 1999. p. 65-72.  Back to cited text no. 2
Park JR, Eggert A, Caron H. Neuroblastoma: Biology, prognosis, and treatment. Hematol Oncol Clin North Am 2010;24:65-86.  Back to cited text no. 3
DuBois SG, Kalika Y, Lukens JN, Brodeur GM, Seeger RC, Atkinson JB, et al. Metastatic sites in stage IV and IVS neuroblastoma correlate with age, tumor biology, and survival. J Pediatr Hematol Oncol 1999;21:181-9.  Back to cited text no. 4
Monclair T, Brodeur GM, Ambros PF, Brisse HJ, Cecchetto G, Holmes K, et al. INRG Task Force. The International Neuroblastoma Risk Group (INRG) staging system: An INRG Task Force report. J Clin Oncol 2009;27:298-303.  Back to cited text no. 5
Howman-Giles RB, Gilday DL, Ash JM. Radionuclide skeletal survey in neuroblastoma. Radiology 1979;131:497-502.  Back to cited text no. 6
Swift CC, Eklund MJ, Kraveka JM, Alazraki AL. Updates in diagnosis, management, and treatment of neuroblastoma. Radiographics 2018;38:566-80.  Back to cited text no. 7
Vik TA, Pfluger T, Kadota R, Castel V, Tulchinsky M, Farto JC, et al. (123) I-mIBG scintigraphy in patients with known or suspected neuroblastoma: Results from a prospective multicenter trial. Pediatr Blood Cancer 2009;52:784-90.  Back to cited text no. 8
Sharp SE, Trout AT, Weiss BD, Gelfand MJ. MIBG in neuroblastoma diagnostic imaging and therapy. Radiographics 2016;36:258-78.  Back to cited text no. 9
Kembhavi SA, Shah S, Rangarajan V, Qureshi S, Popat P, Kurkure P. Imaging in neuroblastoma: An update. Indian J Radiol Imaging 2015;25:129-36.  Back to cited text no. 10
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