SHM Converge Scientific Abstract ePoster Gallery-Don't Fall for the Most Likely Diagnosis: Incidental Finding of Sternal Metastasis as a Rare Presentation of Metastatic Urothelial Cell Carcinoma

Don't Fall for the Most Likely Diagnosis: Incidental Finding of Sternal Metastasis as a Rare Presentation of Metastatic Urothelial Cell Carcinoma

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This case report describes an 83-year-old man who presented to the emergency department with chest pain after a fall. Imaging done to evaluate possible pulmonary embolism instead revealed an incidental pathologic sternal fracture with an underlying osseous lesion, plus an additional manubrial metastasis. Because of the patient’s thrombocytopenia, acute kidney injury, and bone lesion, multiple myeloma was initially considered. However, CT of the abdomen and pelvis identified a new solid left renal mass, raising concern for renal cell carcinoma versus urothelial carcinoma.<br /><br />A biopsy of the sternal lesion was essential for diagnosis. Pathology showed metastatic carcinoma with immunophenotype suggestive of urothelial origin, and urology and oncology agreed that the most likely diagnosis was metastatic urothelial cell carcinoma (UCC). This was an unusual presentation because isolated bone metastases from UCC are rare, and sternal involvement is especially uncommon.<br /><br />The report emphasizes the importance of not anchoring on the most likely diagnosis when evaluating malignancy. In this patient, the differential shifted from multiple myeloma to renal cell carcinoma and ultimately to urothelial carcinoma as additional imaging and pathology results became available. Given the poor prognosis associated with metastatic UCC, the diagnosis allowed for a rapid and appropriate transition to hospice care, which the patient and family chose.<br /><br />Overall, the case highlights that incidental findings on imaging can uncover rare metastatic disease, and that biopsy of a suspected metastatic site is often necessary to establish the correct diagnosis and guide timely goals-of-care decisions.

Asset Subtitle

David Haughey

Meta Tag

Author List Corbin Dameron, David Haughey

Category Clinical Vignettes

Concept Sternal Fracture

Concept Metastatic Disease

Concept Bone Lesions

Concept Brain Metastasis

Concept Biopsy

Distinguished Non-Finalist

Presenter Organization Dartmouth Hitchcock Medical Center

Presenting Author David Haughey

Track Adult

Keywords

urothelial carcinoma

sternal fracture

bone metastasis

multiple myeloma

renal cell carcinoma

biopsy

metastatic carcinoma

imaging

thrombocytopenia

hospice care

Sternal Fracture

Metastatic Disease

Bone Lesions

Brain Metastasis

Biopsy