In medicine, a diagnosis is not always straightforward. Many diseases or conditions can present in various ways, depending on the circumstances. So how do you train for the uncommon presentations?

Case in Point  allows radiologists to evaluate common findings as well as diseases and conditions that can present in interesting ways. The 2022 Case in Point Case of the Year , “Collateral vertebral enhancement mimicking metastases in a patient with a superior vena cava obstruction,” is an example of the latter.

Check out the case and then read on to learn more about the Case of the Year and its authors in this Q&A.

Why did you select this case for submission?
I selected this case because we were going to biopsy a lesion but it had disappeared. At that time, Joshua Wallace was our MSK fellow and Fangbai Wu was our MSK attending. When we saw nothing to biopsy, we were stumped. Our MSK team was able to arrange same-day MRI thoracic spine with and without contrast to confirm our suspicion. No evidence of osseous metastasis was found on the MRI and our final diagnosis came to be collateral vertebral body enhancement mimicking metastases in a patient with superior vena cava obstruction - "vanishing bone mets."

What should readers learn from this case?
Sometimes you have to stop, think, and reflect about what is presented to you at the time of interpreting images and assess during a procedure. If what you thought beforehand does not fit with what is right in front of you, revisit the drawing board and rethink your differential. Working on this skillset is what makes us better radiologists. If our team did not stop and shift our thinking, this patient would have gotten an unnecessary bone biopsy. "First, do no harm" - Hippocrates.

What did you learn from working on the case?
Collaboration is key. Putting our minds together, searching the literature, and having an open discussion about the case with several different attendings ultimately led us down the right path to the correct diagnosis.

How did guidance from senior staff at your institution impact your learning and case development?
Senior staff served as role models, helped think through the differential, and provided guidance on how to arrive at the final diagnosis.

Josh and I were the ones who thought something was not right. Fangbai Wu showed us how to think in this situation, ask for a second opinion, and cancel the biopsy. Daniel Nissman has always been a pragmatist and considered other differentials. Carlos Zamora helped bring clarity to the diagnosis once it was confirmed on MRI. Together we worked well as a team.

Special shoutout to Carlos Zamora: I found a lifelong friend and mentor who has helped cultivate a thirst for knowledge and instilled a fire in me to be better every day as a radiologist. He even had to deal with me for another year during neuroradiology fellowship - he must have been thinking why is Izzy torturing me, haha! Hopefully it was not too bad.

Why did you choose Case in Point for submission of your case?
Case in Point has been a gold mine of fantastic cases from all over the country. I just thought that many in the ACR community would appreciate this case from the resident to the attending level - I like learning from the new daily cases that arrive in my inbox.

Are you a regular reader of Case in Point? What are your favorite types of cases?
Yes. My favorite type of cases are the ones that make you think of a certain diagnosis but as you are doing the questions you are learning something new along the way.

What else should we know about the case that you’d like to share?
Take each clue given to you and put the pieces of the puzzle together. Vascular lesions are something to include within the differential of an enhancing bone lesion. Not everything is mets, look for reasons that support your final diagnosis, and be humble.

Israel Saramago, MD Diagnostic Radiologist Department of Radiology, Neuroradiology Progressive Physician Associates Bethlehem, PA				Joshua Wallace, MD, MPH Affiliate Associate Professor of Radiology, Brody School of Medicine at East Carolina University Department of Radiology, Musculoskeletal Imaging Eastern Radiologists Inc Greenville, NC

Carlos Zamora, MD, PhD Associate Professor of Radiology Department of Radiology, Neuroradiology University of North Carolina at Chapel Hill Chapel Hill, NC		Daniel Nissman, MD MPH MSEE Professor of Radiology, Musculoskeletal Imaging Co-Director of Clinical Faculty Development Department of Radiology UNC School of Medicine Chapel Hill, NC					Fangbai Wu, MD Associate Staff Radiologist Diagnostic Radiology, Musculoskeletal Radiology Cleveland Clinic Foundation Cleveland, OH

Congratulations to all case contributors.

The College could not maintain such a high level of quality without a steady supply of incredible cases.

  
Thank you to our Case in Point Senior Editor, Michael Opatowsky, MD, for editing this case.