QJM Advance Access published May 21, 2015
Case report
Cookie bite cortical osteolytic lesions: a hint of skeletal
metastasis from bronchogenic carcinoma
Hsing-Hao Ho, Yi-Chih Hsu, Hsian-He Hsu, Guo-Shu Huang
Department of Radiology, Tri-Service General Hospital, National Defense Medical
Center, Taipei, Taiwan
Fax: (886-2)8792-7245
Email: [email protected]
© The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians.
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Correspondence to:
Guo-Shu Huang,
Department of Radiology,
Tri-Service General Hospital,
National Defense Medical Center,
No. 325, Sec. 2, Cheng-kung Rd., Neihu 114, Taipei, Taiwan
Tel: (886-2)8792-7244
Learning Point for Clinicians
Cookie bite lesions indicate focal eccentric osteolytic destruction of the external cortex
of a long tubular bone. These lesions are suggestive of cortical metastasis typically
originating from bronchogenic carcinoma. Therefore, the lung should be the first target of
investigation in patients with cookie bite cortical lesions.
Introduction
A cookie bite lesion indicates focal eccentric intracortical osteolytic destruction of a
long tubular bone. Deutsch and Resnick1 coined the term to describe cortical bone
metastases from bronchogenic carcinoma. Although cookie bite metastasis can develop
from other primary sources, the most common primary is bronchogenic carcinoma.2,3 Here
metastatic lesions involving bilateral tibia.
Case Report
A 39-year-old woman visited a local clinic complaining of right leg pain for 6 months.
She had no past medical history. A radiograph revealed an osteolytic lesion involving the
diaphyseal cortex of the right proximal tibia. The lesion had a cookie-bite appearance
indicating focal eccentric cortical osteolysis (Figure 1a). There was no periosteal reaction.
She was referred to our orthopedic clinic for further evaluation.
The patient also reported mild left knee pain; therefore, magnetic resonance imaging
(MRI) of both legs was performed. MRI showed two foci of eccentric cortical osteolytic
destruction, one at the diaphysis of the right proximal tibia and the other at the
metadiaphysis of the left proximal tibia, with juxtacortical soft tissue masses. The soft
tissue masses showed isointense to slightly hyperintense relative to muscle on T1weighted images and hyperintense on T2-weighted images with fat suppression. There
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we present a case of adenocarcinoma of the lung presenting with cookie bite cortical
was medullary involvement to a lesser extent in both lesions, and perilesional edema of
bone marrow and soft tissues. Heterogeneous enhancement of the lesions was observed on
postcontrast T1-weighted images.
The chest radiograph showed a soft tissue mass in the retrocardiac region of the left
lower lung (Figure 1b). Contrast-enhanced computed tomography (CT) revealed a
lobulated soft tissue mass in the medial region of the left lower lung and multiple enlarged
lymph nodes in the mediastinum. The findings were suggestive of bronchogenic
carcinoma with nodal metastases. Whole-body bone scan showed additional metastatic
foci in the third lumbar vertebra, left iliac spine, and left patella.
Surgical resection of the masses in both legs was performed. Histopathology confirmed
metastatic adenocarcinoma and positive thyroid transcription factor-1 staining was
the lung with multiple bone metastases and was referred to a thoracic oncologist for
further treatment.
Discussion
The term cookie bite bone metastasis was originally used to describe a small
intracortical lesion.1 In 1988, Greenspan et al.3 described four radiographic patterns of
bone destruction from osteolytic cortical metastases from bronchogenic carcinoma: small
intracortical lesions; large osteolytic cortical destruction; saucerized intracortical
destruction with well-defined periosteal reaction; and predominantly cortical destruction
extending into the soft tissue and medullary cavity. Snoeckx et al.,4 used the term cookie
bite to describe an eccentric osteolytic lesion with predominant cortical destruction
extending into soft tissue and the medullary cavity. This lesion was similar in those in the
present case.
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compatible with a pulmonary origin. The patient was diagnosed with adenocarcinoma of
Skeletal metastases are usually intramedullary, and cortical invasion is not unusual.
However, primary cortical metastases with pure cortical involvement or only minor
medullary involvement are relatively rare. The majority of cookie bite metastases develop
from bronchogenic carcinoma.2,3 The possible mechanism of distal spread of cancer cells
to bone cortex may be arterial dissemination through a unique vascular network
originating in the overlying periosteum.3 However, it is unclear why bronchogenic
carcinoma is more likely to spread to cortex than other primary malignancies.3,5
Here we report a case of cookie bite metastases to the tibia from adenocarcinoma of the
lung. Cookie bite lesions are suggestive of cortical metastasis associated with
bronchogenic carcinoma. Therefore, the lung should be the first target of investigation in
patients with cookie bite cortical lesions.
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References
1. Deutsch A, Resnick D. Eccentric cortical metastases to the skeleton from bronchogenic
carcinoma. Radiology 1980; 137:49.
2. Davis TM, Roger LF, Hendrix R. Cortical bone metastasis. Radiology 1991; 181:40913.
3. Greenspan A, Norman A. Osteolytic cortical destruction: An unusual pattern of skeletal
metastases. Skeletal Radiol 1988; 17:402-6.
4. Snoeckx A, Vanhoenacker FM, Petre C, Parizel PM. Cookie bite lesion. JBR-BTR.
2006; 89:48.
5. Kurishima K, Kagohashi K, Mammoto T, Satoh H. Tibia metastasis from small cell
lung cancer. Tuberk Toraks. 2014;62(1):89-90.
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Figure Legend
Figure 1. (a) A radiograph of the right leg shows a cookie bite at the diaphysis of right
proximal tibia indicating an eccentric osteolytic cortical lesion (arrow). (b) Posteroanterior
radiograph of the chest shows a soft tissue mass (arrow) in the retrocardiac region of left
lower lung.
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(a) A radiograph of the right leg shows a cookie bite at the diaphysis of right proximal tibia indicating an
eccentric osteolytic cortical lesion (arrow). (b) Posteroanterior radiograph of the chest shows a soft tissue
mass (arrow) in the retrocardiac region of left lower lung.
171x109mm (300 x 300 DPI)