- Case report
- Open Access
- Published:
Bone single photon emission computed tomography with computed tomography disclosing chronic uterine perforation with intrauterine device migration into the anterior wall of the bladder: a case report
Journal of Medical Case Reports volume 7, Article number: 154 (2013)
Abstract
Introduction
Extraosseous uptake of 99mTc-hydroxymethylene diphosphonate is a common situation of variable clinical relevance.
Case presentation
A 52-year-old Caucasian woman presented to our department for breast cancer staging. A 99mTc-hydroxymethylene diphosphonate bone scan was performed and showed focal pelvic hyperfixation that disclosed intrauterine device migration into the anterior wall of the bladder on single photon emission computed tomography with computed tomography.
Conclusion
This observation confirms the major role of single photon emission computed tomography with computed tomography in achieving an exact diagnosis.
Introduction
Extraosseous soft tissue uptake of 99mTc-hydroxymethylene diphosphonate (HMDP) is a common situation but of variable clinical relevance. These lesions are often encountered as incidental findings and may sometimes change the therapeutic approach for certain patients. The intrauterine device (IUD) is a frequently used and effective contraceptive method. Complications after IUD insertion, such as chronic uterine perforation, are rare but serious.
We present a case of a patient with chronic uterine perforation with IUD migration into the anterior wall of the bladder, discovered on bone single photon emission computed tomography with computed tomography (SPECT/CT).
Case presentation
A 52-year-old Caucasian woman was referred to the Breast Diseases Center of the Strasbourg University Hospitals for the management of a bifocal infiltrating lobular carcinoma located in the upper outer quadrant of her right breast. She was multiparous (three children) and had been menopausal for one year. Her medical history showed no relevant data except for a Cesarian section. An IUD had been inserted after the last pregnancy 12 years ago. Another hormonal IUD had been inserted five years ago and removed before her breast surgery. A recent clinical pelvic examination had not revealed an IUD string. After neoadjuvant chemotherapy, she underwent a lumpectomy and axillary clearance. The histological examination revealed a residual focus of lobular carcinoma (pT1c) and each of the 30 axillary lymph nodes removed was negative. Breast surgery was followed by locoregional radiotherapy and hormonal therapy. A chest X-ray and an abdominal ultrasound for cancer staging were performed and revealed no metastasis. Cancer antigen (CA 15-3) showed a normal value (23U/ml).
A bone scan for cancer staging was also performed in November 2012 (Figure 1). It showed symmetrical and homogeneous uptake of the tracer compound in bone structures. However, bone scintigraphy disclosed a focal pelvic hyperfixation in her bladder area on anterior incidence. SPECT/CT was performed and showed a mislocated IUD in the anterior vesical wall (Figure 2) corresponding to focal 99mTc-HMDP hyperfixation due to a probable inflammatory granuloma surrounding the IUD.
Pelvic single photon emission computed tomography with computed tomography reveals a focal 99m Tc-hydroxymethylene diphosphonate hyperfixation (plain arrow) centered at a mislocated intrauterine device (arrow head) in the anterior vesical wall. (A) Axial computed tomography slice. (B) Axial single photon emission computed tomography. (C) Axial single photon emission computed tomography with computed tomography. (D) Volume-rendering single photon emission computed tomography with computed tomography.
Discussion
Uterine perforation is a rare yet serious event and occurs at a rate between 1 out of 10,000 and 1 out of 350 IUD insertions [1]. In contrast to acute uterine perforation, which is often symptomatic and occurs during insertion, chronic perforation may occur at any time and is generally asymptomatic [2]. Several risk factors have been identified and can be classified into three categories [2–4]: (i) uterine factors: myometrial weakness (multiparity, Cesarean section), pronounced retro- or anteversion, uterine hypoplasia, insertion in the early post-partum period; (ii) IUD insertion technique including operator experience; and (iii) IUD type: perforation might be more frequent with copper IUDs [1].
Transuterine migration consists of two steps: uterine infraction and uterine migration. Spontaneous uterine contractions and local inflammation are found in these cases.
Migration usually occurs to the peritoneal cavity or to adjacent neighboring organs. In a review of the literature, we found 140 cases of intra-abdominal migration and 50 cases of intravesical migration of which 42.9 percent presented with lithiasis [2, 4, 5]. Indeed, calcification may occur when the IUD migrates into the bladder. However, there is no correlation between calcification and time spent in the bladder [3, 4].
Mechanisms of extraosseous fixation are multiple and often intricate. When lesions contain microcalcification, the mechanism for increased accumulation is considered similar to that which occurs in normal bone: chemisorption onto calcium [6]. In injured tissue, intracellular calcium influx and calcium precipitation are responsible for the fixation.
Several diagnoses may be suspected when a pelvic hyperfixation occurs on a bone scan [7–9]. Typical causes are fourfold:
-
Focal hyperfixation due to urinary tract pathology such as vesical diverticulum, calcified foreign body granuloma, bilharziasis or tuberculosis;
-
Genital tract pathology: calcified uterine fibroid, endometrial tumor and a variety of ovarian tumors;
-
Peritoneal metastasis;
-
General causes: postradiation lesions, hematoma.
Conclusions
IUD migration is a rare cause of pelvic extraosseous accumulation of bone radiotracers, which should be kept in mind.
This observation also confirms the major role played by SPECT/CT in achieving an exact diagnosis.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Abbreviations
- SPECT/CT:
-
single photon emission computed tomography with computed tomography
- IUD:
-
intrauterine device.
References
Ceccato V, Boileau A, Roblin M, Tariel D, Bon D, Estrade V: Migration intravésicale d’un dispositif intra-utérin. Stratégies d’exploration et modalités thérapeutiques. Prog Urol. 2007, 17: 256-259. 10.1016/S1166-7087(07)92276-9.
Ech-Cherif El Kettani N, Dafiri R: Imagerie de la migration des dispositifs intra-utérins. Feuil Radiol. 2007, 47: 159-166. 10.1016/S0181-9801(07)88852-X.
El Ammari JE, El Fassi MJ, Farih MH: Migration intravésicale des dispositifs intra-utérins. Presse Med. 2009, 38: 1185-1188. 10.1016/j.lpm.2008.10.021.
Haouas N, Sahraoui W, Youssef A, Thabet I, Mosbah AT: Migration intra-vésicale de dispositif intra-utérin compliquée de lithiase. J Gynecol Obstet Biol Reprod. 2006, 35: 288-292. 10.1016/S0368-2315(06)78316-8.
Bacha K, Ben Amna M, Ben Hassine L: Dispositif intra-utérin migré dans la vessie. Prog Urol. 2011, 11: 1289-1291.
Mihara F, Nakayama C, Nakata H, Sakakibara N, Zeze F, Kitahara J, Sanefuji H: 99mTc-methylene diphosphonate uptake by ossifications and calcifications of non-osseous metastatic tumors. Eur J Nucl Med. 1986, 12: 413-416.
Elgazzar AH: Diagnosis of soft tissue calcification. Orthopedic Nuclear Medicine. Edited by: Elgazzar AH. 2004, Berlin, Heidelberg: Springer-Verlag, 197-210.
Beres RA, Patel N, Krasnow AZ, Isitman AT, Hellman RS, Veluvolu P, Patillo RS, Collier BD: Concentration of Tc-99m MDP in ovarian carcinoma and its soft tissue metastases. Clin Nucl Med. 1991, 16: 550-552. 10.1097/00003072-199108000-00003.
Goldfarb CR, Ongseng F, Kuhn M, Metzger T: Non-skeletal accumulation of bone seeking agents: pelvis. Semin Nucl Med. 1988, 18: 159-161. 10.1016/S0001-2998(88)80007-2.
Author information
Authors and Affiliations
Corresponding author
Additional information
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
DM and IJN diagnosed and drafted the manuscript. CM and AW followed up and managed the patient. All authors read and approved the final manuscript.
Authors’ original submitted files for images
Below are the links to the authors’ original submitted files for images.
Rights and permissions
Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
About this article
Cite this article
Morland, D., Mathelin, C., Wattiez, A. et al. Bone single photon emission computed tomography with computed tomography disclosing chronic uterine perforation with intrauterine device migration into the anterior wall of the bladder: a case report. J Med Case Reports 7, 154 (2013). https://doi.org/10.1186/1752-1947-7-154
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/1752-1947-7-154
Keywords
- Intrauterine device complication
- Bone scan
- SPECT/CT