Case presentation:

• Male.
• 67 y.o.
• Complaint:abdominal pain for the past 4 months.
• Initial treatment: as if viral gastroenteritis.
• Evolution: persistent abdominal pain, mass sensation and gastrointestinal bleeding.
• Blood tests: hemoglobin 7.7 g dl^(-1), whiste blood cell count 1600, neutrophil 310, platelets 55000.
• Blood smear: immature granulocytes ando some nucleated red blood cells (suggestive of marrow infiltration by tumor).
• Upper gastrointestinal endoscopy: 4cm corporo-antral gastric ulcer, Bormann III; gastric mucosa biopsy: intestinal-type adenocarcinoma, moderately well differentiated.
• Abdominal ultrasound: Liver metastases, omental cake, retroperitoneal lymph node metastases.

Teaching points:

• Regarding extraosseous Tc-99m MDP uptake:

1. First rule out artifact: i. free pertechnetate uptake by stomach , thyroid and salivary glands. ii. radiopharmaceutical colloid formation uptake by liver, spleen and lungs. iii. Aluminium breakthrough. iv. Contamination. v. Gamma camera malfunction.

(More teaching points in the case).