Vertebral "clover" scintigraphic image in a vertebral metastasis misdiagnosed with Paget's disease

The diagnosis of Paget's bone disease (PD) is often reached fortuitously with X-ray or scintigraphy. The peculiar distribution of the bone tracer in some skeletal locations, such as vertebra, may be highly suggestive of this disorder. Indeed, there are two distinct vertebral images on the bone scan highly specific of PD: the "clover" and the "heart" images. It has been previously reported that the specificity of these images for PD diagnosis is very high, nearly 100%, then suggesting that these findings could be patognomonic of this process. We have recently observed a 55-year-old male patient with back pain secondary to a vertebral metastasis due to a hepatocellular carcinoma. Initially, the bone scan showed the characteristic "clover" image at T-12 level and he was misdiagnosed with PD. Afterwards, the MRI suggested the diagnosis of a vertebral metastasis, and a computed tomography-guided needle biopsy further confirmed the diagnosis. In view of the present data, this image cannot be considered as patognomonic of PD.