imaging of bone metastases review

8/11/2019 Imaging of Bone Metastases Review

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Q JN U CL M ED 2001;45:53-64

Radiological imaging for the diagnosis of bone metastasesL.D .RYB AK , D .I.RO SEN TH AL

Primary neoplasms of the skeleton are rare, but metastat-ic involvement is, unfortunately, a common occurrence.This is particularly true for certain primary tumors.Skeletal metastases are clinically significant because of associated symptoms, complications such as patholog-ical fracture and their profound significance for stag-ing, treatment and prognosis.Detection of bone metastases is, thus, an important partof treatment planning. The frequency with which metas-tases are detected varies considerably with the type of primary tumor and with the methodology utilized for

detection.Four main modalities are utilized clinically: plain filmradiography, CT scan, nuclear imaging and magneticresonance imaging. In this discussion, we will review lit-erature on the radiology of skeletal metastases withrespect to lesion detection, assessment of response totreatment and possible therapeutic implications. Thebulk of the discussion will focus on MRI and nuclear studies since most of the recent advances have beenmade in these areas.Key words: N eoplasm m etastasis - B on e neo plasm s secon -dary - To m ography, em ission com puted - M agnetic resonan-ce im aging - Radiography.

Skeletal m etastases are unfortunately com m on.The frequency w ith w hich they are detectedvaries considerably w ith the typ e o f tum or. Italso varies w ith the m ethodology used for detection.Fo r som e types of tum or, such as breast cancer, ske-letal m etastases are read ily detected by im aging stu-

From th e Departm en t of Radi ology, Ha rvar d Medical School Massachusetts Gen eral Hospita l, Boston , MA, USA

dies and form an im portant aspect of the clinical disea-se m anagem ent because of the sym ptom s they p ro-duce. Fo r other conditions (such as chordom a), disse-m inated skeletal m etastases are frequently detected atthe tim e of autopsy, but are less apparent during life.

In general, the prognosis for patien ts presentingw ith bone m etastasis is poor. Patien ts w ith few erm etastases or solitary lesions appear to have a b etteroutlook than those w ith m ultiple m etastatic deposits.

Mechanisms

D irect invasion of the skeleton m ay result from anadjacen t prim ary tum or (Fig. 1). Perhaps the m ostprevalen t exam ple is invasion of the chest w all by alung cancer. Lym phogenous spread to bone is uncom -m on and difficult to docum ent. H ow ever, secondaryinvasion of bone from involved lym ph nodes is not

rare. The spine is the m ost com m only affected site. Theleft side of the verteb ral bodies is m ore often invo lvedbecause the left-sided nodes are closer to bone thanthe right. 1 D irect skeletal invasion is usually accom pa-nied by a detectab le soft tissue m ass, a feature that isunusual in m etastases that arise by h em atogenousspread.

M ost tum or im plants occur through the hem atoge-nous route. The venous, rather than arterial routeappears m ore im portan t, especially B atsons paraver-tebral plexus. Presum ably, the absence o f valves in

A ddress rep rint requests to: D .I.Rosenthal, M assachusetts G eneralH ospital, D epartm ent of Radiology, W A C 515, 15 Parkm an Street, Boston ,M A 02114 (U SA).

Vol. 45 - N o. 1 TH E Q U A RTERLY JO U RN A L O F N U CLEA R M ED ICIN E 53


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54 TH E Q U A RTERLY JO U RN A L O F N U CLEA R M ED IC IN E M arch 2001

these veins perm its retrograde distribution of tum orcells. B atsons plexus com m unicates w ith the axialskeleton and the p roxim al long bones resulting in a

predilection for these sites. The preference for axialinvolvem ent is also due to the greater vascularity of thered (hem atogenous) m arrow found in the axial skele-ton as opposed to the yellow (fatty) m arrow found inthe appendicular bones.

Clinical features

M any of the patients com plain of bone pain, w hichm ay be due to various m echanism s including release

of chem ical m ediators, elevated intra-osseous pressure,

and periosteal elevation.2

The p robability that a skel-etal m etastasis w ill be painful m ay partly dep endupon the nature of the prim ary. M etastases from lungand breast prim aries are m ore likely to be sym ptom at-ic than are those from prostate cancer. Fractures andim pending fractures are also an im portant source ofpain, particularly in w eight-bearing bones. Such frac-tures are m ore com m on in areas involved w ith lyticm etastases rather than blastic ones. They are d ifficultto m anage, and often fail to heal.

Sym ptom s of arthritis m ay result from tum or inbone adjacent to a joint, m echanical collapse of anarticu lar surface due to lytic m etastasis, or from syn-ovial im plants of tum or. Prim ary m alignancies thathave been rep orted to presen t in the latter fashioninclude lung, colon, breast, m elanom a, and rhabdom -yosarcom a. 3 Synovial im plantation is very rarely doc-um ented on im aging stud ies.

A rthritic sym ptom s m ay also be due to paraneo-plastic effects such as carcinom a polyarthritis, a con-dition in w hich there is sudden onset of rheum atoid-like sym ptom s w ith an asym m etric distribution in apatien t w ho is rheum atoid-factor negative. H yp ertro-phic (pulm onary) osteoarthropathy is another paraneo-plastic syndrom e that m ay result in joint and long

bone sym ptom s w ithout local involvem ent.Secondary gout is a know n com plication in can-

cer patients, especially after treatm ent. Skeletal chang-es due to radiation, such as osteonecrosis and fracturem ay be difficult to distinguish from m etastatic lesionson im aging studies, but are usually not sym ptom atic.Finally, sym ptom s m ay be due to the onset of carci-nom a-related rheum atic con ditions such as Sjogrenssyndrom e, lupus, and d erm atom yositis. 4 The m ostcom m on m alignancy associated w ith arthritic sym p-tom s is leukem ia. 5

Detection - radiography

Radiography is com m only used to evaluate sym p-tom atic sites and to confirm findings on other im ag-ing studies. It is no t generally reco m m ended as ascreening m ethod because of poor sensitivity. Theradiographic survey rem ains valuable in staging ofm ultiple m yelom a due to the p oor sensitivity o f therad ioisotope scan in this condition.

Fig. 1.B one invo lvem en t by d irect exten sion. Squam ous cell carci-nom a of the skin w hich h as invad ed the ad jacent first m etacarpalbone.


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Sensitivity depends partly on location. For instance,

m etastases to dense cortical bone are easier to detectthan those involving trabecular (m edullary) bone. Inthe axial skeleton, m edullary m etastases m ay not bedetectable until 50% of the trabecular bone has beendestroyed.

Am ong the advantages of radiography is the fact thatcertain features m ay help to distinguish m etastasesfrom other conditions and aid in identification of theprim ary tum or. Radiography m ay be used to assess therisk of pathological fracture, w hich is said to be highif 50% of the cortex is destroyed by a lesion. This is acrude m easure at best. Recent w ork using quantitativeanalysis of CT scans for this purpose has show n m uch

greater prom ise.

Detection - CT

C T scanning has had a lim ited im pact upon theclinical detection of skeletal m etastases. A lthoughm ore sensitive than conventional radiography for thedetection of destructive bone lesions, CT is a cum ber-som e tool for screening the entire skeleton.Interestingly, CT can detect m etastases w ithin bonem arrow before bone destruction has occurred (Fig. 2).Tum or w ithin the m arrow causes an increase in atten-uation due to fat rep lacem en t. A n attenuation differ-ence of m ore than 20 H U betw een the righ t and leftextrem ities is abnorm al. 6 Such findings are subtle,and easily o verlooked by the radiologist. They arefar less apparent than the m arrow changes seen onM RI.

Detection - nuclear methods

Since the introduction of technetium -based scanagen ts, approxim ately 25 years ago, the radioisotope

bone scan has been the standard m ethod for detectionof skeletal m etastases. Isotope scanning is m ore sen-sitive than radiography for detection of m ost m etas-tases. Tracer accum ulates in the reactive new bone thatis form ed in response to the lesion. Thus, althoughm ost m etastatic lesions are hot, co ld lesions due tocom plete absence of reactive bone m ay be encoun-tered in particu larly aggressive m etastases (Fig. 3). Inaddition, the am ount of accum ulation is sensitive tothe level of blood flow . D iffuse accum ulation of trac-

er through out the skeleton due to dissem inated skel-etal disease (super scan) m ay lead to the false im pres-sion of a norm al scan (Fig. 4).

The bone scan suffers from a lack of specificity.Tracer accum ulation m ay occur in any skeletal loca-tion w ith an elevated rate of bone turnover and, thus,m ay accom pany traum a, infection or arthropathy.The p robability that an abnorm al scan rep resentsm etastatic tum or is directly related to the num ber of

abnorm al foci. In a p atien t w ith foci of increaseduptake and a know n p rim ary tum or, the scan strong-ly suggests m etastases. A sm all num ber (less than 4)of abnorm alities is m ore likely to rep resent m etastat-ic d isease in som e locations than others, w ith riblesions being particularly low -yield. 7 O nly 50% of sol-itary foci rep resen t m etastases, even am ong p atien tsw ith cancer.

This lack of specificity is w ell know n and has leadto recom m endations that positive scans be accom pa-nied by radiographic correlation. H ow ever, given thegreater sensitivity of the bone scan, a positive radio-graph m ay confirm a finding, but a negative radio-graph does not exclude a m etastasis.

Recent advances in isotope scanning m ethods, par-ticularly single photon em ission com puter tom ography(SPECT), have im proved the detection of m etastases.SPECT im aging has increased both the sensitivity andspecificity of bone scanning. 8 The tom ograph ic pres-en tation of SPEC T im ages helps to iden tify foci ofabnorm al uptake especially in the thicker body p artssuch as the spine and pelvis. In addition, im provedspatial localization helps to distinguish betw een m et-

Fig. 2.C T scan of the proxim al fem ora d em on strates increased den-sity of the left-sided m arrow . This is du e to rep lacem en t of the n or-m al m arrow fat by tum or, a find ing that m ay precede m ore obviou sbone lysis.


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astatic foci and other abnorm alities causing increaseduptake, such as spondylosis. Increased uptake thatinvolves the posterior vertebral body is m ore likely tobe due to m etastasis.

A baseline radio-isotope bone scan is no longerrecom m ended in stage 1 or 2 breast cancer becauseof low yield. 9 Several recent studies have suggestedthat the diagnostic yield of bone scan in patien ts w ithsm all and w ell-differentiated prostate carcinom as andPSA values


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(98% ), and m ay have som e value in lesion detec-

tion.17

Yehet al .

rep orted dism al results in a sm allseries of 13 patien ts w ith m ultiple bone m etastasesfrom prostate cancer in w hich FD G -PET only detect-ed 18% of the lesions apparent by bone scan. Theauthors concluded that prostate m etastases m ust havem eans other than glycolysis for m etabolism and ener-gy. 18 W ith regards to breast m etastases, one groupreported that PET dem onstrated sup eriority to bonescan w ith osteo lytic m etastases, but failed to consis-tently detect osteoblastic m etastases. 19 These observa-tions suggest a possible role for PET sim ilar to plainfilm rad iography, as confirm ation of positive resultsfrom conventional technetium scans, rather than a

m eans of initial detection.FD G appears not to be taken up by Paget disease,and, therefore, PET im aging m ay be u seful to separ-ate Pagets disease and other benign conditions fromm etastases and/or sarcom atous degeneration. 8 20H ow ever, despite undeniable u tility in certain circum -stances, presently there is no estab lished role for PETim aging in the clinical evaluation of bone m etasta-ses.

M arrow scanning has been reported to be m oresensitive than the conventional bone scan in detectionof m etastases from prostate cancer. 21 In one studycom paring m arrow im aging using 99m Tc anti-N CA -95

m onoclonal antibody w ith con ven tional M D P, them arrow im aging technique detected alm ost doublethe num ber of lesions seen on M D P scans. H ow ever,the num ber of patien ts iden tified as having m etasta-ses w as the sam e: 13 in both instances 22. In anotherstudy of 23 patients w ith breast m etastases, bone m ar-row im m unoscintigraphy (anti-N CA 95 M ab 250/183)dem onstrated better specificity (88 vs 75% ) and pos-itive predictive value (92 vs 85% ) than conventionalbone scan w ith no significant difference in sensitivity. 23Like PET, m arrow scanning has not yet found a rolein routine clinical practice.

For certain typ es o f prim ary tum ors, (especially

lym phom as and soft tissue sarcom as) G allium scan-ning m ay b e a useful staging tool, detecting m etasta-ses that are not otherw ise observed. 24 It m ay also behelpful to follow the effect of treatm ent in thesepatients. 25

Detection - MRI

M agnetic resonance im aging (M RI) is high ly sensi-tive to the p resence of skeletal m etastases w ithin the

bone m arrow . Since bo ne m arrow (includ ing hem at-opoietic or redm arrow ) contains a high percent-age of fat, T1-w eigh ted m agnetic resonance im agesgenerally reveal m etastases as focal areas of low sig-nal intensity. Lesions can be o ften be d istinguishedfrom focal deposits of red m arrow on T1-w eightedim ages because the latter are m ore focal and m ay

have cen trally located fat, giving the appearance o f abulls eye. 26 O n fat-suppressed T1-w eighted im ages,m etastases dem onstrate m ixed to high signal inten-sity. 27 O n T2-w eighted im ages, m etastatic lesions usu-ally are m uch brighter than norm al m arrow due totheir high w ater-content (Fig. 6). M etastases often,but not alw ays, have a rim of brigh t T2 signal aroundthem (halo sign ). 26

A variety of different M RI pulse sequences have beenevaluated. In general, conventional spin-echo pulse

Fig. 4.Super Scan. D iffuse uptake o f Tech netium -99m M D P inthis patien t w ith w idespread breast can cer m etastasis. The u se ofinap prop riate tech nical settings m ay result in a relatively norm alappearance in the absence o f focal sites of m ore p rom inent up take.


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sequences provide the best signal-to-noise ratios andanatom ical detail. H ow ever, because o f the need forrap id evaluation of large regions, fast spin echo andinversion recovery im age sequences have been testedand found to be acceptable. 28 Castillo et al . reported that

diffusion w eighted im aging had no advantage overnon-contrast enhanced T1 w eighted im aging in detec-tion and characterization of verteb ral m etastases, butw as som ew hat sup erior to T2 w eighted im aging. 29

U nfortunately, it can be difficu lt to distinguishchanges due to tum or from the affects of treatm ent,fracture, and inflam m ation. In one study, M RI scansw ere com pared w ith h istological specim ens at 21sites. Seven of these contained tum or, 14 did not. A llof the tum or-positive sites show ed abnorm alities on

M RI scans. H ow ever, in the sites show n to be free o ftum or, a sign ificant (m ore than 50% , depending uponpulse sequence) false-positive rate w as encountered,presum ably due to the effects of treatm ent. 30

It has becom e clear the m agnetic resonance im ag-

ing can detect m etastases that are not apparent onradioisotope bone scans. 31 M RI is particularly w ell suit-ed to detect spinal m etastases, and m ost authoritiesagree that it is superior to planar scintigrap hy for thispurpose. This m ay be partly due to the difficulty of rec-ognizing subtle rad ionuclide abnorm alities, since ret-rospective review of the isotope scans m ay revealm any abnorm alities that w ere initially m issed . 32 O nestudy of breast cancer patients concluded that M RIw as specifically sup erior to bone scan in detection of

Fig. 5.The u tility o f PET in the d etection of m etastatic disease w as dem onstrated in this patien tw ith past history of Ew ings sarcom a of the sacrum . A ) A bone scan revealed foci of uptakein the low er righ t ribs w hich corresponded to a site o f prior surgery, but no other suspicioussites. B) A subsequent PE T scan revealed a focus of increased FD G up take in the proxim al righthum erus suspicious for m etastasis. C) Plain film s of the area revealed no obvious abn orm al-ity. D ) A T1 fat saturated coronal im age of the righ t sho ulder dem onstrated an obvious focusof m etastatic disease dem onstrating diffuse enhancem en t.


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aggressive spinal m etastases that dem onstrated estro-gen recep tor negativity and increased biologic activity. 33M ost studies that have com pared M RI to bone scanninghave used p lanar bone scans, not SPECT. Planar scin-tigraphy detects about 1/3-2/3 of the lesions seen byM RI. M ultiple investigators have dem onstrated thesuperiority of SPECT to planar im aging w ith regards todetection of verteb ral m etastases. 34-36 Som e authorsbelieve that SPECT m akes nuclear scanning com par-able to M RI, w ith M RI better for vertebral body lesionsand SPECT better for the posterior elem ents. 37

A dvantages of the isotope scan include a large fieldof view , inexpensive radiopharm aceutical, low m or-bidity, and the ability to provide som e functional andvascular inform ation. M RI m ay be a sim pler and lessexpensive m ethod to evaluate the axial skeleton, butit has been considered less w ell-suited for screen ingthe long bones. B ecause of this, som e investigatorshave recom m ended that the role of M RI be restrictedto clarifying an equivocal bone scan. 38 H ow ever, one

group took the p osition that lesions m issed in theextrem ities w ere not significant. In their analysis of 200patien ts w ith breast and prostate carcinom a, 3 o f 4peripherally located skeletal lesions that w ere m issedby M RI w ere detected by p lain film radiographybecause they w ere painful. 39

Iden tification of appendicular lesions by M RI hasbeen facilitated by developm en t of faster pulsesequences. Several recent papers have rep orted thatin com parison to conventional bone scan, w hole body

M RI utilizing w hole body fast short tau inversionrecovery (ST IR) seq uen ces has significan tly bettersensitivity and specificity. 40-43 O ne of these pap ersnoted that detectab ility of rib lesions w as suboptim alutilizing M RI. 40 W alker et al . further suggest that w holebody M RI for patients w ith breast cancer m ay p roveto be an effective m eans of detecting skeletal, brainand liver m etastases w ith one study. 44

There are a num ber of specific situations in w hich iso-tope scanning m ay be preferred to M RI. They includepatients w ith contraindications to M RI such as claustro-phobia and pacem akers, and patients w ith thyroid can-cer in w hich scanning m ay be done w ith iodine. M RIis preferred w hen the differential diagnosis includesm arrow diseases such as lym phom a, leukem ia, m yelo-m a and W aldenstrom m acroglobulinem ia. 45-47

The factors that influence the choice of im agingm odalities continue to evolve. Progress in M RI hasbeen particularly rap id, and it appears probable thatits role in screening and staging in reference to skel-

etal m etastases w ill continue to grow and that it m ayultim ately replace the isotope scan. U ntil that tim e, iso-tope scanning, especially w ith SPECT im aging, w illcontinue to have an im portant role.

Identification of the primary tumor

U nfortunately, patients m ay first com e to m edicalattention as the result of skeletal m etastasis from an

Fig. 6.T he relative sensitivity o f CT and M RI in the d etection of skeletal m etastasis. A ) A C T scan of the p elvis in this patien t w ith know ncolon can cer revealed no o bvious area of abnorm ality. B ) A T2 w eigh ted axial im age o f the sam e patient dem on strated innum erous areasof abnorm al high sign al corresponding to m etastatic dep osits.


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unknow n p rim ary tum or. For such individuals, im ag-

ing studies m ay be used to help identify the p rim arylesion. C om m on tum ors w ith a high rate of bonem etastasis include: breast 72% , prostate 84% , thyroid50% , lung 31% , kidney 37% , pancreas 33% . Together,these account for m ore than 80% of prim ary tum ors inpatien ts presen ting w ith m etastases. 48-50

Previous studies have rep orted lim ited success inidentifying the prim ary tum or w hen a patient presentsw ith skeletal m etastasis of unknow n origin. In gener-al, the prim ary tum or has been iden tified in less than50% , even w hen patients w ere follow ed to autopsy.

In one of the m ost positive reports, the relative val-ue of the h istory an d physical exam ination, C B C ,

erythrocyte sedim en tation rate, blood chem istries,alkaline phosphatase, plain film s of the lesion, rad io-isotop e bone scan and com puted tom ography of thechest, abdom en, and pelvis w ere com pared. The pri-m ary tum or w as identified in 34/40 (85% ).Interestingly, the laboratory values w ere unhelpful.H istory and physical exam ination revealed the p ri-m ary in 4, chest X -ray iden tified 17, CT of chest add-ed ano ther 6, and C T of abd om en/pelvis add edanother 5. If used alone, C T w ould h ave diagnosed75% of all prim aries on the initial evaluation. A ll oth-er m odalities, including follow -up C T only added anadditional 10% . 51

CT has an im portant role in providing im aging guid-ance for tissue sam pling. B iopsy of the skeletal lesion,follow ed by exam ination of the tissue using sophisti-cated histologic techniques to lim it the im aging searchm ay be an eq ually valid ap proach to this difficultprob lem . 48 O ne study, how ever, con cluded that inthe m ajority of cases, the com bination of CT scan andclinical inform ation provided com parable results to CT-directed biopsy. 52

Radiograp hic features o f the skeletal m etastasesm ay help direct the search for a prim ary lesion. Som eprim ary tum ors tend to result in m etastases that arepurely lytic in nature, such as lung, renal and thyroid

cancer, others to be associated w ith variable degreesof sclerosis, especially prostate, breast, carcinoid andtum ors of endocrine glands (Fig. 7).

Evaluation of treatment

The progn osis for patien ts presenting w ith bonem etastases is poor. In one series, only 4/578 patientsw ere free of disease 10 years after diagnosis of bone

disease. M ean survival for patien ts w ith all prim aries

w as 5 m onths after diagnosis.48

In general, patientsw ith solitary lesions or a sm all num ber of m etastaseshave a better outlook than those w ith m ultiple m eta-static deposits.

Skeletal m etastases m ay respond to the chem other-apy or horm one therapy used for the prim ary tum or.They m ay also respo nd to radiation, or agentsdesigned to block bone resorption such as the newclass of bisph osphonate drugs. 53

Response of the skeletal lesions m ay result in reac-tive bone form ation on conventional radiographs 54 55(Fig. 8).

Sclerosis tends to progress from the periphery of the

lesion tow ard its center. Progressive sclerosis m aym ake subtle areas of bone involvem ent m ore visible,contributing to the false im pression of disease progres-sion. In one study of the effects of treatm en t, carefulretrospective analysis of bone scans revealed subtlefoci of increased uptake in m any areas w hich show edprogressive sclerosis, indicating that the lesions hadbeen presen t prior to treatm ent. 56

Isotope uptake usually decreases follow ing treat-m ent of a m etastasis. O ccasionally, increased uptakeis seen, particu larly in the early p hases of therap y.This is kn ow n as the flare phenom enon(Fig. 9).B ecause of this, it has been suggested that an increas-

ing n um ber of lesions is a m ore reliable m arker ofdisease p rogression than increasing inten sity o fuptake.

A reas of bone necrosis as a result of chem othera-py m ay m im ic m etastases, further confusing interpre-tation of post-treatm en t scans. 57 B one m arrow scansusing 99mTc antigranulocyte m onoclonal antibody haveshow n prom ise as an alternative m ethod of assessingtreatm ent response. 50

A t least one author has suggested radiopharm aceu-ticals m ay be used to im prove the tim ing o f treatm entw ith chem otherapeutic bone seeking agents. In thatstudy, m any p atien ts w ith prostate cancer receivingand rogen ablation therapy w ere fou nd to dem on-strate a p eak in uptake of 99m Tc-M D P about 3 w eeksafter institution of horm one treatm ent. 58

Q uantitative m ethods to evaluate the response totreatm ent have been elusive. In one study, CT densityw as used to evaluate response. Im m ediately after suc-cessful radiotherapy of vertebral m etastases as judgedby relief of pain, there w as a decrease in density by25% w ithin the lesions, follow ed by an increase of61% 3 m onths later. The bone surrounding the lesions


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increased consistently from beginning to end. 59 O therstudies utilizing d ual-en ergy X -ray absorptiom etry(D X A ) and quantitative bone scintigraphy to m onitordisease progression and response to treatm ent have

yielded equivocal results and further study in this areais necessary. 60-62

M RI has show n som e prom ise as a m eans of assess-ing treatm ent respo nse. O ne group had good results

Fig. 7.Initial clinical presentation of bonem etastasis w ith subsequent discovery of theprim ary. A ) A plain film of the p elvis in thispatien t w ho p resented w ith hip painrevealed an obvious destructive lytic focusin the righ t sup ra-acetabular region. B ) Thisarea w as hot on Technetium -99m M D P bonescan. C) Th e co rtical destruction and m ed i-al soft tissue exten sion w as further charac-terized by C T. D ) C T im ages w ith intrave-no us contrast m ore proxim ally in the abd o-m en revealed large bilateral renal cell carci-nom as. E) Th e large, necrotic tum ors aredem onstrated in the coronal plain on a T1fat saturated postgadolinium im age.

Fig. 8.Progressive sclerosis on plain film s in resp onse to treatm en t. A ) Plain film of the p elvis in a m an w ith m etastatic prostate cancer revealsm ultiple sites of m ixed lytic an d sclerotic m etastases. B ) O ne year later after rad iation treatm en t the lytic areas have b een rep laced by p ro-gressive sclerosis.


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using changes in the volum e of the bone and soft tis-sue com ponen ts of lesions on T1 w eighted im agesas criteria in patients w ith breast cancer m etastases. Infour of the patients, M RI revealed a response w henblood m arkers w ere equivocal and bone scan resultssuggested disease p rogression. 63 A nother studyrevealed sim ilarly encouraging results in utilizing M RIin prediction of disease p rogression or stab ility inpatients w ith breast can cer m etastatic to the spine. 64

Several different M RI m ethods have been devised tofollow the p rogress of therapy of the p rim ary tum or.O f these, the m ost prom ising is the rate of uptake o fgadolinium (so-called dynam ic scanning). B y thism ethod, it appears to be possible to distinguish viabletum or from necrotic tissue and treatm en t effects. 65Sim ilar m ethods have been applied to the evaluationof m etastases. 66 These m ethods, w hile show ing prom -ise in the investigational context, are not yet readyfor routine clinical im plem en tation.

Image guided percutaneous biopsy and other interventions

Progress in im aging technology, and especially theincreased use of CT scanning for gu idance, has great-ly increased the safety and ap plicab ility of needlebiopsy for skeletal m etastases. Prior to the era of CT-gu ided procedures, need le biopsy w as considereddangerous for spinal lesions above the lum bar spine.

It is currently rare to encounter a lesion for w hichneed le biopsy is not feasible. 67

A ccuracy rates vary depending upon the nature ofthe lesions being b iopsied. In general, how ever, biop-sies of m etastatic lesions have higher levels of accu-racy than infections and prim ary tum ors. 68

A particularly interesting evaluation of im age-guid-ed biopsy accuracy introduced the concep t of effec-tive accuracy, defined as the ability o f the p rocedureto replace open biopsy. In this rep ort, the overall

Fig. 9.Flare phenom en on. A ) Tech netium -99m M D P scan at tim e of presentation d em onstrated m ultiple hotlesions due to m etastasis inthis patien t w ith breast can cer. B ) Six m onths after the initiation of treatm en t, the p atien t w as clinically im proved. H ow ever, the b one scandem onstrated increased u ptake an d an increased n um ber of lesion s.


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