Workup/Staging

Question 1

What is the workup for bone mets?

Answer 1

Bone met workup: H&P, characterization of pain, assessment of fracture risk, assessment for weight-bearing bone, orthopedic consult as necessary, plain films, and bone scan

Question 2

What imaging test is 1st line in evaluating bone mets?

Answer 2

Initial imaging of asymptomatic bone mets usually involves a bone scan (skeletal scintigraphy). If symptomatic, directed plain films and bone scan as well as subsequent clinically directed CT and/or MRI may be beneficial.

Question 3

When may plain films be useful when evaluating bone mets?

Answer 3

In the setting of bone pain with a positive bone scan, plain films may show an impending fracture or a pathologic fracture.

Question 4

What cancer is associated with mixed lytic and sclerotic lesions?

Answer 4

Breast cancer is associated with mixed sclerotic and lytic lesions.

Question 5

What cancers are associated with primarily blastic lesions?

Answer 5

Tumors with predominantly blastic lesions:

Prostate
Small cell lung cancer
Hodgkin lymphoma

Question 6

What cancers are associated with primarily lytic lesions?

Answer 6

Tumors with predominantly lytic lesions:

Renal cell
Melanoma
Multiple myeloma
Thyroid
Non–small cell lung cancer
NHL

Question 7

What imaging test can help to differentiate degenerative Dz from mets?

Answer 7

CT and/or MRI can help to distinguish b/t degenerative Dz and bone mets.

Question 8

When cord compression is suspected, what imaging is indicated?

Answer 8

MRI of the entire spine is indicated if cord compression is suspected.

Question 9

What scoring system predicts for pathologic fracture?

Answer 9

The Mirels scoring system is a weighted system based on a retrospective review that predicts the risk of pathologic fracture through metastatic lesions in long bones. Score ranges from 4–12. A score <7 can be treated with RT alone, while a score ≥8 requires internal fixation prior to RT. (Mirels H et al., Clin Ortho Res 1989)

Question 10

What 2 risk factors predict for pathologic fracture of the femur?

Answer 10

Factors predicting for pathologic fracture of the femur:

(Van der Linden Y et al., J Bone Joint Surg Br 2004)

Axial cortical involvement >30 mm
Circumferential cortical involvement >50%

Question 11

What scoring system can predict for stability of a spine met, and what are its components?

Answer 11

The Spine Instability Neoplastic Score (SINS) was found to be a useful tool to evaluate spine stability. It takes into account location (junctional are higher risk), pain, bone lesion type (lytic are higher risk), spinal alignment on films, degree of vertebral height collapse (>50% is higher risk), and involvement of post spinal elements (bilat is higher risk). Higher scores predicted higher risk. Refer to Fourney et al., JCO 2011.