Diagnostic Imaging Pathways - Bone Metastases
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This pathway provides guidance for imaging cancer patients with suspected bony metastases.
Date reviewed: August 2013
Date of next review: 2017/2018
Published: August 2013
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Pathological Fracture Secondary to Metastatic Disease Image 1a (Plain Radiograph): Pathological fracture (arrow) secondary to a lytic bone metastasis (arrowhead) in the distal femoral shaft. |
| 2a |  |
Metastatic breast cancer Image 2a (Computed Tomography): Metastatic disease (from primary breast cancer) is present in the thoracic vertebral body (arrow). |
| 2b |  |
Image 2b (Isotope Bone Scan): Bone scan of the same patient demonstrating disseminated metastatic disease in the head of the left humerus, thoracic vertebral bodies, pelvic bones, femur and tibia bilaterally. |
| 3 |  |
Bone Metastasis
Image 3: Metastatic deposits are present within the medullary cavity of the body and neck of the femur from a transitional cell carcinoma of the bladder. |
| 4a |  |
Bone Metastasis
Image 4a (H&E, x2.5) and 4b (H&E, x10): Core biopsy fragments showing bone with infiltrating sheets of malignant cells. The patient had a history of renal cell carcinoma and the features are consistent with metastatic carcinoma. |
Teaching Points
Teaching Points
- Initial investigation of choice in suspected metastatic disease is a nuclear medicine scan, with radiography of the area of interest
- Further diagnostic strategy depends on primary cancer type and clinical situation
b_scan
Isotope Bone Scan
- Initial imaging modality of choice in detecting bone metastases, regardless of presence of symptoms
- Technetium-99 (99m Tc) accumulates at sites of elevated bone turnover. In a patient with foci of increased uptake and a known primary tumour, the scan strongly suggests metastases. Cortical involvement is the likely cause of positive findings on bone scan 1
- Advantages: allows total body survey 2
- Limitations
- Non-specific. Radiographic correlation may be required to help identify benign processes. Lack of anatomic detail often requires further characterisation with MRI or CT
- Some metastases may not show increased uptake on bone scan, particularly those that are lytic, 3,4 for example kidney, thyroid and melanoma. Lytic tumours are better detected by metabolic scans such as FDG-PET because they have a high glucose metabolism, 5 or anatomical assessment with CT or MRI
ct
Computed Tomography (CT)
- Superior to MRI in revealing cortical integrity and extent of structural destruction 1,11
- Sensitivity for diagnosis of breast cancer metastasis to bone ranges from 71% to 100% 29
- Useful in guiding needle biopsy
- Multidetector CT is able to scan the whole body in a short period of time is often used in staging on discovery of a primary tumour and may have a role in screening
mri
Magnetic Resonance Imaging (MRI)
- MRI can evaluate suspicious findings on bone scan, providing better spatial resolution, anatomical detail and soft tissue involvement 11
- MRI may detect small skeletal metastases not yet detectable on bone scan by revealing abnormal bone marrow 12-14
- More sensitive in detecting vertebral metastasis than bone scintigraphy. Where there is a high clinical suspicion of vertebral metastasis, MRI should be considered even if bone scintigraphy is negative or equivocal 15-18
- However there is overlap in the appearance of metastases and a variety of benign lesions (eg. degenerative disc disease, benign compression fracture, osteomyelitis and infarct) which affects specificity (usually less than 90%) 19,20
- A recent metaanalysis concluded MRI can help distinguish benign from malignant vertebral compression fractures 21,22
- May be used to guide biopsy in lesions not adequately visualised by CT 23
- Recent studies have investigated a role of whole-body MRI in the evaluation of bony metastases, 24-27 but it is questioned whether this feature is clinically beneficial compared to MRI of the axial skeleton, 28 or cost-effective
pet
Positron Emission Tomography (PET)
- Can identify metabolically active skeletal metastases that may or may not have detectable structural destruction. Its use in staging and follow up evaluation is increasing for a number of malignancies. However, it is associated with high radiation and cost 11
- May be useful in differentiating malignant from benign vertebral compression fractures where MRI is equivocal (slightly more sensitivity, lower specificity) 30
- 18F-FDG-PET/CT is more sensitive than bone scintigraphy in detecting bone metastases, with added advantage of detecting unknown primary cancer and visceral metastases 31
- 18F-FDG-PET/CT is more sensitive and equally specific in comparison to bone scintigraphy for detection of bony metastases in breast cancer 30
- A single study found C11-choline PET/CT was less sensitive but more specific than bone scintigraphy in detecting bone metastases and helped reduce the number of equivocal findings in patients with prostate cancer 32
- A recent metaanalysis studying imaging of bony metastases in patients with lung cancer found FDG-PET was the best modality, with PET/CT better than PET, compared to MRI and bone scintigraphy. MRI was the most specific on a per-lesion basis 33
xray
Plain Radiography
- Certain radiographic features may help to distinguish metastases from other conditions and aid in identification of the primary tumour
- In patients with multiple myeloma, a radiographic skeletal survey is more sensitive than bone scintigraphy 3,4 and currently still considered the gold standard initial imaging modality to detect osteolytic lesions 6
- However, skeletal survey still requires at least 30% cortical bone destruction for the detection of osteolytic lesions, at which time the patient is already at risk for pathological fractures 7
- Limitations: Poor sensitivity for detection of bone metastases. 2,8,9 13% of metastatic bone lesions are in appendicular regions not included in radiographic skeletal surveys 10
References
References
Date of literature search: April 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Taoka T, Yuh WTC, Mayr NA, Lee HJ, Simonson TM, Rezai K, et al. Factors influencing visualization of vertebral metastases on MR imaging versus bone scintigraphy. AJR Am J Roentgenol. 2001;176(6):1525-30. (Level III evidence)
- Schaffer DL, Pendergrass HP. Comparison of enzyme, clinical, radiographic, and radionuclide methods of detecting bone metastases from carcinoma of the prostate. Radiology. 1976;121(2):431-4. (Level III evidence)
- Ludwig H, Kumpan W, Sinzinger H. Radiography and bone scintigraphy in multiple myeloma: a comparative analysis. Br J Radiol. 1982;55(651):173-81. (Level III evidence)
- Woolfenden JM, Durie BGM, Pitt MJ, Moon TE. Comparison of bone scintigraphy and radiography in multiple myeloma. Radiology. 1980;134(3):723-8. (Level III evidence)
- Du Y, Cullum I, Illidge T, Ell P. Fusion of metabolic function and morphology: sequential [18F]fluorodeoxyglucose positron-emission tomography/computed tomography studies yield new insights into the natural history of bone metastases in breast cancer. J Clin Oncol. 2007;25(23):3440-7. (Level II evidence)
- Dimopoulos M, Terpos E, Comenzo RL, Tosi P, Beksac M, Sezer O, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple myeloma. Leukemia. 2009;23(9):1545-56. (Evidence based guidelines)
- Edelstyn GA, Gillespie PJ, Grebbell FS. The radiological demonstration of osseous metastases. Experimental observations. Clin Radiol. 1967;18(2):158-62. (Level IV evidence)
- Silberstein EB, Saenger EL, Tofe AJ, Alexander GW, Park H-M. Imaging of bone metastases with 99mTc-Sn-EHDP (diphosphonate), 18F, and skeletal radiography: a comparison of sensitivity. Radiology. 1973;107(3):551-5. (Level III evidence)
- Roberts JG, Gravelle IH, Baum M, Bligh AS, Leach KG, Hughes LE. Evaluation of radiography and isotopic scintigraphy for detecting skeletal metastases in breast cancer. Lancet. 1976;1(7953):237-9. (Level II evidence)
- Krishnamurthy GT, Tubis M, Hiss J, Blahd WH. Distribution pattern of metastatic bone disease. A need for total body skeletal image. JAMA. 1977;237(23):2504-6. (Level III evidence)
- Yu HHM, Tsai Y-Y, Hoffe S. Overview of diagnosis and management of metastatic disease to bone. Cancer Control. 2012;19(2):84-91. (Review article)
- Schweitzer ME, Levine C, Mitchell DG, Gannon FH, Gomella LG. Bulls-eyes and halos - useful MR discriminators of osseous metastases. Radiology. 1993;188(1):249-52. (Level III evidence)
- Uchida N, Sugimura K, Kajitani A, Yoshizako T, Ishida T. MR imaging of vertebral metastases - evaluation of fat saturation imaging. Eur J Radiol. 1993;17(2):91-4. (Level III evidence)
- Watanabe H, Sato T, Hisinuma T, Ogata Y. Comparison of MRI, CT and bone scintigraphy in metastases of experimental neoplasm. Tohoku J Exp Med. 1991;163(3):229-31. (Level IV evidence)
- Chiewvit P, Danchaivijitr N, Sirivitmaitrie K, Chiewvit S, Thephamongkhol K. Does magnetic resonance imaging give value-added than bone scintigraphy in the detection of vertebral metastasis? J Med Assoc Thai. 2009;92(6):818-29. (Level III evidence)
- Thariat J, Toubeau M, Ornetti P, Coudert B, Berrielo-Riedinger A, Fargeot P, et al. Sensitivity and specificity of thallium-201 scintigraphy for the diagnosis of malignant vertebral fractures. Eur J Radiol. 2004;51(3):274-8. (Level II evidence)
- Aitchison FA, Poon FW, Hadley MD, Gray HW, Forrester AW. Vertebral metastases and an equivocal bone scan: value of magnetic resonance imaging. Nucl Med Commun. 1992;13(6):429-31. (Level III evidence)
- Algra PR, Bloem JL, Tissing H, Falke TH, Arndt JW, Verboom LJ. Detection of vertebral metastases: comparison between MR imaging and bone scintigraphy. Radiographics. 1991;11(2):219-32. (Level II evidence)
- Talbot JN, Paycha F, Balogova S. Diagnosis of bone metastasis: recent comparative studies of imaging modalities. Q J Nucl Med Mol Imaging. 2011;55(4):374-410. (Review article)
- Pui MH, Mitha A, Rae WID, Corr P. Diffusion-weighted magnetic resonance imaging of spinal infection and malignancy. J Neuroimaging. 2005;15(2):164-70. (Level II evidence)
- Thawait SK, Marcus MA, Morrison WB, Klufas RA, Eng J, Carrino JA. Research synthesis: what is the diagnostic performance of magnetic resonance imaging to discriminate benign from malignant vertebral compression fractures? Systematic review and meta-analysis. Spine. 2012;37(12):E736-44. (Level I/II evidence)
- Pozzi G, Garcia Parra C, Stradiotti P, Tien TV, Luzzati A, Zerbi A. Diffusion-weighted MR imaging in differentiation between osteoporotic and neoplastic vertebral fractures. Eur Spine J. 2012;21 Suppl 1:S123-7. (Level III evidence)
- Wu H-TH, Chang C-Y, Chang H, Yen C-C, Cheng H, Chen PC-S, et al.Magnetic resonance imaging guided biopsy of musculoskeletal lesions. J Chin Med Assoc. 2012;75(4):160-6. (Level III evidence)
- Lauenstein T, Goehde S, Herborn C, Goyen M, Oberhoff C, Debatin Jr, et al. Whole-body MR imaging: evaluation of patients for metastases. Radiology. 2004;233(1):139-48. (Level II evidence)
- Tamada T, Nagai K, Iizuka M, Imai S, Kajihara Y, Yamamoto S, et al. Comparison of whole-body MR imaging and bone scintigraphy in the detection of bone metastases from breast cancer. Nippon Igaku Hoshasen Gakkai Zasshi. 2000;60(5):249-54. (Level III evidence)
- Ohlmann-Knafo S, Kirschbaum M, Fenzl G, Pickuth D. Diagnostic value of whole-body MRI and bone scintigraphy in the detection of osseous metastases in patients with breast cancer: a prospective double-blinded study at two hospital centers. Rofo. 2009;181(3):255-63. (Level II evidence)
- Ketelsen D, Rothke M, Aschoff P, Merseburger AS, Lichy MP, Reimold M, et al. Detection of bone metastasis of prostate cancer - comparison of whole-body MRI and bone scintigraphy. Rofo. 2008;180(8):746-52. (Level III evidence)
- Lecouvet FE, Simon M, Tombal B, Jamart J, Vande Berg BC, Simoni P. Whole-body MRI (WB-MRI) versus axial skeleton MRI (AS-MRI) to detect and measure bone metastases in prostate cancer (PCa). Eur Radiol. 2010;20(12):2973-82. (Level III evidence)
- Hamaoka T, Madewell J, Podoloff D, Hortobagyi G, Ueno N. Bone imaging in metastatic breast cancer. J Clin Oncol. 2004;22(14):2942-53. (Review article)
- Hahn S, Heusner T, Kümmel S, Köninger A, Nagarajah J, Müller S, et al. Comparison of FDG-PET/CT and bone scintigraphy for detection of bone metastases in breast cancer. Acta Radiol. 2011;52(9):1009-14. (Level II/III evidence)
- Ozulker T, Kucukoz Uzun A, Ozulker F, Ozpacac T. Comparison of (18)F-FDG-PET/CT with (99m)Tc-MDP bone scintigraphy for the detection of bone metastases in cancer patients. Nucl Med Commun. 2010;31(6):597-603. (Level II evidence)
- Picchio M, Spinapolice EG, Fallanca F, Crivellaro C, Giovacchini G, Gianolli L, et al. [11C]Choline PET/CT detection of bone metastases in patients with PSA progression after primary treatment for prostate cancer: comparison with bone scintigraphy. Eur J Nucl Med Mol Imaging. 2012;39(1):13-26. (Level II evidence)
- Liu T, Xu J-Y, Xu W, Bai Y-R, Yan W-L, Yang H-L. Fluorine-18 deoxyglucose positron emission tomography, magnetic resonance imaging and bone scintigraphy for the diagnosis of bone metastases in patients with lung cancer: which one is the best? A meta-analysis. Clin Oncol (R Coll Radiol). 2011;23(5):350-8. (Level I evidence)
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