Imaging in Bone Metastases

Joko Santoso
1410029053
Fakultas Kedokteran
Universitas Mulawarman
Samarinda
2015

Overview
Metastases to bone the most common
malignant tumors involving bone.
Imaging detection, diagnosis,
prognostication, treatment planning, and
follow up of bone metastases.

Overview
Bone metastases multiple at time of
diagnosis.
In adult occur in the axial skeleton and
other sites with residual red marrow.
90% site of bone metastases vertebra,
pelvis, proximal part of femur, ribs, proximal
part of humerus, and skull.

Overview
Certain carcinoma may have a predilection
skeletal sites.
50% bone metastases to hands and feet ca
lung.
Tumor from pelvis lumbosacral spine.

Pathophysiology
Direct extension
Retrograde venous flow metastased from
intra abdominal cancer
Seeding with tumor emboli via blood
circulation

Patophysiology
Metastatic lession grow in the medullary
cavity surrending bone is remodeled by of
either osteoblastic or osteoclastic proccess
depands on type and location original cancer

Differential Diagnosis

Bone island
Eosinophilic granuloma of the skeleton
Bone lymphoma
Osteomalacia
Renal osteodystrophy
Chronic osteomyelitis
Paget disease
Pelvic insufficiency fractures
Stress fractures
Tuberous sclerosis
Secondary OA

Radiography
Maybe osteolytic, sclerotic, or mixed
predominantly osteolytic
Arise in medulla destroying cortex
Without periosteal reaction
Soft tissue extention is relative uncommon

Radiography
Specific appearance of bone metastases is
useful in suggesting of underlying primary
malignancy.
Osteolytic lession carcinoma of breast,
lung, renal, thyroid.
Osteoblastic lession carcinoma of prostate,
stomach, carcinoid, colon, breast (10%),
bladder, melanoma, and sof tissue sarcoma.

Radiography
In vertebrae, clue of metastases pedicular
destruction, associated soft-tissue mass, and
angular or irregular deformity of vertebral
endplates

Radiography
Response of therapy initial manifestation
of healing in osteolytic metastases is a
sclerotic rim of reactive bone.
Response therapy of mixed lession
manifestation of healing is uniform lesional
sclerosis.
For sclerosis lession difficult to assess
compare to previous radiograph
manifestation of healing is shrink or
complately disappear.

Degree of Confident
Relative insensitive only 2 cm lession are
radiographically apparent.
Apparent in radiograph after loss of 50% bone
mineral content.

False Positives/Negatives
On radiograph, destructive lesions of the
trabecular bone may not be visible
particularly in absence of reactive new bone
or cortical envolement especially in elder.
Osteolytic lesion can mimic OA,
amyloidosis, cystic angiomatosis, infiltrative
bone marrow lesions.
Osteoblastic lesion can mimic bone island,
tuberous sclerosis, mastocytosis,
osteopoikilosis.

Computed Tomography
Useful in further assessment of
radiographically negative areas in patients
who are symptomatic and in whom
metastases are sugested clinically.

Degree of Confidence
CT scanning is vastly superior to radiography
in detection of trabecular and cortical bone
destruction, soft tissue extension, and
involvement of neurovascular structures.
Usefulness on detecting early deposits in bone
marrow is limited.

Magnetic Resonance Imaging

MRI is more sensitive than 99Tc bone
scitiscanning in detection of bone metastases.
Metastatic seeding in bone marrow is
characterized by long T1 relaxation times,
whereas T2 relaxation times are variable,
depending on tumor morphology.

Continue
Lesions are seen as focal or difuse areas of
hypointensity on T1-weighted images and as
areas of intermediate or high signal intensity
on T2-weigted images
The Bulls eye or halo sign useful in
distinguishing metastatic with benign lesions.

Continue
In vertebrae, additional criteria for malignancy
include bulging of the posterior margin of the
vertebral body, signal intensity changes that
intense into the pedicle, and paraosseus
tumor spread.

Degree of Confidence
MRI depicts early hematogenous
dissemination of the tumor to the bone
marrow before reaction in adjacent bone are
detectable on 99mTc Scintiscan.
Flickinger and Sanal reported sensitivities of
100% for MRI and 62% for scintiscanning and
specificities of 62% for MRI and 100% for
scintiscanning.

Nuclear Imaging
99mTc bone scintigraphy is an effective
method for screening the whole body for
bone metastases.
Detecting metastatic bone deposits by the
increased osteoblastic activity they induce.

Indications for bone scintiscanning

Staging in asymptomatic patients.
Evaluating persistent pain in the presence of
equivocal or negative radiographic findings.
Determining the extent of bone metastases in
patients with positive radiograph finding.
Differentiating metastatic from trauma
fractures.
Determining the therapeutic response to
metastases.

 PET scan can identifying bone metastases at

an early stage of growth, before host reaction
to the osteoblast occur.
PET scan detecting early increased glucose
metabolism in neoplastic cells.

 Isotop imaging methods depict bone

metastatic lesions as areas of increased tracer
uptake.
The classical pattern appears as presence of
multiple randomly distributed focal lesions
througout the skeleton.
Finding of a solitary scintigraphic abnormality
or just a few lesions may present special
problems in interpretation of findings.

Terima Kasih