Radiologic Diagnosis of Spinal Metastases

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1 September 2002 Radiologic Diagnosis of Spinal Metastases Natalie J. M. Dailey, Harvard Medical Student Year III

2 Our Patient s Presenting Story 70 year old male Presents to the hospital for laparascopic cholecystectomy Receives pre-operative chest x-ray 2

3 Pre-operative Chest X-Ray: PA view Findings: Abnormal lobulated pleural thickening Material of density greater than cortical bone Decreased volume of right lung field From BIDMC PACS 3

4 Pre-operative Chest X-Ray: lateral view Findings: Major fissure Right middle lobe opacity Objects of density greater than cortical bone Loculations From BIDMC PACS 4

5 What s going on here?!! 5

6 The Importance of Obtaining a Full Patient History Past history of renal cell carcinoma with resection in 1999 (hence sutures) Past history of non-small cell lung carcinoma with resection of right middle lobe 7/02 (hence more sutures and decreased right lung volume) Current complaints of low back pain, urinary retention, and paresthesias in right lower extremity 6

7 Differential Diagnosis Knowing that our patient has a history of two types of cancer that frequently metastasize Knowing of his symptoms of back pain and parasthesias Metastatic Disease of the Spine must be at the top of our list. 7

8 Differential Diagnosis for Chest X-Ray Findings Multiple myeloma- punched out lytic lesions Paget s-large, sclerotic bones;coarse trabeculae Infection Infarction Trauma Primary bone tumor Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

9 Common Bone Metastases Radiographic Appearance Lytic Lesions: Breast Lungs Kidney Thyroid Sclerotic Lesions: Breast Prostate Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

10 Example of Sclerotic Lesions Comparison Patient I Patient diagnosed with prostate cancer Sclerotic bone lesions Courtesy of Ferris Hall, MD 10

11 Common Sites of Bone Metastasis Spine Pelvis Ribs Skull Proximal humerus or femur Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

12 Classical Presentation of Metastatic Bone Disease History of new onset bone pain (present in our patient) Pathologic fracture (no current indication of this) Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

13 How to Work Up Possible Spinal Metastases If no symptoms, first do a bone scan. If positive scan, perform focused radiography. If symptoms, evaluate sites of pain by radiography. If radiograph is negative or equivocal, perform bone scan. Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

14 How to Work Up Possible Spinal Metastases (cont d) If radiograph and bone scan disagree, remember that bone scan is more sensitive. Use CT or MRI as follow-up study. Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

15 Skeletal Scintigraphy Nuclide usually polyphosphates labeled with technetium-99 IV injection Visualization after 2 hours Increased uptake in areas of increased bone turnover: tumor, infection, fracture, arthritis, periostitis Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

16 Bone Scan of Spinal Metastases-Comparison Patient II Patient with renal cell carcinoma metastatic disease Lesions with increased uptake Enlarged soft tissue due to lymphedema Courtesy of K.P. Donohoe, MD. 16

17 Bone Scan of Spinal Metastases- Comparison Patient III Patient with colon cancer Areas of increased radionuclide uptake likely to be metastatic disease Area of increased uptake likely to be degenerative joint disease Courtesy of K.P. Donohoe, MD 17

18 Findings on Abdominal X-Ray- Comparison Patient III PA view: Pedicle sign destruction of cortical outline of pedicle Malalignment Increased radiolucency or radiopacity From BIDMC PACS Courtesy of K.P. Donohoe, MD. 18

19 Findings on Chest X- Ray Comparison Patient III(cont d) From BIDMC PACS Courtesy of K.P. Donohoe, M.D. Lateral view: Compression fractures/vertebral body collapse Changes in bone density Cortical destruction Nearby soft tissue mass 19

20 After Radiography Although our patient did not exhibit classical signs of spinal metastases on plain radiographic studies, his history indicates a high suspicion for metastatic disease. What comes next? 20

21 CT vs. MR Advantages of CT Better visualization of cortical destruction Good visualization of replacement of fatty marrow with soft tissue density of metastasis Advantages of MR Visualizes the relationship between the vertebra and spinal cord (neurological symptoms) No need to inject contrast to view vascular structures Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

22 Axial Spinal Anatomy Vertebral Body Spinal Cord Rib Paraspinal Musculature Lungs Sternum From Digital Anatomist: 22

23 Anatomy (cont d) Vertebral Detail Pedicle Neural Foramen Spinous Process Spinal Cord CSF Space Exiting vertebral nerve From Digital Anatomist: 23

24 Our Patient s CT Scan Findings with Lung Window Settings: Loculated Pleural Effusion (13 HU indicating fluid); probably resulting from resection of RML From BIDMC PACS 24

25 Our Patient s CT Scan (cont d) Findings with CT Bone Window: Loss of cortical margin Change in density within vertebral body From BIDMC PACS 25

26 Characteristics of MR Studies T1-weighted images are best for determining extent of marrow involvement T2-weighted images are best for examining cortical bone destruction and soft-tissue extension T2 with fat suppression: signal from fat is suppressed allowing for better contrast between normal and diseased bone marrow and better visualization of free water/edema Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1):

27 Our Patient s MR Study Findings on T1-weighted Image (sagittal view): CSF low-signal intensity Low-signal intensity lesions in vertebral bodies (Normal marrow should approach the brightness of subcutaneous fat.) From BIDMC PACS 27

28 Our Patient s MR Study (cont d) More Findings on T1- Weighted Imaging (Axial View): Low-signal intensity lesion in vertebral body From BIDMC PACS Involvement of right pedicle No apparent impingement of spinal cord 28

29 Our Patient s MR Study (cont d) Findings on T1- Weighted Image (sagittal view): CSF low-intensity signal Low-signal intensity lesions in vertebral bodies Bright subcutaneous fat From BIDMC PACS 29

30 Our Patient s MR Study (cont d) Findings on T2- Weighted Image: CSF highsignal intensity Lesions within vertebral body Obliteration of neural foramen (compare with other side) From BIDMC PACS 30

31 Our Patient s MR Study (cont d) Findings on T2-weighted image with fat suppression: Degenerative change Unsuppressed marrow lesions (Signal from normal marrow should be suppressed with fat.) From BIDMC PACS 31

32 Our Patient s MR Study (cont d) Findings on T2-weighted image with fat suppression: Unsuppressed marrow lesions (indicating the presence of edema) Compression fracture From BIDMC PACS 32

33 So what do we do now that we know that it s metastatic disease? 33

34 Reasons for Performing CT-guided Bone Biopsy Distinguish between metastatic disease and infection To make a pathological diagnosis in order to determine further treatment (especially in our case with two primary malignancies) Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York,

35 Approach for CT-Guided Bone Biopsy From BIDMC PACS 35

36 Pathology Results: Atypical squamous cells consistent with non-small cell lung cancer. Types of Non-Small Cell Lung Cancer Cotran, RS, Kumar, V, and Collins, T. Robbins Pathological Basis of Disease. Sixth edition. W.B. Saunders Company: Philadelphia,

37 Treatment Options/Prognosis Because our patient has widespread metastatic disease, his most likely treatment option is radiation therapy. This therapy is only palliative. It is likely to reduce his pain and may decrease any compression on his spinal cord, possibly ameliorating his neurological symptoms. However, his five-year survival probability is very low. Abeloff, MD, Armitage, JO, Lichter, AS, and Niederhuber, JE. Clinical Oncology. Second edition. Churchill Livingstone: New York,

38 Summary of Course of Action for Metastases 1. Bone Scan/Plain Film Radiography depending on whether or not the patient is symptomatic 2. CT and/or MRI 3. Bone Biopsy for Pathological Diagnosis, if necessary 38

39 Special thanks to: Chad Brecher, MD K.P. Donohoe, MD Daniel Saurborn, MD Ferris Hall, MD Pamela Lepkowski Larry Barbaras and Cara Lyn D amour 39

40 References Abeloff, MD, Armitage, JO, Lichter, AS, and Niederhuber, JE. Clinical Oncology. Second edition. Churchill Livingstone: New York, Cotran, RS, Kumar, V, and Collins, T. Robbins Pathological Basis of Disease. Sixth edition. W.B. Saunders Company: Philadelphia, Digital Anatomist: Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1):

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