Q J NUCL MED 2001;45:53-64
Radiological imaging for the diagnosis of bone metastases
L. D. RYBAK, D. I. ROSENTHAL
Primary neoplasms of the skeleton are rare, but metastatic 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 pathological fracture and their profound significance for staging, treatment and prognosis.
Detection of bone metastases is, thus, an important part
of treatment planning. The frequency with which metastases are detected varies considerably with the type of
primary tumor and with the methodology utilized for
detection.
Four main modalities are utilized clinically: plain film
radiography, CT scan, nuclear imaging and magnetic
resonance imaging. In this discussion, we will review literature on the radiology of skeletal metastases with
respect to lesion detection, assessment of response to
treatment and possible therapeutic implications. The
bulk of the discussion will focus on MRI and nuclear
studies since most of the recent advances have been
made in these areas.
Key words: Neoplasm metastasis - Bone neoplasms secondary - Tomography, emission computed - Magnetic resonance imaging - Radiography.
S
keletal metastases are unfortunately common.
The frequency with which they are detected
varies considerably with the type of tumor. It
also varies with the methodology used for detection.
For some types of tumor, such as breast cancer, skeletal metastases are readily detected by imaging stu-
Address reprint requests to: D. I. Rosenthal, Massachusetts General
Hospital, Department of Radiology, WAC 515, 15 Parkman Street, Boston,
MA 02114 (USA).
Vol. 45 - No. 1
From the Department of Radiology, Harvard Medical School
Massachusetts General Hospital, Boston, MA, USA
dies and form an important aspect of the clinical disease management because of the symptoms they produce. For other conditions (such as chordoma), disseminated skeletal metastases are frequently detected at
the time of autopsy, but are less apparent during life.
In general, the prognosis for patients presenting
with bone metastasis is poor. Patients with fewer
metastases or solitary lesions appear to have a better
outlook than those with multiple metastatic deposits.
Mechanisms
Direct invasion of the skeleton may result from an
adjacent primary tumor (Fig. 1). Perhaps the most
prevalent example is invasion of the chest wall by a
lung cancer. Lymphogenous spread to bone is uncommon and difficult to document. However, secondary
invasion of bone from involved lymph nodes is not
rare. The spine is the most commonly affected site. The
left side of the vertebral bodies is more often involved
because the left-sided nodes are closer to bone than
the right.1 Direct skeletal invasion is usually accompanied by a detectable soft tissue mass, a feature that is
unusual in metastases that arise by hematogenous
spread.
Most tumor implants occur through the hematogenous route. The venous, rather than arterial route
appears more important, especially Batson’s paravertebral plexus. Presumably, the absence of valves in
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Fig. 1.—Bone involvement by direct extension. Squamous cell carcinoma of the skin which has invaded the adjacent first metacarpal
bone.
these veins permits retrograde distribution of tumor
cells. Batson’s plexus communicates with the axial
skeleton and the proximal long bones resulting in a
predilection for these sites. The preference for axial
involvement is also due to the greater vascularity of the
red (hematogenous) marrow found in the axial skeleton as opposed to the yellow (fatty) marrow found in
the appendicular bones.
Clinical features
Many of the patients complain of bone pain, which
may be due to various mechanisms including release
54
of chemical mediators, elevated intra-osseous pressure,
and periosteal elevation.2 The probability that a skeletal metastasis will be painful may partly depend
upon the nature of the primary. Metastases from lung
and breast primaries are more likely to be symptomatic than are those from prostate cancer. Fractures and
impending fractures are also an important source of
pain, particularly in weight-bearing bones. Such fractures are more common in areas involved with lytic
metastases rather than blastic ones. They are difficult
to manage, and often fail to heal.
Symptoms of arthritis may result from tumor in
bone adjacent to a joint, mechanical collapse of an
articular surface due to lytic metastasis, or from synovial implants of tumor. Primary malignancies that
have been reported to present in the latter fashion
include lung, colon, breast, melanoma, and rhabdomyosarcoma.3 Synovial implantation is very rarely documented on imaging studies.
Arthritic symptoms may also be due to paraneoplastic effects such as carcinoma polyarthritis, a condition in which there is sudden onset of rheumatoidlike symptoms with an asymmetric distribution in a
patient who is rheumatoid-factor negative. Hypertrophic (pulmonary) osteoarthropathy is another paraneoplastic syndrome that may result in joint and long
bone symptoms without local involvement.
Secondary gout is a known complication in cancer patients, especially after treatment. Skeletal changes due to radiation, such as osteonecrosis and fracture
may be difficult to distinguish from metastatic lesions
on imaging studies, but are usually not symptomatic.
Finally, symptoms may be due to the onset of carcinoma-related rheumatic conditions such as Sjogrens
syndrome, lupus, and dermatomyositis.4 The most
common malignancy associated with arthritic symptoms is leukemia.5
Detection - radiography
Radiography is commonly used to evaluate symptomatic sites and to confirm findings on other imaging studies. It is not generally recommended as a
screening method because of poor sensitivity. The
radiographic survey remains valuable in staging of
multiple myeloma due to the poor sensitivity of the
radioisotope scan in this condition.
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Sensitivity depends partly on location. For instance,
metastases to dense cortical bone are easier to detect
than those involving trabecular (medullary) bone. In
the axial skeleton, medullary metastases may not be
detectable until 50% of the trabecular bone has been
destroyed.
Among the advantages of radiography is the fact that
certain features may help to distinguish metastases
from other conditions and aid in identification of the
primary tumor. Radiography may be used to assess the
risk of pathological fracture, which is said to be high
if 50% of the cortex is destroyed by a lesion. This is a
crude measure at best. Recent work using quantitative
analysis of CT scans for this purpose has shown much
greater promise.
Detection - CT
CT scanning has had a limited impact upon the
clinical detection of skeletal metastases. Although
more sensitive than conventional radiography for the
detection of destructive bone lesions, CT is a cumbersome tool for screening the entire skeleton.
Interestingly, CT can detect metastases within bone
marrow before bone destruction has occurred (Fig. 2).
Tumor within the marrow causes an increase in attenuation due to fat replacement. An attenuation difference of more than 20 HU between the right and left
extremities is abnormal.6 Such findings are subtle,
and easily overlooked by the radiologist. They are
far less apparent than the marrow changes seen on
MRI.
Detection - nuclear methods
Since the introduction of technetium-based scan
agents, approximately 25 years ago, the radioisotope
bone scan has been the standard method for detection
of skeletal metastases. Isotope scanning is more sensitive than radiography for detection of most metastases. Tracer accumulates in the reactive new bone that
is formed in response to the lesion. Thus, although
most metastatic lesions are “hot”, cold lesions due to
complete absence of reactive bone may be encountered in particularly aggressive metastases (Fig. 3). In
addition, the amount of accumulation is sensitive to
the level of blood flow. Diffuse accumulation of trac-
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RYBAK
Fig. 2.—CT scan of the proximal femora demonstrates increased density of the left-sided marrow. This is due to replacement of the normal marrow fat by tumor, a finding that may precede more obvious
bone lysis.
er throughout the skeleton due to disseminated skeletal disease (super scan) may lead to the false impression of a normal scan (Fig. 4).
The bone scan suffers from a lack of specificity.
Tracer accumulation may occur in any skeletal location with an elevated rate of bone turnover and, thus,
may accompany trauma, infection or arthropathy.
The probability that an abnormal scan represents
metastatic tumor is directly related to the number of
abnormal foci. In a patient with foci of increased
uptake and a known primary tumor, the scan strongly suggests metastases. A small number (less than 4)
of abnormalities is more likely to represent metastatic disease in some locations than others, with rib
lesions being particularly low-yield.7 Only 50% of solitary foci represent metastases, even among patients
with cancer.
This lack of specificity is well known and has lead
to recommendations that positive scans be accompanied by radiographic correlation. However, given the
greater sensitivity of the bone scan, a positive radiograph may confirm a finding, but a negative radiograph does not exclude a metastasis.
Recent advances in isotope scanning methods, particularly single photon emission computer tomography
(SPECT), have improved the detection of metastases.
SPECT imaging has increased both the sensitivity and
specificity of bone scanning.8 The tomographic presentation of SPECT images helps to identify foci of
abnormal uptake especially in the thicker body parts
such as the spine and pelvis. In addition, improved
spatial localization helps to distinguish between met-
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Fig. 3.—A) Technetium-99m MDP scan. There is a focal absence of isotope uptake in the left ninth rib. At the margins of the “cold” area, slight
increased uptake is visible. Very destructive lesions may produce focal cold areas as the result of complete bone destruction in the affected
area. Increased uptake in the marginal, less destroyed bone is not unusual. B) An oblique radiograph of the chest demonstrates complete
absence of the posterior ninth rib.
astatic foci and other abnormalities causing increased
uptake, such as spondylosis. Increased uptake that
involves the posterior vertebral body is more likely to
be due to metastasis.
A baseline radio-isotope bone scan is no longer
recommended in stage 1 or 2 breast cancer because
of low yield.9 Several recent studies have suggested
that the diagnostic yield of bone scan in patients with
small and well-differentiated prostate carcinomas and
PSA values <20 is too low to warrant routine use.10 11
If scanning is withheld from such individuals the
national savings would be $ 38 million/year.12
However, recent data indicates that for patients who
have received androgen depletion therapy, the PSA
may be unreliable in excluding metastases.
At present, the conventional bone scan has no role
in the detection of metastases from renal cell carcinoma and head and neck cancer.13 14 For non-small cell
lung cancer, the bone scan is still recommended at the
time of diagnosis to aid in selection of patients for
56
surgery, although FDG-PET is also promising.8
There have been conflicting reports as to the efficacy of PET scanning and, as of yet, a consensus
has not been reached. One study of 44 patients with
known metastatic disease from lung, prostate and
thyroid primaries showed FDG-PET to be more sensitive and specific than conventional bone scan.15
Schirrmeister et al. studied 34 patients with breast
cancer and concluded that FDG PET allowed for
earlier detection of small marrow metastases than
conventional bone scan and lead to clinically significant changes in management of four patients 16
(Fig. 5).
Other results have not been as encouraging. A
recent publication based on imaging of 98 bone
lesions in 24 patients reported better specificity, but
lower sensitivity for FDG-PET as compared to conventional bone scan.1 Another study similarly concluded
that FDG-PET can detect prostate metastases to bone
with moderate sensitivity (65%), but high specificity
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(98%), and may have some value in lesion detection.17 Yeh et al. reported dismal results in a small
series of 13 patients with multiple bone metastases
from prostate cancer in which FDG-PET only detected 18% of the lesions apparent by bone scan. The
authors concluded that prostate metastases must have
means other than glycolysis for metabolism and energy.18 With regards to breast metastases, one group
reported that PET demonstrated superiority to bone
scan with osteolytic metastases, but failed to consistently detect osteoblastic metastases.19 These observations suggest a possible role for PET similar to plain
film radiography, as confirmation of positive results
from conventional technetium scans, rather than a
means of initial detection.
FDG appears not to be taken up by Paget disease,
and, therefore, PET imaging may be useful to separate Paget’s disease and other benign conditions from
metastases and/or sarcomatous degeneration. 8 20
However, despite undeniable utility in certain circumstances, presently there is no established role for PET
imaging in the clinical evaluation of bone metastases.
Marrow scanning has been reported to be more
sensitive than the conventional bone scan in detection
of metastases from prostate cancer.21 In one study
comparing marrow imaging using 99mTc anti-NCA-95
monoclonal antibody with conventional MDP, the
marrow imaging technique detected almost double
the number of lesions seen on MDP scans. However,
the number of patients identified as having metastases was the same: 13 in both instances 22. In another
study of 23 patients with breast metastases, bone marrow immunoscintigraphy (anti-NCA 95 Mab 250/183)
demonstrated better specificity (88 vs 75%) and positive predictive value (92 vs 85%) than conventional
bone scan with no significant difference in sensitivity.23
Like PET, marrow scanning has not yet found a role
in routine clinical practice.
For certain types of primary tumors, (especially
lymphomas and soft tissue sarcomas) Gallium scanning may be a useful staging tool, detecting metastases that are not otherwise observed.24 It may also be
helpful to follow the effect of treatment in these
patients.25
Detection - MRI
Magnetic resonance imaging (MRI) is highly sensitive to the presence of skeletal metastases within the
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RIBAK
Fig. 4.—“Super Scan”. Diffuse uptake of Technetium-99m MDP in
this patient with widespread breast cancer metastasis. The use of
inappropriate technical settings may result in a relatively “normal”
appearance in the absence of focal sites of more prominent uptake.
bone marrow. Since bone marrow (including hematopoietic or “red” marrow) contains a high percentage of fat, T1-weighted magnetic resonance images
generally reveal metastases as focal areas of low signal intensity. Lesions can be often be distinguished
from focal deposits of red marrow on T1-weighted
images because the latter are more focal and may
have centrally located fat, giving the appearance of a
“bull’s eye”.26 On fat-suppressed T1-weighted images,
metastases demonstrate mixed to high signal intensity.27 On T2-weighted images, metastatic lesions usually are much brighter than normal marrow due to
their high water-content (Fig. 6). Metastases often,
but not always, have a rim of bright T2 signal around
them (halo sign).26
A variety of different MRI pulse sequences have been
evaluated. In general, conventional spin-echo pulse
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Fig. 5.—The utility of PET in the detection of metastatic disease was demonstrated in this patient
with past history of Ewing’s sarcoma of the sacrum. A) A bone scan revealed foci of uptake
in the lower right ribs which corresponded to a site of prior surgery, but no other suspicious
sites. B) A subsequent PET scan revealed a focus of increased FDG uptake in the proximal right
humerus suspicious for metastasis. C) Plain films of the area revealed no obvious abnormality. D) A T1 fat saturated coronal image of the right shoulder demonstrated an obvious focus
of metastatic disease demonstrating diffuse enhancement.
sequences provide the best signal-to-noise ratios and
anatomical detail. However, because of the need for
rapid evaluation of large regions, fast spin echo and
inversion recovery image sequences have been tested
and found to be acceptable.28 Castillo et al. reported that
diffusion weighted imaging had no advantage over
non-contrast enhanced T1 weighted imaging in detection and characterization of vertebral metastases, but
was somewhat superior to T2 weighted imaging.29
Unfortunately, it can be difficult to distinguish
changes due to tumor from the affects of treatment,
fracture, and inflammation. In one study, MRI scans
were compared with histological specimens at 21
sites. Seven of these contained tumor, 14 did not. All
of the tumor-positive sites showed abnormalities on
58
MRI scans. However, in the sites shown to be free of
tumor, a significant (more than 50%, depending upon
pulse sequence) false-positive rate was encountered,
presumably due to the effects of treatment.30
It has become clear the magnetic resonance imaging can detect metastases that are not apparent on
radioisotope bone scans.31 MRI is particularly well suited to detect spinal metastases, and most authorities
agree that it is superior to planar scintigraphy for this
purpose. This may be partly due to the difficulty of recognizing subtle radionuclide abnormalities, since retrospective review of the isotope scans may reveal
many abnormalities that were initially missed.32 One
study of breast cancer patients concluded that MRI
was specifically superior to bone scan in detection of
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RIBAK
Fig. 6.—The relative sensitivity of CT and MRI in the detection of skeletal metastasis. A) A CT scan of the pelvis in this patient with known
colon cancer revealed no obvious area of abnormality. B) A T2 weighted axial image of the same patient demonstrated innumerous areas
of abnormal high signal corresponding to metastatic deposits.
aggressive spinal metastases that demonstrated estrogen receptor negativity and increased biologic activity.33
Most studies that have compared MRI to bone scanning
have used planar bone scans, not SPECT. Planar scintigraphy detects about 1/3-2/3 of the lesions seen by
MRI. Multiple investigators have demonstrated the
superiority of SPECT to planar imaging with regards to
detection of vertebral metastases.34-36 Some authors
believe that SPECT makes nuclear scanning comparable to MRI, with MRI better for vertebral body lesions
and SPECT better for the posterior elements.37
Advantages of the isotope scan include a large field
of view, inexpensive radiopharmaceutical, low morbidity, and the ability to provide some functional and
vascular information. MRI may be a simpler and less
expensive method to evaluate the axial skeleton, but
it has been considered less well-suited for screening
the long bones. Because of this, some investigators
have recommended that the role of MRI be restricted
to clarifying an equivocal bone scan.38 However, one
group took the position that lesions missed in the
extremities were not significant. In their analysis of 200
patients with breast and prostate carcinoma, 3 of 4
peripherally located skeletal lesions that were missed
by MRI were detected by plain film radiography
because they were painful.39
Identification of appendicular lesions by MRI has
been facilitated by development of faster pulse
sequences. Several recent papers have reported that
in comparison to conventional bone scan, whole body
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MRI utilizing whole body fast short tau inversion
recovery (STIR) sequences has significantly better
sensitivity and specificity.40-43 One of these papers
noted that detectability of rib lesions was suboptimal
utilizing MRI.40 Walker et al. further suggest that whole
body MRI for patients with breast cancer may prove
to be an effective means of detecting skeletal, brain
and liver metastases with one study.44
There are a number of specific situations in which isotope scanning may be preferred to MRI. They include
patients with contraindications to MRI such as claustrophobia and pacemakers, and patients with thyroid cancer in which scanning may be done with iodine. MRI
is preferred when the differential diagnosis includes
marrow diseases such as lymphoma, leukemia, myeloma and Waldenstrom macroglobulinemia.45-47
The factors that influence the choice of imaging
modalities continue to evolve. Progress in MRI has
been particularly rapid, and it appears probable that
it’s role in screening and staging in reference to skeletal metastases will continue to grow and that it may
ultimately replace the isotope scan. Until that time, isotope scanning, especially with SPECT imaging, will
continue to have an important role.
Identification of the primary tumor
Unfortunately, patients may first come to medical
attention as the result of skeletal metastasis from an
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unknown primary tumor. For such individuals, imaging studies may be used to help identify the primary
lesion. Common tumors with a high rate of bone
metastasis include: breast 72%, prostate 84%, thyroid
50%, lung 31%, kidney 37%, pancreas 33%. Together,
these account for more than 80% of primary tumors in
patients presenting with metastases.48-50
Previous studies have reported limited success in
identifying the primary tumor when a patient presents
with skeletal metastasis of unknown origin. In general, the primary tumor has been identified in less than
50%, even when patients were followed to autopsy.
In one of the most positive reports, the relative value of the history and physical examination, CBC,
erythrocyte sedimentation rate, blood chemistries,
alkaline phosphatase, plain films of the lesion, radioisotope bone scan and computed tomography of the
chest, abdomen, and pelvis were compared. The primary tumor was identified in 34/40 (85%).
Interestingly, the laboratory values were unhelpful.
History and physical examination revealed the primary in 4, chest X-ray identified 17, CT of chest added another 6, and CT of abdomen/pelvis added
another 5. If used alone, CT would have diagnosed
75% of all primaries on the initial evaluation. All other modalities, including follow-up CT only added an
additional 10%.51
CT has an important role in providing imaging guidance for tissue sampling. Biopsy of the skeletal lesion,
followed by examination of the tissue using sophisticated histologic techniques to limit the imaging search
may be an equally valid approach to this difficult
problem.48 One study, however, concluded that in
the majority of cases, the combination of CT scan and
clinical information provided comparable results to CTdirected biopsy.52
Radiographic features of the skeletal metastases
may help direct the search for a primary lesion. Some
primary tumors tend to result in metastases that are
purely lytic in nature, such as lung, renal and thyroid
cancer, others to be associated with variable degrees
of sclerosis, especially prostate, breast, carcinoid and
tumors of endocrine glands (Fig. 7).
Evaluation of treatment
The prognosis for patients presenting with bone
metastases is poor. In one series, only 4/578 patients
were free of disease 10 years after diagnosis of bone
60
disease. Mean survival for patients with all primaries
was 5 months after diagnosis.48 In general, patients
with solitary lesions or a small number of metastases
have a better outlook than those with multiple metastatic deposits.
Skeletal metastases may respond to the chemotherapy or hormone therapy used for the primary tumor.
They may also respond to radiation, or agents
designed to block bone resorption such as the new
class of bisphosphonate drugs.53
Response of the skeletal lesions may result in reactive bone formation on conventional radiographs 54 55
(Fig. 8).
Sclerosis tends to progress from the periphery of the
lesion toward its center. Progressive sclerosis may
make subtle areas of bone involvement more visible,
contributing to the false impression of disease progression. In one study of the effects of treatment, careful
retrospective analysis of bone scans revealed subtle
foci of increased uptake in many areas which showed
progressive sclerosis, indicating that the lesions had
been present prior to treatment.56
Isotope uptake usually decreases following treatment of a metastasis. Occasionally, increased uptake
is seen, particularly in the early phases of therapy.
This is known as the “flare phenomenon” (Fig. 9).
Because of this, it has been suggested that an increasing number of lesions is a more reliable marker of
disease progression than increasing intensity of
uptake.
Areas of bone necrosis as a result of chemotherapy may mimic metastases, further confusing interpretation of post-treatment scans.57 Bone marrow scans
using 99mTc antigranulocyte monoclonal antibody have
shown promise as an alternative method of assessing
treatment response.50
At least one author has suggested radiopharmaceuticals may be used to improve the timing of treatment
with chemotherapeutic bone seeking agents. In that
study, many patients with prostate cancer receiving
androgen ablation therapy were found to demonstrate a peak in uptake of 99mTc-MDP about 3 weeks
after institution of hormone treatment.58
Quantitative methods to evaluate the response to
treatment have been elusive. In one study, CT density
was used to evaluate response. Immediately after successful radiotherapy of vertebral metastases as judged
by relief of pain, there was a decrease in density by
25% within the lesions, followed by an increase of
61% 3 months later. The bone surrounding the lesions
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RIBAK
Fig. 7.—Initial clinical presentation of bone
metastasis with subsequent discovery of the
primary. A) A plain film of the pelvis in this
patient who presented with hip pain
revealed an obvious destructive lytic focus
in the right supra-acetabular region. B) This
area was hot on Technetium-99m MDP bone
scan. C) The cortical destruction and medial soft tissue extension was further characterized by CT. D) CT images with intravenous contrast more proximally in the abdomen revealed large bilateral renal cell carcinomas. E) The large, necrotic tumors are
demonstrated in the coronal plain on a T1
fat saturated postgadolinium image.
Fig. 8.—Progressive sclerosis on plain films in response to treatment. A) Plain film of the pelvis in a man with metastatic prostate cancer reveals
multiple sites of mixed lytic and sclerotic metastases. B) One year later after radiation treatment the lytic areas have been replaced by progressive sclerosis.
increased consistently from beginning to end.59 Other
studies utilizing dual-energy X-ray absorptiometry
(DXA) and quantitative bone scintigraphy to monitor
disease progression and response to treatment have
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yielded equivocal results and further study in this area
is necessary.60-62
MRI has shown some promise as a means of assessing treatment response. One group had good results
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Fig. 9.—Flare phenomenon. A) Technetium-99m MDP scan at time of presentation demonstrated multiple “hot” lesions due to metastasis in
this patient with breast cancer. B) Six months after the initiation of treatment, the patient was clinically improved. However, the bone scan
demonstrated increased uptake and an increased number of lesions.
using changes in the volume of the bone and soft tissue components of lesions on T1 weighted images
as criteria in patients with breast cancer metastases. In
four of the patients, MRI revealed a response when
blood markers were equivocal and bone scan results
suggested disease progression.63 Another study
revealed similarly encouraging results in utilizing MRI
in prediction of disease progression or stability in
patients with breast cancer metastatic to the spine.64
Several different MRI methods have been devised to
follow the progress of therapy of the primary tumor.
Of these, the most promising is the rate of uptake of
gadolinium (so-called dynamic scanning). By this
method, it appears to be possible to distinguish viable
tumor from necrotic tissue and treatment effects.65
Similar methods have been applied to the evaluation
of metastases.66 These methods, while showing promise in the investigational context, are not yet ready
for routine clinical implementation.
62
Image guided percutaneous biopsy
and other interventions
Progress in imaging technology, and especially the
increased use of CT scanning for guidance, has greatly increased the safety and applicability of needle
biopsy for skeletal metastases. Prior to the era of CTguided procedures, needle biopsy was considered
dangerous for spinal lesions above the lumbar spine.
It is currently rare to encounter a lesion for which
needle biopsy is not feasible.67
Accuracy rates vary depending upon the nature of
the lesions being biopsied. In general, however, biopsies of metastatic lesions have higher levels of accuracy than infections and primary tumors.68
A particularly interesting evaluation of image-guided biopsy accuracy introduced the concept of effective accuracy, defined as the ability of the procedure
to replace open biopsy. In this report, the overall
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accuracy was approximately the same for metastases, infection and primary lesions. Effective accuracy
was best for metastases (77%), since clinicians tended to disbelieve negative biopsies for infection (72%),
and pathologists asked for more tissue in primary
lesions (59%). The authors noted that if a biopsy (or
other test) has to be repeated, it is worse than worthless since it adds expense and discomfort without
improving care.68
The increased ease and safety of access to lesions
in a variety of different anatomical locations has also
opened up therapeutic possibilities, including ablative
techniques for palliation, (and potentially cure). At
present, most such work has been concentrated on
soft tissue metastases, especially in the liver.
The skeletal implications of this work are just being
realized. In one study, 25 terminally ill patients with
painful lesions previously treated unsuccessfully by
radiation and/or chemotherapy, a small amount of
95% alcohol was injected under CT guidance. Seventyfour per cent of cases experienced reduction in analgesic needs within 1-2 days after the procedure.69
Another interesting report used CT guidance to perform tumor ablation with radiofrequency energy.70 It
is likely that the near future will bring rapid growth in
the role played by radiologists in the management of
patients with metastatic disease.
RIBAK
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