eMedicine Specialties > Orthopedic Surgery > Neoplasms

Metastatic Carcinoma: Differential Diagnoses & Workup

Author: Howard A Chansky, MD, Associate Professor, Department of Orthopedics and Sports Medicine, University of Washington Medical Center
Coauthor(s): John Eady, MD, Chief, Orthopaedic Surgery, Dorn VA Hospital, Columbia, SC 29209
Contributor Information and Disclosures

Updated: Jan 29, 2008

Differential Diagnoses

Chondrosarcoma
Paget Sarcoma
Malignant Lymphoma
Postradiation Sarcoma
Myeloma
Non-neoplastic Conditions Simulating Bone Tumors
Osteomyelitis

Other Problems to Be Considered

Primary bone sarcoma (malignant fibrous histiocytoma and others)

Workup

Laboratory Studies

  • Serum alkaline phosphatase
    • Indirect reflection of bone destruction because it is a reflection of osteoblastic response
    • May not be elevated in purely lytic tumors, such as plasma cell myelomas
    • Nonspecific because it can also be elevated in Paget disease, benign insufficiency fractures, endocrine disease, and others
  • Serum protein electrophoresis (SPEP)
  • Urinalysis, urine protein electrophoresis (UPEP)
  • N-telopeptide (NTx) of type II collagen - Marker of bone resorption, but not widely used

Imaging Studies

  • Radiography
    • Basic assessment of the extent of a tumor and the degree of cortical erosion
    • Skeletal survey in multiple myeloma
  • Computed tomography (CT) scanning
    • Best assessment of the extent of cortical destruction
    • Not always indicated if radiography and the clinical picture are informative and the surgical plan is clear
    • Most sensitive imaging modality to detect bone destruction
  • Technetium-99m (99m Tc) bone scanning
    • Very sensitive study to detect occult lesions and assess the biologic activity of lesions
    • Not useful by itself for multiple myeloma
    • Part of the workup for an unknown primary site to identify any other lesions and to identify the easiest lesion from which to obtain a biopsy
    • Indirect measure of destruction because it actually reflects the activity of osteoblasts
    • Can demonstrate increased activity because a lesion consolidates in response to radiotherapy
  • Magnetic resonance imaging (MRI) - Most sensitive study to assess the anatomic (intramedullary and extraosseous) extent of a lesion
  • Angiography
    • Essentially has been supplanted by MRI
    • Still useful for the preoperative embolization of vascular lesions, such as renal cell carcinomas, thyroid metastases, and (occasionally) myelomas

Procedures

  • Biopsy
    • Any isolated (solitary), presumed metastasis should be treated as a resectable primary tumor until there is proof to the contrary.
    • A biopsy should be obtained from any soft-tissue mass that is present.
    • If no soft-tissue mass is present, a biopsy should be obtained from the most accessible bone; preferably, the biopsy should be performed in a mechanically safe area (eg, metaphysis vs diaphysis, acetabulum vs subtrochanteric femur).

More on Metastatic Carcinoma

Overview: Metastatic Carcinoma
Differential Diagnoses & Workup: Metastatic Carcinoma
Treatment & Medication: Metastatic Carcinoma
Follow-up: Metastatic Carcinoma
Multimedia: Metastatic Carcinoma
References
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References

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  2. Quattrocchi CC, Piciucchi S, Sammarra M, et al. Bone metastases in breast cancer: higher prevalence of osteosclerotic lesions. Radiol Med (Torino). Oct 2007;112(7):1049-59. [Medline].

  3. Yazawa Y, Frassica FJ, Chao EY, et al. Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures. Clin Orthop Relat Res. Feb 1990;(251):213-9. [Medline].

  4. British Association of Surgical Oncology Guidelines. The management of metastatic bone disease in the United Kingdom. The Breast Specialty Group of the British Association of Surgical Oncology. Eur J Surg Oncol. Feb 1999;25(1):3-23. [Medline].

  5. Mundy GR, Yoneda T. Facilitation and suppression of bone metastasis. Clin Orthop Relat Res. Mar 1995;(312):34-44. [Medline].

  6. Guise TA, Yin JJ, Taylor SD. Evidence for a causal role of parathyroid hormone-related protein in the pathogenesis of human breast cancer-mediated osteolysis. J Clin Invest. Oct 1 1996;98(7):1544-9. [Medline]. [Full Text].

  7. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. Dec 1989;(249):256-64. [Medline].

  8. Hipp JA, Springfield DS, Hayes WC. Predicting pathologic fracture risk in the management of metastatic bone defects. Clin Orthop Relat Res. Mar 1995;(312):120-35. [Medline].

  9. Harrington KD. Orthopedic surgical management of skeletal complications of malignancy. Cancer. Oct 15 1997;80(8 Suppl):1614-27. [Medline]. [Full Text].

  10. Harrington KD. Orthopaedic management of extremity and pelvic lesions. Clin Orthop Relat Res. Mar 1995;(312):136-47. [Medline].

  11. Clayer MT, Tang X. Low risk of cardiac events during intramedullary instrumentation of lung cancer metastases. Acta Orthop. Aug 2007;78(4):547-50. [Medline]. [Full Text].

  12. Camnasio F, Scotti C, Peretti GM, et al. Prosthetic joint replacement for long bone metastases: analysis of 154 cases. Arch Orthop Trauma Surg. Oct 9 2007;[Medline].

  13. Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery. Sep 2007;61(3):531-7; discussion 537-8. [Medline].

  14. Forauer AR, Kent E, Cwikiel W, et al. Selective palliative transcatheter embolization of bony metastases from renal cell carcinoma. Acta Oncol. 2007;46(7):1012-8. [Medline].

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Further Reading

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Keywords

bone cancer, adenocarcinoma, skeletal metastases, bone carcinoma, carcinoma of the bone, metastatic bone disease, bone metastases, pathologic fracture

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Contributor Information and Disclosures

Author

Howard A Chansky, MD, Associate Professor, Department of Orthopedics and Sports Medicine, University of Washington Medical Center
Howard A Chansky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

John Eady, MD, Chief, Orthopaedic Surgery, Dorn VA Hospital, Columbia, SC 29209
John Eady, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Lynn A Crosby, MD, FACS, Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine
Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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