Natalie J. M.

Dailey
Gillian Lieberman, MD

September 2002

Radiologic Diagnosis of Spinal

Metastases
Natalie J. M. Dailey, Harvard Medical
Student Year III
Gillian Lieberman, MD

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients Presenting Story

70 year old male
Presents to the hospital for laparascopic
cholecystectomy
Receives pre-operative chest x-ray

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

Whats going on here?!!

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

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.

Natalie J. M. Dailey
Gillian Lieberman, MD

Differential Diagnosis for Chest X-Ray

Findings
Multiple myeloma-punched out lytic lesions
Pagets-large, sclerotic bones;coarse trabeculae
Infection
Infarction
Trauma
Primary bone tumor

Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhls Essentials of Radiologic
Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

Natalie J. M. Dailey
Gillian Lieberman, MD

Common Bone Metastases

Radiographic Appearance
Lytic Lesions:
Breast
Lungs
Kidney
Thyroid

Sclerotic Lesions:
Breast
Prostate

Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

Natalie J. M. Dailey
Gillian Lieberman, MD

Example of Sclerotic
Lesions
Comparison Patient I
Patient diagnosed with prostate
cancer
Sclerotic bone lesions

Courtesy of Ferris Hall, MD

10

Natalie J. M. Dailey
Gillian Lieberman, MD

Common Sites of Bone Metastasis

Spine
Pelvis
Ribs
Skull
Proximal humerus or femur
Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.
11

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.
12

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic
Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

13

Natalie J. M. Dailey
Gillian Lieberman, MD

How to Work Up Possible Spinal

Metastases (contd)
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 Juhls Essentials of Radiologic
Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998.
14

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

15

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

Bone Scan of Spinal

MetastasesComparison 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

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

Findings on Chest XRay Comparison

Patient III(contd)
Lateral view:
Compression
fractures/vertebral
body collapse
Changes in bone
density
Cortical destruction
Nearby soft tissue
mass

From BIDMC PACS Courtesy of K.P. Donohoe, M.D.

19

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic
Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

21

Natalie J. M. Dailey
Gillian Lieberman, MD

Axial Spinal Anatomy

Vertebral Body
Spinal Cord
Rib
Paraspinal Musculature
Lungs
Sternum

From Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform

22

Natalie J. M. Dailey
Gillian Lieberman, MD

Anatomy (contd) Vertebral Detail

Pedicle
Neural Foramen
Spinous Process
Spinal Cord
CSF Space
Exiting vertebral nerve

From Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform

23

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients CT Scan

Findings with Lung
Window Settings:
Loculated Pleural
Effusion (13 HU
indicating fluid);
probably resulting
from resection of RML

From BIDMC PACS

24

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients CT Scan (contd)

Findings with CT Bone
Window:
Loss of cortical
margin
Change in density
within vertebral body

From BIDMC PACS

25

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.
Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1): 115-135.

26

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients 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

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients MR Study (contd)

More Findings on T1Weighted Imaging
(Axial View):
Low-signal intensity
lesion in vertebral body

From BIDMC PACS

Involvement of right
pedicle
No apparent
impingement of spinal
cord

28

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients MR Study

(contd)
Findings on T1Weighted Image
(sagittal view):
CSF low-intensity
signal
Low-signal intensity
lesions in vertebral
bodies
Bright subcutaneous fat
From BIDMC PACS

29

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients MR Study (contd)

Findings on T2Weighted Image:
CSF highsignal intensity
Lesions within
vertebral body
Obliteration of
neural foramen
(compare with
other side)
From BIDMC PACS

30

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients MR Study (contd)

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

Natalie J. M. Dailey
Gillian Lieberman, MD

Our Patients MR Study

(contd)
Findings on T2-weighted
image with fat suppression:
Unsuppressed marrow
lesions (indicating the
presence of edema)
Compression fracture

From BIDMC PACS

32

Natalie J. M. Dailey
Gillian Lieberman, MD

So what do we do now that we know that

its metastatic disease?

33

Natalie J. M. Dailey
Gillian Lieberman, MD

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 Juhls Essentials of Radiologic Imaging.
Seventh edition. Lippincott Williams and Wilkins: New York, 1998.

34

Natalie J. M. Dailey
Gillian Lieberman, MD

Approach for CT-Guided Bone Biopsy

From BIDMC PACS

35

Natalie J. M. Dailey
Gillian Lieberman, MD

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, 1999.

36

Natalie J. M. Dailey
Gillian Lieberman, MD

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, 2000.

37

Natalie J. M. Dailey
Gillian Lieberman, MD

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

Natalie J. M. Dailey
Gillian Lieberman, MD

Special thanks to:

Chad Brecher, MD
K.P. Donohoe, MD
Daniel Saurborn, MD
Ferris Hall, MD
Pamela Lepkowski
Gillian Lieberman, MD
Larry Barbaras and Cara Lyn Damour
39

Natalie J. M. Dailey
Gillian Lieberman, MD

References
Abeloff, MD, Armitage, JO, Lichter, AS, and Niederhuber, JE. Clinical Oncology.
Second edition. Churchill Livingstone: New York, 2000.
Cotran, RS, Kumar, V, and Collins, T. Robbins Pathological Basis of Disease. Sixth
edition. W.B. Saunders Company: Philadelphia, 1999.
Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform
Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhls Essentials of Radiologic
Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998.
Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1): 115-135.

40