Ecase #4 - January 22-26

Ms. N is a 78 year old woman who came in for evaluation of R hip pain, worse with lying on the R side or getting up from a chair, and aching continuously around the greater trochanter. She responded to treatment for trochanteric bursitis, but Xray of the pelvis incidentally showed a sclerotic lesion possibly consistent with osteoblastic metastasis in the R supra-acetabular region.

Past medical history is significant for:

1. "Fibrocystic change" on HRT. HRT was discontinued 10 months ago with normal mammogram and breast exam 6 months ago and normal breast exam 1 month ago.

2. Microscopic hematuria x many years; cystoscopy in 1988 was normal, as was ultrasound 1year ago. Urologist declined to repeat cystoscopy during evaluation last year as irritative voiding symptoms were absent.

3. History of "colon polyp" 5 yrs ago; colonoscopy 11/99 normal.

4. S/P hysterectomy for fibroids and endometriosis.

5. Distant history of thyroiditis.

6. Osteoporosis treated with alendronate 10 mg/d.

Family history: mother died of MI in her 50's, also had CVA and osteoporosis, father died of colon CA at 61, brother with CAD and alcoholism, sister with CAD.

Questions

• What cancers may present with bony metastases?

• What review of systems questions might be most helpful? Key physical exam points?

• What tests might be helpful at this point?

• How good is a bone scan for determining whether the lesion on plain film is malignant?

Discussion

Case #4

Davonna Cufley, M.D.

What cancers most frequently metastasize to bone?

"The carcinomas that most frequently metastasize to bone arise in prostate, breast, lung, thyroid, kidney, and bladder,"

Harrison's, 13th ed

When skeletal mets occur in pts without known primary cancers, lung and kidney are the most likely sources: Rougraff, BT. Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy.

Journal of Bone and Joint Surgery - American Volume. 75(9): 1276-81, 1993 Sep.

If you don't have time for the complete review of systems and physical exam during this appt, what might you want to cover in today's visit?

"The seven warning signals widely publicized by the American Cancer Society are useful to remember":

Change in bowel or bladder habits

A sore that does not heal

Unusual bleeding or discharge

Thickening or lump in breast or elsewhere

Indigestion or difficulty swallowing

Obvious change in wart or mole

Nagging cough or hoarseness

-Harrison's, 13th ed.

Physical exam of: prostate, breast, thyroid based on most frequent pattern of metastasis.

Unfortunately, complete history and physical exam focused on breast or prostate and thyroid identified only 3% of primary cancers in the 40 patient series by Rougraff cited above.

Other tests?

Kyle Bryan, M.D., oncologist at PacMed, starts with BMP, CBC, mammogram, and UA.

The Rougraff study above looked at 40 pts with skeletal pain, no cancer history and an osseous lesion with poor margination on plain film. Other tests done were CBC, ESR, electrolytes, LFTs, alk phos, SPEP, technetium bone scan, CXR, and CT of chest, abdomen, and pelvis:

The CXR dx'd 17 pts with lung CA, and CT found an additional 6. CT of abd and pelvis dx'd 5 pts (with liver, kidney, and colon tumors). Skeletal biopsy was done in all, but was diagnostic in only 3 pts (8%) and is NOT recommended as a part of the initial work-up because in addition to offering low yield, it may limit limb-sparing surgery later in treating sarcoma and is unnecessary in multiple myeloma. Also renal tumors can be quite vascular, and prior embolization or needle approach can be used if renal primary has been identified prior to biopsy. Mammography was also done but found to be very low yield as breast cancers are not usually occult at the time of bony metastasis, and therefore was not recommended as part of the initial evaluation.

How good is bone scan to determine if this sclerotic bony lesion is really malignant?

Per Swedish radiology, excellent. In fact the differential of the sclerotic lesion on Ms N's plain film includes benign sclerotic bone island, and in the absence of prior films to determine stability, bone scan was done...and was negative. The patient was reassured that she has a benign lesion in the bone. All 40 pts in the Rougraff study above had positive technetium bone scans.