Orthopedic Oncology cases metastatic bone disease

A left-hand-dominant, 66-year-old female is sent to your office for shoulder pain, possibly a rotator cuff tear. She has pain in her left shoulder and upper arm that is limiting her ability to use the extremity. It is exacerbated by weight bearing, although it does hurt her at night when she tries to sleep as well. She also reports a 30-lb weight loss in the past year. On examination, impingement signs are negative, although she does report pain in the upper arm when it is loaded or palpated.

1. ray of her right shoulder is shown in Figure 8–33. What is the most likely cause of her shoulder pain?

   1. Impending fracture through metastatic lesion in the proximal humerus

   2. Osteoarthritis

   3. Rotator cuff tear

   4. Primary bone tumor of the proximal humerus

 

 

Figure 8–33

 

Discussion

The correct answer is (A). Metastatic bone disease is the most common reason for destructive bone lesions in adults. More than 1.4 million cases of cancer per year are diagnosed in the United States, and bone metastases develop in about 50% of patients. In this case, an impending fracture of the proximal humerus is responsible for the pain, based on the destructive imaging features.

Which of the following is unlikely to be the primary cancer site?

1. Breast

2. Kidney

3. Lung

4. Uterus

 

Discussion

The correct answer is (D). The most common primary cancer sites that metastasize to bone are breast, thyroid, prostate, lung, and kidney.

Which of the following is not included in the workup of an older patient with a destructive bone lesion?

1. CT scan of chest, abdomen, pelvis

2. Liver function tests

3. Electrolyte panel

4. Whole-body bone scan

 

Discussion

The correct answer is (B). The workup of an older patient with a destructive bone lesion includes a thorough history and physical examination (focusing on breast, lung, prostate, thyroid, and lymph nodes), electrolyte panel (with calcium), prostate-specific antigen, alkaline phosphatase, complete blood count, serum protein electrophoresis/urine protein electrophoresis, urinalysis, plain radiographs of the bone lesion (in two planes, including the entire bone), a CT scan of the chest, abdomen, and pelvis, and a whole-body bone scan. In up to 85% of patients, this workup will reveal the primary site of malignancy. Liver function tests are not routinely included in this workup, as hepatocellular cancer rarely metastasizes to bone.

 

Objectives: Did you learn...?

 

To recognize metastatic bone disease on imaging?

 

 

The workup of a patient who presents with a bone lesion? The common sites of primary disease which spreads to bone?