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Case Discussions

in Palliative Medicine

JOURNAL OF PALLIATIVE MEDICINE


Volume 12, Number 2, 2009
Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2008.0055

Feature Editor: James Hallenbeck

The Role of Plain Radiographs in Management


of Bone Metastases
Nadia Salvo, B.Sc.(C).,1 Monique Christakis, M.D.,2 Joel Rubenstein, M.D.,2
Eric de Sa, B.Sc.,1 Julie Napolskikh, B.Sc.,1 Emily Sinclair, M.R.T.(T).,1 Michael Ford, M.D.,3
Philiz Goh, B.Sc.,1 and Edward Chow, M.B.B.S.1
Abstract

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant
pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays
necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions
will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare
false-positive results. We present a case with a false-positive result in a patient with lung cancer.
Case History

70-year-old male was investigated for an enlarged


prostate in July 2007. During the work-up, a computed
tomography (CT) scan was performed that revealed a large
lesion in the upper left lobe measuring 12  10 cm and abutting against the chest wall. Biopsy confirmed a diagnosis of
poorly differentiated non-small cell lung cancer. A left
pleural effusion was also noted, rendering his tumor nonresectable. He was referred to the Rapid Response Radiotherapy Program (RRRP) at the Odette Cancer Centre in September 2007 for palliative radiation therapy. The patient
arrived at the clinic with plain x-ray images of the pelvic region. From the x-rays, a radiologist reported an osteolytic lesion within the right femoral neck, extending into the right
femoral shaft with an increased risk of fracture (Figs. 1 and
2). However, a subsequent bone scan revealed no uptake at
the corresponding site (Fig. 3). The patient, however, did not
complain of pain at the region of interest. The patient later
brought a set of CT scans performed at another facility,
which were reviewed by two radiologists who agreed that
the lesion was an intraosseous lipoma, a benign finding that
does not increase the risk of fracture (Figs. 4 and 5). The patient was referred to an orthopedic surgeon who also confirmed that no surgical intervention was necessary. The patient was not treated with radiation to the right hip.
Discussion
Approximately 50% of patients with cancer will develop
skeletal metastases, which are often associated with considerable morbidity.1 Bone is the third most common site of me1Department
2Department

tastasis following liver and lung1,2 and has a 30%40% incidence in patients with advanced lung cancer.2 Common
skeletal related events associated with bone metastases include hypercalcemia, severe bone pain, pathologic fracture
at the site, and spinal cord compression,26 all of which can
significantly reduce ones quality of life. Diagnosis of bone
metastases often results in treatment, including external
beam radiation, chemotherapy, or surgical interventions.7
The primary identification of bone metastases occurs
through the use of a bone scintigraphy scan, which has a
high sensitivity for recognizing any type of lesion within
bone,8 and is frequently followed by a radiograph of the region of interest. Bone scintigraphy is a sensitive but nonspecific imaging modality that uses technetium-labeled radionuclides and gamma cameras to detect areas of metabolic
activity within bone.9 Positive bone scans followed by negative x-rays are not uncommon; a bone scan will detect any
active lesion,8 such as a fracture or an arthritic area, whereas
a positive radiograph followed by a negative bone scan is
unusual.8 Another diagnostic tool frequently used is the
computed tomography (CT) scan, which has the advantage
of producing a high-contrast resolution, cross-sectional
three-dimensional image.9 CT scans help identify lipomas
without difficulty due to the low density of fat cells, making
them distinguishable from bone.9
Magnetic resonance imaging (MRI) has surpassed all other
imaging modalities because without a loss in resolution, it
produces multiple-planed images based on the number of
free water protons within a tissue rather than its density as
is used in radiography.9 This property allows for superior
characterization of tissues sufficient to suitably stage skele-

of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario.


of Diagnostic Radiology, 3Department of Orthopedics, Sunnybrook Health Sciences Centre, Toronto, Ontario.

195

196

SALVO ET AL.

FIG. 1. Plain x-ray of the right femur. An osteolytic lesion


was documented at the right femoral head, extending into
the femoral neck (arrow).

FIG. 3. The bone scan does not show uptake in the region
of interest.

FIG. 2. Plain x-ray of the right femur. The arrows indicate


the region of interest.

tal lesions.9 Positron emission tomography (PET) is an alternative scanning approach that uses biologic tracers that
reveal uptake in metabolically active tissue.10 The advantage
of a PET scan is its ability to detect some occult lesions that
other imaging modalities are unable to identify; however,
further research into the use of PET scans for the identification of bone metastases must be carried out.10 While both
MRI and PET scans are modern and technologically advanced imaging techniques, they are expensive to operate
and many rural centers do not have access to them. In many
cases, plain x-ray, bone scintigraphy, and a CT scan are the
most affordable and accessible methods of identifying osseous tumors.
Plain radiography remains the standard for providing a
differential diagnosis of skeletal lesions911 but it should be
used in combination with other imaging modalities.7,9,10,12
Fletcher and Hanna,7 in a discussion of identification of pediatric musculoskeletal lesions using various imaging techniques, warned that in some cases plain film may lead one
to infer a specific diagnosis, while in many instances x-ray

PLAIN X-RAY FALSE-POSITIVE REPORT

197

FIG. 4. The computed tomrography (CT) scan of the pelvis shows evidence of an intraosseous lipoma beginning in the
femoral head and extending into the femoral neck.

images are nonspecific, especially when the area in question


appears to be a boney metastatic lesion. A study conducted
by Whyne et al.3 looked at methods of quantitatively characterizing bone lesions through the use of CT scans and
found that plain x-rays do not provide adequate information
to determine tumor dimensions and bone destruction,
whereas CT offers superior bone detail and is able to accurately identify a bone metastasis 71%100% of the time.
On the other hand, Pomeranz et al.11 stated in a comparative report of imaging methods that plain x-rays provide
the most accurate information when considering the histo-

FIG. 5.

logical nature of a lesion; however, there are times when it


is essential to evaluate multiple imaging techniques to make
accurate clinical decisions. Tudor et al.13 in a study assessing the inter-observer agreement when analyzing plain radiography, noted that skilled x-ray analysts miss approximately 30% of instances that do show evidence of disease
and are likely to over-interpret up to 2% of films that are
negative for disease. Previous knowledge of the clinical presentation of disease aided study participants to precisely
evaluate the x-ray.13 The authors also found that interobserver agreement was higher when the plain radiograph

An image from the computed tomography (CT) scan shows the intraosseous lipoma (arrow).

198
showed abnormal findings than for normal radiographs and
this consensus was strengthened with knowledge of the clinical history of the patient.13 False-positives most often appear to occur when a diagnosis is significant for disease and
cytology or further radiologic evidence proves otherwise, indicating a lower specificity of the technique.14 Furthermore,
sensitivity is considered lower with an increased occurrence
of false-negatives, which involve a lack of a diagnosis when
upon further investigation the existence of disease or injury
is discovered.14 Consequently, exercising a systematic approach when assessing bone lesions with a variety of imaging modalities should supply adequate information for an
accurate differential diagnosis15 and lower the incidence of
false-positive or false-negative findings.
It is essential that careful interpretation is used when assessing plain film, especially when clinical symptoms do not
correlate with image findings. This case report serves to remind that although bone metastases are a common occurrence among patients with cancer it is imperative to investigate the clinical manifestation of illness, use and correlate
available imaging methods, seek interrater reliability, and if
needed, consult with other specialists prior to management.16
Acknowledgments
The studentship was funded by the Michael and Karyn
Goldstein Cancer Research Fund.
References
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Trials 2005;26:252259.
15. Parsons TW III, Frink SJ, Campbell SE: Musculoskeletal neoplasia: Helping the orthopaedic surgeon establish the diagnosis. Semin Musculoskelet Radiol 2007;11:315
16. MacVicar D, Crawshaw J: Radiology. In: Davies A (ed): Cancer-Related Bone Pain. Sutton: Oxford University Press, 2007,
pp. 3739.

Address reprint requests to:


Edward Chow, M.B.B.S., Ph.D., FRCPC
Department of Radiation Oncology
Odette Cancer Centre
Sunnybrook Health Sciences Centre
University of Toronto
2075 Bayview Avenue
Toronto, Ontario M4N 3M5
Canada
E-mail: Edward.Chow@sunnybrook.ca

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