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in Palliative Medicine
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
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-
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SALVO ET AL.
FIG. 3. The bone scan does not show uptake in 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
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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.
FIG. 5.
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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