Diagnostic imaging algorithm for the detection of osseous metastases in patients with known or suspected cancer and vertebral back pain

CT: computed tomography; FDG-PET: 18-F fluorodeoxyglucose positron emission tomography; MRI: magnetic resonance imaging; PET: positron emission tomography; POEMS: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes syndrome.

* Following surgery, the patient will need a comprehensive skeletal survey to assess for other metastases.

¶ For example, in a patient with a monoclonal (M) protein (which can be detected by protein electrophoresis of the serum [SPEP] and/or of an aliquot of urine [UPEP] from a 24-hour collection combined with immunofixation of the serum and urine), hypercalcemia, abnormal immunoelectrophoresis, anemia, or kidney failure.

Δ The presence of multiple skeletal lesions influences choice of therapy.

◊ The vast majority of patients without an unstable spine or evidence of a cord compression do not require surgery. For very highly selected patients who present with or develop a vertebral bone lesion as the only focus of cancer beyond the primary site, resection of the metastasis may optimize local tumor control, provide durable pain relief, and possibly prolong patient survival.

§ A negative repeat biopsy should prompt re-evaluation of the original MRI result.