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Vertebral metastases

Vertebral metastatic disease must be included in any differential diagnosis of a bone lesion in a patient older than age 40. 

Epidemiology

Vertebral metastases are already present in 10% of newly diagnosed cancers. They are much more frequent in higher age groups (> 50 years). 

Clinical presentation

Vertebral lesions are very frequently asymptomatic in the setting of widespread metastatic disease, and are thus often found incidentally when imaging is performed for other resons (e.g. staging).

Lesions may become sympomatic due to bone pain, pathological compression fractures, or extension into spinal canal with cord compression and ensuing neurology. 

Pathology

The most common primary neoplasms to involved the vertebrae include: 

Metastases are eitehr osteoblastic versus osteolytic, however osteoid formation and mineralisation is of limited help in determining the primary tumour as some metastases may secrete osteoblast- and osteoclast-stimulating factors at the same time. New bone formation may also occur after chemotherapy or radiation therapy. Having said that some primaries more frequently result in sclerosis than others. 

Primaries with predominantly osteoblastic metastases (sclerotic extradural bone lesions) include: 

Primaries with predominantly osteolytic metastases, that may rarely become osteoblastic (mixed sclerotic and lytic extradural bone lesions)

Primaries with osteolytic metastases

Radiographic features

Metastatic lesions can have virtually any appearance. They can mimic a benign lesion or an aggressive primary bone tumor. It can be difficult, if not impossible, to judge the origin of the tumor from the appearance of the metastatic focus, although some appearances are fairly characteristic.

Plain film

Radiographs are useful as an overview but are insensitive to small lytic lesions and struggle to assess for compromise of the canal. As metastases have a predilection for involving the posterior vertebral body and pedicle, a missing pedicle (see: absent pedicle sign) is a useful and subtle sign to seek on AP films. 

CT

The appearance on CT will depend on the degree of mineralisation of the metastasis. The more common lytic metastases appear as regions of soft tissue attenuation with irregular margins. The mass may breach the cortex and result in compromise of the spinal canal. 

Sclerotic lesions appear hyperdense and irregular but are less likely to extend beyond the vertebrae. 

MRI

MRI is sensitive to metastatic disease and is able also assess for cord compression. The signal intensity of the metastatic deposits will vary according to the degree of mineralisation. 

Osteoblastic metastases
  • T1: hypo-intense
  • T2: hypo-intense
Mixed sclerotic and lytic extradural bone lesions
  • T1: hypo-intense
  • T2: hypo - or / and hyper-intense
Lytic extradural bone lesions
  • T1: intermediate to hypo-intense
  • T2: hyper- or iso-intense
  • T1 C+ )GD): enhancement usually present

Differential diagnosis

 For osteoblastic metastases consider 

(mostly solitary lesions, patients may however present with a history of cancer)

For mixed sclerotic and lytic extradural bone lesions consider

For lytic extradural bone lesions consider

See also


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The differential diagnosis for bone tumours is dependant on the age of the patient, with a very different set of differentials for the paediatric patient.

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