Diagnostic Tests for Bone cancer
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Bone cancer Diagnosis: Book Excerpts
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BONE MASS OR SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, serum protein electrophoresis, and plain films of the involved bones. A skeletal survey may be necessary. Bone scans are often useful. A search for a primary tumor may require chest x-ray, upper GI series, barium enema, intravenous pyelogram, mammography, prostatic examination, PSA titer, thyroid scans, lymph node biopsy, and bone marrow examinations.
CT scans of the area may help differentiate the mass or swelling. Needle biopsy or exploratory surgery and bone biopsy may be necessary before deciding what surgical approach should be undertaken.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Bone Cyst:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Focused physical examination (PE). Bone cyst is a diagnosis that should be kept in mind during routine examinations of children, even those not suspected of harboring bone cysts. However, once it appears on x-ray, remember to examine the area on every visit. This should include careful palpation of the bone and entire limb, looking for tender areas or associated soft tissue masses. Comparative measurement should be done with the other limb in any cases of deviation from normal or any protrusion of bone or soft tissue, looking for signs of progression between visits. All these should prompt referral, because they may be signs that the cyst is actually another lesion, or that it is growing, heading for impending fracture, or impinging on the epiphysis.
B. Additional PE. Routine growth charts should be maintained meticulously. Measurement of leg and arm lengths to ascertain whether growth is being interfered with is especially pertinent if the bone cyst is near the epiphysial growth plate.
Testing
A. Clinical laboratory tests. No special tests are necessary, apart from those usually ordered in the course of routine care.
B. Diagnostic imaging. The diagnosis is made by x-ray study, but further studies may be indicated to delineate the lesion better. Initial evaluation begins with routine radiography. Certain features help to determine the “biologic activity” or aggressiveness and growth rate of a lesion, which, combined with location and clinical and epidemiologic data can lead to a decision to order additional imaging studies (5).
1. Plain radiography. In a study of 709 cases of solitary bone lesions, 40 unicameral bone cysts (UBCs) were analyzed according to demographic, anatomic, and radiographic features (6). Of the 40, 33 (83%) were in long bones and 7 were in the pelvis or calcaneus. All 40 UBCs were geographic, medullary, and lytic. None had an associated soft-tissue mass. Pathologic fractures were present in 55% and 10% had fallen fragment signs; 98% had no cortical break and 88% had well-defined margins. In their conclusion, the authors found a quantitative sensitivity of 80% and specificity of 93% that included the radiographic features of metaphyseal, diaphyseal, or flat bone location; geographic, lytic, or medullary based; no matrix, no satellite lesions, no subarticular extension, no soft-tissue mass, and no cortical break; and a central location in long bones.
2. Magnetic resonance imaging has multiplanar imaging and better contrast sensitivity, allowing it to help differentiate benign lesions from malignant ones. The signal intensity on spin-density images can indicate the type of fluid and the presence of septa, and can show if the lesion is fibrous or not. T2-weighted images can show presence or absence of soft-tissue mass. The relationship to the epiphysial plate can be seen well. In addition to causing encroachment into the physis, a large cyst can cause subchondral collapse, joint incongruity, and avascular necrosis (4).
3. Serial repeat x-ray study. If electing to follow the cyst, serial plain x-ray studies can be done, cyst diameter measurement taken, or computer assisted densitometric image analysis of serial radiographs obtained.
Diagnostic assessment
The key to the diagnosis of bone cyst is the typical appearance on x-ray film. When a deviation from the expected image is seen, try to ascertain that the lesion is not a more serious one, either by referral or further imaging. “Active cysts,” which abut the growth plate, have the potential to cause damage and should be followed carefully or treated. Fracture of the cyst is commonly the presenting sign.
References
1. Capanna R, Campanacci DA, Manfrini M. Unicameral and aneurysmal bone cysts. Orthop Clin North Am 1996;27:605–614.
2. Lokiec F, Wientroub S. Simple bone cyst: etiology, classification, pathology and treatment modalities. J Pediatr Orthop Part B 1998;7(4):262–273.
3. Leither A, Windhager R, Lang S, Hass OA, et al. Aneurysmal bone cyst: a population based epidemiological study and literature review. Clin Orthop 1999;363:176–179.
4. Gupta AK, Crawford AH. Solitary bone cyst with epiphyseal involvement: confirmation with magnetic resonance imaging. A case report and review of the literature. J Bone Joint Surg Am 1996;78:911–915.
5. Deely D, Schweitzer ME. Imaging evaluation of the patient with suspected bone tumor. In: Taveras JM, Ferrucci JT, eds. Radiology: diagnosis-imaging-intervention. Philadelphia: Lippincott-Raven Publishers 1998;5(74):1–6.
6. Lee JH. Reinus WR, Wilson AJ. Quantitative analysis of the plain radiographic appearance of unicameral bone cysts. Invest Radiol 1999;34(1):28–37.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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