Metastatic disease

Question 1

What are the most common tumours causing bone metastases in descending order?

Answer 1

Prostate, breast, lung

Question 2

What are the most common sites for bone metastases in descending order?

Answer 2

Spine, pelvis, ribs, skull, long bones

Question 3

What are the features of bone metastases other than bone pain?

Answer 3

Pathological fractures, hypercalcaemia, raised ALP

Question 4

What are lung metastases?

Answer 4

Lung metastases are secondary cancer growths in the lungs originating from other cancers.

Question 5

Which cancers commonly cause lung metastases?

Answer 5

Lung metastases are seen with a wide variety of cancers including breast cancer, colorectal cancer, renal cell cancer, bladder cancer, and prostate cancer.

Question 6

What are ‘cannonball metastases’?

Answer 6

Multiple, round well-defined lung secondaries are often referred to as ‘cannonball metastases’.

They are most commonly seen with renal cell cancer but may also occur secondary to choriocarcinoma and prostate cancer.

Question 7

Is calcification common in lung metastases?

Answer 7

Calcification in lung metastases is uncommon except in the case of chondrosarcoma or osteosarcoma.

Question 8

What investigations does NICE recommend for all patients with metastatic disease of unknown primary?

Answer 8

FBC, U&E, LFT, calcium, urinalysis, LDH, Chest X-ray, CT of chest, abdomen and pelvis, AFP and hCG

Question 9

What specific investigations does NICE recommend for patients with lytic bone lesions?

Answer 9

Myeloma screen

Question 10

What specific investigation does NICE recommend for patients with symptoms requiring endoscopy?

Answer 10

Endoscopy directed towards symptoms

Question 11

What specific investigation does NICE recommend for men?

Answer 11

PSA

Question 12

What specific investigation does NICE recommend for women with peritoneal malignancy or ascites?

Answer 12

CA 125

Question 13

What specific investigation does NICE recommend for men with germ cell tumours?

Answer 13

Testicular US

Question 14

What specific investigation does NICE recommend for women with clinical or pathological features compatible with breast cancer?

Answer 14

Mammography

Question 15

What investigations does NICE recommend for all patients with metastatic disease of unknown primary?

Answer 15

FBC, U&E, LFT, calcium, urinalysis, LDH, Chest X-ray, CT of chest, abdomen and pelvis, AFP and hCG

Question 16

What specific investigations does NICE recommend for patients with lytic bone lesions?

Answer 16

Myeloma screen

Question 17

What specific investigation does NICE recommend for patients with symptoms requiring endoscopy?

Answer 17

Endoscopy directed towards symptoms

Question 18

What specific investigation does NICE recommend for men?

Answer 18

PSA

Question 19

What specific investigation does NICE recommend for women with peritoneal malignancy or ascites?

Answer 19

CA 125

Question 20

What specific investigation does NICE recommend for men with germ cell tumours?

Answer 20

Testicular US

Question 21

What specific investigation does NICE recommend for women with clinical or pathological features compatible with breast cancer?

Answer 21

Mammography

Question 22

What are the types of metastatic bone tumours?

Answer 22

Metastatic bone tumours may be described as blastic, lytic, or mixed.

Question 23

Which type of metastatic disease has the lowest risk of spontaneous fracture?

Answer 23

Osteoblastic metastatic disease has the lowest risk of spontaneous fracture when compared to osteolytic lesions of a similar size.

Question 24

Which region is most prone to spontaneous fracture?

Answer 24

Lesions affecting the peritrochanteric region are most prone to spontaneous fracture due to loading forces at that site.

Question 25

What system is used to stratify the risk of spontaneous fracture for bone metastasis?

Answer 25

The factors are incorporated into the Mirel Scoring system.

Question 26

What are the scoring criteria for the Mirel Scoring system?

Answer 26

Score points are based on Site, Radiographic appearance, Width of bone involved, and Pain.

Question 27

What is the treatment for a Mirel score of 9 or greater?

Answer 27

Prophylactic fixation ## Footnote Risk of fracture is 33%.

Question 28

What is the treatment for a Mirel score of 8?

Answer 28

Consider fixation ## Footnote This score is borderline.

Question 29

What is the treatment for a Mirel score of 7 or less?

Answer 29

Non operative management ## Footnote Risk of fracture is 4%.

Question 30

What is a key concern for patients with spinal metastases?

Answer 30

Patients may present with spinal metastases before developing metastatic spinal cord compression. It is important to detect these patients early before any neurological compromise develops.

Question 31

What are the symptoms of spinal metastases?

Answer 31

Unrelenting lumbar back pain, any thoracic or cervical back pain, worse with sneezing, coughing or straining, nocturnal pain, and associated tenderness.

Question 32

What should be suspected if neurological features are present?

Answer 32

If any neurological features are present, then spinal cord compression must be suspected and acted on promptly.

Question 33

What imaging should be completed without neurological features?

Answer 33

Without neurological features, a whole spine MRI should be completed within one week.

Question 34

Why should the whole spine be imaged?

Answer 34

The whole spine should be imaged as patients commonly present with multi-level disease.