Metastases from carcinoma are by far the most common malignant tumors involving the skeleton.

Imaging has an important role in the detection, diagnosis, prognostication, treatment planning, and follow-up monitoring of bone metastases. In patients with proven nonskeletal tumors, imaging is useful for screening the skeleton to assess metastatic disease and, if it is present, to determine its extent.[1, 2, 3] In a patient without a known malignancy, a possible diagnosis of bone metastases may be made by recognizing radiographic and other imaging findings. If bone metastases are present or suspected, further imaging or imaging-guided techniques may be required to confirm the diagnosis, to establish the extent of the disease, and to find the primary tumor. Bone metastases are often multiple at the time of diagnosis. In adults, the lesions generally occur in the axial skeleton and other sites with residual red marrow, although the lesions may be found anywhere in the skeletal system. Common sites for metastases are the vertebrae, pelvis, proximal parts of the femur, ribs, proximal part of the humerus, and skull. More than 90% of metastases are found in this distribution. Certain carcinomas may have a predilection for particular skeletal sites. For example, metastases to the bones of the hands and feet are rare, but 50% of hand metastases originate from lung neoplasms (see the image below). Primary tumors arising from the pelvis have a predilection for spread to the lumbosacral spine.

Bone metastases to the finger. Radiograph shows a destructive expanded osteolytic lesion in the metacarpal of the thumb in a 55-year-old man with lung carcinoma.

Occasionally, patients with bone metastases may present with a pathologic fracture; therefore, checking the state of underlying bone for disease is important if such a fracture is suspected (see the first image below).[4] In addition, patients may present with complications of bone metastases, such as neurologic impairment due to spinal epidural compression (see the second image below).

Pathologic fracture. Radiograph shows a displaced fracture through an osteolytic lesion in

the distal femur of a 53-year-old woman with lung carcinoma. Spinal epidural compression in a 70-year-old man with leg weakness. Lateral lumbar myelogram shows a complete epidural block due to a destructive osteolytic lesion of the L3 vertebral body. Lumbar puncture was performed at the L2-3 level.

Pathophysiology
A basic knowledge of the processes by which metastases involve bone helps in understanding radiologic findings. Bone involvement in metastases occurs by means of 3 main mechanisms: (1) direct extension, (2) retrograde venous flow, and (3) seeding with tumor emboli via the blood circulation. Seeding occurs initially in the red marrow; this process accounts for the predominant distribution of metastatic lesions in the red marrowcontaining areas in adults. In contrast, bone metastases are usually widespread in children. Retrograde venous embolism is probably the major mechanism when spread from intraabdominal cancer involves the vertebrae. Increased intra-abdominal pressure causes blood to be diverted from the systemic caval system to the valveless vertebral venous plexus of Batson; this diversion allows the caudal and cranial flow of blood. As a metastatic lesion grows in the medullary cavity, the surrounding bone is remodeled by means of either osteoclastic or osteoblastic processes. The relative degree of resultant bone resorption or deposition is highly variable and depends on the type and location of the tumor. The relationship between the osteoclastic and osteoblastic remodeling processes determines whether a predominant lytic, sclerotic, or mixed pattern is seen on radiographs.[5, 6]

Differential diagnosis and other problems to be considered

When evaluating for bone metastases, also consider bone islands, eosinophilic granuloma of the skeleton, bone lymphoma, osteomalacia and renal osteodystrophy, chronic osteomyelitis, Paget disease, pelvic insufficiency fractures, stress fractures, tuberous sclerosis, and secondary osteoarthritis.

Preferred examination
Technetium-99m (99m Tc) bone scintiscanning (ie, radionuclide bone scanning) is widely regarded as the most cost-effective and available whole-body screening test for the assessment of bone metastases. Conventional radiography is the best modality for characterizing lesions that are depicted on bone scintiscans. Combined analysis and reporting of findings on radiographs and 99m Tc bone

scintiscans improve the diagnostic accuracy in detecting bone metastases and assessing the response to therapy.[7, 8, 9] Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are useful in evaluating suspicious bone scintiscan findings that appear equivocal on radiographs. [10, 11, 12, 13] MRI can also help in detecting metastatic lesions before changes in bone metabolism make the lesions detectable on bone scintiscans.[14, 15, 16] CT scanning is useful in guiding needle biopsy, particularly in vertebral lesions. MRI is helpful in determining the extent of local disease in planning surgery or radiation therapy. The first screening test used for the detection of bone metastases depends on the relative availability of MRI and99m Tc bone scintiscanning. The selection will become less of an issue when more MRI units are established and when its cost decreases. Factors such as cost and relatively long imaging times, as well as considerations of patient throughput, are important. MRI is estimated to cost 2-3 times as much as99m Tc bone scintigraphy[17, 18] ; fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning costs 8 times as much.[19, 20, 21, 22, 23]

Limitations of techniques
Radiographs are relatively insensitive in the detection of early or small metastatic lesions. Although CT scans are superior to radiographs, CT scanning is also relatively insensitive in showing small intramedullary lesions, and it has the disadvantage of limited skeletal coverage. Bone scintiscan findings are sensitive but nonspecific. Whole-body MRI and FDG-PET scanning are accurate techniques that are currently limited by their high cost.[24, 25, 26, 27, 28]