Pathological fracture cancer8/11/2023 There are six recognized reasons to complete a staging workup prior to biopsy: Ī biopsy is performed following the completion of laboratory and radiological workup. The specificity of positron emission tomography alone is only 30%, though it increases to 50% when combined with computed tomography. Positron emission tomography is becoming more popular and is highly sensitive for identifying infection and malignant tumors. Consider mammography for indicated patients when a primary breast carcinoma cannot be excluded. Reasons to consider magnetic resonance imaging (MRI) of the extremity include evaluation of the degree of soft-tissue involvement as well as neurovascular involvement. Other reasons to obtain local CT imaging are to evaluate the degree of osteolysis and to better understand the 3-dimensional anatomy of lesions, particularly in locales with complex dimensional anatomy such as the pelvis. Īdvanced imaging of the extremity may be included for preoperative planning or if there is a concern for primary bone sarcoma. This comprehensive strategy is the gold standard and is successful in identifying the origin of the lesion in 85% of cases. If laboratory analysis has confirmed the diagnosis of multiple myeloma, a skeletal survey may be obtained in lieu of a bone scan, which might fail to identify the degree of osteolysis present in other sites. Bone scans are particularly useful for identifying osteoblastic activity. Whole-body bone scintigraphy should also be obtained. Computed tomography (CT) of the chest, abdomen, and pelvis with oral and intravenous contrast should be obtained for staging purposes. A chest radiograph should also be obtained. There are a number of aggressive features suggestive of a pathologic lesion that may be identified on X-ray, which include: lesion diameter > 5 cm, cortical interruption, periosteal reaction, and associated pathologic fracture. A plain radiograph is the single most important imaging modality and provides the most information about a pathologic lesion. Radiological analysis of pathologic fractures begins with orthogonal radiographs of the fracture site and the involved bone in its entirety. Pregnancy tests should also be obtained in women of child-bearing age prior to imaging. If Bence-Jones proteins are present, multiple myeloma is likely the diagnosis. If hematuria is present, renal cell or uroepithelial carcinoma should be considered. For example, a urinalysis may provide some insight into the primary pathology. Laboratory abnormalities may exist secondary to malignancy and may elucidate the source of malignancy. Disease-specific markers, including prostate-specific antigen (PSA) and carcinoembryonic antigen (CEA), etc., may also be considered. Laboratory analysis should include a complete blood count, comprehensive metabolic panel (with special attention to serum calcium and alkaline phosphatase), prothrombin/INR, activated partial thromboplastin, erythrocyte sedimentation rate, urinalysis, urinary protein electrophoresis, and serum protein electrophoresis. When a pathologic fracture is identified through a lesion of unknown origin, a comprehensive workup must be conducted to identify the etiology and stage of the disease.
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