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Blastic Osseous Metastases


KEY FACTS

Terminology

  • Extension of primary tumor to spine where bone production exceeds bone destruction

Imaging

  • Multiple osteoblastic lesions in spine

    • May coexist with areas of osteolytic tumor, soft tissue mass

  • Lesion distribution proportional to red marrow (lumbar > thoracic > cervical)

  • MR signal typically diminished on T1, T2WI in areas of osteoblastic metastases

  • Sclerotic metastases usually tracer avid on bone scan

Top Differential Diagnoses

  • Treated metastases

  • Discogenic sclerosis

  • Hemangioma

  • Paget disease

  • Osteosarcoma

Pathology

  • Marrow infiltration, tumor stimulates osteoblastic response

    • New bone deposition on trabeculae, within intertrabecular spaces

  • Primary tumor, adults: Prostate, breast, carcinoid, lung, GI, bladder, nasopharynx, pancreas

  • Primary tumor, children: Medulloblastoma, neuroblastoma, Ewing sarcoma

Clinical Issues

  • Pain: Progressive axial, referred, or radicular

  • Epidural tumor, if present, may cause neurologic dysfunction

  • 90% of prostate metastases involve spine, with lumbar 3x more often than cervical

Anteroposterior plain film shows diffuse extensive bone sclerosis of the spine, with all the vertebral bodies appearing whiter than normal, and pelvis
due to diffuse osseous metastases from breast carcinoma.

Anteroposterior bone scan shows diffuse, patchy tracer uptake
in the thoracolumbar spine, pelvis, sternum, and multiple ribs due to diffuse osseous metastases from breast carcinoma.

Axial NECT shows diffuse sclerosis involving the left half of the vertebral body
due to blastic metastasis in this patient with metastatic prostate carcinoma. A smaller abnormal area is present on the right
.

Sagittal T1-weighted MR shows low signal involving the L3 body and sacrum, reflecting diffuse metastatic disease. Extraosseous extension into the epidural space is seen at L3
. There is no specific signal change on the MR to define the blastic nature of these metastatic lesions.

TERMINOLOGY

Synonyms

  • Sclerotic metastases, osteosclerotic metastases, osteoblastic metastases

Definitions

  • Spread of primary tumor to spine where bone production exceeds bone destruction

IMAGING

General Features

  • Best diagnostic clue

    • Multiple blastic lesions in spine

  • Location

    • Vertebral body and posterior elements

    • Lesion distribution proportional to red marrow (lumbar > thoracic > cervical)

  • Size

    • Any size from a few millimeters to entire vertebral body (ivory vertebra)

  • Morphology

    • Round focus of sclerosis or mixed lytic/sclerotic

Radiographic Findings

  • Radiography

    • Discrete or mottled areas of sclerosis, typically multiple

CT Findings

  • NECT

    • Multiple sclerotic lesions, possibly coexisting with areas of osteolysis

    • May see paravertebral and epidural soft tissue mass

  • CECT

    • Enhancement typically not detectable due to sclerosis

    • May see enhancement in adjacent areas of osteolysis or in extraosseous extension of tumor

  • CT myelography

    • Multiple sclerotic lesions as per NECT

    • Extradural compression by epidural tumor

      • –

        Better assessment of cord compression than with NECT or CECT

      • –

        Reserve for when patient is unable to undergo MR

MR Findings

  • T1WI

    • Low or no signal in areas of osteoblastic metastases

    • ± compression fracture

    • ± paravertebral and epidural soft tissue

    • Intervertebral discs generally spared

  • T2WI

    • Variable, may be hyperintense or hypointense

  • STIR

    • Variable, may be hyperintense or hypointense

  • DWI

    • Controversial efficacy of DWI for spinal metastases

    • Several reports of false-negatives for sclerotic metastases with DWI

  • T1WI C+

    • Variable enhancement depending upon degree of sclerosis

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