Imaging of bone metastases

Transcription

1 Imaging of bone metastases Antoine Feydy Service de Radiologie B Hôpital Cochin APHP Université Paris Descartes antoine.feydy@aphp.fr MEXICO 2016

2 INTRODUCTION Diagnostic Imaging Imaging Modalities Strengths, Weaknesses Spine Appendicular Skeleton, Long bones

3 OBJECTIVES Survival Guide for the Radiologist Detection of bone metastases Differentials? Pitfalls Long bones, fractures Spine, instability? SINS Follow-up after treatment

4 Imaging for Metastatic Spine What is the best choice? NM Hybrid Imaging PET-CT MRI Full Spine / Whole Body MRI Spine (Lumbar/Thoracic/Cervical) CT Body CT Bone

5 Oncologic Imaging Bone Marrow NM and Hybrid Imaging PET SCAN (FDG and others) Diagnostic value depends on.

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7 MRI T1w Detection / Follow-up after treatment Detection of bone marrow replacement by tumoral tissue Reproducibility Sufficient for the detection if the bone marrow is fatty (age, radiotherapy)

8 MRI T2w Detection / Follow-up after treatment STIR or fat sat T2 or DIXON Water Fibrosis Sclerosis

9 MRI Gado T1w Extra osseous Extension T1 T2 fat sat T1 Gado

10 Whole Body MRI : TECHNIQUE 3D T1 Coronal Sagittal T1-w STIR-w Gadolinium? Diffusion?

11 M64 Prostate K PSA > 700

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13 Whole Body MRI Key Points Standardization of Sequences T1 and STIR Gadolinium optional Morphologic MR Imaging with an extended FOV Variable performances depending on bone marrow tumoral infiltration pattern Useful also for differentials diagnoses

14 DWI and oncologic bone marrow DWI and lesion Detection T1 T2 T1 gado b 600

15 DWI AJR 2014 M64 Prostate K Bone mets

16 DWIBS

17 DWIBS and signal interpretation

18 DWI - Key Points Possible with recent MR scanners Imaging for lesion detection Alternative / Complement of PET-CT ADC Modifications : complex to understand Ongoing studies for different types of cancers, medullary metastases, posttherapeutic changes, etc

19 MRI and CT Why? Bone Mets Extension / SRE SRE (pathologic fracture, spinal cord compression, and hypercalcemia) : urgent imaging and therapeutic management Unique or multiple lesions (MRI) Extension in bone/skeleton (MRI) Epiduritis (MRI) Vertebral Fracture (MRI and CT) Osteolysis (CT) Osteosclerosis (CT) Spinal Stability (CT)

20 F51 Melanoma and back pain

21 F51 Melanoma MRI

22 Spinal MRI TUMORAL EPIDURITIS MRI : diagnosis + extension Compressive Epiduritis? Therapeutic Decision > Surgery > Radiotherapy

23 BODY CT and Bone Mets Usual CT in oncology : first line imaging Caracterisation of a lesion detected on PET FDG and/or other modalities Lytic metastases (50%) Sclerotic metastases (35%): (prostate, carcinoid tumors) with bisphosphonates Combined lytic+sclerotic (15%) breast, lung Analysis of bone is warranted on Body CT

24 M75 Prostate K

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26 CT SPINE / BONES Tailored protocols Analysis focused on: Lesion limits and matrix Medullary and Cortical bone Diagnosis of pseudo-tumoral lesions: Paget, Fractures, etc Spinal Instability?

27 Paget

28 M58 Myeloma? Vertebral hemangioma

29 Vertebral Hemangioma Polka dot sign Fatty content

30 F84 Previous Radiotherapy for Epidermoid Carcinoma

31 M65 Thyroid Cancer (2010) MRI 2014 Spinal Pain Risk of vertebral fracture?

32 Risk of vertebral fracture? Thyroid Cancer CT 2014

33 SINS Spinal Instability Neoplastic Scale SOSG Spine Oncology Study Group 6 parameters : pain + 5 CT and MRI for assessment

34 SINS : 6 items Pain? Lesion Location Mineralization Spinal alignment? Vertebral Fracture? Posterior Arch? SINS Score stable instable

35 Appendicular Skeleton and long bones Pathologic fracture (XRays) Pain related to bone and/or joint involvement by metastasis? Asymptomatic : MRI or PET-CT detection

36 RADIOGRAPHS LONG BONES Available Simple Diagnosis before surgery Bone pain Pathologic Fracture

37 M54 Lung K

38 MRI Appendicular Skeleton and long bones Pathologic fracture (XRays) Pain related to bone and/or joint involvement by metastasis? Asymptomatic : PET CT detection

39 F63 with shoulder pain and breast K MRI Diagnosis?

40 F63 with shoulder pain and breast K Enthesopathy with calcification resorption

41 M57 Thyroid K Shoulder pain Metastasis involving the Scapula +

42 M64 with Melanoma Positive PET CT No hip pain

43 BONE METASTASES IMAGING FOLLOW-UP AFTER TREATMENT

44 FOLLOW-UP AFTER TREATMENT CT and MRI Favorable outcome of lytic lesions : Sclerosis : global or ring-like No progression in volume and/or number MRI : stability or regression of signal abnormalities, sometimes fatty signal - No RECIST criteria for mets limited to Bone - MDA criteria

45 FOLLOW-UP AFTER TREATMENT CT and MRI Poor outcome (all patterns): Progression of osteolysis Progression of osteosclerosis Progression in volume and number MRI : extension of signal abnormalities, epiduritis

46 F57, breast cancer, bone metastases Sept 2010 Nov 2010

47 F57, breast cancer, bone metastases Sept 2010 Nov 2010

48 F55 Breast Cancer

49 F55 Breast Cancer

50 F55 Breast Cancer

51 JAN 2013 F75 Melanoma

52 MAR 2013 F75 Melanoma Rapid Progression

53 CONCLUSION Imaging of Bone Metastases Initial Diagnosis : Asymptomatic / SRE Detection and Extension : MRI Bone and Fracture Risk : XRay and CT Follow-up after treatment CT and MRI with limitations NM Hybrid Imaging (PET CT)