Diagnostic imaging algorithm for the detection of osseous metastases in patients with known or suspected cancer and vertebral back pain

MRI: magnetic resonance imaging; PET: positron emission tomography; CT: computed tomography; POEMS: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes syndrome; FDG-PET: 18-F fluorodeoxyglucose positron emission tomography.
* Following surgery, the patient will need a comprehensive skeletal survey to assess for other metastases.
¶ For example, in a patient with a monoclonal (M) protein (which can be detected by protein electrophoresis of the serum [SPEP] and/or of an aliquot of urine [UPEP] from a 24-hour collection combined with immunofixation of the serum and urine), hypercalcemia, abnormal immunoelectrophoresis, anemia, or renal failure.
Δ The presence of multiple skeletal lesions influences choice of therapy.
◊ The vast majority of patients without an unstable spine or evidence of a cord compression do not require surgery. For very highly selected patients who present with or develop a vertebral bone lesion as the only focus of cancer beyond the primary site, resection of the metastasis may optimize local tumor control, provide durable pain relief, and possibly prolong patient survival.
§ A negative repeat biopsy should prompt reevaluation of the original MRI result.