Diagnostic imaging algorithm for evaluation of non-vertebral bone pain in patients with known or suspected cancer

CT: computed tomography; FDG-PET: 18-F fluorodeoxyglucose positron emission tomography; MRI: magnetic resonance imaging; POEMS: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes syndrome; EFT: Ewings sarcoma family of tumors.
* Indications for urgent surgery: displaced pathologic fracture, severe pain due to pathologic fracture.
¶ Following surgery, the patient will need a comprehensive skeletal evaluation to assess for other metasteses.
Δ 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, renal failure.
◊ The majority of patients without an impending or completed fracture do not require surgery. For highly selected patients who present with or develop a bone lesion as the only focus of cancer beyond the primary site, en bloc 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 imaging and need for integrated FDG-PET/CT.