Vertebral metastases represent the secondary involvement of the vertebral spine by haematogenously-disseminated metastatic cells. They must be included in any differential diagnosis of a bone lesion in a patient older than 40 years.
This article will focus only on the metastasis involving the bony structures of the spine; please refer to the specific articles for other spinal metastatic diseases:
Vertebral metastases are already present in 10% of newly-diagnosed cancers. They are much more frequent in higher age groups (>50 years).
Vertebral lesions are very frequently asymptomatic in the setting of widespread metastatic disease, and are thus often found incidentally when imaging is performed for other reasons (e.g. staging).
The most common primary malignancies to involve the vertebrae include:
- breast cancer
- lung cancer
- prostate cancer
- renal cell carcinoma
- gastrointestinal tract malignancies
- pancreatic cancer 7
- thyroid carcinoma 8
- carcinoid 9
Metastases are either osteoblastic or osteolytic, however osteoid formation and mineralisation is of limited help in determining the primary tumor as some metastases may secrete osteoblast- and osteoclast-stimulating factors at the same time. New bone formation may also occur after chemotherapy or radiation therapy. Having said that some primaries more frequently result in sclerosis than others.
Primaries with predominantly osteoblastic metastases (sclerotic extradural bone lesions) include:
Primaries with predominantly osteolytic metastases, that may rarely become osteoblastic (mixed sclerotic and lytic extradural bone lesions) include:
Primaries with osteolytic metastases include:
Metastatic lesions can have virtually any appearance. They can mimic a benign lesion or an aggressive primary bone tumor. It can be difficult, if not impossible, to judge the origin of the tumor from the appearance of the metastatic focus, although some appearances are fairly characteristic.
Radiographs are useful as an overview but are insensitive to small lytic lesions and struggle to assess for compromise of the canal. As metastases have a predilection for involving the posterior vertebral body and pedicle, a missing pedicle (see: absent pedicle sign) is a useful and subtle sign to seek on AP films.
The appearance on CT will depend on the degree of mineralisation of the metastasis. The more common lytic metastases appear as regions of soft tissue attenuation with irregular margins. The mass may breach the cortex and result in compromise of the spinal canal.
Sclerotic lesions appear hyperdense and irregular but are less likely to extend beyond the vertebrae.
MRI is sensitive to metastatic disease and is able also to assess for cord compression. The signal intensity of the metastatic deposits will vary according to the degree of mineralisation.
- T1: hypointense
- T2: hypointense
Mixed sclerotic and lytic extradural bone lesions
- T1: hypointense
- T2: hypo- and/or hyperintense
Lytic extradural bone lesions
- T1: intermediate to hypointense
- T2: hyper- or isointense
- T1 C+ (Gd): enhancement usually present
Treatment and prognosis
The spinal instability neoplastic score (SINS) can be used to assess for spinal stability in the presence of vertebral metastases. A score of 7-18 warrants surgical consultation.
For osteoblastic metastases consider:
- bone islands (enostoses)
- spondylosclerosis hemispherica
- primary bone tumors (osteoblastoma, osteoid osteoma)
- therapy effects (radiation, chemotherapy, vertebroplasty)
(mostly solitary lesions, patients may however present with a history of cancer)
For mixed sclerotic and lytic extradural bone lesions consider:
- primary bone tumors
- therapy effects
For lytic extradural bone lesions consider:
- primary bone tumors
- aneurysmal bone cyst
- infective spondylitis
- atypical hemangioma
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- 2. Guillevin R, Vallee JN, Lafitte F et-al. Spine metastasis imaging: review of the literature. J Neuroradiol. 2007;34 (5): 311-21. doi:10.1016/j.neurad.2007.05.003 - Pubmed citation
- 3. Rodallec MH, Feydy A, Larousserie F et-al. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 28 (4): 1019-41. doi:10.1148/rg.284075156 - Pubmed citation
- 4. Guise TA, Mohammad KS, Clines G et-al. Basic mechanisms responsible for osteolytic and osteoblastic bone metastases. Clin. Cancer Res. 2006;12 (20 Pt 2): 6213s-6216s. doi:10.1158/1078-0432.CCR-06-1007 - Pubmed citation
- 5. Bubendorf L, Schöpfer A, Wagner U et-al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum. Pathol. 2000;31 (5): 578-83. - Pubmed citation
- 6. Gokaslan ZL, Aladag MA, Ellerhorst JA. Melanoma metastatic to the spine: a review of 133 cases. Melanoma Res. 2000;10 (1): 78-80. - Pubmed citation
- 7. Borad MJ, Saadati H, Lakshmipathy A, et al. Skeletal metastases in pancreatic cancer: a retrospective study and review of the literature. (2009) The Yale journal of biology and medicine. 82 (1): 1-6. Pubmed
- 8. Kushchayeva YS, Kushchayev SV, Carroll NM,et al. Spinal metastases due to thyroid carcinoma: an analysis of 202 patients. (2014) Thyroid : official journal of the American Thyroid Association. 24 (10): 1488-500. doi:10.1089/thy.2013.0633 - Pubmed
- 9. Wolfgang F. Dahnert. Radiology Review Manual. (2011) ISBN: 9781496360694
Related Radiopaedia articles
The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient.
- bone-forming tumors
- cartilage-forming tumors
- chondromyxoid fibroma
- juxtacortical chondroma
- fibrous bone lesions
- bone marrow tumors
- other bone tumors or tumor-like lesions
- aneurysmal bone cyst
- benign fibrous histiocytoma
- giant cell tumor of bone
- Gorham massive osteolysis
- haemophilic pseudotumour
- intradiploic epidermoid cyst
- intraosseous lipoma
- musculoskeletal angiosarcoma
- musculoskeletal hemangiopericytoma
- primary intraosseous hemangioma
- post-traumatic cystic bone lesion
- simple bone cyst
- impending fracture risk