The Journal of Bone and Joint Surgery, Vol 75, Issue 9 1276-1281, Copyright © 1993 by Journal of Bone and Joint Surgery, Inc
Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy
BT Rougraff, JS Kneisl and MA Simon
Department of Surgery, University of Chicago Medical Center 60637.
We carried out a prospective study of the effectiveness of a diagnostic
strategy in forty consecutively seen patients who had skeletal metastases
of unknown origin. The diagnostic strategy consisted of the recording of a
medical history; physical examination; routine laboratory analysis; plain
radiography of the involved bone and the chest; whole-body
technetium-99m-phosphonate bone scintigraphy; and computed tomography of
the chest, abdomen, and pelvis. After this evaluation, a biopsy of the most
accessible osseous lesion was done. The laboratory values were non-specific
in all patients. The history and physical examination revealed the occult
primary site of the malignant tumor in three patients (8 per cent): one
patient who had carcinoma of the breast; one, of the kidney; and one, of
the bladder. Plain radiographs of the chest established the diagnosis of
carcinoma of the lung in seventeen patients (43 per cent). Computed
tomography of the chest identified an additional six primary carcinomas of
the lung (15 per cent). Computed tomography of the abdomen and pelvis
established the diagnosis in five patients (13 per cent): three patients
who had carcinoma of the kidney; one, carcinoma of the liver; and one,
carcinoma of the colon. Examination of the biopsy tissue established the
diagnosis in only three additional patients (8 per cent) and confirmed it
in eleven others. On the basis of the biopsy alone, we were unable to
identify the primary site of the malignant tumor in twenty-six (65 per
cent) of the patients. In thirty-four (85 per cent) of the forty patients,
the primary site was identified with the use of the diagnostic strategy
described here, and only two additional occult malignant tumors were found
on follow-up studies. Our diagnostic strategy was simple and highly
successful for the identification of the site of an occult malignant tumor
before biopsy in patients who had skeletal metastases of unknown origin.
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