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Breast Cancer then Lower Back Pain?

8K views 41 replies 12 participants last post by  Novobiocin 
#1 ·
A 55-year-old female presents for a 1-week history of low back pain. She denies any recent falls or trauma. She is otherwise well but has a history of breast cancer 2 years ago. She denies any weight loss or night sweats. She denies any bowel or bladder incontinence or lower extremity weakness. Vital signs are heart rate 69 beats/min, respiratory rate 18 breaths/min, blood pressure 133/81 mm Hg, and oxygen saturation 95% on room air. Physical examination reveal minimal lumbar spine pain on palpation and accompanying paraspinal muscle spasm. What is the next step in her management?

A. Bone scan
B. Magnetic resonance imaging
C. Mammogram
D. Nonsteroidal antiinflammatory drugs (NSAIDs)
E. X-ray
 
#2 ·
mmmm nice question she either has osteoporosis secondary to menopuase (eventho she is too young) or she has bone metastases from the primary breast cancer:confused:
they dont mention she was treated from the cancer.. jeez i guess an MRI to look for the metastases but i think im wrong :(
 
#8 ·
I'll go with X-ray as the next step in management. this is confirm a compression fracture or rule it out ( as the only clue in the examination points to it).

MRI is not the answer since there is no evidence of spinal compression on HPE. (This would have been my answer if the question asked for the next BEST step in management since it will give the most information about her condition)

Bone scan is not the answer since she has a history of Breast Ca and is most likely on Tamoxifen.

Mammogram is not the answer since she must be being followed up for Breast Ca.

NSAIDs are not the answer since we don't know what we are dealing with here.
 
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#10 ·
Metastatic disease to the bone causes severe, progressive pain, and, less commonly, pathological fracture, erythema over the affected bone, and swelling.
According to question stem she is otherwise well ...................She denies any weight loss or night sweats..............
So bony mets are unlikely.
 
#12 ·
No. I just want to answer the question-What is the next step in her management? ............based on the information provided in the question stem.
 
#15 ·
I disagree, but it is obviously only my opinion because none of us really know what the answer is.
I believe that the reason she comes to the doctor is not to getHappy-2 painkillers, that she had probably taken already.
Considering her history she would be worried why she has the symptoms and the next step in management would be to diagnose, especially if the pain is minimal.
 
#17 ·
I think that even if there is a compression fracture, we would have to do nuclear bone scan to rule out metastasis as the underlying cause, so I'm with tyagee on this one - A. Bone scan.

Novobiocin has a good point about the wording of "minimal pain" ruling out nsaids as the answer. X-ray (lateral film of thoracic and lumbar spine) is the first step in diagnosing a vertebral compression fracture (if there were a recent trauma, it would be CT, I think). However, even if a VCF were diagnosed on the x-ray and characterized on the MRI (usually with STIR sequence in order to see if it is old or acute, I just learned in a grand rounds lecture today), we'd still want to rule out metastases given the history of breast cancer.
:notsure:
 
#19 ·
I think that even if there is a compression fracture, we would have to do nuclear bone scan to rule out metastasis as the underlying cause, so I'm with tyagee on this one - A. Bone scan.
Bone scan is NOT a good test to detect Bone Mets. Since it cannot detect lytic bone lesions. Bone scan can only detect a lesion where active bone remodeling is going on. That's why it is of no use in Multiple Myeloma.
Since Breast Ca mets are mostly lytic lesions. Bone Scan is NOT a good test for detecting Breast Ca mets.

However, a nuclear bone scan is a functional test, which means it measures an aspect of bone metabolism or Bone remodeling, which most other imaging techniques cannot.
Also, since according to the question stem, it could be some other cause for her back pain leading to a positive bone scan but we will still not know what is causing it. So, X-ray as the initial test ( MRI as the best test) is the best choice.

Areas of active bone changes appear as "hot spots" on the skeleton because they attract the radioactivity. These areas may suggest the presence of cancer, but other bone diseases can also cause the same pattern. To know exactly what is causing the hot spots, other imaging tests such as plain x-rays or MRI scans, or even a bone biopsy might be needed.
References:

http://www.ajronline.org/content/185/4/1082.full

http://www.learningradiology.com/archives05/COW 142-Osteoblastic mets/blasticmetscorrect.htm

http://en.wikipedia.org/wiki/Bone_scintigraphy
 
#30 · (Edited)
Bone metastases may be osteolytic, sclerotic, or mixed on radiographs (see the first image below). Lesions usually appear in the medullary cavity, spread to destroy the medullary bone, and then involve the cortex. Osteolytic metastases are encountered most frequently, especially in breast and lung carcinomas (see the second image below).[29, 30, 31, 32] The specific appearance of bone metastases is often useful in suggesting the nature of the underlying primary malignancy.
Radiography remains the best method for characterizing bone metastases.

Indications for bone scintiscanning include staging in asymptomatic patients, evaluating persistent pain in the presence of equivocal or negative radiographic findings, determining the extent of bone metastases in patients with positive radiograph findings, differentiating metastatic from traumatic fractures by assessing the pattern of involvement, and determining the therapeutic response to metastases.
Nuclear Imaging

Results from a recent retrospective study conducted by Memorial Sloan-Kettering Cancer Center investigators suggest that PET/CT scanning might offer the most efficient and effective detection of newly diagnosed breast cancer that has spread to the bone. The new findings may mean less stress and more timely therapy for patients, and could make the longtime use of radionuclide bone scans for breast cancer obsolete in this setting.
http://www.mskcc.org/news/announcement/using-pet-ct-detection-breast-metastases
 
#31 ·
http://cancer.swedish.org/types-of-cancer/bone-cancer/
Mentions that's the initial test of choice should be an X-ray.

X-ray When a patient experiences pain that is suspected to be a result of bone cancer, the first step in diagnosis is usually to X-ray the area near the pain. When enough of the healthy bone in any area is worn away by metastatic lesions, the damaged area will show up as a dark spot on the X-ray that look like holes in the bones.
 
#34 ·
Ok...so according to Wiki... It depends on the patients presentation, whether they are symptomatic or asymptomatic.....

In the detection of bone metastases, skeletal scintigraphy (bone scan) is very sensitive and is recommended as the first imaging study in asymptomatic individuals with suspected breast-cancer metastases.[8] X-ray radiography is recommended if there is abnormal radionuclide uptake from the bone scan and in assessing the risk of pathological fractures, and is recommended as the initial imaging study in patients with bone pain.[8] MRI or the combination PET-CT may be considered for cases of abnormal radionuclide uptake on bone scan, when radiography does not give an acceptably-clear result.[8]

http://en.wikipedia.org/wiki/Metastatic_breast_cancer#Workup
 
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