How to Confirm Bone Metastasis in Lung Adenocarcinoma?

Q: How to Confirm Bone Metastasis in Lung Adenocarcinoma?

Hello： There is a type of Bone Scan in nuclear medicine that can help.

How to confirm if it is bone metastasis from lung adenocarcinoma?

Hello Doctor: My mother is 58 years old and has type 2 diabetes (controlled with medication, no insulin required).
She was hospitalized for examination from June 24 to July 6.
A tumor was found on her thyroid, which was diagnosed as thyroid cancer, and she underwent surgery for removal by a general surgeon.
On July 4, she was diagnosed with stage IV lung adenocarcinoma and is currently awaiting genetic testing; treatment has not yet begun.
Her current symptoms include frequent coughing with phlegm, shortness of breath, occasional difficulty breathing, and persistent pain in her back, rated at about 6-7 on a pain scale, which decreases to 3-4 after taking pain medication.
During a follow-up appointment on July 24, the attending physician explained that after a discussion among the medical team and pathology department, the thyroid tumor is likely a metastasis from the lung adenocarcinoma.
There is no evidence of brain or bone metastasis.
A referral to neurosurgery was recommended.
After evaluation by the neurosurgery department, they could not rule out a pathological compression fracture at the sixth thoracic vertebra and suggested a referral to radiation oncology for a PET scan and MRI.
However, since January 2019, there has been a regulation that repeats of examinations within 28 days are not covered by health insurance.
When faced with completely different opinions from the doctors, what should we do? Should we directly consult the original attending physician in the pulmonary medicine department for clarification and advice? Could the attending physician assist in quickly identifying the cause of her pain? Thank you for reading my inquiry.
Gratefully, Jenny, July 25, 2023.

JENNY, 30~39 year old female. Ask Date: 2023/07/25

Dr. Tao Ruiming reply Pulmonology

Hello: There is a type of Bone Scan in nuclear medicine that can help.

Reply Date: 2023/07/25

More Info

To confirm bone metastasis in a patient with lung adenocarcinoma, several diagnostic approaches can be utilized. Given your mother's recent diagnosis of stage IV lung adenocarcinoma and her symptoms, it is crucial to address the potential for bone metastasis, especially since she is experiencing back pain. Here’s a comprehensive overview of the methods and considerations involved in confirming bone metastasis.

Diagnostic Imaging
1. Bone Scintigraphy (Bone Scan): This is a common initial imaging study used to detect bone metastases. It involves injecting a small amount of radioactive material that accumulates in areas of high bone turnover, which is often indicative of metastatic disease. A bone scan can show areas of increased uptake (hot spots) that may suggest metastasis.

2. Computed Tomography (CT) Scan: A CT scan can provide detailed images of the bones and can help identify any lesions or abnormalities that may not be visible on a bone scan. It is particularly useful for assessing the spine and pelvis, where lung cancer often spreads.

3. Magnetic Resonance Imaging (MRI): MRI is particularly useful for evaluating spinal involvement, especially if there is concern about a pathological fracture or spinal cord compression. It provides excellent soft tissue contrast and can help visualize any lesions in the vertebrae.

4. Positron Emission Tomography (PET) Scan: A PET scan can be used to assess metabolic activity in the bones. Areas of increased metabolic activity may indicate the presence of metastatic disease. PET scans are often combined with CT scans (PET/CT) for more comprehensive evaluation.

Clinical Evaluation
- Symptoms: The presence of back pain, especially if it is persistent and worsening, raises suspicion for bone involvement. Pain that is not relieved by typical analgesics may warrant further investigation.

- Physical Examination: A thorough physical examination can help identify any neurological deficits or signs of spinal cord compression, which may indicate metastatic disease affecting the spine.

Laboratory Tests
- Tumor Markers: While not definitive for bone metastasis, elevated levels of certain tumor markers (like CEA) can indicate disease progression. However, they are not specific for bone involvement.

Multidisciplinary Approach
Given the complexity of your mother's case, involving multiple specialists is crucial. Here are some steps you can take:
1. Consultation with Oncologists: Discuss the findings and concerns with her oncologist. They can provide insights into the necessity of further imaging based on her symptoms and current treatment plan.

2. Communication with Radiologists: If there are conflicting opinions regarding imaging results, it may be beneficial to have a radiologist review the imaging studies in conjunction with the clinical findings.

3. Follow-Up Appointments: Ensure that follow-up appointments are scheduled with the relevant specialists, including oncology, radiology, and possibly palliative care for pain management.

Addressing Conflicting Opinions
In cases where there are differing opinions among healthcare providers, it is essential to advocate for your mother's health:
- Request Clarification: Ask for a detailed explanation of the reasoning behind each specialist's recommendations. Understanding their perspectives can help you make informed decisions.

- Seek a Second Opinion: If there is significant uncertainty, consider seeking a second opinion from another oncologist or a specialized cancer center. This can provide additional insights and options for management.

- Patient Advocacy: Don’t hesitate to express your concerns and ask for a coordinated approach to her care. A case manager or patient advocate can help facilitate communication among the healthcare team.

Conclusion
Confirming bone metastasis in lung adenocarcinoma involves a combination of imaging studies, clinical evaluation, and laboratory tests. Given your mother's symptoms and the complexity of her case, it is vital to maintain open communication with her healthcare team and advocate for thorough investigations to determine the cause of her pain. By collaborating with her oncologist and other specialists, you can ensure that she receives the most appropriate care tailored to her needs.

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