Figure 1. Anteroposterior radiograph of the left shoulder.
Figure 2. Coronal magnetic resonance imaging of the left shoulder.
A 70-year-old woman presents with pain in her shoulder that has persisted for 3 weeks. She recalls experiencing the first symptom of pain after reaching for a box from the top cabinet in her kitchen. The pain intensifies with shoulder movement and, over the past week, is getting worse at night. The patient does not have any known history of medical problems, including cancer. Anteriposterior radiograph of the left shoulder is obtained (Figure 1); coronal magnetic resonance imaging (MRI) (Figure 2) shows a destructive lesion involving the glenoid fossa of the scapular.
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Metastatic disease should be the primary consideration in any patient aged >40 years with a destructive bone lesion. Bone is the third most common site for metastatic disease, after the lung and liver.1 The most common primary sources of metastatic disease include prostate, breast, lung, kidney, and thyroid cancers.2 The most common site for metastatic disease of the bone is the thoracic spine followed by the proximal femur and humerus.1
The first step in the treatment of suspected metastatic disease (without an established diagnosis of cancer) is to find the primary source of tumor and stage the condition. Computed tomography scans of the chest and abdomen are frequently ordered to locate the source of the tumor and a bone scan of the entire body is common to identify other areas of metastatic bony involvement.2
Up to 30% of metastatic bone tumors may still have an unknown origin despite a thorough history, physical examination, and diagnostic work-up.2 A solitary bone tumor should be biopsied following a bone scan, but if multiple lesions are found, the most accessible lesion should be biopsied. Solitary tumors are more likely to be musculoskeletal in origin and require a core needle biopsy.2,3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Macedo F, Ladeira K, Pinho F, et al. Bone metastases: an overview. Oncol Rev. 2017;11(1):321.
2. Piccioli A, Maccauro G, Spinelli MS, Biagini R, Rossi B. Bone metastases of unknown origin: epidemiology and principles of management. J Orthop Traumatol. 2015;16(2):81-86.
3. Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009;91(6):1503-1516.