Rougraff B T, Kneisl J S, Simon M A
Department of Surgery, University of Chicago Medical Center 60637.
J Bone Joint Surg Am. 1993 Sep;75(9):1276-81. doi: 10.2106/00004623-199309000-00003.
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.
我们对40例连续就诊的不明原因骨转移患者进行了一项关于诊断策略有效性的前瞻性研究。该诊断策略包括病史记录、体格检查、常规实验室分析、受累骨骼及胸部的X线平片、全身锝-99m-膦酸盐骨闪烁显像以及胸部、腹部和骨盆的计算机断层扫描（CT）。在进行上述评估后，对最易取材的骨病变进行活检。所有患者的实验室检查结果均无特异性。病史和体格检查发现3例患者（8%）的恶性肿瘤隐匿原发部位：1例为乳腺癌患者；1例为肾癌患者；1例为膀胱癌患者。胸部X线平片确诊17例患者（43%）为肺癌。胸部CT又发现另外6例原发性肺癌（15%）。腹部和骨盆CT确诊5例患者（13%）：3例为肾癌患者；1例为肝癌患者；1例为结肠癌患者。活检组织检查仅额外确诊3例患者（8%），并在另外11例患者中得到证实。仅根据活检结果，我们无法确定26例（65%）患者恶性肿瘤的原发部位。在40例患者中的34例（85%）中，通过本文所述的诊断策略确定了原发部位，随访研究仅发现另外2例隐匿性恶性肿瘤。我们的诊断策略对于在活检前确定不明原因骨转移患者隐匿性恶性肿瘤的部位简单且非常成功。
