What is the next step in managing a patient with a history of cancer, now presenting with nocturnal pain unrelieved by ibuprofen (ibuprofen), mild-grade fever, weight loss, normal senses, and a negative straight leg raise test?

From the Guidelines

The next step in managing this patient should be an urgent magnetic resonance imaging (MRI) scan. Given the patient's history of cancer, now presenting with nocturnal pain unrelieved by ibuprofen, mild-grade fever, weight loss, and a negative straight leg raise test, there is a high suspicion for tumor recurrence or metastasis 1. The presence of night pain, a "red flag" requiring further investigation, and systemic symptoms such as fever and weight loss, which may indicate metastatic disease, warrant advanced imaging 1.

Key Considerations

• The patient's history of cancer and current symptoms suggest a possible recurrence or metastasis, making an MRI scan essential for diagnosis and guiding appropriate management.
• An MRI scan provides superior soft tissue contrast and can detect bone marrow infiltration earlier than other imaging techniques.
• A negative straight leg raise test suggests the pain is not due to nerve root compression, but the constellation of night pain, constitutional symptoms, and cancer history strongly warrants advanced imaging.

Diagnostic Approach

• An urgent x-ray of the affected site is required, but a "normal" x-ray does not exclude the possibility of primary malignant bone tumors (PMBT) 1.
• Further investigation, including an MRI scan, is necessary if the x-ray shows any signs of bone destruction, new bone formation, periosteal swelling, or soft tissue swelling 1.
• Patients with suspected PMBT should be referred to a commissioned bone sarcoma centre on an urgent cancer pathway, and all histological diagnoses of PMBT should be reviewed by a specialist pathologist within a bone sarcoma MDT 1.

From the Research

Next Steps in Managing a Patient with a History of Cancer

The patient presents with nocturnal pain unrelieved by ibuprofen, mild-grade fever, weight loss, normal senses, and a negative straight leg raise test. Given the history of cancer, the next step would be to investigate the possibility of metastatic disease.

• Investigating Metastatic Disease: Metastasis is a complex process where primary tumor cells migrate and establish secondary tumors in an adjacent or distant location in the body 2. Early detection of metastatic disease is crucial for effective treatment and improved patient outcomes.
• Imaging Modalities: Various imaging modalities can be used to detect metastatic disease, including MRI, which provides excellent spatial and contrast resolution for bone and soft tissues 3. Whole-body MRI has emerged as a highly sensitive and radiation-free alternative imaging modality for detecting metastatic disease 4.
• Diagnostic Approach: A diagnostic approach using whole-body MRI can be used to assess metastasis in patients newly diagnosed with cancer 5. This approach can accurately detect nodal, skeletal, and visceral metastases.
• Considerations: The choice of imaging modality and diagnostic approach should be based on the patient's specific condition, tumor entity, and tumor biology 6. A multidisciplinary approach involving orthopedic surgeons, pathologists, oncologists, radiotherapists, and radiologists is essential for effective patient management.

Potential Diagnostic Tests

Based on the patient's symptoms and history of cancer, the following diagnostic tests may be considered:

• Whole-body MRI to detect metastatic disease
• MRI of specific areas of concern, such as the spine or pelvis, to evaluate for metastatic lesions
• Other imaging modalities, such as CT or PET/CT, may also be considered depending on the patient's specific condition and the suspected location of metastatic disease 3, 4