From the Guidelines
Metastasis workup should include a combination of imaging techniques, such as CT, MRI, and bone scans, tailored to the specific type of cancer and patient symptoms.
Diagnostic Guidelines for Metastasis Workup
The following are general guidelines for metastasis workup:
- Prostate cancer: Bone scintigraphy or radiography is recommended during routine disease staging, except in low-risk disease 1.
- Breast cancer: Asymptomatic distant metastases are rare, and tests for metastases are recommended only for patients with locally advanced or symptomatic disease 1.
- NSCLC: Standard staging includes routine bone biochemistry tests and CT of the chest and upper abdomen; bone imaging techniques such as PET ± CT, bone scintigraphy, or 18FDG–PET MRI are recommended if bone metastases are suspected 1.
- Renal cell carcinoma: Contrast-enhanced chest, abdominal, and pelvic CT is mandatory; bone scintigraphy is not recommended unless indicated by signs and symptoms of bone metastases 1.
Imaging Techniques
- CT scans: Recommended for staging locoregional disease and assessing distant metastatic disease 1.
- Bone scans: Recommended for patients with bone pain, elevated serum calcium or alkaline phosphatase levels, or suspicious symptoms in regions not imaged by other modalities 1.
- MRI: Recommended for documenting localized bone metastases or assessing the extent of metastatic disease 1.
- PET/CT: Recommended for identifying the site of relapse when traditional imaging methods are equivocal or conflicting, or for assessing the extent of metastatic disease 1.
Patient-Specific Factors
- Symptoms: Patients with symptoms such as bone pain, chest pain, or neurological symptoms should undergo imaging studies to assess for metastatic disease 1.
- Tumor markers: Tumor markers such as PSA, CEA, or CA 125 may be useful in monitoring response to treatment, but their clinical value for diagnostic purposes has not been proven 1.
- Risk stratification: Patients with high-risk tumors or those who have undergone partial nephrectomy may require more frequent follow-up and imaging studies 1.
From the Research
Diagnostic Guidelines for Metastasis Workup
- The diagnostic workup for metastasis involves various imaging studies, including chest X-rays, bone scans, CT scans, and PET scans 2, 3.
- For patients with carcinoma of unknown primary (CUP), the national CUP guideline recommends a range of tests, including chest X-ray, PET-CT, and biopsies with histopathological markers such as Cytokeratin 7 4.
- In patients with breast cancer, a metastatic workup is recommended for those with clinical stage IIB disease or higher, as well as those with T3 or T4 primary lesions 2, 5.
- Whole-body SPECT/CT is considered the optimal modality for metastatic workup, including detection of extra-axial lesions, with improved sensitivity and similar specificity compared to targeted SPECT/CT 3.
Patient Selection for Metastasis Workup
- Patients with node-positive breast cancer, particularly those with N2 or N3 disease, may require a metastatic workup, especially if they have T3 or T4 primary lesions 2.
- Patients with invasive breast cancer and advancing clinical stage, tumor size, and nodal status are at higher risk of upstaging to stage IV disease and may benefit from a metastatic workup 5.
- Patients with a history of cancer and suspected bone metastases may undergo a bone scan with either targeted SPECT/CT or whole-body SPECT/CT 3.
Imaging Modalities for Metastasis Workup
- Chest X-ray is a commonly performed imaging study in the diagnostic workup for metastasis, particularly in patients with CUP 4.
- PET-CT is a useful imaging modality for detecting metastases, especially in patients with CUP or breast cancer 4, 2.
- Whole-body SPECT/CT is a sensitive and specific imaging modality for detecting bone metastases and extra-axial lesions 3.