Report the number and distribution of lesions, their character (lytic, sclerotic, mixed), and the ones that threaten: cortical destruction in weight-bearing long bones, spinal instability (SINS) and epidural cord compression.
Orient first
- Sclerotic: prostate, breast (treated); lytic: renal, thyroid, lung; mixed: breast, lung.
- Response on CT is hard: healing lytic metastases become sclerotic and can look like progression (flare).
- Mirels score for long bones and SINS for the spine structure the fracture risk (verify the versions in use).
Acquire the study
- Staging CT with bone window review and sagittal and coronal reformats of the spine and pelvis.
The manoeuvre
- Bone window, axial and sagittal reformats: every lesion — lytic, sclerotic, mixed; size in mm.
- Long bones: cortical destruction as a percentage of the circumference; axial cortical involvement over 30 mm.
- Spine: vertebral collapse, posterior element involvement, alignment — SINS components.
- Compare with the prior study: new lesions vs sclerosis of known ones.
What confirms it
- Multiple characteristic lesions in a patient with a known primary; biopsy when solitary or the primary is unknown.
What licenses you to exclude it
- A normal whole-spine T1 excludes spinal metastases of detectable size; CT misses marrow-only disease.
The classic misread
- Calling a healing flare progression.
- Not stating the epidural extent in the spine.
- Missing a lytic lesion in the femoral neck on a staging CT.