Eighty-six osteolytic lesions of the rib cage were examined on means of conventional radiography and ultrasonography.

Eighty-six osteolytic lesions of the rib cage were examined on means of conventional radiography and ultrasonography. The ultrasonographic criteria of osteolysis are described. simply 1 rib metastasis was missed by way of ultrasonography while 13 lesions were not discovered by x-ray film. Of 63 ultrasonographically guided biopsies, 62 eventuateed in the final diagnosis; complications were not observ The ensues recommend ultrasonographic examination combined with guided biopsy as the first diagnostic stair if a metastasis of the rib cage is suspected after physical examination or after a pathologic bone scan.

The bone scan is admittedly the principally sensitive screening device for bone metastasis, on the other hand the results remain ambiguous. Therefore, the diagnosis usually has to be confirmed on radiographs and often by definitive tissue diagnosis.

Especially in rib metastasis, guided biopsy and also surgical exploration not absent problems of localization unless the lesion is palpable. Thus, more expensive imaging practices like nuclear scan-guided biopsy were introduced.[1-3]

During ultrasonography of the thoracic wall in a patient with lung cancer, we accidentally noticed signs of an osteolytic rib metastasis. Since that time, we have tried to define the typical ultrasonographic image of osteolysis and to estimate the validity of ultrasonography and conventional x-ray films detecting malignant thoracic osteolysis.

MATERIALS AND METHODS

Between 1983 and 1991 we examined 86 patients showing osteolytic lesions in the ribs (77) and the sternon (9). Ultrasonography was performed by way of means of the usual linear array scanners with 35 Mhz (Philips SDR 2000 or Aloka SD 630) Conventional radiographs included standard thoracic x-ray films, fluoroscopy, and if necessary, comput tomography.

Cytologic biopsies were performed subject to ultrasonographic guidance for the following reasons: if definitive tissue diagnosis was necessary for staging the known disease; or if an unknown primary tumor had to be elucidated, especially if the suspected region be seened to be normal under radiologic examination.

Biopsies were performed with usual one-way syringes and needle as used for intramuscular or intravenous injection, after local anesthesia with 1 percent solution of procaine. The specimens were immediately stained and air-fixed. Repeated biopsy specimens were taken if the Diff-Quik preparation showed no usable material, ie, tissue that was necrotic or too bloody

RESULTS

Ultrasonographic Signs of Osteolysis

Healthy bone cannot be examined sufficiently from usual ultrasonography because of the total healthy reflection resulting in a unbroken shadow behind the leading zest This total reflection changes if the metastatic part of the bone make no use ofs calcium and thus achieves conductivity.

If the los of calcium is total, the osteolytic metastasis appears as an echo-poor area of mainly increased volume, and the whole shadow disappears, as demonstrated in Figure 1

Partial destruction of a rib is shown in Figure 2 The unbroken shadow is only slightly diminished, on the contrary the improvement of sound conductivity is clearly demonstrated by means of the intact white line representing the pleural surface. Behind the normal ribs, this line is impaired by the sound shadow.

In an early stage of osteolysis, the change of conductivity is too small to bring to light which part of the bone is diseased. on the contrary in those cases, often a slight swelling of the surrounding tissue exists, probably owed to periosteal edema. This phenomenon is not recognizable through x-ray film. Thus, the scintigraphic passionate spot in Figure 3 was not explained from conventional computed tomography, but clearly bring to lighted by ultrasonography and confirmed as a metastatic adenocarcinoma from cytologic biopsy.

Ultrasonographically Guided Biopsy

Sixty-three cytologic biopsies were performed subject to ultrasonographic guidance, localized to the ribs in 57 and to the breastbone in 6 cases. The proceeds are listed in Table 1

barely one biopsy was not diagnostic, to be paid to insufficient technique rather than to the disease itself. It make anxiouss a hemangioendothelioma, which is known to be barely confirmed on a small cytologic sample. In the remaining 62 cases, the biopsy was definitive or consistent with the final diagnosis.

There were no complications, especially no pneumothorax or abnormal bleeding.

Ultrasonography v Radiography in the Discerning of Osteolysis

Eighty-six osteolytic lesions of the thoracic skeleton (ribs, 77; stenum 9) were examined by means of both techniques, after the localization was suspected according to physical examination, thoracic x-ray film, or scintigraphy.

single one rib metastasis recognizable from x-ray film was missed by way of ultrasonography because it was partially hidden behind the scapula. Moreover, this lesion looked to be osteoplastic rather than osteolytic, therefore, an increase of sonic conductivity could not be look fored In comparison, seven of the rib and six of the breastbone metastases were not seen by the agency of x-ray film but clearly ascertained by ultrasonography; an example is shown in Figure 3

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