ANSWER 67
The X-ray shows collapse of the T6 vertebra. If there is nothing to suggest osteoporosis or
trauma then the commonest cause of this is a tumour metastasis. The tumours that most
frequently metastasize to bone are carcinoma of the lung, prostate, thyroid, kidney, and
breast. Examination of the patient’s breasts, not done before the X-ray result, revealed a firm
mass 1–1.5 cm diameter in the tail of the left breast. Urgent biopsy confirmed a carcinoma
and she was referred to an oncologist for further management.
The common lesions affecting the lumbosacral and cervical spine, e.g. inflammation of
ligaments and other soft tissues and lesions of the intervertebral discs, are much less com-
mon in the thoracic spine, and bony metastases should be considered as a cause of per-
sistent pain in the thoracic spine in patients of an appropriate age.
Review of the first X-ray after the lesion was seen on the second film still failed to iden-
tify a lesion, emphasizing the need to repeat an investigation if there is sufficient clinical
suspicion of an abnormality, even if an earlier investigation is normal.
Examination of the breasts in women should be part of the routine examination, particu-
larly after the age of 40 years, when carcinoma of the breast becomes common.
- Pain in the thoracic vertebrae should raise the possibility of bony metastases in patients
over the age of 40 years. - Repeating previously normal or negative investigations is an important part of a patient’s
management when clinical diagnoses remain unconfirmed.