CT Scans: Staging
In the absence of reliable evidence, it is the opinion of the work group that staging CT scans in the setting of a destructive bone lesion should be ordered by, or in consultation with, an oncology specialist.

Rationale
We did not find any acceptable investigations that directly addressed this question. However, it is well accepted, that a critical early imaging study is a CT scan that visualizes the chest, abdomen, and pelvis of the patient (Weber, 2010). This allows for assessment of common sites of origin of metastatic carcinoma (lung, breast, prostate, kidney, colon) and common sites of regional (axillary and inguinal lymph nodes) and distant (lung, liver, axial skeleton) disease. Contrast may be helpful to determine true pathologic lesions from other non-neoplastic conditions and should be used if there are no patient contraindications, such as a contrast allergy. It can be difficult to distinguish between the more common scenarios of metastatic carcinoma and multiple myeloma and the uncommon scenario of a primary sarcoma. However, the treatment of a primary sarcoma is vastly different than the treatment of metastatic carcinoma and multiple myeloma, and the early recognition of the underlying disease is critical for optimal treatment.

Therefore, we recommend that a staging CT scan is most appropriately ordered by an oncologic specialist, and encourage non-specialist practitioners to consider an early referral to or consultation with a specialty provider on suspicion of a bone or soft tissue malignancy prior to obtaining a CT chest/abdomen/pelvis. If there is no apparent site of primary carcinoma on the staging CT scan, or if the solitary destructive bone lesion is the only focus of additional disease, a referral to an orthopaedic oncologist is necessary prior to any biopsy or stabilization of the bone lesion to address the potential for a primary sarcoma.

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