Table 1.

Summary of patient’s investigations, imaging, serology and invasive procedures

Imaging/time postinitial MRI investigation
MRI whole spine	0 week	Multiple sclerotic and mostly lytic bone lesions suspicious of metastases
Nuclear medicine bone scan	6 weeks	Increased isotype uptake in the pelvis, spine, ribs and right shoulder suggestive of widespread bone metastases
CT chest, abdomen and pelvis with contrast	6 weeks	Multiple metastatic bone lesions. No obvious primary identified. No abnormality within kidneys
MRI pelvis/prostate	9 weeks	No evidence of malignancy within prostate
18F-FDG-PET (figure 1)	12 weeks	Intense uptake in bony deposits throughout the axial skeleton and proximal long bones. No uptake in major organs or lymph nodes
Ultrasound thyroid	26 weeks	Normal
Invasive procedures
Flexible cystoscopy	9 weeks	Non-occlusive prostate and no urothelial abnormality
Gastroscopy	11 weeks	Normal
Transrectal ultrasound-guided prostate biopsy	11 weeks	Benign prostate tissue
Bone marrow aspirate and trephine	15 weeks	Appearances are those of carcinoma but immunohistochemistry unhelpful in determining primary
CT-guided targeted bone biopsy	22 weeks	Metastatic carcinoma—immunohistochemistry strongly supports metastasis from renal cell carcinoma
Ultrasound-guided targeted liver biopsy	42 weeks	Metastatic carcinoma—immunoprofile confirms renal cell carcinoma; racemase positive suggests high-grade papillary subtype

¹⁸F-FDG-PET, fluorodeoxyglucose F 18-positron emission tomography.