Metastatic Bone Disease

Background

 Bone is a common site of metastatic cancer.

 Bone metastases occur in most tumor types but are most prevalent in cancers of the breast,
prostate, and lung.
 These bone lesions can cause serious skeletal complications, including spinal cord or nerve
root compression, bone surgery, hypercalcemia of malignancy, pathologic fractures, and
severe bone pain requiring palliative radiotherapy,
 Palliation of pain, prevention of skeletal complications, and maintenance of quality of life
are the primary objectives in managing patients with metastatic bone disease.
 The skeleton is one of the commonest sites of secondary cancer; in patients over 50 years
bone metastases are seen more frequently than all primary malignant bone tumours
together.
 The commonest source is carcinoma of the breast; next in frequency are carcinomas of the
prostate, kidney, lung, thyroid, bladder and gastrointestinal tract. In about 10 per cent of
cases no primary tumour is found.
 The commonest sites for bone metastases are the vertebrae, pelvis, the proximal half of the
femur and the humerus.
 Spreading is usually via the blood stream; occasionally, visceral tumours spread directly to
adjacent bones (e.g. the pelvis or ribs).
 Metastases are usually osteolytic, and pathological fractures are common.
 Bone resorption is due either to the direct action of tumour cells or to tumour-derived
factors that stimulate osteoclastic activity.
Clinical Features

 The patient is usually aged 50–70 years; with any destructive bone lesion in this age group,
the differential diagnosis must include metastasis.
 Pain is the commonest – and often the only – clinical feature.
 The sudden appearance of backache or thigh pain in an elderly person (especially someone
known to have been treated for carcinoma in the past) is always suspicious.
 Some deposits remain clinically silent and are discovered incidentally on x-ray
examination or bone scanning, or after a pathological fracture. Sudden collapse of a
vertebral body or a fracture of the mid-shaft of a long bone in an elderly person are
ominous signs; if there is no history and no clinical clue pointing to a primary carcinoma, a
biopsy of the fracture area is essential.
 Symptoms of hypercalcaemia may occur (and are often missed) in patients with skeletal
metastases.
 These include anorexia, nausea, thirst, polyuria, abdominal pain, general weakness and
depression.
 In children under 6 years of age, metastatic lesions are most commonly from adrenal
neuroblastoma.
 The child presents with bone pain and fever; examination reveals the abdominal mass.
Laboratory Results

 The ESR may be increased and the haemoglobin concentration is usually low.
 The serum alkaline phosphatase concentration is often increased, and in prostatic
carcinoma the acid phosphatase also is elevated.
 Patients with breast cancer can be screened by measuring blood levels of tumour-
associated antigen markers.
Imaging

 X-rays Most skeletal deposits are osteolytic and appear as rarified areas in the medulla or
produce a moth-eaten appearance in the cortex; sometimes there is marked bone
destruction, with or without a pathological fracture.
 Osteoblastic deposits suggest a prostatic carcinoma; the pelvis may show a mottled
increase in density which has to be distinguished from Paget’s disease or lymphoma.
 Radioscintigraphy Bone scans with 99mTc-MDP are the most sensitive method of
detecting ‘silent’ metastatic deposits in bone; areas of increased activity are selected for x-
ray examination.
Treatment

 By the time a patient has developed secondary deposits the prognosis for survival is poor.
 Occasionally, radical treatment (combined chemotherapy, radiotherapy and surgery)
targeted at a solitary secondary deposit and the parent primary lesion may be rewarding
and even apparently curative. This applies particularly to solitary renal cell, breast and
thyroid tumour metastases tumour metastases; but in the great majority of cases, and
certainly in those with multiple secondaries, treatment is entirely symptomatic.
 For that reason, the effort to discover the source of an occult primary tumour are avoided,
though it may be worthwhile investigating for tumours that are amenable to hormonal
manipulation.
Palliative Care

 Control of pain and metastatic activity: Most patients require analgesics, but the more
powerful narcotics should be reserved for the terminally ill.
 Radiotherapy is used both to control pain and to reduce metastatic growth. This is often
combined with other forms of treatment (e.g. internal fixation).
 Hormone therapy: stilboestrol for prostatic secondaries and androgenic drugs or oestrogens
for breast carcinoma.
 Hypercalcaemia should be treated by ensuring adequate hydration, reducing the calcium
intake and, if necessary, administering bisphosphonates.
 Treatment of limb fractures: Shaft fractures should almost always be treated by internal
fixation and (if necessary) packing with methylmethacrylate cement.
 If there are multiple fractures, more than one bone may be fixed at the same sitting, though
one must bear in mind that the risk of fat embolism increases with multiple intramedullary
nailing.
 Pain is immediately relieved, nursing is made easier and the patient can get up and about
or attend for other types of treatment without unnecessary discomfort.
Pathological fractures

 Usually require some form of support.

 If the spine is still completely stable, a well fitting brace may be sufficient.
 However, spinal instability may cause severe pain, making it almost impossible for the
patient to sit or stand – with or without a brace. For these patients, operative stabilization is
indicated – either posterior or anterior spinal fusion, depending on the individual need.
 Spinal decompression should be carried out at the same time as soon as possible if present
Metastatic spinal disease

 40 times more common than all primary tumours of the spine together
 Between 41 and 70 per cent of all malignant tumours have a spinal metastasis, mostly in
the thoracic spine and mainly in the vertebral body
 The aims of intervention are to decrease pain, preserve the ability to walk, maintain urinary
and faecal continence and prolong survival.
Refference

 1. Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics and Fractures.

CRC press; 2010.
 2. Heatley FW. Rockwood and Green’s fractures in adults. Edited by CA Rockwood Jr,
DP Green, RW Bucholz and JD Heck-man. Pp 2584. Philadelphia, etc: Lippincott Raven
Publishers, 1996. ISBN: 0-397-51602-9.£ 227.00. 1997.
 3. Li S, Peng Y, Weinhandl ED, et al. Estimated number of prevalent cases of metastatic
bone disease in the US adult population. Clin Epidemiol. 2012;4:87.
 4. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal
morbidity. Clin cancer Res. 2006;12(20):6243s-6249s.